Trends in incontinence management.

This fast-growing field is evolving in several ways

Incontinence management has been a "growth sector" in long-term care for many years - from a $99 million market in 1972(*) to $496 million in 1987 (the latest figures available), and very likely reaching the $1 billion level this year. Accompanying this product sales growth has been growth in consumer awareness and acceptance of incontinence as a "respectable" problem and, with this, a large consumer marketing effort. Meanwhile, product development has resulted in a large range of sizes, designs and absorptive capacities.

All of these factors have come into play in creating the modern incontinence care environment in long-term care including, in recent years, assisted living. The principles guiding product selection haven't changed, however - in sum, incontinence products are not and never were substitutes for careful evaluation and, where possible, active treatment of incontinence.

By the same token, treatment trends have changed. Ten years ago surgery was considered to be the treatment of choice; today, it is recommended after alternative treatments have been tried. This is especially true, of course, concerning the flail elderly residents who increasingly inhabit our nursing homes, because the gentler and less invasive the management option selected for this population, the better.

There are treatment alternatives to surgery that meet this need. For example, bladder infection can and should be routinely checked for and antibiotics prescribed when indicated. Appropriately evaluated elderly residents can benefit from a pharmacologic trial of oxybutinin chloride (Ditropan) for urge incontinence, and for those residents in whom stress incontinence is a predominant feature, periurethral bulking agents, i.e., collagen injections, may be indicated; these are relatively noninvasive, although they typically require more than one administration.

The most useful active approach to incontinence in the nursing home remains behavioral management - specifically, such measures as scheduled toileting, prompted voiding and habit training. Assuming that staffing is available for these options, habit training will help establish individualized patterns of wetting throughout the day and night, and thus clarify appropriate toileting schedules and product selection.

Whatever management approach is selected, incontinence products will be useful as back-up during treatment trials, as well as for routine maintenance.

The good news is that nursing homes are becoming increasingly selective and targeted in their purchasing of these products. While there remains a "one size fits all" and "pick the cheapest product" ethic in some quarters, more and more facilities are recognizing the advantages of individualized product selection. These facilities are realizing, for instance, the cost-effectiveness of purchasing somewhat more expensive but higher-quality briefs in terms of saving staff time and avoiding skin care issues. Similarly, individualizing the product to the problem, rather than using a superabsorbent pad for everyone, is much more cost-efficient. Interestingly, one potential benefit of today's move toward managed care may be that facilities will become more focused on true cost-effectiveness, as opposed to simply minimizing expenses.

As mentioned, today's products have evolved to expedite these individualized management approaches - for example:

Adult briefs. Pioneered by Procter & Gamble in the 1980s with its Attends line, newer polyester fibers and gels used in these products are offering increased absorption and next-to-the-skin dryness. Further, some of the disposables manufacturers have made efforts toward solving waste management concerns by creating biodegradable cores that begin to disintegrate upon contact with water (i.e., "flushable" pads).

Meanwhile, washable briefs, while still controversial from the cost standpoint (laundering, etc.), are using sophisticated rayon or polyester fiber cores and, like the disposables, are chemically treated to reduce odor and infection. Some nursing homes are purchasing both disposables and washables and leaving it up to their staffs to choose between them according to staffers' preference.

Undergarments and shields. Kimberly Clark's Depends have, of course, become a widely recognized product on the consumer market. Users of this product both outside and inside nursing homes must remember, though, that the pair of elastic sidestraps that comes with each package of 12 is meant to be reusable; once those are disposed, the remaining briefs are, of course, unusable.

Shield-type products include such pleasant-sounding choices as Serenity and Poise. The most recent advance in this type of product has been the growth in choice of sizes available, adding not only to comfort but adaptability to social situations.

Pad/pant systems. These are especially useful for residents engaged in activities and other social events. The Dignity line by Humanacare is designed for urinary incontinence only, while the Promise line by Scott Paper - which is sized by body weight - is useful for fecal incontinence, as well. Pad/pant products have increasingly become adapted to men over the years, e.g., with "drip collectors" that fit in underwear and conform to the scrotum and penis.

These products may have particular appeal in the assisted living environment, with its relatively active clientele.

Collection devices. The humble urinal continues to evolve in variety and design. Openings, handles and storage tanks are becoming more adaptable to wheelchair and bedside use. One relatively new product, the Feminal by A-Plus Medical Products, purports to be so anatomically designed for female use that no handles are required.

It is worth noting that all external catheter devices for females have by now been removed from the market. The problems in skin irritation and attachment that they caused eventually eliminated their usefulness. For men, on the other hand, the tried-and-true condom-type devices remain as options, with the newer models offering molding and tube design that prevent problems with twisting of the tube or urinary reflux.

Occluding devices. For women a new device, the urethral plug, is available to do the job that pessaries were once used but not designed for - i.e., compress the urethra; pessaries were of course designed for use with vaginal prolapse. For men, the traditional Cunningham clamp remains a useful urethral compression device. Obviously, occluding devices are intended only for short-term use on particular occasions, such as visits to the dining room.

Chair and bed pads. The old "blue chux" have become historical artifacts with the development of more highly absorbent pads that keep the bed and chair surface dry. These are of particular usefulness in allowing residents to sleep without having to wear briefs, thus allowing the skin to "breathe" and reducing the risk of irritation and pressure ulcers. Interestingly, the Australian-produced Kylie pads that were starting to make market inroads a few years back are no longer generally available in this country, in favor of the American-made Patient Guard.

The principal limit to the usefulness' of these pads is that particularly restless sleepers tend to shove them out of the way, since they are not secured to the mattress. It is also important to remember that, no matter how absorptive the pad - or brief, for that matter - none of these products is "leakproof"; all have a saturation point. This is of particular importance with nighttime use, because research has shown that the elderly are prone to voiding higher volumes during sleep because of physiological changes associated with aging. Therefore, the need for higher-absorption products may be greater at night.

To conclude, all incontinent residents should be carefully evaluated for cause and type of incontinence. Behavioral techniques should be attempted for all incontinent residents, but those who appear to be viable candidates for other approaches should receive treatment trials, as indicated, of drugs, periurethral injections or surgery. In any case, today's many and varied absorptive products can and should be adapted to each resident's need, situation and management strategy.

* AHCPR. Clinical Practice Guidelines, Urinary Incontinence in Adults: Acute and Chronic Management. Number 2, 1996 update.

Carol Brink, RN, MPH, is Associate Professor of Clinical Nursing at the University of Rochester. She was co-founder of the first continence clinic in the United States, located at the University of Michigan.