Your skills and diligence can make a huge difference in the quality of life and health of your incontinent clients. Incontinence is a major disaster for the elderly, and a big challenge for caregivers in home care. It’s a huge problem for the client; it can be one of the most devastating things that can happen and destroys much of the quality of life that they’re used to. In fact, it may be the main reason that they are moved into a nursing home, as it’s one of the most frequent reasons for nursing home admission.

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Research shows that half, or more, of all nursing home residents have incontinence. So, not only does it have a very adverse effect on their quality of life, but it also can be very embarrassing and cause social isolation and depression. And, interestingly enough, incontinence problems are a direct cause of hip fractures! Many hip fractures are caused by an emergency urge to go to the bathroom at night. They are afraid of having an accident, so they may hurry to the bathroom, fall and have a hip fracture.

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Incontinence is also a major cause of pressure ulcers, which can be catastrophic for our clients and lead to a lower quality of life, amputation, or even an early death. Because of the serious impact that incontinence has on your clients, you need to do everything
you can to improve the situation for them. Don’t just accept it as another problem that comes with aging that you can’t do anything about. Your clients are depending on you to help find a solution to this devastating problem.

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As a caregiver, you are immensely important in helping your client deal with this unfortunate situation. Your skilled, compassionate caregiving methods can go a long way in giving these clients a happy, high-quality life in spite of their impairment. Thoughtful, understanding caregiving can make all the difference:

• Be kind and understanding. This is an extremely embarrassing situation and your kindness and understanding can go a long way to deal with the problem and keep quality of life as high as possible.

• Keep your clients clean and dry. This is one of your most important jobs as a caregiver. Be very attentive to this situation. You should never let your client stay soaked or dirty. Not only is this humiliating, but it also substantially increases the risk of a serious infection, which can become life-threatening in someone who is at risk. 

• Always be very watchful for signs of infection or other serious medical problems in your incontinent clients and report them immediately. Your diligent reporting may well save your client from a serious infection that can be life-threatening.

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URINARY INCONTINENCE
Urinary incontinence is a major problem for patients in nursing homes – in fact, it’s one of the most frequent reasons for admission to a nursing home. Studies show that over half of all nursing home residents have some form of urinary incontinence. Because of this, it’s probably one of the most frequent problems that you may deal with as a caregiver. And it’s an area of huge distress and reduced quality of life for your clients.

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There are many causes of urinary incontinence – some of which are treatable and others which are not. It’s also a major problem in those suffering with dementia as their disease progresses. Types of urinary incontinence include:

• Stress. This occurs when small amounts of urine are released as the result of coughing, laughing, lifting and so on. This is a common incontinence problem in the elderly, and can be caused by bladder infections, weakened pelvic muscles due to childbearing, or prostate removal in men.

• Urge. This is the strong desire to go to the bathroom – so strong that may seem virtually impossible to get to a bathroom. This is the most common type of urinary incontinence and has many causes including cancer, certain diseases such as Parkinson’s, and infections. Oftentimes, no cause can be determined.

• Overflow. This happens when the bladder overfills and small amounts of urine leak out. This is a common problem in men, often caused by an enlarged prostate or prostate cancer.

• Total. This is the complete loss of all bladder control.

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Here’s something to keep in mind: Research shows that most problems with urinary incontinence can be successfully treated and improved, even for those with dementia.

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CMS GUIDELINES
The Centers for Medicare and Medicaid Services (CMS) has specific rules and guideline requirements relative to what you need to do for urinary incontinence. Their guidelines include the following, which can be found in their surveyor’s State Operations
Manual under F-Tag 315:

• Clients who suffer from urinary incontinence are to be assessed, diagnosed and provided appropriate treatment and services. The goal should be to maintain as much normal urinary function as possible.

• A catheter is not to be used unless medically necessary. Catheters are not to be used just for caregiver/family convenience, and are to be removed as soon as possible.

• Caregivers need to do everything they possibly can to prevent infections.

• Your clients are to be involved in decisions involving urinary incontinence care and their preferences initiated, whenever possible.

