Managing Incontinence: How Are Nursing Homes Really Doing?

A review of Minnesota's 1998 Incontinence Study

It has been said that what separates the "men from the boys" in nursing home care is management of urinary incontinence (UI). Success in this is often a hallmark of all-around excellence; the results of failure are readily detectable by almost anyone passing by.

But how are nursing homes really doing these days in meeting this major challenge? Recently the Minnesota Department of Human Services (DHS) attempted to answer the question by studying the UI status quo in some 70 nursing homes across the state and involving some 480 residents. (The study also examined community-based management of UI for comparative purposes, but that won't be addressed in this article.) It focused specifically on Medicaid-funded residents and residents who were members of the state's groundbreaking Senior Health Options plan for managing the dually eligible. The data were collected and analyzed by the Minnesota-based non-profit consulting firm Stratis Health. Some key findings:

* An 80% prevalence of UI among this population--substantially higher than reported typically in the medical literature--and, in most cases, of a reasonably severe nature (rated at least 3 of 4 on the MDS scale).

* A relatively low (or at least undocumented) utilization of diagnostic procedures, most particularly urinalysis.

* A common presence of incontinence-inducing medications in the residents' prescription regimens (for approximately 80% of residents).

* Active treatment and/or management undertaken in 96% of cases.

At first glance this would seem to indicate a mixed picture for the nursing homes studied: In general, they're doing a lot about a very common problem that they don't understand very well. Is that a fair summation? To get a perspective, Nursing Homes/Long Term Care Management Editor Richard L. Peck asked Kathleen Brooks, MD, a family physician and medical consultant to the Minnesota DHS, to elaborate.

Peck: Did the 80% prevalence of UI in this population surprise you?

Dr. Brooks: These data were derived from the MDS and encompassed all levels of incontinence above "0" up to 4. It is possible that other studies showing a lower prevalence used different criteria for UI, so you have to interpret the difference with some caution. Still, in this particular setting, an 80% prevalence is not particularly surprising to me.

Peck: What about the apparently low utilization of diagnostic modalities? What did you make of that?

Dr. Brooks: I think this might relate in part to the fact that many of these residents had high levels of impairment--84% had problems with two or more activities of daily living (ADLs), and 57% were cognitively impaired. Since this would restrict the choices available in evaluating or treating incontinence, it might be that specific diagnosis of the incontinence was considered less important.

It is also conceivable--particularly since only 31 of the 480 cases were new-onset cases--that many of these residents had already been evaluated in their physicians' offices prior to admission, and that's where the diagnostic records are located.

Peck: Is there evidence, though, of treatment being directed toward a specific diagnosis of either stress or urge incontinence? Or is making that distinction important in the nursing home?

Dr. Brooks: The fact is that much of the urinary incontinence seen in nursing homes is of the mixed type--both stress and urge. Applying treatment specific to a diagnosis becomes very difficult. More likely you will see a variety of treatment and management techniques being applied.

Peck: And that is apparently what the study shows--use of scheduled toileting, prompted voiding, bladder control training, medication, fluid and diet control, etc., for treatment, and absorbent pads, catheters, etc., for management--and in various combinations.

Dr. Brooks: Yes, and I find that very encouraging. Nursing homes are clearly recognizing urinary incontinence and dealing with it. They're really going after it.

Peck: Does the high occurrence of incontinence-inducing medications in residents' prescription regimens concern you?

Dr. Brooks: It is noteworthy, but it should be remembered that there might be no feasible alternatives for these residents. I think it is very dangerous to presume that residents can be taken off some of these medications without very careful evaluation. What this does indicate to me is the usefulness of some type of pharmacy reminder system, so that the physician can be alerted when the patient is on an incontinence-inducing drug and can give some thought to a possible alternative.

Peck: What were some of the incontinence-inducing medications found in this study?

Dr. Brooks: Loop diuretics, anti-depressants and calcium channel blocking agents were the most commonly used.

Peck: How would you size up nursing homes' overall performance in addressing urinary incontinence, as disclosed by this study?

Dr. Brooks: I think this documents a trend toward increasing recognition of the importance of incontinence and a more active response. It is, overall, an encouraging result.