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DATE DUE DATE DUE DATE DUE 5/08 KrlProj/Acc8Pres/ClRC/DateDue.indd "IMPLEMENTATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH GUIDELINES ON URINARY INCONTINENCE FOR THE GERIATRIC PATIENT IN PRIMARY CARE I, by Cynthia Denise Munro/rand Robert James Trout A SCHOLARLY PROJECT Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE College of Nursing 1999 Abstract IMPLEMENTATION OF THE AGENCY FOR HEALTH CARE POLICY AND RESEARCH GUIDELINES ON URINARY INCONTINENCE FOR THE GERIATRIC PATIENT IN PRIMARY CARE By Cynthia Denise Munro and Robert James Trout Currently there are no comprehensive and systematic tools or protocols available to the primary care provider to evaluate and treat urinary incontinence in accordance with the Agency for Health Care Policy and Research (AHCPR) guidelines. This study reviews literature since the 1996 revision and incorporates Orem's Self-care Deficit Theory in the creation of a two-sided easy-to-use protocol. The protocol is organized to recognize patient's perceptions and capabilities. history, risk factors, medications. lifestyle and specific physical exam findings to direct the practitioner’s assessment. Diagnostic tests are suggested. Indicators to the specific type of incontinence (transient, urge, stress, mixed, overflow or functional) are given to clarify diagnosis. Treatment options specific to primary care are provided with referral criteria to continence centers or urologists. Implications for the advance practice nurse, evaluation. research and professional education are included. To Mike, my life partner and best friend. who has encouraged, supported. and believed in me through this long ordeal and always. I am a better person because of you. To my sons Michael and Tyler. who provide daily inspiration and purpose. iii Acknowledgments I wish to thank all my friends in Women‘s Services at Sparrow Hospital for their never ending encouragement and support. They have no idea how great they really are. I would also like thank the Sparrow library staff for their patients and assistance in collecting numerous literature searches. I would like to express my sincere gratitude to the members of my scholarly project committee, Diana Roush, Sharon King, and Kate Lein. I thank Diana for her encouragement, enthusiasm, and willingness to chair my committee even when I changed topics in midstream. I thank Kate for her kindness and clinical guidance, and I thank Sharon for her infinite wisdom and advice. I will be forever indebted to my friend and colleague. Bob Trout, who has taught me how deceiving first impressions can be. I cherish his friendship, respect his expertise and admire his undying faith. iv Table of Contents List of Figures ................................................................................................................... vi Introduction ........................................................................................................................ I Background ............................................................................................................ I Purpose of the Study .............................................................................................. 3 Conceptual Definitions .......................................................................................... 4 Conceptual Framework ...................................................................................................... 5 Review of Literature ........................................................................................................ I I Introduction .......................................................................................................... l 1 Age related changes ............................................................................................. l 1 Types of Urinary Incontinence ............................................................................ 13 Gender Specific Issues ......................................................................................... 17 Risk Factors ......................................................................................................... 19 Assessment ........................................................................................................... 22 Treatments ............................................................................................................ 26 Behavioral ................................................................................................ 27 Pharmacological ....................................................................................... 32 Surgical .................................................................................................... 38 Supplemental and Gender Specific .......................................................... 43 Protocol Development ..................................................................................................... 48 Overview .............................................................................................................. 48 Description of Protocol ........................................................................................ 49 Implementation Plan ............................................................................................ 51 Discussion ........................................................................................................................ 53 Implications for the Advance Practice Nursing .................................................... 53 Evaluation ............................................................................................................ 55 Implications for Research .................................................................................... 56 Implications for Professional Education .............................................................. 58 Summary .............................................................................................................. 59 Appendix .......................................................................................................................... 60 List of References ............................................................................................................ 63 List of Figures Figure l: Orem's Self Care Deficit Theory ..................................................................... IO Figure 2: Orem's Self Care Deficit Theory for Geriatric Urinary Incontinence .............. l I vi Introduction MPH—Nd The 1996 Agency for Health Care Policy and Research (AHC PR) Clinical Practice Guideline Urinary Incontinence in Adults: Acute and Chronic Management describes urinary incontinence (UI) as the involuntary loss of urine sufficient to be a problem. It affects all age groups but is particularly common in the elderly. At least 13 million adult Americans suffer from UI, including approximately 30 percent of community-dwelling persons older than 60 years of age (Diokno. Brock, Brown. & Herzog, 1986). A significant percentage of these women and men have frequent incontinent episodes, usually daily or weekly (Burgio, Matthews, & Engel, I991; Diokno, et al., 1986). The total economic impact of urinary incontinence among persons over the age of 65 was conservatively estimated in 1986 at $8.2 billion a year (Hu, 1990). In 1994, the ‘ estimated cost had increased to $16.4 billion annually (Hu, Gabelko, Weis, Fogarty, Diokno, & McCormick, 1994). Most costs are associated with pads and diapers, which is a tremendous out-of-pocket expense for persons with incontinence who are typically older with less income. Urinary incontinence is a symptom rather than a disease. It appears in a limited number of clinical patterns, and has several possible causes. In some cases, the disorder is transient, such as when it is secondary to medications or a urinary tract infection. Unfortunately, many cases are chronic, persisting for long periods unless properly diagnosed and treated. Medical efforts to treat UI often fail due to the failure of providers to identify and diagnose it as a treatable problem (Bushman, 1994). l Though age does not cause Ul. several age-related Changes and age-associated factors contribute to its development. Primary health care providers specializing in the care of the elderly must be aware of the effects aging has on Ul since prevalence increases with age (Bushman, I994). Weakening and other changes in the pelvic structure, increased numbers of risk factors such as associated comorbidities make identification of U1 more difficult. The immense psycho-social burden of UI to older persons affects both their identity and sense of self. Urinary incontinence disrupts the quality of daily living and interpersonal relationships (Mitteness, 1990). Payne (1998) argues that it is not the severity of U1 that affects quality of life but merely the state of being incontinent. Because of U1, many older adults make significant changes in social activities and sometime become depressed and/or socially isolated. Anxiety may develop regarding disclosure to friends, embarrassment about accidents in public. and alterations in sexual activity (Clark & Romm, 1993). Because of the social stigma of U1, many sufferers do not report the problem to a health care provider. When UI is reported, many physicians and nurses fail to pursue an investigation. As a result. this medical problem is vastly under diagnosed and under reported (Jeter & Wagner, 1990). Inappropriate management of U] by primary care providers may be attributed to the belief that leakage of urine is a normal part of aging. In a study by Simons (I985), 27% of subjects were told by their primary care provider that leaking urine was a normal part of aging; 18% were told not to won'y about the symptoms, and 9% had their complaints ignored. According to Beckman (1995), the advanced practice nurse (APN)is not only in a position to provide care to 2 patients with U l. but also to provide education about proper care to other primary health care providers. One great obstacle to effective diagnosis and treatment of U1 in the geriatric population is the perception by providers and patients that Ul is an inevitable and irreversible part of aging. With the publication of the 1996 AHCPR guidelines, primary care providers have had the opportunity to become more aware of the prevalence and problems associated with UI. Nevertheless. access to trained providers who can assess and treat patients remains limited. These authors believe the problem stems from the absence of an easy-to-use protocol to operationalize the AHCPR guidelines. Williams, Crichton and Roe (1997) demonstrate improved outcomes in the home care setting using a standard protocol and set of information for the UI patient in home care. Hundreds of printed articles and thousands of Internet sites reference the guidelines; yet, no comprehensive tools were found that employ a forthright approach for care of the UI patient in primary care. This project will provide a protocol to implement the AHC PR guidelines in a primary care practice. Purgose of Study A recommendation of the AHCPR guidelines for the management of acute and chronic urinary incontinence is to "reduce variations among health care providers while maintaining flexibility to individualize treatment to individual patients" (1996). Currently there are no comprehensive and systematic UI tools or protocols available to the primary health care provider for the general adult patient or the geriatric patient. The purpose of this project is to develop a protocol that will be used in primary care to evaluate and treat 3 the geriatric client with U l. The protocol is based on the AHCPR (I996) guidelines and will utilize Dorothea Orem's (I99l) nursing model. Orem's self-care deficit theory of nursing is used as a guiding conceptual framework for examining the relationship of urinary incontinence. patient strengths and weaknesses. treatment guidelines and educational responsibilities. Important differences exist between the geriatric and younger adult UI patient necessitating a separate protocol for use with elderly patients. Examples of these differences include greater pelvic floor musculature changes. estrogen related changes in urethral competency. benign prostatic hyperplasia and increased numbers and types of drug usage. The development of separate systematic protocols to evaluate and manage urinary incontinence in females and males may also decrease variability between practitioners and improve clinical outcomes, overall goals of the AHCPR guidelines. Conceptual Definitions Several key concepts are defined here as the basis for a discussion of urinary incontinence. Terms used in Dorothea Orem’s Self-care Deficit Theory of Nursing as they relate to the authors' perspective of U1 care are described in the conceptual framework section. In depth definitions of the types of U] are provided in the literature review. Urinary incontinence is defined by the AHC PR guidelines (I996)as the involuntary loss of urine sufficient to be a problem. Categories of U1 described by the AHCPR guidelines include urge, stress, mixed and overflow. The Agency for Health Care Policy and Research (AHCPR) is an agency of the 4 US. Department of Health and Human Services and was established to enhance the quality. appropriateness and effectiveness of health care services. It facilitates the development. periodic review and updating of clinical practice guidelines. The guidelines assist the practitioner in the prevention. diagnosis. treatment and management of clinical conditions (AHC PR. 1996). The geriatric patient is an individual of age 60 years or older and the recipient of health care services (C atanzaro. I996). Primary care is the point of entry into the health care system that should provide management of the majority of health problems of individuals. a sense of ongoing responsibility for the patient's overall health care. and an approach that considers biological, psychological and social factors (Ham & Sloan, 1997). Primary care geriatrics concerns itself with both the relatively healthy patient between the ages of 65 and 80, and the frail elderly generally above the age of 75 and who require special monitoring and services (Ham & Sloan. 