Q&A Continence Care and Dementia

Continence expert, Dr Joan Ostaszkiewicz, in consultation with the Continence Foundation of Australia, presents this Q&A relating to the management of incontinence in dementia patients in aged care.
We have many residents with dementia in our facility. How do we assess the best methods of toileting assistance for them?
The diagnosis of dementia complicates the management of incontinence. For example, it can be difficult to obtain accurate information about the frequency of incontinence or continence. In addition, people with dementia may not always understand or appreciate a health worker’s efforts to help them wash, use the toilet, or change a pad.
However, residents with dementia may have incontinence for the same reasons as residents without dementia. They should receive the same assessment as residents without dementia.
The Continence Tools for Residential Aged Care, available from www.bladderbowel.gov.au, provides a structured process to help staff conduct an individualised assessment of any resident’s continence status and implement a targeted management plan.
Often, the staff/residents ratio in residential aged care facilities are blamed for inadequate toileting assistance programs. At the hands-on level how can we best work within our staffing capacity to identify which residents are most likely to respond to a toileting assistance program?
According to research conducted in the US, up to 50 percent of residents living in aged care homes can maintain continence if they receive toileting assistance up to four times during a 12-hour day, particularly if they also participate in a program to improve their functional abilities. This includes residents with mild cognitive impairment.
However, providing such assistance requires one staff member to five residents. This explains why many staff find it difficult to implement and sustain toileting assistance programs at rates that improve residents’ continence.
It’s important to note that all residents will derive benefit from a toileting assistance program. For example, a distressed response to toileting assistance should always be regarded as a desire to maintain independent bladder or bowel control.
A realistic response to workforce constraints involves targeting those residents most likely to respond to a toileting assistance program.
In the first instance, residents should receive a multidisciplinary continence assessment in order to identify and address potentially reversible causes of incontinence, and to inform the development of an individualised continence care plan. The plan may or may not include the use of toileting assistance programs.
The Continence Tools for Residential Aged Care, provides an evidence-based set of resources to assist staff working in residential aged care facilities to conduct this assessment and determine the most appropriate individualised intervention.
What steps would you suggest to take before prescribing a laxative to a frail older adult?
The key to good bowel management is regular and ongoing assessment. Assess the frail older adult to identify and treat reversible causes of constipation including side effects of medication.
Conservative treatment of constipation can include exercise, abdominal massage, increased fluids, fruit and fibre. This can be tailored according to the frail older adult’s individual needs.
A recent study undertaken by a Victorian regional health service showed it was possible to substantially reduce the need for suppositories to manage constipation in frail older adults in a dementia unit by introducing new assessment guidelines to individualise residents’ care, and by increasing the use of non-laxative agents.
Vigilant daily bowel charting was carried out using a stool form scale. Other measurements were also noted, including behavioural response of resident, and if any laxatives were administered, type and dose.
Before administering laxatives to the frail older adult, consideration is given to the presenting symptoms, the individual’s fluid intake, swallowing ability, diet and potential side effects of any current medications.
In choosing a laxative, it is important to know how they work. Selection is also dependent of goals; for example to prevent constipation, increase bulk, to soften or push stool or a combination of these.
I am a physiotherapist in an acute Older Adult Mental Health facility and have noted that quite a number of our older female patients get recurrent UTIs. The increase in their confusion adds significantly to their already present dementia-related confusion and side-effects from further medications to treat the UTIs. What is “best practice” management of this population?
This is a big topic and there is considerable debate about diagnosis and treatment. The signs and symptoms of UTI in older adults may include altered mental status, fever, haematuria, dysuria, urgency and suprapubic pain. UTIs can also cause frail older adults, particularly those with pre-existing dementia, to develop delirium. Once they have delirium they are at greater risk of falling.
The question is one of treatment; the clinical assessment of people with dementia and living in care homes is challenging because of their limited verbal communication, and the difficulty of obtaining a clean catch specimen of urine.
Moreover, frail older persons are at higher risk for unintended adverse effects from treatment (eg., fulminant Clostridium difficile colitis from antibiotics used to treat otherwise asymptomatic bacteriuria in the presence of urinary incontinence). Asymptomatic bacteriuria should not be treated as it may increase antimicrobial resistance.
The Society for Healthcare Epidemiology of America (SHEA) developed a set of minimum criteria to help clinicians determine the appropriateness of antimicrobial therapy for individuals with advanced dementia. The clinical indicators include: acute dysuria OR fever, and at least one of the following symptoms: i) new or worse urinary frequency, (ii) urinary urgency, (iii) gross haematuria, (iv) suprapubic pain, (v) costovertebral tenderness, (vi) rigours, and (vii) changes in mental status.

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Joan Ostaszkiewicz
Dr Joan Ostaszkiewicz is a registered nurse with a clinical and academic background in the management of incontinence in frail older adults. Dr Ostaszkiewicz is a Postdoctoral Research Fellow in the Centre for Quality and Patient Safety Research at Deakin University.