Older people require assessment of bowel and bladder function problems
Katherine Wilkinson, MA, DN, RGN, FAE 730/7, non-medical prescriber, is nurse consultant/continence service manager, Bradford and Airedale Teaching PCT.
Wilkinson, K. (2009) A guide to assessing bladder function and urinary incontinence in older people. Nursing Times; 105: 40, early online publication.
This article provides a brief overview of the causes of urinary incontinence in older people and the factors that need to be taken into account when assessing and treating the condition.
Keywords: Age-related bladder change, Plan of care, Polypharmacy
- This article has been double-blind peer reviewed.
- Understand the complex nature of incontinence in older people and how to undertake a comprehensive and holistic assessment to identify the causative factors.
- Be aware of the therapies available to promote continence in older people.
The incidence of incontinence is increasing as there has been a steady increase in the number of older people in the UK and this group has a higher prevalence of continence problems (Fonda et al, 2005). However, fewer than half of those affected by incontinence seek professional help (Staskin et al, 2005 ).
The psychosocial implications of incontinence are huge, often resulting in people becoming afraid to leave home because they are worried that they will not be able to find a toilet and are fearful of being incontinent. This in turn can lead to loss of mobility and depression. Incontinence is also known to be a cause of falls in older people (Teo et al, 2006).
The National Service Framework for Older People (Department of Health, 2001) stated that older people should have access to an integrated continence service as described in Good Practice in Continence Services (DH, 2000). However, the Royal College of Physicians (2006), in its audit of continence care provision for older people, reported that there still remains inadequate access to integrated services.
The aetiology of urinary incontinence in the frail older person is often multifactorial. This should be borne in mind when assessing an older person who is experiencing bladder symptoms or incontinence as there may be a combination of age-related changes that contribute to the problem.
Age-related changes in the bladder
The urinary bladder is a hollow muscular organ that has two main purposes: to store urine and to void urine.
The bladder wall is composed of several layers, including the detrusor muscle – made up of smooth muscle fibres and elastic connective tissue – which enables the bladder to fill without an increase in bladder pressure. It is also responsible for contracting, thus enabling the bladder to void (Fig 1).
Continence is maintained by a complex coordination between the bladder, urethra, pelvic floor muscles, the endopelvic fascia and the nervous system. To maintain continence urethral pressure must exceed the pressure of the bladder.
The ‘normal’ bladder can hold approximately 500ml, and most people feel the first sensation that they need to void when it is about half full. As the bladder fills, it sends sensory signals via afferent nerves to the brain. If it is not convenient to pass urine the brain sends an inhibitory message back to the bladder asking it to ‘hold on’. This continues until the person finds an appropriate place to void, and then the brain sends a message to the bladder causing the detrusor muscle to contract.
Age-related changes to the urinary system
It is known that the bladder and associated structures undergo age-related changes, which can affect bladder function and continence.
The ageing bladder is likely to have a decreased capacity with a smaller voided volume and increased involuntary detrusor contractions, which will result in urinary symptoms such as overactive bladder and urge incontinence. There may also be decreased bladder contractility during voiding, resulting in an increased residual volume that may cause frequency, urgency, incontinence and urinary tract infections (Fonda et al, 2005).
A decrease in oestrogen levels in older women results in a reduction of periurethral and vaginal collagen, leading to atrophic changes in the urethra and vagina. This can result in a decreased urethral pressure in women, increasing the likelihood of stress and urge incontinence, prolapse and also an increased risk of urinary tract infections.
In men the risk of benign prostatic hyperplasia (BPH) increases with age and can give rise to a number of symptoms, including urgency and frequency, hesitancy and straining, and urinary retention.
Microscopic BPH is seen in about 65% of men aged 60–70 years, 80% of men aged 70–80 years and 90% of men aged 80–90 years. It is estimated that around 25% of these men will develop bladder symptoms due to outflow obstruction (Slack et al, 2008).
Older people are also more likely to have an increased urine production at night (nocturnal polyuria), which can result in nocturia and nocturnal enuresis. This can have an impact on quality of life and is also a common cause of falls when trying to reach the toilet (Slack et al, 2008).