1997). Conceptual Framework While public interest in healthier lifestyles has grown within the past decade, nursing has long encouraged patients to achieve competency in their own self-care. Orem's (I991) self-care deficit theory of nursing provides a framework for nursing as a practice discipline and is an appropriate framework for the implementation of the AHCPR guidelines on Urinary Incontinence. Within Orem’s framework, self-care is designated as a universal requirement for health maintenance and continued life (Orem, 199] ). Orem (I 991) states that nursing is based on the principle that individuals should be 5 helped in their immediate distress and assisted to attain or regain responsibility within their existing capabilities. The goal of nursing then is to help individuals improve themselves or to change conditions in their environments. Furthermore. Orem (I991) states that. "from a nursing point of view. human beings are viewed as needing ' continuous self-maintenance and self-regulation through a type of action named self-care" (p. 73). Orem's theories are based upon "six central concepts and one peripheral concept" (p. 45). The six central concepts are self-care. self-care agency, therapeutic self-care demand, self-care deficit, nursing agency. and nursing system. The peripheral concept is basic conditioning factors. Orem’s self-care deficit theory of nursing is utilized to organize and further understand the concepts related to the assessment and treatment of U1. Orem (1991) defines self-care as "the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well being" (p. 64). This is a two dimensional process involving both decision and action on the part of the individual. Self-care activities are goal oriented and are learned by individuals according to cultural beliefs, habits, and practices that characterize the group to which the individual belongs. There are a number of basic conditioning factors that affect the individual's ability to perform self-care. Some of these factors are age, developmental state, health, family position and role. An individual's established pattern of responding, as well as values and goals. will also affect the selection and performance of self-care behaviors. "Self-care 6 measures compatible with a person's goals and values are likely to be seen as beneficial. Their practice. however. is dependent on the person's judgment of whether he or she can perform the measures" (Orem. I991. p.155). The APN in primary care can assist the geriatric patient with UI to strengthen self-care behaviors by assessing basic conditioning factors. The self-care agency is the client or client's system that provides self care (client. caregiver or support system). Here, the self-care agency within the older population will increasingly become a caregiver (dependent self-care agency). regardless of cognitive presentation. Therapeutic Self-Care Demand (TSCD) is the set of actions required to meet health state or self-care. Orem (1991) identified three types of self-care requisites. or requirements for action: universal, developmental. and health deviation. Universal self- care requisites are those that are present for all persons throughout the life span, though are adjusted for specific living conditions; they are essentially Maslow's hierarchy of needs. There are two developmental self-care requisites: one that evolves through maturational changes and another that emerges through life events such as marriage. childbearing, changes in social situations and death. Six health deviation requisites exist for individuals who are "ill, injured, have specific forms of pathology including defects and disabilities, and who are under medical diagnosis and treatment" (Orem, 1991). An example of a developmental requisite is the need for estrogen replacement therapy with urethral coaptation changes related to the normal aging process. The self-care deficit is the difference between the therapeutic self-care demand 7 and what can be provided by the self-care agency and determines the need for nursing. For example. if the self-care agency is not familiar with how to do Kegels or how much fluid is adequate. nursing agency is required. The Nursing Agency is the person and abilities available to meet therapeutic self- care demand or support self-care identified within the self-care deficit. Similar to the concept of self-care agency, nursing agency is a complex. acquired ability of adults to engage in deliberate action. Basic conditioning factors of the nursing agency include specialized ability that varies through education. experience. skills and ability to work with and care for others (Orem, 1991). Nursing systems can be wholly compensatory. partly compensatory or supportive-educative. The APN in primary care will rarely provide wholly compensatory care, and occasionally partially compensatory care as in assisting a patient to the toilet. The focus of this project is to provide primarily supportive-educative nursing. These invaluable. truly nursing activities of educating and directing toward wholeness, and the ensuing provision of encouragement toward progress, is essential to the success of evaluation and treatment of urinary incontinence within Orem's framework. Other subtypes of supportive/educative nursing activities are guiding. supporting and teaching. It becomes readily apparent that Orem‘s theory is of paramount importance in the care of the geriatric patient with UI because interventions are directed toward self-care efficacy and enhancement. Her theory identifies strengths and needs and recognizes the patient's perception of the problem. Nursing must ask if it is "right” for the patient along with whether it will work (Fawcett, 1995). 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Emcmm 5.500 \\\ gamma _ m.O.>m:®m .3 59:50.35. / Enouzom _ 050.:0m .m....._50_oom // 85580 “ 5.8: 59.5 Eben; was: / / IIIIIIII .— / _ / _ / /. @552 ©2553. 02:95.5 5. >59: 5:2. 050 row WEED Review of the Literature W The AHCPR guidelines were created with the intent to provide direction based upon a solid foundation of research and expert practice up to the year I996. Thus. this literature review will focus on research available since the 1996 update unless past research is particularly pertinent to the geriatric or a gender-specific population. The review attempts to examine each guideline area as it relates to Orem's conceptual framework. The community dwelling geriatric patient seen in the primary care practice is the focus of most research. Age related garage; The lower urinary tract can be functionally divided into the bladder and the bladder outlet. In order to function properly the lower urinary tract must be capable of adequately storing and emptying urine. During storage, the bladder functions as a low- pressure reservoir and the outlet as a competent sphincter. Any change in the bladder that results in an elevated storage pressure or change in the urethra which results in a decrease in the outlet resistance, can affect the ability to store urine. During urinary emptying, the bladder acts as a pumping mechanism and the outlet functions as an unobstructed conduit. A sufficient bladder contraction and a bladder outlet that relaxes appropriately and is free from obstruction are necessary for efficient emptying (Wein. 1991). In addition to an intact lower urinary tract, continence requires mentation, motivation. mobility, and manual dexterity (Wetle, Scherr, Branch, Resnick, Ham's, Evans & Taylor, 1995). Self-care for urine control also depends on the awareness of medications that 11 adversely affect the lower urinary tract function (Miller. 1995). Studies have revealed a number of age related changes and factors that can contribute to the inability of the lower urinary tract to adequately store urine. These developmental changes effect the patient's basic conditioning factors and potentially increase therapeutic self-care demands. As the collagen content of the bladder increases with age. there is a corresponding and significant loss of striated muscle fibers (DeLancy. 1998; & Gosling & Dixon, 1981). In males, these changes are usually associated with outlet obstruction. In women, the loss of muscle fibers in the ventral wall of the urethra is associated with stress incontinence. Aging is also associated with a decline in bladder outlet and urethral resistance pressure in women. This pressure decline is related to diminished estrogen influence and laxity of pelvic structures; it is associated with prior childbirths, surgeries, and deconditioned pelvic floor muscles, predisposing older women to the development of stress incontinence (Fantl, Wyman, Anderson. Matt, & Bump, 1988; Ghomiem & Hassouna. 1997; Staskin, 1986). Decreased estrogen is associated with atrophic vaginitis and urethritis that can lead to symptoms of dysuria and urgency, increasing the likelihood of developing urinary infections and urge incontinence in elderly women (Fantl et al., 1988; Staskin, 1986). Prostatic hyperplasia in the male, beginning as early as the forties but widespread in men by their sixties often acts as an obstructive mechanism. Little research is found on muscular changes in pelvic support or urethral changes in men. Hormonal changes have not been identified in males as being associated with incontinence. Similar detrusor 12 hyperactivity changes occur in males as with females (Gormley. I993). Resnick (1995) noted that although data from continent elderly are sparse. age related changes in the lower urinary tract do occur. Bladder capacity. contractility. and the ability to postpone voiding decline in both males and females. while urethral closing pressure and length decrease with age in women. The prevalence of involuntary bladder contractions increases in both sexes as does the post voiding residual volume. An intracranial lesion can affect lower urinary tract function by directly influencing one of the neural pathways or by indirectly influencing the physical or mental status of the patient. Cerebral disease such as Parkinson’s. degenerative dementias. and cerebrovascular accidents may result in a loss of the inhibitory influence, resulting in uninhibited bladder contractions (Khan, Hertanu. Yang. Melman. & Lieter, 1981). Diseases affecting the sensory or motor function of the bladder such as arthritis. osteoporosis, disc disease, peripheral neuropathy, and vitamin B12 deficiency may result in bladder overdistention (Staskin, 1986). Dyes of Urinary Incontinence Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void (urgency). Urge incontinence is usually associated with the urodynamic findings of involuntary detrusor contractions or detrusor instability. Urge incontinence increases in frequency and severity with advancing age and cognitive dysfunction (Weiss, 1998). and is the most common form of U1 among both elderly men and women (Elbadawi, Yalla, & Resnick, 1993; Geirsson, Fall, & Lindstrom, 1993; Resnick, 1995; Resnick. Yalla, & Laurino, 1989). Patients with urge U] will often present 13 with complaints of severe urgency. sudden incontinence at rest. and/or incontinence precipitated by environmental cues such as running water (Payne, 1998). Urge incontinence results from bladder contractions that overwhelm the ability of the cerebral centers to inhibit them (Weiss, 1998). Involuntary detrusor contractions without a neurological cause is referred to as detrusor instability. Common causes of detrusor instability include local genitourinary conditions such as atrophic vaginitis, cystitis. outflow obstruction. and impaired bladder contractility. Involuntary detrusor contractions with a known neurological cause such as a stroke, Parkinson’s disease or dementia is referred to as detrusor hyperreflexia (Resnick, 1995). Urge incontinence is also caused by detrusor hyperactivity with impaired contractility (DHIC). Detrusor instability with impaired contractility is the most common cause of U1 among institutionalized elderly and is becoming increasingly prevalent among community dwelling elderly (Resnick & Yalla. 1987). Impaired bladder contractions often result in incomplete bladder emptying and large post void residuals. According to Resnick and Yalla (1987) the uninhibited contractions associated with DHIC cause the bladder to empty only one half to one quarter of its volume. Therefore, elderly patients with DHIC may present not only with signs and symptoms of urge incontinence, but with symptoms that mimic stress incontinence, overflow incontinence. and obstruction (Diokno, 1998). Many may also report the need to strain to empty their bladders (AHCPR, 1996). Stress urinary incontinence is characterized by the involuntary loss of urine from the urethra during physical exertion. The clinical hallmark of stress UI is immediate leakage with stress maneuvers such as laughing. coughing, sneezing, or lifting heavy l4 objects (AHCPR, 1996; Gallo. Fallon. & Staskin. 1997; Ouslander. 1997; Rackley & Appell. 1997; Resnick. 1995). Stress urinary incontinence is the second most common cause of incontinence in elderly women (Genadry. 1995; Ouslander. 