Here’s what CMS guidelines require specifically for improvement and management of urinary incontinence:

• Manage pain and provide necessary adaptive equipment to bring overall function to as near-normal as possible.

• Do an environmental analysis and make improvements that will help such as removing impediments getting to the bathroom, improve lighting, use a bedside commode or reduced distance to bathroom, etc.

• Make sure that any underlying medical conditions are treated that may be contributing to urinary incontinence.

• Adjust medications as necessary, as certain medications can cause urinary incontinence while others can improve it. Have a pharmacist help with this.

• Use pelvic organ support devices, incontinent products, garments and an external collection system when necessary.

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BEHAVIORAL MODIFICATION
The CMS recommends that you use a behavioral modification program as your first step, in all cases where this may be an alternative. This consists of training the client to postpone or delay voiding, and to use the bathroom according to a timetable.

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A program called “prompted voiding” has been shown in research to reduce incontinence episodes up to 40 percent, says the CMS. And, the CMS says this works even for those elders that have Alzheimer’s disease, “provided they are at least able to say their name or reliably point to one or two objects.”

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The elements of this program include:

1. Regular monitoring of the client, all the while encouraging them to report to caregivers when they need to go to the bathroom.

2. Getting them used to going to the bathroom on a regularly scheduled basis.

3. Giving praise and positive feedback when the resident does use the bathroom on the scheduled timing. This training can take a bit of time, but it’s quite simple to do and with a 40 percent success rate, it’s worth a try with your elders.

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WHAT ABOUT ABSORBENT PRODUCTS?
Here’s what the CMS says about absorbent products: “Although many residents have used absorbent products prior to admission to the nursing home, and the use of absorbent products may be appropriate, absorbent products should not be used as the primary long-term approach to continence management until the resident has been appropriately evaluated and other alternative
approaches have been considered.” In other words, they’re okay, but the CMS wants an evaluation to take place, and to try other methods first, using absorbent products as a last resort.

 

KEEP SKIN DRY
Proper hygiene is extremely important for those who are incontinent. Skin breakdown and erosion can be a serious problem, so you need to keep the skin clean and dry at all times. But the CMS cautions that frequent washing with soap and water can dry out the skin too much, and a recommended perineal lotion may be preferred.

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Moisturizers can help keep skin from drying out, but should be used very sparingly, if at all, on damaged skin until it heals. Remember, skin problems should always be reported immediately, as they can quickly develop into a very serious situation, such as a pressure ulcer.

 

CARE FOR CATHETERS DILIGENTLY
The CMS does not recommend catheters unless needed for a medical problem. They strongly advise against using them for the convenience of caregivers. There’s good reason for this – they cause a huge decline in quality of life; plus they are a dangerous source of potentially very serious infections – some of which can become life-threatening.

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For those who do have medically-necessary catheters, you need watch these very carefully and regularly, and quickly report any types of problems. Make sure the catheter is properly anchored, that the collection bag is always lower than the catheter, that there is absolutely no leakage, and that the catheter (including the area around it) is kept clean at all times.

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Please make sure you are aware of the signs of UTIs as urinary tract infections can be a problem for anyone and should be reported immediately:

• pain or tenderness in the flank or groin area

• increased burning pain upon urination

• fever

• worsening of mental status

• cloudy, bloody or foul-smelling urine

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ABOUT BPH
BPH (benign prostatic hyperplasia) is a problem frequently encountered in men as they age. BPH occurs when the prostate gland
enlarges, and since this gland wraps around the urethra (the tube that drains the bladder), it can partially, or completely, restrict the flow of urine.

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Men who have this condition often have a difficult time urinating and cannot completely empty their bladder. Therefore, they often need to go to the bathroom frequently, which can cause problems at night and also when traveling. In some cases, BPH causes men to occasionally have an extreme urge to urinate, and they’ll either be unable to hold it or they will have leakage.