Other factors that can affect bladder function in older people
The frail older person often has health conditions that can cause bladder and bowel dysfunction. Polypharmacy is common in older people and incontinence may be a result of medication that has been prescribed for other conditions (Slack et al, 2008). For example, diuretic medication can result in increased urinary frequency, urgency and urge incontinence, and alpha-blockers prescribed for hypertension can weaken the urethral muscle resulting in stress incontinence.
Many medicines can have an adverse effect on bladder and bowel function, so when assessing an older person with incontinence or bladder symptoms a medication review should be undertaken.
Diabetes mellitus occurs in 15–20% of frail older people (Fonda et al, 2005) and can result in a range of bladder problems, including polyuria, urinary retention and urinary tract infection.
Older people with chronic chest conditions such as COPD are at increased risk of stress incontinence due to the strain on the pelvic floor muscle as a result of coughing.
Congestive heart failure can contribute to nocturnal polyuria, nocturia and nocturnal enuresis. Diuretic medication for heart failure can cause daytime urgency, frequency and incontinence.
Severe constipation is a common problem in older people and faecal impaction can cause urinary retention and both urinary and faecal incontinence. Neurological conditions such as stroke and Parkinson’s disease may interfere with the nervous pathways that control bladder function, resulting in urgency and frequency and sometimes retention of urine.
Older people with dementia may have good bladder function but because of cognitive impairment, and associated mobility problems, they are often unable to recognise the need to pass urine or to find the toilet. This can result in “inappropriate voiding”, when, for example, the older person with dementia voids in a waste bin or similar receptacle.
Assessment of the older person with bladder dysfunction
When assessing the older person with incontinence or bladder dysfunction, a holistic and comprehensive approach is essential. It is important not to have any preconceived thoughts as to causes.
The person may be embarrassed and ashamed, and therefore time should be set aside to talk about their feelings. The underlying cause is often multifactorial and the nurse has to undertake the role of detective to try to identify the cause of the bladder problem.
It is advisable to use an assessment tool to guide the assessment process and ensure that all the essential information is gathered. This is vital if a balanced judgement about the cause of the problem is to be made.
The bladder record diary has been cited as the single most valuable tool in assessing urinary incontinence (Norton, 2001). NICE (2006) recommends maintaining a three-day bladder diary (box 1).
Box 1. Bladder diary
A well-completed bladder diary provides useful information to support the assessment process and it is worth spending time explaining how to complete it to the patient or carer. When reviewing the bladder diary the following should be observed:
- Number of voids per day;
- Number of voids at night;
- Maximum void;
- Minimum void;
- Average void;
- Number of incontinent episodes and degree of wetness;
- Fluid intake and type.
Symptoms of urgency, frequency and nocturia and urge incontinence are all indicative of an overactive bladder, while leaking on coughing, sneezing and exertion are more likely to suggest stress urinary incontinence.
The amount and type of fluid drunk can affect continence. Drinks containing caffeine, for example coffee, tea and alcohol, may cause increased urgency and frequency and it may be helpful to reduce this type of fluid (Wilson et al, 2005). However, total fluid intake should be 2L a day.
Urinalysis is an essential part of a continence assessment, providing valuable information that can lead to a diagnosis or disprove a suspected condition. It is advisable to dip test urine with a multi-property reagent stick to detect any abnormalities.
A detailed medical and surgical history should be taken and a list of all medications, including over-the-counter medications, and the potential side-effects of these drugs should be checked to find out if the bladder symptoms may be related to them.
A bladder scan should be used to assess the post-micturition residual bladder volume of urine. There is no evidence-based agreed specific maximum post residual volume (PVR) that is considered normal or a minimum PVR that is considered abnormal. When assessing the significance of a bladder residual volume it is important to look at the bladder function and symptoms of the individual before considering any intervention such as intermittent catheterisation.
With the older person’s informed consent it may be appropriate to undertake a vaginal or digital rectal examination. This should only be done by a practitioner who has been trained and is competent in the procedure. The examination can determine the strength or weakness of the pelvic floor muscles, and also identify conditions such as prolapse, vaginal atrophy, constipation and BPH in men. The modified Oxford grading system may be used to grade the strength and endurance of the pelvic floor muscles (Laycock and Haslam, 2002).
An abdominal examination should be undertaken by a doctor or nurse practitioner to exclude an abdominal mass and in men a digital rectal examination is used to assess the prostate gland. The doctor may also take blood to measure the prostate specific antigen (PSA) which, if raised, may indicate prostate cancer.