1997: Rackley & Appell. 1997; Resnick. 1995). Stress UI may be confirmed by observing urine loss coincident with an increase in abdominal pressure during which there is no detrusor contraction or overdistended bladder. It occurs when an increase in abdominal pressure places stress on the bladder and its support mechanisms (Rackley & Appell. 1997). In women, anterior vaginal wall relaxation that allows hypermobility of the bladder neck and urethra is the most common cause of stress U1 (AHCPR, 1996). In men. it is most often found in early post- prostatectomy patients. According to Rackley. et al., (1997) hypermobility accounts for 85% of cases of stress Ul; it develops most commonly with advancing age, decreased estrogen levels, pelvic surgery or traumatic/prolonged child birth. The remaining 15% of cases are caused by intrinsic sphincter deficiency (ISD). In intrinsic sphincter deficiency, the urethra is essentially rigid and unable to function. The proximal urethral sphincter may not be able to withstand increases in bladder pressure and severe urine leakage occurs. Women with ISD often leak urine continuously (AHCPR, 1996) and will frequently report Ul during sexual activity (Snella. Stach-Klysh, Retzky, Benderev, & Neuman, 1996). It is also commonly associated with damage to the bladder neck during pelvic or anti-incontinence surgery, radiation, trauma. hypoestrogenism or aging (AHCPR, 1996; Rackley & Appell. 1997). Mixed Incontinence is the combination, in a patient, of urge urinary incontinence and stress urinary incontinence. Mixed UI is especially common in elderly women 15 (AHCPR. I996; Starer. 1993). Molander ( l993)reported that. of women with a history suggestive of pure stress incontinence. over 20% also had urge incontinence. Rackley and Appell (1997) found 50% to 60% of patients presenting for evaluation of stress incontinence also had urge incontinence. Overflow incontinence is the involuntary loss of urine associated with the overdistention of the bladder. It results from urinary retention that causes the capacity of the bladder to be overwhelmed. Continuous or intermittent leakage of a small amount of urine results. The bladder may be distended because of an acontractile detrusor or an outlet obstruction of the bladder or urethra. Outlet obstruction is most commonly seen in men who have an enlarged prostate (Gallo, et al., 1997). In women. the most common reason for outlet obstruction is prior genitourinary surgery or pelvic prolapse (Gallo. et al., 1997; Rackley & Appell, 1997; Starrer, 1993), though other causes include pharmacological, neurological, or idiopathic (Gallo, et al., 1997; Rackley and Appell, 1997; & Starer. 1993). The elderly patient with overflow UI will usually present with frequent to constant dribbling of urine in the absence of detrusor contractions and will typically have a large post void residual volume on exam (Snella, et al., 1996). Functional incontinence is the inability to achieve effective urination due to functional disabilities, environmental factors, cognitive impairment or psychological unwillingness (Ouslander. 1997; & Snella, et al., 1996). Even though there is a strong relationship between U1 and factors such as poor mobility and confusion in elderly patients, providers must first consider other causes of U1 in a geriatric patient presenting with symptoms (Campbell, Reinken, & McCosh, 1985; Giersson, et al., 1993; Skelly & Flint. 1995; Tinnetti, Inouye, Gill, & Doucette. 1995; Wetle. et al., 1995). I6 Gendemecific Urinary Incontinence Lew Urinary incontinence is over twice as prevalent in women as men with one third of community-dwelling geriatric adults reporting frequent incontinent episodes (Burgio. et. al.. 1991). Payne (1998) asserts. that the prevalence of U 1 depends on the population being discussed. Most studies include only women and have classified UI as stress. urge or mixed incontinence based on responses to questionnaires. Stress UI is most prevalent in premenopausal women, whereas urge incontinence is most common among both elderly men and women (Elbadwi. et al., 1993; Geirsson, et al.. 1993; Resnick, 1995). History of vaginal deliveries and estrogen depletion are risk factors prevalent among elderly women. Although UI does occur in nulliparous women. persuasive evidence identifies vaginal birth as a significant predictor of U1 (DeLancy. 1993; Sommer, Bauer, Nielsen, Kristensen. Hermann. & Nordling, 1989). Women who have had even one vaginal birth are more than two and a half times as likely to report incontinence than are nulliparous women (Jolleys, 1988; Sommer et al., 1989). Rates have also been shown to increase with the number of deliveries; after one vaginal delivery 38% reported some U], 57% after two deliveries, and 73% after three deliveries (N ygaard. DeLancey, Arnsdorf, & Murphy. 1990). Estrogen receptors are found in the female bladder, urethra, and pelvic muscles (Neuman, 1997). The reduction of circulating estrogen levels as seen after menopause, causes atrophy and decreased vascularization of vaginal. urethral, and pelvic tissue (Molander, 1993). Decreased estrogen levels have also been associated with intrinsic urethral sphincter deficiency resulting in stress Ul (AHCPR. 1996). 17 Male Of the estimated 19 million North American Adults ‘ who have urinary incontinence. 20 percent are men; the severity ranges from partial to complete loss of control and may vary over time (Kimberly-Clark. 1999 [Online]). Diokno. et al. (1986) identifies that in older men 35% had urge U1. 8% stress U1. 29% had mixed and 28% were classified as "other". The severity of urinary incontinence in men ranges from partial to complete loss of bladder control. They may experience varying degrees of urine loss, and the incontinence may change over time. For example, men with light incontinence may leak a little when they laugh or cough, while men with heavy incontinence may be experiencing continuous leakage. Some men included post-void dribbling in responses that might otherwise not be considered incontinence (Hunskaar, 1992a). Benign prostatic hyperplasia with urethral obstruction is frequently accompanied by detrusor instability, resulting in frequency. urgency and urge incontinence. Woodside (1992) believes since sphincter incompetence is rarely associated with the U1 of elderly men, the etiology of U] in these patients is usually of a neurological origin and likely represents a central nervous system abnormality. Apart from being older, post-prostatectomy patients do not differ significantly from other men in regard to severity or type of U1. Of twelve surgical patients undergoing prostatectomy who showed detrusor instability preoperatively. detrusor stability occurred postoperatively in only one patient. Preoperatively 1 1 of 12 were incontinent with eight improving to some extent postoperatively. The majority of those who improved were the most urodynamically and cognitively impaired. Urinary symptoms and detrusor instability are likely to persist after prostate surgery (Fowler, 1995; Gonnley et. al., 18 1993). For 30% of post prostatectomy patients. pads or clamps are used indefinitely. Hunskaar (1992a) reports that men do not consider symptoms of U1 serious enough to require treatment. Talbot (1994) found that ifa man seeks medical intervention for prolonged urination and dribbling related to an enlarged prostate, and stress incontinence results from the surgery, he may not seek further medical assistance. Mazur & Merz (1995) further interviewed older VA patients and found the large majority of men. given hypothetical situations. appeared willing to sacrifice incontinence for 10% chance at 5-year life extension. Willingness to accept incontinence was not necessarily related to experience with UI in the past. Risk Factors for Urinary Incontinence In utilizing Orem's Self-Care Deficit Theory of Nursing. risk factors are potential therapeutic self-care demands. As the number or severity of therapeutic self-care demands increase, so does the patient’s potential for self-care deficits. When the self-care agency of the patient is equipped to meet the increased demands. self-care remains intact. The primary health care provider must be able to identify potential therapeutic self-care demands and recognize when the demands have exceeded the patient’s self-care abilities. Documented risk factors associated with UI are summarized in the AHCPR guidelines (1996). These risk factors are (a) immobility/chronic degenerative disease, (b) impaired cognition, (c) certain medications, (d) morbid obesity, (e) diuretics, (0 smoking, (g) fecal impaction, (h) delirium, (1) low fluid intake. 0) environmental barriers, (k) high- impact physical activities, (I) diabetes, (m) stroke. (n) estrogen depletion, (o) pelvic muscle weakness, (p) childhood nocturnal enuresis, (q) race, and (r) pregnancy, vaginal delivery and/or episiotomy. Identification of these factors will clarify the presentation of 19 U1 in the older adult. Risk factors related to changes in cognition. mobility. environment. and pharmacology must be examined in understanding U1. Even though age does not cause UI. prevalence does increase with age as well as the number of the cited risk factors (Herzog and Fultz. 1990). Although the prevalence of difficulty holding urine increases with age, the increasing prevalence can be explained by risk factors of aging rather than by age itself; women and men compare quite similarly (Wetle, et al., 1995). The effects of cerebral changes on UI are demonstrated in a study by Pavalkis, Siorky, and Goldstein (1983). Urinary symptoms were identified in 75% of the study population presenting with Parkinson’s disease. Urodynamically. uninhibited bladder contractions were demonstrated in 100% of the patients. Giersson, et al., (1993) investigated 814 urge U1 patients aged 65 years or older using cystometry and confirmed overactive bladder in 267 of the participants. Among those, 126 (42%) also had a neurological diagnosis affecting mobility and/or cognition. Skelly and Flint (1995) found U1 is common in patients with dementia and is more prevalent in the demented than in non-demented older individuals. Twenty-two percent of those living at home with dementia had U1. The study also revealed that UI associated with dementia occurs with equal or greater frequency in males than in females. Two thirds of the people with dementia and incontinence have at least one episode a week, which contrasts 5% in the general public (Herzog & F ultz, 1990). Berrios (1986) reported that UI was significantly more prevalent with Alzheimer's disease than with vascular dementia. Urinary incontinence in persons with dementia has received limited study despite being a potentially treatable condition. 20 A population-based cohort study by Tinetti. et al.. (1995) identified shared risk factors associated with UI, falls. and functional dependence in older adults. The study consisted of 927 participants. aged 71 to 99 years. Shared risk factors predisposing subjects to UI, falls and functional dependence were: 1) slow timed chair stands. 2) vision and hearing impairment, 3) arm strength impairment. and 4) high depression or anxiety scores. Slow timed chair stands showed the strongest relationship with UI. Vision and hearing impairments, depression and anxiety were also strongly associated with UI. while arm strength was marginally associated. As the number of functional deficits increased. the proportion of participants with UI increased. Similar results were found in a study conducted by Wetle, et al., (1995). Data for the study was obtained from a population survey carried out in 1982 of 3.809 residents aged 65 years and older. The question used in the study, "How often do you have difficulty holding your urine until you can get to a toilet" addressed not only U1 but also other aspects of urinary difficulty such as. urinary precipitancy, physical mobility problems and toilet accessibility. The goal of the study was to estimate the prevalence and correlates of difficulty holding urine among a population of community-dwelling older people. Results showed difficulty holding urine was related to advancing age, female gender, functional limitations. poor self perception of health and medical conditions such as diabetes, stroke, depression, chronic cough, sleep disturbance and fecal incontinence. Men and women in all age categories who received assistance with one or more ADL were more likely to report difficulty holding urine. Another risk factor associated with U1 that increases in prevalence with age is adverse effects of medication (AHCPR, 1996). Adults age 65 years or older account for 71 one-third of all prescription purchases although representing only 13% of the US population (DeVita. 1995). Older adults commonly are prescribed multiple medications. dramatically increasing the chance of drug interactions and adverse drug reactions. In addition to their desired therapeutic effects. drugs may inadvertently cause or exacerbate UI. Any medication that interferes with detrusor and sphincter musculature or neurologic control can cause UI (Duxbury, 1996). These include alcohol. alpha-receptor blockers and antagonists, anticholinergics, antispasmodics, calcium channel blockers, diuretics, muscle relaxants, and sedatives. (Catanzaro. 1996; Ghoniem & Hassouna. 1997; Miller. 