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INCONTINENCY CARE IN NURSING HOMES

Urinary incontinence, the inability to control the bladder, is one of the most common reasons people seek nursing home care. Over half of Michigan nursing home residents are incontinent.

Incontinence can cause many other problems, including skin rashes, pressure sores, falls, isolation, and psychological harm. In the past, treatment was often limited to constant changing of clothing, diapers, pads and bedding. However, recent studies show that incontinence is not a normal part of aging and is often reversible. This Fact Sheet discusses care options for incontinence, including residents’ rights to choice of incontinency care products.

CARE OPTIONS

The first step in treating incontinence is determining its cause. Nursing homes are required to evaluate incontinence and develop an individual plan of care for each resident with this condition.

Incontinence may be caused by physical or mental disorders or by decreased mobility. Many of the causes are correctable or treatable. Some common causes or types of incontinence are described below:

Lack of Toilet Access: Many residents need help in getting to the toilet; regular staff assistance is necessary. This may mean helping residents to the toilet or providing a bedside commode, urinal, or a room or a bed that is closer to the bathroom. Residents in wheelchairs should have access to barrier-free bathrooms.

Immobility: Residents who are immobile may have control of their bladder but be unable to reach the toilet. Improving the resident’s ability in walking and transferring to the toilet will often reduce incontinence.

Dexterity: Some residents may not be able to adjust their clothing to use the toilet. Special clothing or staff assistance may be needed to help overcome this obstacle.

Depression: Severe depression can reduce a resident’s desire to stay dry. Treating the depression may resolve this problem. While the depression is being treated, the nursing home should encourage the resident to use the toilet as needed.

Disorientation: Some residents are no longer aware of their surroundings or no longer sense their own needs. Scheduled toileting—reminding and assisting the resident to a toilet on a regular basis—may overcome this problem.

Medications: Many medications can affect the bladder and cause incontinence. Residents on diuretics, for example, may need to toilet frequently after taking the drug. Changing administration of the drug from the evening to the morning may help a resident remain continent through the night. Some medications help relax the bladder and are used to treat incontinence.

Diet: Some types of food products, such as caffeine and alcohol, irritate the bladder. Reducing or eliminating their use may be helpful.

Medical Problems: Conditions such as congestive heart failure, urinary tract infection, fecal impaction, and pedal edema may contribute to incontinence. Treatment of these conditions will improve both incontinence and functional abilities.

Fluid Intake: Do not decrease fluids. Adequate fluids—four to six glasses of juice or water daily—are needed for the bladder to operate properly. Exceptions exist for residents whose medical condition requires fluid restrictions. Decreasing fluid intake before bedtime will help reduce night-time toileting.

Urge Incontinence: Residents with this common condition may feel the need to urinate but be unable to suppress the need long enough to reach the toilet. A scheduled toileting routine can address this problem.

Stress or Overflow Incontinence: Stress incontinence, often triggered by coughing, laughing, or sneezing, results in small amounts of leakage between toileting times. Inability to completely empty the bladder is a symptom of overflow incontinence. The resident’s physician can help identify treatments for these conditions.

It is a good idea to check with the nursing home’s director of nursing and the attending physician for information about assessment and treatment of incontinence.

MANAGING INCONTINENCE

If the treatments and environmental modifications do not prevent episodes of incontinence, some type of absorbent clothing may be needed. Cloth or disposable adult briefs or diapers, are most often used for this purpose. Regardless of which product is used, it is important that the resident be kept clean and dry and that briefs, clothing and bedding be changed as often as needed.

Use of a urinary catheter to manage incontinence is not recommended unless absolutely necessary. Catheters cause discomfort and increase the risk of infections, bladder stones and cancer.

The U.S. Department of Health and Human Services has published three excellent booklets on urinary incontinence. One of the booklets is for consumers, “Urinary Incontinence In Adults, A Patient’s Guide.” Two other versions, which have the same title but the following subtitles are designed for professionals: “Quick Reference Guide for Clinicians,” and “Clinical Practice Guideline.”

The booklets are free. To order, call toll free 1/800 358-9295, or write to:

Center for Research Dissemination and Liaison
AHCPR Clearinghouse
POB # 8547
Silver Spring, MD 20907

CLOTH VS. DISPOSABLE ADULT BRIEFS

Residents of Michigan nursing homes have the right to choose the type of incontinency product used in their care. Michigan requires that nursing homes, county medical care facilities and hospital long term care units provide a choice of cloth or disposable adult diapers or briefs. The choice of which one or any one is up to you or your legal representative. If you are paying privately for your nursing home care, your home may charge you extra for the product you select. If Medicaid is paying for your care, the nursing home cannot charge you for either cloth or disposable adult briefs. Medicaid rules state:

1. The nursing home must not charge you for cloth or disposable diapers/briefs,
   
2. The nursing home must not limit the number of diapers/briefs; this should be based on your need,
   
3. The nursing home is not required to supply more than one brand of each type of diaper/briefs,and
   
4. If you want a different brand, you can purchase it yourself.

Michigan’s Medicaid agency notified all Medicaid-approved nursing homes of this policy in June 1992.

Some factors to consider when making the choice between cloth and disposable briefs include dignity, health considerations, and environmental impact. For some residents, cloth briefs may be more comfortable and less likely to cause a rash or skin discomfort. Others may need a more absorbent product and find disposable briefs able to fit that need. Residents should determine what product will best meet their needs and ask the nursing home to honor their choice.

There has been some controversy regarding the impact of disposable briefs or diapers (plastic liners) on the environment because the plastic is not easily bio-degradable. On the other hand, constant washing of cloth briefs is also hazardous to the environment, and can be costly. It may be best to consider your own locality’s concerns as there are no clear answers on the total impact that each choice has on the environment.

WHAT CAN YOU DO IF CHOICE IS NOT PROVIDED

If you feel that you are not being offered a choice of incontinency product, or if you are unsure as to the best choice for you, you may consider speaking with the Director of Nursing during a care plan meeting or at any other time. Explain your preferences. If choice is not offered, you may contact your local Long Term Care Ombudsman office for further assistance.

No Medicaid recipient or his/her family should be paying extra for incontinence care.

Rev: 97,98,99, 03/00, 10/00