In people known to have problems with cognitive function, for example dementia, their ability to recognise the need to void and that the toilet is the appropriate place to void should be assessed. It is also important to assess their ability to reach the toilet unassisted and whether they have appropriate help.
For people with mobility problems, for example as a result of a stroke, a functional assessment should be undertaken to ensure that they can either access the toilet, commode or urinal independently and, if not, that help is readily available.
Plan of care following assessment
A good assessment will help to identify any underlying causes of the incontinence and enable appropriate treatment to be initiated. The options should be discussed with the older person and their willingness and ability to participate in self-help strategies assessed and a clear explanation should be given to the individual and/or carer.
Patients’ preferences for care must be established and the care plan individualised with patient-centred goals (Fonda et al, 2005). In frail older people some interventions may be inappropriate, but advanced age alone should not preclude treatment if the assessment identifies that it is necessary (Fonda et al, 2005).
Conservative therapies such as bladder retraining, ensuring a good fluid intake and reducing caffeine, constipation management and pelvic floor exercises are effective.
Referral to a urotherapist may be advisable for further pelvic floor assessment and re-education if the pelvic floor muscles are weak.
There is evidence that prompted voiding during the day time for older people in care homes is effective (Fonda et al, 2005).
Older men with benign prostate disease may be managed with medication for example alpha–blockers. Those with early prostate cancer may carefully monitored with regular blood tests for PSA (prostate specific antigen), digital rectal examination and observation of symptoms. Other treatment options include Surgery“>surgery and radiotherapy. Advanced prostate cancer may be treated with hormonaltherapies and monitoring of symptoms.
Antimuscarinics for overactive bladder should be prescribed with caution in older people due to the risk of drug interactions with other medications they may be taking, the effect of co-existent disease and also the risk of side-effects such as impaired cognitive function (Wagg, 2007).
There is trial evidence in the following for fail older people:
- Oxybutynin, modified release;
- Tolterodine (Wagg, 2007).
NICE (2006) recommends the use of topical oestrogen for vaginal atrophy and report that it can also improve symptoms of frequency, dysuria, urge or stress urinary incontinence.
Surgery should only be considered after conservative therapies have been tried (NICE, 2006). Age is not a barrier to incontinence surgery. However older people, particularly those who are frail, are susceptible to delirium and loss of mobility post-operatively, so pre-operative assessment and careful post-operative care is essential to minimise complications (Fonda et al, 2005)
Older people are more susceptible to incontinence and this can have a huge impact on daily activities. A holistic assessment by a nurse who has a good understanding of the complex nature of incontinence in older people can identify the causative factors and enable an appropriate plan of treatment to be initiated. For many individuals this will result in a cure or improvement in their incontinence, which will help both the patient’s and their carer’s quality of life.
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Department of Health (2001) National Service Framework for Older People. London: DH.
Department of Health (2000) Good Practice in Continence Services. London: DH.
Fonda, D. et al (2005) Incontinence in the frail elderly. Chapter 18. Incontinence Volume 2: Management. Paris: International Continence Society Health Publication Ltd.
Laycock, J., Haslam,J. (2002) Urinalysis. Therapeutic Management of Incontinence and Pelvic Pain. London: Springer.
NICE (2006) Urinary Incontinence: the Management of Urinary Incontinence in Women. Clinical Guideline CG40. London: NICE.
Norton, C. (2001) Nursing For Continence (2nd edn). Beaconsfield: Beaconsfield Publishers.
Royal College of Physicans (2006) National Audit of Continence Care for Older People. Clinical Effectiveness and Evaluation Unit. London: RCP.
Slack. M. et al (2008) Fast Facts: Bladder Disorders. Oxford: Health Press.
Staskin, D. et al (2005) Initial assessment of incontinence in Incontinence Volume 1: Basics and Evaluation. Paris: International Continence Society Health Publication Ltd.
Teo, J.et al (2006) Do sleep problems or urinary incontinence predict falls in elderly women? Australian Journal of Physiotherapy; 52, 19-24
Wagg, A. (2007) GP Fact File: Overactive Bladder in the Elderly Patient. London: Medical Imprint.
Wilson, P. et al (2005) Adult conservative management in incontinence. Incontinence Volume 2: Management. Paris: International Continence Society Health Publication Ltd.