1995; Pallow, Stoller, Forster, & Duniko, 1994; Rondorf-Klym, Colling, & Simonson, 1998; Shimp, Wells, Brink, Diokno, & Gillis, 1988). Diuretics are often blamed for U1 but this is not well supported (Hunskaar, 1992a). Assessment It can be problematic for the provider to identify UI, with patients reluctant to discuss it, for the reasons previously described. Self-administered health questionnaires may be vague and unreliable means to detect UI. Questions such as "Do you have bladder problem?" may not give desired information. "Do you have trouble holding your urine?" may be more determinate of U1 self-care deficits. The primary care provider needs to recognize patients' concerns with UI and their desire to keep dry (Bushman, 1994). Talbot (1994) reminds providers that with the care of the elderly, trust must be gained giving assurance that revealing U1 will not mean taking steps to question competency. Gaining trust, exploring the situation, reinforcing positive coping behaviors and assisting to replace ineffective ones should be the provider’s goal in addressing this delicate condition. 22 According to the AHCPR Guideline on Ul (1996) primary care providers are encouraged to become knowledgeable about and able to initiate the basic evaluation of U 1. Awareness of potential causes. risk factors and presenting symptoms of U1 among the elderly is only the beginning. The primary care provider must be knowledgeable about and able to initiate a basic evaluation of U1 (AHCPR, 1996). The AHCPR guideline update (1996) provides specific recommendations to primary care providers for assessing and managing UI in adults. The guidelines recommend that a basic evaluation of all patients with UI include a thorough history and physical examination. urinalysis and post void residual volume (p. 19). The goals of the evaluation of an incontinent older patient are to confirm the presence of U1, identify transient and established causes of incontinence, assess the patient’s environment and what support is available, detect conditions that may underlie Ul, develop differential diagnoses based on presenting symptomatology, and implement appropriate interventions (AHCPR, 1996; Resnick, 1995). A number of articles written since the release of the updated AHCPR guidelines describe incorporating the recommendations into practice, yet few are controlled studies measuring outcomes (Payne, 1998). Other studies have modified the recommendations given for the basic evaluation of the adult patient with UI to meet the unique needs of the geriatric population presenting with U1 (Engberg, McDowell, Donovan, Brodt & Wever, 1997; Ouslander, 1997; Penn, 1996; Weiss, 1998; Wynne, Carty, & Rees, 1997). Authors of these studies state modifications are needed due to the increased prevalence of risk factors associated with UI in the geriatric patient. Interpretative consistency among studies is lacking. 23 Studies by Engberg. et al. (1997). Penn. (1996). and Wynne. et al. (1997) include I the Mini-Mental State Exam as part of the basic evaluation of geriatric patients with U1. The studies argue that aggressive investigation and treatment may be unwarranted in those with significantly impaired mental function because treatment is less likely to be successful. The argument is supported in an earlier study by C astleden. Duffen. Asher & Yeomanson (1985) which found the major prognostic factor influencing outcomes among elderly patients attending a continence clinic was mental ability. Ouslander. Leach. & Staskin (1989) found that patients with a Mini Mental State Exam score of less than 20 were significantly less likely to undergo complex urodynamic testing because they were not able to cooperate and/or would not derive benefit from the results. Conversely, Resnick (1990) argues that since detrusor instability coexists with outlet abnormalities especially stress U] in a significant number of elderly patients. urodynamic evaluation can be of benefit in the management of appropriately selected cases. The AHCPR guidelines (1996) state evaluation of mobility and environment may be warranted in certain populations. Engberg, et al. (1997). Ouslander (1997). and Wynne (1997) include these in the basic evaluation of the geriatric subjects in their studies. The rationale given is that an unidentified environmental or mobility hindrance may impact successful response to treatment and that early identification may correct potential factors that had contributed to the UI. In addition to the basic evaluation, Weiss (1998) suggests primary care providers perform simple cystometry prior to urologist referral for a multi-channel cystometry, citing less cost and trauma to the patient with equal diagnostic findings. Wynne (1997) also supports the use of simple cystometry in the geriatric population to that of more 24 invasive studies. Fonda, Brymage. & D‘Astoli (1993) studied simple vs. multichannel cystometry and found a specificity of 75% and a sensitivity of 88% for the diagnosis of detrusor instability in geriatric patients using simple cystometry. It is important to note that detrusor instability may be present in some patients who are asymptomatic (continent) while causing Ul in others (Payne, 1998). Many patients have urgency but a stable cystometrogram; if a patient reports sudden leakage with urgency, detrusor instability should be assumed even if it is not present on the cystometrogram. In a review of urodynamic data on 2416 patients over 75 years of age, Malone-Lee (1990) concluded that a urodynamic study to diagnose detrusor instability in a symptomatic geriatric patient may be inappropriate because of the high probability of that diagnosis. Nonetheless, the clinician should be convinced that instability is present. Rackley & Kursh, (1996) state that from urology's perspective, many causes of incontinence in the elderly are too complex for primary care physicians. Bushman (1994), also, advocates a urologist referral for complex cases. Patients with overflow incontinence or history of prior continence surgeries should be referred to a continence center or urologist. UI is recognized more often by geriatric assessment units (59%) than by community-based primary care providers (16%) and management of condition depends on where it is identified (McDowell, Silverman & Marin, 1994). Primary care providers refer to gynecologists or urologists, while geriatricians frequently refer to nurse run continence clinics. Hilton & Stanton (1981) reported 60% of invasive studies could be avoided if an algorithmic method to diagnose UI in elderly women were used. The algorithm gave an accurate diagnosis in about 83% of the patients studied. Treatment corresponded in 95% 25 of patients where diagnosis was made using the algorithm and standard urodynamic investigations. A modified algorithm by Resnick (1990) used to assess the validity of algorithmic diagnoses in elderly women confirmed earlier results; distinguishing between genuine stress incontinence and that which involved detrusor instability was difficult without urodynamic studies. A study by Griffiths. McCracken. Harrison and Gorrnley (1992) established that a 24-hour period of non-invasive monitoring of incontinence in elderly persons, including fluid intake, voiding and residual urine. provides information that is suitable for designing successful intervention and management strategies. Treatment Treatments for U1 include behavioral, pharmacological and surgical interventions. Shah. Maly, Frank, Hirsch, and Reuben (1997) performed a survey with follow up interviews with patients and primary care providers following referrals to a geriatric assessment center at which U] was evaluated. Of the recommendations made, providers implemented 79% and patients initiated 46%. Support and consistent follow up appear essential to effective treatment of U1 with commitment from patient and provider. The results of treatments described by Mclnemey, Robinson, Weston, Cox, and Stephenson (1990) appear to be exceptional. Most of the older patients in their study had been treated for outlet obstruction with surgery (25/44), though 17 had none. While some treatments showed a general lack of success, the exception was imipramine; none were helped with prazosin or urecholine. Four people were helped with an artificial urinary sphincter. Pelvic muscle exercises were not documented as being attempted. Otherwise, their current policy was to advise these patients to live with their symptoms and to discharge them, even though many are severely disabled and very unhappy. No reported 26 treatments were clearly effective. Behavioral Behavioral techniques include specific interventions designed to alter the relationship between the patient's symptoms. behaviors and/or environment for the treatment of maladaptive urinary voiding patterns (AHCPR. p. 125). Behavioral management techniques involve analysis of individual symptoms and voiding habits followed by application of treatment methods such as habit training, prompted voiding, pattern urge response toileting, pelvic muscle exercises, biofeedback, and bladder training. Behavioral treatment requires that patients be able to learn new skills and participate actively in their own treatment plan. Orem’s self-care deficit theory of nursing is focused on increasing the patients self-care abilities. Routine or Scheduled Voiding. In routine or scheduled voiding, the patient is given a fixed voiding schedule that remains unchanged and is provided by the caregiver. Unlike bladder retraining, no effort is made to motivate the patient to delay voiding and resist urge (AHCPR, 1996). Habit Training. In habit training the toileting schedule is adjusted to fit the patient’s individual voiding pattern rather than voiding at scheduled intervals. Although this program encourages regular toileting at fixed, personalized intervals, the interval can be reset if there is an unscheduled void. Habit training is frequently used in patients who are home-bound and is recommended for those in which a natural voiding pattern can be determined (AHCPR, I996). Prompted Voiding= With this behavioral strategy patients are asked on a regular schedule if they need toileting assistance but are toileted only if they request assistance. 27 Prompted voiding is usually combined with positive reinforcement in the form of praise for appropriate toileting requests and for dryness (AHC PR. 1996). Skelly and Flint (1995) evaluated a number of studies that used prompted voiding in patients with dementia. They concluded that in all trials. prompted voiding had a statistically significant effect in reducing incontinence. On average, when checked every 1 to 2 hours during waking hours, patients were dry 64% of the time at baseline and 76% after treatment. Even though this intervention is used primarily in the cognitively impaired geriatric population, these same studies suggest that the more severely demented and immobile patients are the least likely they are to benefit from toileting programs. Bladder Training. Bladder retraining is routine voiding through mandatory voiding schedule. Weekly increases in lengths of span between scheduled urination are determined by the individuals ability to maintain continence and adhere to the established voiding schedule. The first-line treatment of D1 is bladder retraining (AHCPR. 1996; Wynne et al., 1997). Publicover and Bear (1997) conducted a study of 19 functionally independent, community-dwelling women. aged 64 to 88 years with a history of U1 occurring at least once a week. Methods consisted of a mandatory voiding schedule and self-monitored voiding records. Each participant given a copy of “Urinary Incontinence in Adults: A Patient's Guide” (AHCPR, 1996). At six month follow up, the mean reduction in number of incontinent episodes was 87.3%, and 11 participants reported complete cure. In a randomized clinical trial by Fantl, Wyman, McClish, Harkein, Elswick, and Taylor (1991) of elderly non-demented women with DI treated with bladder retraining, a 12% cure rate was reported and 75% had an improvement of at least 50% in the number 28 of incontinent episodes. Conclusions from their study were that bladder training is beneficial in non-institutionalized older women with stress, urge and mixed Ul. O’Brien. and Long (1995) reported benefits of a short course of training are apparent for several years but that positive reinforcement and frequent nursing contact are necessary. Burgio (1990) found that when bladder retraining was supplemented with biofeedback in non- demented elderly patients in the community, a mean reduction of 85% in the frequency of accidents was observed. Pelvic muscle exercises (PME). Pelvic muscle exercises are a behavioral technique that requires repetitive. active exercise of the pubococcygeus muscle to improve urethral resistance and urinary control by strengthening periurethral and pelvic muscles. Pelvic muscle exercises are also called Kegel exercises (AHCPR, 1996). Wells, Brink, Diokno, Wolf and Gills (1991) reviewed 22 studies that used PME’s as an intervention for stress UI in women. Cure rates of 31% to 73% and successful outcomes of 38% to 93% were reported. Although the studies used different outcome measures at least one third of the patients were reported cured in the absence of surgical treatment. Nonetheless, DeLancy (1998) states pelvic muscle exercises are not as effective in older women due to significant loss of striated muscle with age. This intervention has not been studied in cognitively impaired individuals and according to Skelly et al. (1995). it is highly unlikely many could successfully master and comply with the exercises. Gendry (1995) cites patient education involving goals achievement, purpose of the exercises, and what is being measured as the most important factors in the motivation and proper performance of successful PME programs. Hahn, Milsom, Fall, and Ekelund 29 (1993) studied the long term effects of PME in women age 55 and older with stress UI and found that the number of women who were cured or whose condition