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To avoid accidents, make sure these clients use the bathroom regularly. Make sure bathrooms are readily available on trips and allow for several bathroom breaks. Allow plenty of time in the bathroom as it may take them longer. Also, restricting fluids after 7pm can sometimes reduce frequent nighttime awakenings.

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There are drugs that help with BPH, so if you believe one of your clients has this condition, be sure and report it. Also report it if you notice symptoms suddenly worsening. In some cases. clients with BPH will be unable to urinate at all, which is a medical emergency.

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BOWEL INCONTINENCE
Bowel incontinence is a very difficult problem for both the client and the caregiver. It can be caused by several diseases and conditions, and it can be a devastating situation regarding quality of life. Also, as dementia progresses into its later stages, incontinence gets increasingly difficult to resolve.

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It is important to note that in many instances, bowel incontinence can be helped or cured, either through medicine or surgery. Be sure and report this when it starts occurring in any of your clients. Some tips on dealing with bowel incontinence include:

• Start a scheduled toileting program. During the day, take your client to the bathroom every two hours, including 30 minutes after meals.

• Before visiting the toilet, encourage your client to walk or perform up to eight sit-to-stands. And, if chair bound, let them wheel their chairs.

• At night, ensure there is a commode or a bedpan within easy reach of the client’s bed, and give them help if needed.

• Check with a nurse or physician about reducing consumption of foods and drinks high in caffeine (coffee, tea, chocolate and certain soft drinks) and high-fiber foods (bread, beans, cereals and potatoes). These can increase bowel movements, thus making incontinence worse.

• The same goes for physical activity soon after waking. Be sure you’re following medical recommendations for the patient – diet should not be changed substantially without the okay from medical personnel.

• Some clients need the help of a walker or a cane to get to the bathroom. Make sure these are kept close to them at all times.

• If the client needs help getting to the bathroom, be sure and instruct them to let caregivers know immediately each time they need to make a bowel movement. Don’t delay.

• Check that the bathroom is comfortable, well lit and heated. Grab bars, handrails and adjustable toilet seats make the toilet easier and safer to use.

• With the client’s permission, you may want to try adult briefs, plastic outer pants, absorbent pads or panty liners. Consider, however, that these products are costly and sometimes humiliating to the wearer. Try a scheduled toileting program first.

• Praise your client every time they use the bathroom.

• Keep a written record of number and frequency of accidents. Document what the client eats and drinks, especially before incontinence episodes, and where accidents happen (in the bathroom, on the way there, in bed, etc.).

• After analyzing the situation, adjust your caregiving accordingly. For example, if accidents happen on the way to the bathroom, then perhaps educating the client to tell caregivers immediately when the urge occurs will help. If in bed or at other regular times, then perhaps a scheduled program of visits to the bathroom will help.

• Is the stool an unusual color or consistency? If so, report to medical personnel.

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WHENEVER ACCIDENTS OCCUR

• Don’t make your client feel guilty or ashamed and do your best to reassure them that everything’s okay.

• A friendly smile and talking in a supportive way will help them to cope with the situation.

• This is a hugely embarrassing problem and your kind compassion is very important at this time.

• Gently clean them with water or moist tissue paper (baby wipes) rather than with dry toilet paper, which can irritate the skin.

• Check for skin damage.

• Dry thoroughly and apply a recommended barrier cream.

• Above all, avoid reminding your client of their incontinence. Treat them with respect, maintain their dignity and allow them as much privacy as possible. Report serious symptoms.

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The Mayo Clinic also advises that caregivers be very watchful for serious bowel problems. Certain changes can be symptoms of serious diseases and need immediate reporting. Mayo clinicians suggest that caregivers should report any of the following:

• Pain in the rectum

• Bleeding from the rectum

• Changes in usual bowel habits

• Diarrhea that lasts more than a day or two

• Dark or black stools

• Unexplained weight loss

 

Always remember that as a caregiver, you can do a lot to help your clients retain their self-respect and quality of life by:

• Being kind.

• Being very attentive to the situation, always keeping them clean and dry.

• Being compassionate and understanding.

• Having a friendly smile at all times!