Thorough assessment of functional incontinence

9 July, 2002

VOL: 98, ISSUE: 28, PAGE NO: 58

Julie Vickerman, Dip.COT, SROT, is clinical specialist occupational therapist (continence care), Chorley and South Ribble Primary Care Trust; she is also on secondment as a research occupational therapist to PromoCon, Disabled Living, Manchester

There are many documented causes of incontinence. These can be pathophysiological - resulting from neurological disorder, muscular or sphincter weakness - and may be congenital or acquired. Medication, constipation, infection and diet have also been identified as contributing factors (Button et al 1998).

Many people with physical disabilities experience problems of urgency, others may have difficulty emptying their bladder or may need to use assisted techniques such as intermittent self-catheterisation.

It is important to remember, however, that many of these people become incontinent not as a result of their actual bladder or bowel problem but because of a poorly adapted environment. It is possible that a person with completely normal bladder and bowel functions may become incontinent if their physical difficulties are severe and limiting (White, 1996).

Individuals who cannot cope with their bladder or bowel functions are said to have functional incontinence.

Factors contributing to functional incontinenceFactors that can contribute to functional incontinence, either directly - by influencing bladder or bowel function - or indirectly - by influencing the person’s ability to cope with bladder or bowel function - are:

Impaired mental status;
Impaired mobility;
Impaired dexterity;
An unsupportive environment. (Hunt 1993)

Assessment of functionAn individual’s functional ability is an important consideration when assessing their continence needs. This is true whether the problem is caused by dysfunction or a physiological cause is identified.

When continence aids are used as a means of managing incontinence - for example, pads, sheaths, and catheters - it is important that the individual has the functional ability to manage them. This will require a full functional assessment.

Many continence advisers and nurses will not have the necessary skills to assess function and should consider referral to an occupational therapist for a detailed assessment. This applies to both the acute hospital setting and the community.

Points to consider when assessing functionThe following points may be useful to consider when completing a continence assessment. These areas identified are those where an occupational therapist’s expertise could be of particular value in helping to promote continence.

Toilet

Toilet height - assess if this is too low to allow safe and easy sitting and standing. The toilet height can be increased with a raised toilet seat. Consider rails both around the toilet and on the wall adjacent to the toilet, if necessary. Alternatively, a combined raised toilet seat and frame could be used. These are adjustable in height.

Location of toilet - assess the accessibility of both inside and outside facilities. Rails may be needed next to any outside steps. Assess the general condition of any steps and pathways if an outside toilet is used. Grants may be available to make general repairs or to facilitate the installation of an inside toilet.

It is important to consider how far the toilet is away from the bedroom and the living area.

Lighting in the toilet - there should be good illumination. Are the light switches easy to find and use? Consider the position of the lights: are they in the right place for safety?

Space available in the toilet - there should be sufficient space to turn around with any walking aids or a wheelchair, if one is used. Consider the use of a commode if space is inadequate and available space in the toilet is likely to compromise safety.

Bedroom

Bed - the bed should be of a correct height to encourage safe mobility in and out of it. If the person is using a wheelchair, the bed height should equal the wheelchair height to ensure safe transfer. Night-time commodes should be the same height as the bed. Consider the use of bed-attached commodes for safe side transfers. Equipment to assist the individual to sit up may need to be considered, such as a bed rail, pillow lifter or mattress elevator.

Bedding - consider the use of lightweight bedclothes - for example, a duvet. If traditional bedding is used, discourage the carer from tucking it in on the side used to get in and out of bed to allow for safer and easier transfers.

Lighting - ensure easy access to a bedside light from the bed. Consider using a touch lamp or low wattage bulbs to allow a light to be left on.

Access to the toilet - ensure that the pathway to the toilet is clear of all obstacles, particularly where a mobility aid is used.

Living area

Armchair - encourage the use of the correct height of chair. This will enable safe and easy sitting and standing. Consider the use of chair risers if the chair is too low.

Discourage the use of additional cushions to raise the height of the seat, as this impairs the effective use of chair arms to assist in standing. Specialist chairs that assist the individual to a standing position may have to be considered if the existing chair is unsuitable to be adapted.

Access to toilet - see notes in toilet section. Where it is necessary to negotiate stairs, consider additional stair rails to enhance safety. Careful consideration should be given if a stair lift is proposed, as these are slow and individuals with urgency may not make it to the toilet in time.

Lighting - see toilet and bedroom sections.

General issues

Flooring - consider the condition of the flooring in all rooms, particularly the toilet, bedroom, living room and main passageway. Is it non-slip? Are there small mats that could be hazardous? Are there holes in the carpet in which a foot could become caught? A cold surface, such as tiling, can sometimes produce a spontaneous voiding of the bladder if the person has bare feet.

Clothing - check that clothing is loose and easy to manage. It is difficult to maintain continence if clothing is too tight to unfasten or manoeuvre. Many layers of clothing or skirts and dresses with large amounts of fabric make toileting more difficult.

Consider the style of clothes or the use of adapted clothes and underwear. This is particularly useful if someone is having problems with managing fastenings or requires easy access to use a urinal. Zips, for example, can be lengthened or side seams can be released and closed with Velcro.

‘Awear’, the umbrella organisation for clothing advisers, can provide details of specialists who can alter high street clothing (see box).

Footwear - firm, well-fitting footwear with non-slip soles enhances safe mobility and increases confidence. Slippers should be avoided, as they do not provide adequate support for safe mobility.

Medication - assess whether the client can access medication easily. Some modern packaging can be difficult to open. Discuss alternative styles of packaging with the pharmacist. Ensure that all medication is taken according to the prescription and at the correct time. This is particularly important with diuretics. Tablet ‘organisers’ or prompt charts can be useful.

Fluid intake - is the client having too little or inappropriate fluids - for example, fizzy drinks? It is important to consider whether the client can prepare a drink safely.

Eyesight - can the client see well enough to take medication, adjust clothes, walk to the toilet, avoid obstacles?

Orientation - is the client confused? Do they know where the toilet is situated? Can they find the toilet? Consider the use of clear signs or pictures to indicate the correct room. This is important in hospital and home settings. Do they need prompts to go to the toilet? Are these given consistently? Is help available if required?

Hygiene - can they cleanse themselves after toileting? Long-handled wipers are available, and a portable bidet may be required. Alternative types of toilets may have to be considered for people who have difficulties cleansing themselves.

ConclusionIncontinence impacts on an individual’s social, psychological and physical interactions with family and friends. Increased awareness of the functional aspects of continence promotion can often solve the environmental and functional issues that are causing the incontinence. In addition to the promotion of continence, independence can be increased along with self-esteem, dignity and social interactions.

CLOTHING ADVICE

‘Awear ’ Nottingham International, Clothing Centr, Knightbridge Way, Ainsley Road, Hucknall, Nottingham

Tel:0115 953 0439

PromoCon, Redbank House, St Chad’s Street, Cheetham, Manchester M8 8QA

Tel:0161 834 2001 (Monday to Friday,10am-3pm)