improved increased with the duration of training received. According to subjective assessments by the participants, a 71% cured or improved rate was reported. The same study found that exercises had no effect on stress Ul related to urethral hypermobility. Engberg, McDowell, Burgio. Watson, and Belle (1995) examined the self-care behaviors of 147 older women with UI. Although 22% of the participants reported doing pelvic floor exercises, 56% did not feel that they were effective. Based on responses regarding how they had been instructed to do the exercises, many were either not given apprOpriate instructions or misunderstood the instructions they were given. Fried, Goetz, Potts-Nulty, Cioschi. and Staas (1995) examined if behavioral along with usual methods of treating U1 were effective in disabled population. Half of the study population included elders and some men; disabled conditions included strokes, spinal chord injuries, multiple sclerosis. brain injuries, peripheral neuropathies, myopathic conditions, and musculoskeletal disabilities with U1. Improvement was seen with those that could volitionally void and voluntarily do PME; if PME contractions improved so did continence. Two studies show improvement of U1 in the male patient. Gallo and Fallon (1996) provided teaching of PME to incontinent men with electromyeolgram to give immediate feedback. A tape cassette was also given to the patient and education was provided with a family member present. Patients with urge incontinence symptoms were excluded. As the patient’s age increased, the level of control decreased and worry about incontinent experiences increased. Outcomes of discussions with these patients led researchers to 30 change their expectations for patients from total dryness to improved or controlled incontinence. Similar successful results using biofeedback are documented by Jackson. Emerson. Johnston. Wilson and Morales (1996) in the postprostatectomy patient. Biofeedback. Biofeedback therapy is a behavioral technique that uses sensitive machinery to relay information to patients about bodily functions usually thought to be involuntary (AHCPR, 1996). An auditory or visual display of the information provides immediate feedback and reinforcement to the patient for their efforts. According to Burgio (1990) the goal of biofeedback therapy for the patient incontinent of urine is to improve bladder dysfunction by teaching ways to change physiologic responses that mediate bladder control. By consciously visualizing the desired response while observing light, sound or metered feedback, the patient can learn to identify and contract the correct pelvic muscles. Success in the reduction or cure of U1 with biofeedback is reported across a number of studies at between 54% and 95% (AHCPR, 1996). The AHCPR guidelines (1996) recommended biofeedback in conjunction with pelvic muscle exercises and bladder retraining techniques to treat stress, urge, and mixed U1. Elecflal Stimulgtion. Electrical stimulation is a behavioral technique used for the management of urge or stress incontinence. It may be effective alone or in combination with other pelvic floor exercises and biofeedback. A study by Blowman, Pickles, Emery, Creates, Towell, Blackburn, Doyle, and Walkden (1991) showed a cure or improvement rate of 86% with this technique compared with 33% in a control group. Electrical stimulation among the control group was performed using inactive neurostimulation compared with active neurostimulation in the experimental group. Subjects in both groups were taught pelvic muscle exercises. The AHCPR guidelines (1996) state that further research is needed to determine the efficacy ofelectrical stimulation. and that the parameters must be standardized. Lamhut. Jackson. and Wall (1992) found that electrical stimulation was ineffective in a study of nine incontinent women with severe cognitive impairments (MMSE=2. 0-13 range). It was associated with 20% increase in the average number of incontinent episodes. Pharmacological Pharmacological interventions are often utilized as the first response to UI instead of behavioral methods. Overreliance on medications is precipitated by lack of understanding (Bushman, 1994). When caring for the geriatric patient with UI. the provider must consider age-related changes that affect the pharmacokinetics of specific drugs. Studies specific to elderly patients on the relative efficacy of drug and behavioral treatments or a combination of the two were not found. Therefore. treatment decisions should depend on the characteristics and preferences of the patient and the provider while taking into consideration the recommendations from the AHCPR (1996) guidelines. Alpha-adrenergic agonists are used to treat stress UI. These medications stimulate the alpha-adrenergic receptor sites in the intrinsic sphincter and bladder neck producing smooth muscle contraction and urethral closure (AHCPR, 1996). Many of these medications are available as over-the-counter cold preparations and appetite suppressants. The most common are pseudoephedrine (Sudafed) and phenylpropanolamine (PPA). The side effects of alpha-adrenergic agonists include anxiety, insomnia. agitation, respiratory difficulty, headache, hypertension, and cardiac arrhythmias, all of which occur more commonly among geriatric patients. These drugs must be used with caution, especially in the elderly and are not recommended for patients with hypertension. angina, diabetes. and b) k) hyperthyroidism (Wynne. et al., 1997). Estrogen replacement therapy (ERT) is used alone or as combination therapy to treat U1 in the postmenopausal woman. The types of U1 it is used to treat is controversial. According to Rackley and Appell (1997). ERT is a beneficial adjuvant to all types of U1 and should be used as baseline therapy for all post-menopausal women with U1. The AHCPR (1996) guidelines report findings that suggest ERT by oral or vaginal administration may benefit some women with stress or mixed UI but did not find sufficient literature to support the effects on urge UI. Conversely, Dr. Peter Sand (1998). cited several studies that supported the use of ERT for the treatment of urge UI and questioned the effectiveness on stress UI (Fantl, et al., 1988; Karram, Yeko. Sauer, & Bhatia, 1989; Kim & Lindskog, 1988). Other studies looking at the effects of ERT on U! have reported significant subjective improvement or cure with no measurable objective improvement (Faber & Heidenreich, 1977; Fantl, et al., 1994; Hilton, 1983; & Molander, 1993) Because the vagina and urethra are of similar embryologic origin, ERT in postmenopausal women may restore urethral mucosal coaptation and increase vascularity and tone (AHCPR, I996). Estrogen has been shown to improve the cytology of the urethra in postmenopausal women treated with oral (Walter, et al., 1978, & Wilson et al., 1987) and vaginal ERT (Bhatia, 1989). Fantl et al., (1988) reported a significant decrease in nocturia with ERT and found it improves the sensory threshold of the lower urinary tract. Studies by Karram, et al., (1989) and Rud (1980) found ERT in 36 postmenopausal women increased urethral pressure and functional length, thus improving stress UI. Estrogen replacement therapy should be given with a progestin when the uterus is 33 intact to decrease the risk of uterine hyperplasia and neoplasia. The dosages and route of administration to treat U1 and irritative urinary symptoms vary among providers. For the geriatric woman, vaginal application may be the preferred method because of its preferential local uptake. The beneficial and adverse effects of long-term ERT should be explained to the patient prior to administration. According to the AHC PR (1996) guidelines. combination therapy of estrogen and alpha-adrenergic agonist may be more effective than alpha-adrenergic agonist therapy alone. In the geriatric woman, combination therapy should be considered when initial single-drug therapy fails. Again, the risks of alpha-adrenergic agonist in the elderly patient need to be considered prior to administration. Tricyclic agents are to be used with caution to treat UI, according to the AHCPR (1996) guidelines. Though widely used, they can cause many adverse side effects, especially in the elderly population. Tricyclic agents are used to treat both stress UI and urge UI because they simultaneously decrease unstable detrusor contractions and to increase bladder outlet resistance (Ghoniem and Hassouna, 1997). Three randomized controlled studies by Milner and Hills, Lose, Jorgensen and Thunedborg, and Castleden, et al.. (as cited in the AHCPR, 1996 guidelines) used tricyclics to treat urge and stress UI. Results identified a reduction in nocturnal incontinence as the only significant improvement. In a non-randomized, uncontrolled study by Gilja, Radej, Kovacic, and Parazajder (as cited in the AHCPR, 1996 guidelines) 30 women, under the age of 65 years with pure stress UI were treated with Imipramine (Tofranil) for four weeks. Seventy percent claimed continence. This sample did not include the geriatric population and results were subjective. Castleden, Duffin and Gulati (1995) concluded that the use of 34 imipramine (Tofranil) in addition to bladder retraining to treat urge Ul was more beneficial than imipramine alone. In a double-blind study of elderly incontinent patients, 6 of 19 (32%) became continent after bladder retraining plus placebo compared with 14 of 19 (74%) with bladder retraining and imipramine. Due to the sample size conclusions should be made with caution. Side effects of tricyclic agents include hypotension, nausea. insomnia, weakness, fatigue and cardiac conduction disturbances in the elderly (Rackley & Appell, 1997). Because of the lack of controlled studies, the known side effects. and the unimpressive results, these authors do not recommend tricyclic agents as a drug of choice in the treatment of U1 in the geriatric population. Anticholingic agents are the first-line pharrnacologic therapy used to treat detrusor instability (AHCPR, 1996). They inhibit bladder contractions, increase bladder volume before the first involuntary contraction, and increase functional bladder capacity (Ghoniem and Hassouna, 1997). All anticholinergic agents are contraindicated in patients with documented narrow—angle glaucoma (Rackely and Appell, 1997). Common side effects associated with anticholinergic agents (xerostomia, visual blurring, nausea, constipation, tachycardia. drowsiness, confusion and urinary retention) may increase morbidity among the elderly and the decision to use should be made judiciously (Ghoniem and Hassouna, 1997). Skelly, et al., (1995) reported that anticholinergic and antispasmodic medications have not been shown to be effective in treating incontinence in persons with dementia. Oxybutynin (Ditropan) has both anticholinergic and direct smooth muscle relaxant properties. At the time of the publication of the AHCPR (1996) guidelines it was 35 the drug ofchoice for detrusor instability. Of seven randomized controlled studies cited in the guidelines only one failed to report a benefit of oxybutynin over placebo. The dosage and frequency of oxybutynin used in that trial. (5mg bid) was less than recommended (2.5mg-5mg three to four times daily). Tolterdine (Detrol) was recently approved by the FDA for the management of "overactive bladder" manifested as urgency, frequency, or urge incontinence. Tolterodine is tolerated well in the geriatric population because of low anticholinergic side effects. In addition, dosage is twice daily, in contrast to oxybutynin (Ditropan) which is taken three times daily (Diokno, 1998). Propantheline (Pro—Banthene)is the second-line anticholinergic agent used to treat detrusor instability in patients who can tolerate the full dosage. 7.5-30 mg three to five times a day (AHCPR, 1996). Ghoniem and Hassouna (1997) use Propantheline as a first- line therapy in the treatment of elderly patients with detrusor instability, provided they can tolerate a therapeutic dosage. They cite 15mg three times daily as initial therapy with increases to four times daily as needed. Propantheline is inexpensive and has been widely used over time with significant results (AHCPR, 1996). Dicyclomine hydrochloride (Bentyl) is an anticholinergic agent with smooth muscle relaxant properties (AHCPR, 1996). Studies on the use of this drug for the treatment of U1 are limited with no identified studies specific to the geriatric population. Rackley and Appell (1997) report a better response among patients with large bladder capacities to Dicyclomine and those with smaller bladder capacities respond well to Oxbutynin. Since bladder capacity diminishes with age, Dicyclomine may not work as well in the geriatric population. 36 The AHC PR panel could find no clinical research for use of hyoscyamine sulfate (Levbid. C ytospaz) in patients with U1 and offers no recommendations. The use of alpha-adrenergic antagonists to treat overflow UI is not addressed in the AHC PR (1996) guidelines. These agents are first-line therapy in the treatment of prostatic hyperplasia which is the number one cause of overflow U1 among men. Alpha adrenergic receptor blocking agents are used to treat benign prostatic hyperplasia, because they reduce the tone of striated and smooth muscle. thereby decreasing urethral resistance and relieving symptoms of obstruction. Rackley and Appell (1997) recommend the use of alpha-adrenergic antagonists in combination with ERT to treat overflow U1 caused by outlet resistance in women. Controlled studies to support this recommendation were not found. Side effects include dizziness, vertigo. fatigue and hypotension. Alpha blockers should not be used in people who are hypersensitive to such medication or who experience postural hypotension. Doxazosin mesylate (Cardura) is a drug that acts by blocking the alpha-1 adrenergic receptor sites within the body. Doxazosin is prescribed for the treatment of urinary outflow obstruction in BPH and for hypertension. The typical dose is 1-8 mg, taken once daily. Terazosin hydrochloride (Hytrin) also blocks the alpha-l adrenergic receptor sites in the body. Like doxazosin, terazosin is prescribed for the treatment of urinary outflow obstruction in BPH, as well as for hypertension. The typical dose is 1-10 mg, taken once daily. Tamsulosin hydrochloride (Flomax) blocks only the alpha-1a adrenergic receptors in the prostate. Tamsulosin is used to treat the signs and symptoms of BPH; however. because of its prostate-specificity. tamsulosin is not a recommended treatment for hypertension. The usual oral dose of tamsulosin is 0.4-0.8 mg. once daily. (Urologychannel. 1998). Finasteride (Proscar) is an alpha-reductase inhibitor used for prostatic hypertrophy and thus may be helpful in the prevention or treatment of overflow incontinence. Adverse side effects include decreased libido and impotence. Dosage is 5 mg daily. Surgical Various surgeries provided by urologists and gynecologists are available for incontinence. The purpose of a surgical procedure is to correct, compensate for. or circumvent the underlying pathology causing UI (AHCPR, 1996). Studies addressing the effects of surgery for the treatment of U1 should be reviewed with caution. Precise comparisons among studies is impossible due to variations in the procedure, experience of the surgeon. methods used to diagnose, and outcome criteria being measured (AHCPR, 1996). Surgical interventions although not within the primary care domain, may be recommended as first-line treatment for appropriately selected patients who are unable to comply with non-surgical interventions. Primary care providers must therefore be able to inform patients of the options available to treat specific types of U1 and make appropriate referrals when necessary. Most surgical procedures to treat UI are appropriate for both men and women. Consideration of diagnosis. severity of disease, surgical risk, and estimated impact on quality of life is essential especially in the geriatric population. Stress UI and intrinsic sphincter deficiency may be relieved by surgeries that increase outlet resistance. Urge Ul may be corrected by surgeries that decrease detrusor instability and procedures to remove 38 outlet obstruction may resolve overflow U 1. Studies to assess the long term effectiveness of incontinence surgeries are lacking. Sling procedures are used to treat stress Ul in women caused by intrinsic sphincter deficiency and in men with sphincter incompetence following a prostatectomy. A sling made of autologous or heterologous material is positioned to create the urethral compression necessary to achieve urinary continence. Cure rates for women range from 78% to 92% (AHCPR, 1996) and 63% to 75% in men (Schaeffer, Clemens, Ferrari & Stamey. 1998). Complications include erosion. infection, urinary retention. urethral adhesions and irritative voiding symptoms. Bladder suspensions are performed to treat stress U1 caused by hypermobility of the bladder in the female patient. Procedures elevate the bladder neck by anchoring sutures to stable structures in the pelvic area. Two standard suspension surgeries that require abdominal incisions are the Marshall Marchetti Krantz (MMK) and Burch procedure. The MMK is no longer a favored technique because the sutures used to elevate the bladder neck are placed around the urethra and anchored to the surrounding cartilage and pubic bone, creating the potential for obstruction. With the Burch procedure, sutures pass through the vaginal wall and surrounding ligaments. Postoperative symptomatic enterocele/rectocele are most prominent following the Burch procedure (Urologychannel. 1998). The AHCPR guidelines (1996) reviewed 45 studies incorporating 3882 women who underwent an abdominal suspension procedure to treat stress UI. Total cure rates were reported in 79% and 84% were cured or improved. Complications included wound infection, urinary retention and enterocele or rectocele. Vaginal approaches to correct the hyperrnobile bladder include the Stamey. Raz, and Gittes. These procedures are less invasive than the abdominal suspensions although the principles remain the same. Unlike sling procedures. suspensions may not create the urethral compression necessary to achieve bladder control when the cause of stress Ul is intrinsic sphincter deficiency. Data from 3.015 female subjects indicated that 74% were cured and 84% were cured or improved following a vaginal suspension surgery (AHCPR. I996). Complications included urinary tract infections, urinary retention, obstructive urinary symptoms. wound infection and new onset of symptomatic detrusor instability. An alternative to invasive surgery for stress UI caused by intrinsic sphincter deficiency is periurethral bulking injections. Agents such as collagen, Teflon, or autologous fat are injected into the periurethral area compressing the urethra near the bladder outlet. This compression improves the function of the urethral sphincter muscle decreasing or eliminating incontinence. Because the procedure is performed under local anesthesia. it is a good choice for the older patient and the patient who is a high surgical risk. Periurethral bulking injections are recommended as a first-line surgical treatment for men with intrinsic sphincter deficiency lasting longer than one year (AHCPR, 1996). Prior to the development of injection therapy, implantation of an artificial urinary sphincter was the most common surgical procedure for the treatment of sphincter incompetency in men. Artificial sphincters have been used for women with intrinsic sphincter deficiency but only in the most complicated cases which have not responded to prior surgery. According to Urologychannel (1998) the majority of women requiring artificial urinary sphincters are trauma victims or have congenital defects of the urinary system. The artificial sphincter has three components, including a pump, balloon reservoir. and a cuff that encircles the urethra and prevents urinary leakage. The pump 40 implanted in the scrotum or labia. is manually pumped or squeezed to deflate the cuff. facilitating urination. Once the bladder is emptied. the cuff refills and the urethra is again pressed closed. Combined data of 192 women treated with an artificial sphincter indicated that 77% were dry and 80% were cured (AHCPR. I996). Reoperation rates in men vary from 17% to 42% (Elliott & Barrett. 1998). Infection. erosion and mechanical malfunction are infrequent complications. This may not be the most appropriate intervention to use in patients with arthritis or other joint or dexterity limitations. According to the AHCPR guideline update (1996) surgery to manage urge incontinence is very rare. It is considered only in highly symptomatic patients in whom other interventions have failed. When urge UI is caused by a low capacity, hyperactive or non-resilient bladder, surgery to increase bladder size and decrease detrusor contractility may be beneficial. The two surgeries performed to treat urge incontinence are augmentation cystoplasty and intestinocystoplasty. During augmentation cystoplasty, the detrusor muscle is partially resected leaving only intact mucosa and creating a bladder with increased capacity and decreased contractility (Urologychannel, 1998). When intestinocystoplasty is performed, segments of the bowel are used to enhance the size of the bladder. Consequences of augmentation surgeries may include voiding difficulties requiring catheterization, mucus production, stoma formation, metabolic decompensation, and the rare long-range possibility of tumor formation (AHCPR, I996). Persons with kidney disorders, bowel disease or those unable to perform self-catheterization should not have these surgeries (Urologychannel, 1998). Interstim, introduced in 1997, is a completely implantable device used for the 41 control of urge U1 . It is considered a urinary bladder electrical stimulator. Candidates for implantation are screened by having a temporary electrode inserted into the S3 foramen connected to an external neruostimulator and trialing bladder stimulation for up to seven days. Clinical trials sponsored by the manufacturer and reviewed by the FDA have yielded cure rates of 47% and 45% at 6 and 12 months, respectively (Diokno. 1998). Treatment for overflow incontinence depends on the underlying cause. Prostatectomies have often been performed for obstructive disease in a hope to cure overflow incontinence. In contrast, Gormley (1993) showed that detrusor instability is likely to persist after transurethral resection of the prostate. Long term urinary incontinence occurs in 1% of patients following transurethral resection of prostate and more commonly following radical prostatectomy (Schettini. 1998). Surgical options following prostatectomy include periurethral collagen injections and artificial urinary sphincters. Sling procedures during prostatectomies may prevent UI (Schettini. 1998). In women, urethral obstruction can result from prior anti-incontinence surgery or severe pelvic prolapse. If the cause is due to previous surgery. two surgical options are available. The first is merely cutting one of the suspending sutures causing the obstruction. To evaluate the outcome of this procedure, results from five studies were reported in the AHCPR guidelines (1996). Of 182 women who had undergone a bladder neck suspension to relieve stress UI, ten developed obstructive voiding symptoms which resolved after one suture was cut; only one of the ten women developed recurrent stress UI. Urethrolysis is also used to correct female overflow UI caused by obstruction. This procedure involves cutting away obstructive adhesions that may form as a result of 42 previous surgery. The results of three studies cited in the AHCPR guidelines (1996) found that of 41 women who underwent urethrolysis. 71% reported improved voiding patterns. Both surgeries are performed vaginally with minimal recovery time. If pelvic prolapse is the cause of the obstruction and the resulting overflow UI. surgery aimed at correcting the specific prolapsed organ can be performed. The required procedure may be an anterior posterior vaginal repair, a cystocele repair. a rectocele repair or a hysterectomy. Smaplemental and Gender Specific Treatments for U1 Physical__ and environmental alterations. A careful assessment of the environment should be performed for access limitations in toileting. Simple alterations such as the addition of toileting or ambulation devices are strategies to maintain or improve mobility and are likely to reduce incontinence in the frail elderly (AHCPR. 1996). Physical therapy to assist in lowering to or raising from the toilet may need to be addressed. A simple walking program may be of benefit improve physical conditioning. Fluid and Dietary Management. Assessment of daily fluid consumption is essential when evaluating the geriatric patient with UI. Patients often limit fluid intake in an attempt to decrease or eliminate incontinent episodes. It may in fact increase irritative symptoms and incidence of urinary tract infections (Rackley and Appell. 1997) especially among the elderly who are already at risk for dehydration (AHCPR, 1996). Adults should drink 60 ounces, or about eight 8-ounce glasses of fluid each day (Newman. 1997). Timing of fluid intake is another important factor to consider which may correlate with specific UI episodes. For example, a large fluid intake in the evening may increase nocturia or consuming large amounts of fluids at one time rather than spacing it out 43 through the day may cause urgency. Types of fluids consumed should be reviewed. Caffeine. citrus juices. artificial sweeteners. carbonated beverages. tomatoes and tomato- based products. alcohol. chocolate. and highly spiced foods are all bladder irritants that can increase the incidence of U1 (Newman. 1997’). Inadequate fluid intake also contributes to constipation (AHC PR. 1996). A study by Smith (1988) found constipation to be the major contributor to UI among homebound elderly. Bowel function needs to be normalized through the use of natural or bulk laxatives. Once a bowel pattern is established it should be maintained by increasing dietary fiber, adequate fluid intake. and physical activity. Routine use of laxatives. enemas, or stool softeners is discouraged (AHCPR. 1996). Intermittent Qmetefization. Intermittent catheterization is a procedure done to relieve urinary obstruction and assist with overflow incontinence. It is performed by the patient using clean technique or by a caregiver in the home at regular intervals (usually every 3 to 6 hours). Most studies have only examined young. spinal cord injured patients. Short catheters and specially designed guidance systems are available for persons with limited dexterity or visual impairments using clean technique. Sterile technique is suggested by the AHCPR guidelines (1996) for the geriatric patient due to higher risk of infection; this can prove challenging due to the more difficult nature associated with sterile technique and expense. Absorbent Products. According to the AHCPR (1996) guidelines. absorbent products are recommended during evaluation, as an adjunct to other therapy, and for long-term care of patients with chronic intractable U1. They should not however. be used in place of therapeutic interventions. Contrary to this recommendation. a study by 44 McFall. Yerkes. Bernard. and LeRud ( 1997) reported more than 40% of internists and family practitioners routinely recommended absorbent pads. The use of reusable or disposable pads and undergarments is the most common method of managing U 1 among the elderly (Ouslander & Schnelle. 1995). There are a variety of absorbent products available which vary in size and absorbency. They can be made of wood pulp which has greater absorbent power or filled with cellulose gel which is suitable for smaller incontinent episodes. There are no well-controlled studies to assist the provider in selecting or recommending specific pads or garments to patients (AHCPR, 1996; & Ouslander & Schnelle, 1997). The suitability of pads. undergarments and absorbent bed sheets is dependent upon the client’s mobility and independence (Wynne, et al., 1997). Proper use of these products is significant in decreasing the incidence of skin breakdown and infection. Finally, the cost of absorbent products is a concern, especially among the elderly many of whom are on a fixed income. Skin care. Urinary incontinence is a risk factor for skin breakdown, pressure ulcers and fungal infections. Barriers used for prevention should be petrolatum based to repel moisture but to protect the skin. Antifungal preparations are often necessary. The type of the absorbent product is often culprit in development of skin problems related to ill fit or infrequent changing. Routine cleansing should be done after each incontinent episode with soft, gentle wipes avoiding friction (Lyder. 1997). Education and suppgrt. Talbot (1994) provides an overview of patient coping processes for U1. Coping strategies include (a) controlling loss of urine, (b) seeking social networks, (c) controlling the urge. (d) rearranging the physical environment. (e) rearranging the social environment. (I) seeking health care. and (g) c0ping with 45 sexuality. Few studies are published about psychological. social and behavioral aspects of urinary incontinence. Henke-Yarbro and Estwing-Ferrans (1998) explored quality of life issues of patients with prostate cancer treated with surgery or radiation therapy. Patients who were treated with surgery had three times (43% vs. 13%) significantly worse urinary function than those treated with radiation therapy. including frequency and amounts of leakage. lack of urinary control and an increased number of pads used per day. Quality of life indicators did not differ significantly. This information would be important for the APN counseling the prostate cancer patient in treatment options. Female care issues. Reliance is a miniature urethral occlusive catheter that is inserted and removed intemtittently by the female patient. It has been reported to control leakage completely in 80% of patients (Sand, 1998). Pessaries are generally round devices of various sizes and are usually made of silicone. They are inserted into the vagina and rest against the cervix. Pessaries provide support to pelvic structures and can alleviate U1. They are ofien used to temporarily relieve symptoms of U] awaiting surgery or more frequently as a permanent alternative to uterine prolapse surgery (often contraindicated in the elderly) (Goldstein. Wise, & Tancer. 1990). Elderly women with large vaginal vaults and third degree or greater prolapse may have a difficult time retaining the pessaries currently available (DeLancy. 1993; F ritzinger, Newman. & Dinkin, 1997). Male care issues. In surveying 150 men responding to requests for incontinence pads, Hunskaar (1992b) found methods used to control UI included frequent toilet visits, restricted drinking. special clothing, medication, PME, catheters, disposable products. 46 incontinence pads. toilet paper. penile sheaths. towels. sheeting, napkins. cotton. and feminine hygiene pads. Men who consulted a doctor used pads more often then not. Methods often prescribed by doctors include catheters. condom catheters. clamps and drugs. Penile clamps or compression rings are often used as a temporary measure to prevent leakage in the postprostatectomy patient with continual dribbling. These devices can be used to block the flow of urine by squeezing closed the urethra. These devices must be removed at regular 2- to 3-hour intervals to empty the bladder. Therefore, they should be used only by mentally competent individuals who are able to adjust them by hand and who are able to remember the bladder-emptying schedule. Improper use of penile clamps and compression devices can result in penile and urethral erosion. penile edema, pain and obstruction. Little research has been completed to support the use of these products. External collection devices are designed for short term use. They include latex or polyvinyl condom catheters or silicone devices applied to the penis with adhesive, inflatable cuff or jock strap device: attachment is made to a urinary drainage bag. Usage concerns include skin irritation from removal or poor application, edema, ischemia or erythema of the penis. Well designed research on use or effectiveness is unavailable. 47 Protocol Development M1! This protocol was developed with the intent of bringing together the information in the AHCPR guidelines into a useable fomtat for the primary care provider. The protocol is constructed to follow a logical sequence of necessary considerations. The 1996 AHC PR guidelines provide an algorithm to follow for the diagnosis and treatment of U1. The algorithm replaces several separate algorithms from the 1992 version. Unfortunately, it continues to provide little assistance to the provider because the information is not concise or comprehensive. and suggestions for specific processes are not included. Implementation of the guidelines are described in various places in the literature. Though helpful in the interpretation of the guidelines. no format has been found to outline them in a functionally useable stepwise manner. A few tools are found for use in home care or the hospital (Joseph & Lantz, 1996; Pearson & Kelber, 1996) but none have been identified or have been made available for primary care. The Primary Care Protocol for the Management of Geriatric Patients with Urinary Incontinence follows the guidelines except for a few additions. based upon more recent findings. These are: I) a more comprehensive assessment, 2) the use of Orem's Self-Care Deficit Theory and 3) the inclusion of new developments in treatment options. Assessment and treatment are aimed at care for the geriatric patient. The tool is designed to clearly describe behavioral methods as the first line of treatment for the older patient. The "other" column of treatments includes non-surgical options not often presented for the younger patient. Pharmacological options need to consider risks of 48 polypharmacy and dosing modifications. Surgery for the older patient is discussed recognizing the presence of increased risks and decreased overall success rates. The protocol is created in a gender inclusive format due to the redundancies that would be present with separate tools. The 1992 original formation of the AHCPR guidelines included separate algorithms for male and female patients. whereas the 1996 revision merged the two. It is likely that the relevant literature reviewed revealed few differences in the assessment of the patient and many similarities in treatment options. Thus, only one protocol is presented, and gender specific issues are included. This protocol will be easy to use in the primary care setting. It is intentionally limited to those practices that are recommended for the primary care arena. More advanced assessment such as complicated urodynamic testing are excluded from the guidelines as beyond the scope of primary care. Though biofeedback and electrical stimulation are supported options for initial treatment of several types of U1, they are not generally considered viable options in the primary care setting. The protocol is presented in Appendix A. Description of the Protocol The protocol is a double-sided reference sheet that describes the process of data collection. cues to diagnosis and treatment options for the provider. The sections of the protocol are described below in more detail. It is organized to be consistent with SOAP documentation. Patient's perception. The best assessment begins with subjective findings from the patient or caregiver. The information extracted gives the provider an idea of the patient's perspective and importance given to this problem. 49 History. The history is the beginning of the quantifying and qualifying of the patient's perception of the problem. Risk Factors. Information gained here will direct the provider to preventative actions to decrease severity. and may identify transient causes of the UI. Medications. Over-the-counter and prescription drugs often have a causative or additive effect on UI. A good review here may identify sole or combination reasons for the U1. Lifestyle & Environment. Dietary factors often play a large role in the development of U1, as with bladder irritants, adequacy and timing of fluid intake. or fiber intake. Activities such as exercise or one's occupation can shed light on U] precipitating events. Environmental barriers such as lighting, distance to toilets, stairs and environmental cues can interfere with effective toileting. Patient Capabilities. Abilities of the patient will effect the need for provider intervention. Mobility, manual dexterity, motivation and cognition will determine extent to which self-care can be accomplished. This is consistent with Orem's framework in determination of self-care capacity. Physical Exam. The exam is divided into general, neurological. rectal and genitourinary areas, with gender specific issues identified. Diagnostic Testing. Basic testing includes urinalysis, provocative stress test. and post-void residual. The residual can be accomplished via catheterization or bladder scan. A simple cystometry and specific blood indices are also suggested if further testing is indicated. Clinical Presentation and Diagnostic Interpretation. Each type of U1, including 50 transient. stress. urge. mixed. overflow and functional. are described briefly to aid the provider in diagnosis. Treatment. Options for treatment are presented for each type of U1 classified by behavioral, pharmacological. referral and other. Further descriptions are given below. Behavioral interventions. Dietary modification. pelvic muscle exercises. biofeedback and bladder training are included as behavioral interventions. Pharmacological. Suggestions are made based on type of U1 with examples of particular drugs often used. It is reinforced that pharmacological interventions are to be used secondary to or in conjunction with behavioral methods. Referral options. Surgeries and behavioral interventions not routinely performed in the primary care setting are shown. Referral sources for the treatment of U1 include urologists, gynecologists and continence clinics. More in depth description of each surgical procedure is given elsewhere. Supplemental interventions. Although cure of U1 is not always made, improvement with enhancement of pad choices can complete the patient's satisfaction and quality of life. Pessaries, shields, clamps and other options, often used as a last resort. can provide relief and assurance to older patients who deal with intractable UI. Providers are encouraged to refer to AHCPR guidelines for more detailed information and references. Implementation Plan Implementation of the protocol should be completed in two separate stages. The first would include identification of its existence and distribution to interested practitioners. The second would be implementation and evaluation of effectiveness. 51 Protocol Ilse Implementation of the protocol would be individually determined by the provider. The protocol identifies key areas to be addressed and follows the SOAP format so it is consistent with provider process. Options included with the directions are briefly described below. The protocol is used after a patient has identified a concern about urinary incontinence. It is designed to be used in the primary care setting. but may be used in any setting that has facilities and time to intervene (i.e. home care or extended care facilities with adequate staff). The protocol is used for uncomplicated cases of urge, stress. overflow, functional or mixed incontinence, and especially with identification of transient causes. More complicated situations require referral to specialized services provided by a continence center, urologist or gynecologist. Dissemination Information related to the protocol can be shared in the following ways: 1. Identify all primary care providers in a defined area and create a dissemination list for new project or thesis materials. 2. Utilize electronic information services to transfer the protocol with appropriate instructions via Internet. 3. A poster or presentation can be made at conferences or programs such as a research day or primary care conferences. 4. The protocol can be sent to identified geriatric assessment centers locally or nationally; unrestricted use will be encouraged. 5. Publication in journals for primary care. geriatric nursing or APN focused 52 periodicals is encouraged. 6. Newspapers or newsletters can carry a synopsis of this project along with the protocol (e. g. offer to create an article for HouseCalls for the Lansing State Journal.) 7. Other media options may include securing guest appearances on radio or television programs. 8. It can be utilized as a teaching tool for provider education. Discussion Implications for Advance Practice Nursing The role of the APN working with patients who are experiencing UI should not be restricted to specialty center areas. The unique roles of the APN can be employed in whatever clinical setting contact is made with the person with U1. These roles include the following. Assessor role is relevant as APN’s identify the community need for improved UI care. For example, a nurse practitioner recently moved to the Grand Rapids area and determined that only three Geriatric Nurse practitioners were listed in the area. No incontinence services were available other than through urology or gynecology offices. This APN accurately assessed the need for a continence center in that community. As a Change Agent the APN can enhance the understanding and acceptance of needed changes within a primary care practice. The project will present a standardized protocol to improve patient care. The APN may promote this in the office setting through modeling and collaborative sharing with other disciplines. U) U) Influenced by Orem's framework. the protocol has been designed to include patient perceptions and capabilities with the understanding that all health care providers must be aware of the patient’s individuality. With this information, patients can be more fully informed to enhance in their self-care capacity. This is an example of pat_ie_nt advocacv consistent with nursing theory. The clinician/practitioner can utilize information from the protocol to improve practice. The protocol is designed to be used by persons equipped with advanced assessment skills and clinical expertise and is within the scope of the APN practice. The diagnostic criteria and treatment options can be practiced by any certified nurse practitioner. The APN is in a unique position to share and receive information with other members of the health care team. If the protocol is used to its fullest extent, the APN will be coordinating care efforts and collaborating with the physician, physical therapist, pharmacist. social worker, home care provider and patient. This can be accomplished through individual efforts of the APN or through formal networking within treatment centers such as a geriatric assessment clinic. The APN will be essential in the dissemination of new information regarding the protocol. The importance of initial treatment, including primarily behavioral methods, may be largely unknown by physician practitioners. The protocol clearly indicates a critical need for thorough assessment. Inclusion of quality of life issues, patient preferences and the overall bio-psycho-social and sexual perspectives of the patient are factors with which some providers may not be familiar or comfortable addressing. The APN is a vital component in educating others in the synthesis of all information gleaned 54 from the protocol. The protocol provides a clear opportunity to evaluate the level and effectiveness of care provided. The protocol will guide performance and may be the “gold standard“ of practice in UI evaluation and treatment of the geriatric patient. Critical pathways and patient education tools can be created from the protocol to extend the quality of practice and patient care. Behavioral methods are not often used as first line interventions in the medical mode. The APN will excel as a role model in providing quality. research based care with demonstrated effectiveness beginning with non-pharmacological treatments. With the improved outcomes through prescribing pelvic muscle exercises and diet modification, APN actions will be emulated by other providers outside of the nursing profession. As is observed from the extensive literature review. much research is still needed for increasing the scientific base regarding causes and consequences of U1 in the elderly. Using the “Primary Care Protocol for the Management of Geriatric Patients with Urinary Incontinence”, APN’s can design research experiments to explore a multiplicity of outcome measures. Further options are detailed below in the implications for research. Evaluation Effectiveness of clinical tools can sometimes be difficult to measure. The suggested approach would be to include an evaluation form with each protocol distributed so that outcomes could be linked with use. Areas to be included in the evaluation are case of use, number of patients effected by protocol, provider acceptance and patient outcomes. The tool has been piloted and used effectively in a local primary care office with 55 geriatric patients. The results of use within that practice have led to modifications in the tool. One change was in the diagnostic section in that cystometry does not appear to be a functional option and was deleted from the original draft of the protocol. Also. by initially including the patient's perceptions in the care. options for referral (though suggested by the AHCPR guidelines) were modified for the individual upon whom the protocol was tested. The protocol will be evaluated in the primary care setting by performing retrospective and prospective chart reviews and comparing the number of patients identified with UI and their outcomes before and after implementation of the protocol. The appropriateness of the treatment options. success rate of cure or decrease in incontinent episodes and cost/number of pads used would be examined. In a multiprovider practice this type of evaluation would provide outcome data for one of AHCPR’s goals of reducing variability of diagnoses and treatments options among providers. Data may also be collected from providers related to ease of use and time involved in use of the protocol. Implications for Research The protocol will stimulate research questions related to UI treatment in primary care. The inclusion of all information from the AHCPR guidelines plus information from new resources makes it the most current and comprehensive tool available. Examples of research questions that this protocol has provoked: 1. Does use of the protocol increase appropriate interventions in primary care practices? 2. Will the protocol direct providers to more behavioral interventions than 56 pharmacological ones? 3. Will referrals change based on implementation of the protocol in a primary care setting? 4. Does use of the protocol standardize primary care practitioner practice patterns in a multiprovider site? ' 5. How can reimbursement be linked to use of the protocol? 6. Are certain treatment regimens suggested by the protocol not accepted by the older population? 7. Does the type of provider using the protocol impact the patient’s perception of care and outcome? 8. Can qualitative studies using the protocol be completed examining quality of life issues before and after treatment? 9. Does use of the protocol effect care given to the male patient with benign prostatic hyperplasia? 10. Will use of the protocol impact medication usage and polypharmacy issues in the elderly patient with U1? 11. Will costs of incontinence to the patient differ with use versus without use of the protocol? 12. Can the protocol be used effectively in alternative practice settings such as home care and extended care facilities? 13. Will knowledge and implementation of the protocol in practice settings identify patients with UI earlier? As the protocol is used in research situations. data will suggest changes to be 57 made in the protocol. Other modilications based on research findings may include sections on follow-up criteria and supplemental therapies. @lications for Professional Education The AHC PR (1996) guidelines call for continued efforts to educate health care providers regarding UI so that they are sufficiently knowledgeable to diagnose and treat this problem. Incontinence is a problem for which much can be done if it is recognized. addressed and treated appropriately. Effective continence education can lead to improved management and superior outcomes. In response to the guideline recommendations. a task force was formed from a discussion group hosted by the American Nurses Association in 1997. That task force developed educational competencies to be used by schools of nursing in identifying content that should be addressed at various levels of preparation (Jirovec, Wyman, & Wells. 1998). This is a noble beginning, yet more remains to be done. In a study by McFall, Yerkes, Bernard, and LeRud (1997) 155 physicians identified deficiencies in their level of preparation to evaluate and treat U1. The study further reported physicians not only miss opportunities to identify patients with UI but variations in treatment is great despite the recommendations of the AHCPR (1996) guidelines. Furthermore, only 17% were aware of the guidelines. Awareness, consistency of practice protocols. and tools to aid the provider are essential to improve patient outcomes. 58 Summary The AHCPR guidelines were created with the primary goal of reducing or eliminating UI in the adult patient. This protocol provides a clear path to the management of U] in the geriatric population. Augmented by new research. the protocol delineates the steps of appropriate evaluation and treatment. with the goal of reducing variations among health care providers. Based on the literature. it is evident the elderly are particularly prone to transient and established U1. With proper identification. diagnosis, and treatment, U1 can be effectively managed, preventing adverse sequelae and promoting dignity and quality of life for the elderly population. 59 Appendix Primary Care Protocol for the Management of Geriatric Patients with Urinary Incontinence 60 Primary Care Protocol for Management of Geriatric Paients with Urinary Incontinence Steps Key Points Patient's Description of Problem Impact on relationships: Sexual, Social, Family Perception Cost to Manage, Treatment Expectations Histiiry Onset, Duration. Frequency, Timing, Amounts of voids and leakage, Voiding diary, Precipitants, Nocturia, Dysuria Staining, Hematuria, Poor or interrupted stream, Previous treatment Risk Factors Immobility, Impaired cognition, Smoking, Delirium, Obesity, Diabetes, Fecal impaction, Low fluid Intake, Stroke, Childhood enuresis, Episiotomy, Pelvic muscle weakness, Multiparous,Vaginal deliveries, Estrogen depletion Medications Alpha adrenergic agonists and antagonists, Anticholinergic, Antipsychotic, Diuretics, Antidepressants, Sedatives, Hypnotics, CNS depressants, Narcotic analgesics, Alcohol, Beta adrenergic agonists, Calcium channel blockers Lifestyle and Caffeine and Alcohol intake, Dietary fiber, Adequacy and Timing of fluid Environment intake, Environmental barriers, High impact physical activities, Occupation Capabilities Mobility and Manual dexterity, Cognition, Motivation Physical Exam General: abdominal masses, peripheral edema, heart & lung sounds Neuro: sacral nerves, anal wink, bulbocavernosus reflex, cranial nerves Rectal: sphincter tone, masses, impaction, prostate characteristics Genital/Pelvic: atrophy, prolapse, masses, muse. tone, urethral diverticulum Diagnostic UA with C&S if indicated, Post void residual, Stress maneuver, Tests If indicated: BUN, Creatinine, Glucose and Calcium, Simple Cystometry Clinical Presentations and Diagnostic Interpretation Transient DIAPPERS Delirium, Infection, Atrophic Vaginitis, Pharmaceuticals, Psychological & Endocrine disorders, Restricted mobility, Stool impaction Stress Sudden leakage associated with an increase in intra-abdominal pressure: coughing, laughing, sneezing, bending, Iifiing, exercise, sexual intacotn'se. Failure to store. Urge Extremely strong need to void Associated with frequency & nocturia. Often neurologic etiology. Most common in the elderiy. A failure to store. Overflow Frequent or constant dribbling; hesitancy; weak prolonged or interrupted stream; small voids with large post-void residual volumes. Often a neurologic cause. Failure to anpty. Functional Diagnosis should be one of exclusion. May result fiom impairments in mobility, accessibility, dexterity, pain or cognition that interfere with the process of toileting. Medications may exacerbate condition. Mixed Combination of above presentations. Referral Criteria Uncertain diagnosis, patient request, surgical consideration, hematuria without infection, UI associated with recurrent symptomatic UTI, persistent symptoms of difficult emptying, previous pelvic or bladder surgery, beyond hymen prolapse, abdominal prostate findings, abnormal PVR, neurologic condition .25: .0 0.09550 0.0.33. 2.0500555 3208:0535 5.55. 8.03.... $0.68.. «cop—83. 0:02 0:02 Ecuwofivefi 505 35.55:. 0030.. 8.323.500 0.20m EBA. $0.2: 3.. .3805. $0.60.... .EESAZ .5250“. 2.000.553 5.3.4:. 88262 232% ”8.6.. 8.8.5 a 88:58 use»... 352... ass: 5.50. means 523:. :oéfigmg .3258: 0260 25.02:. no 3:090 $3035 "VESSEAEQ 30.80558 .0805 3050.5 A8952... 00030.0 05.95 eoeaaaem .8585 .ofieaméa . asaeoeoa 8.3% BE: .36.. Sacha .3on mean. 5035 33.356 cogeofiwse. 0.32.5592 «damp—88 0.038 03.0“. 305.08.. 809.83. 5.3.62.0“. Sufism Agaoeofiémoqv meowobmm 25.82.3008 50.9 093 5.3.55.8 flog—m v.0an_.000..e.m. £02... .2505 38.5 anew... 322: 82558 8:8... .532 as? 238.9. .83% .553. means €85 me... .8505 «05.08.... m:..m 00.92.0505? 8&0on 0.82: 0.20; Eamon. 05.20%3 62.05 Aaaanoeoefionc mfiwobmm. 30:85.09: 50.0 325 830 ween—coca: co mop—2.0a E065; C0. :00 00:05:80 .3 .3359 c220 .2351 .3.ue_e0efi._e__m .EeSagom 0...; 0.30 hue—5.:— ueu 2.330 50:58.5. List of References References Beckman, N. (1995). An overview of urinary incontinence in adults: Assessments and behavioral interventions. Clinical Nurse Specialist. 9. 241-274. Berrios, G. (1986). Urinary incontinence and the pathophysiology of the elderly with cognitive failure. Gerontology. 32, 119-124. Blowman, C., Pickles, C.. Emery, S., Creates, V.. Towell, L., Blackburn, N., Doyle. N.. & Walkden, B. (1991). 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