Geriatric Syndrome: Urinary Incontinence

By alexandriapaigewatson | Updated: Aug. 28, 2024, 2:23 p.m.

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Geriatric Syndrome:
Urinary Incontinence

Alexandria Watson

NRSE 5013-912

What is Urinary Incontinence (UI)?

According to the National Institute on Aging, the definition of urinary incontinence is when a person leaks urine by accident ("Incontinence," 2017).

When a person urinates, the muscles in the bladder tighten in order to move urine from the bladder to the urethra. From here, muscles around the urethra relax, and then urine passes from the body ("Incontinence," 2017).

While this condition can affect anyone, it is most prevalent in older adults, especially women.
Impact of Urinary Incontinence

Urinary incontinence can have a profound impact on quality of life, as well as an individual's perception of their health (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 99).
Sadly, because urinary incontinence is not a life threatening condition, it is often overlooked.

In addition to this, many patients may be too embarrassed to broach this subject with their medical provider.

Occurrence of Urinary Incontience

Urinary incontinence is typically unreported, but approximately 32% of women over 80 years old report symptoms of UI(Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 99)
In long-term care settings, the rate of UI increases to 43-77% of the population, and is the cause of 1 in 10 nursing home admissions (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 99)
Why So Important to Nursing?

As previously stated, UI is a main cause of nursing home admissions. Today, there are more treatments for this condition than ever before ("Incontinence," 2017).

It is imperative for health care providers to properly diagnose and treat their patients in order to preserve their quality of life and promote independence as well.
UI is also responsible for skin breakdown and pressure ulcers in patients, as well as frequent falls from trying to get to the bathroom.

Types of Incontinence

Stress Incontinence: this occurs as a result of weak pelvic floor support and increased intra-abdominal pressure, resulting in a loss of urine when coughing or laughing (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 99).
Urge Incontinence or overactive bladder (OAB): occurs when urine loss is associated with urgency but not necessarily relating to the quantity of urine in the bladder (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 99).
Overflow Incontinence: refers to the involuntary loss of urine associated with incomplete emptying of the bladder and over-distention (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 99)
Patient Information

86 y.o. female who was admitted to Takoma Regional Hospital with Psychosis. She is a resident of an assisted living facility and needed a referral to a psychiatric doctor for confusion and visual hallucinations.

Her pmhx is significant for Stroke, Hypertension, Hyperlipidemia, UTI, Hypothyroidism, Pallpitations, DVT, Dementia, and Breast Cancer with a Mastectomy.

Allergies: Toradol and Sulfa Antibiotics.

Hospitalizations include admission for combative behavior in 2017, UTI in 2012, Community Acquired Pneumonia and mastectomy approximately 30 years ago.

Health Maintenance: Patient unsure of her last mammogram. and bone density scan.

Immunizations: Patient Unsure.

Patient Presentation

Typical presentation of this syndrome will include obesity, alterations or changes in mental status, rigidty, tremors, general or focal weakness, suprapubic tenderness, history of vaginal childbirth, previous abdominal surgeries and gynecologic surgeries (Domino, 2017, p. 534).

Common complaints of UI include: nocturia, pad usage, leakage of urine, suprapubic pain, dysuria, dyspareunia, and continuous slow leakage of urine between regular voiding patterns(Domino, 2017, p. 534)
ROS would include (+) mental status changes, (+) confusion, (+) decreased mobility, (+) nocturia, (+) continuous leakage of urine, (+) supra-pubic pain, (+) reddened or irritated skin in perineal area, (+) abdominal masses, (+) distended bladder. Pertinent negatives to rule out include dysuria,  hematuria, non-distended bladder, no mental status changes.

Patient Presentation Continued

Vitals: HR-76, RR-20, O2sat- 96% on RA, BP- 130/68, T-99.0, BMI-24.3.

Positive Pertinent Findings: pad usage, mental status change, confusion, decreased mobility, nocturia, supra-pubic tenderness, erythemic skin in the perineal area. Negative Findings: Bladder distention, absence of mental status changes or confusion, abdominal pain and tenderness.

Screening Tools to help determine which patients are at risk of developing UI: Get up and go test, Frailty Tool, Tinetti Gait and Balance Scale, Katz ADL's.

These tools can help determine the patient's ability to ambulate, if they are able to perform ADL's adequately, and if they are at risk for skin breakdown and maluutrition.
Diagnostics and Labs

Urinalysis and Urine culture will help determine if a UTI is also present.

Bladder scan is indicated to determine postvoid residual if overflow incontinence is suspected.

Renal ultrasound and renal function assessment can help determine if renal impairment is present.

Differential Diagnoses: UTI, pelvic organ prolapse, interstitial cystitis, ectopic ureter, urinary fistula, and pelvic mass or malignancy (Domino, 2017, p. 534).

Treatment

Treat correctable causes-like prescribing antibiotics for a UTI.

Encourage weight loss in obese patients by implementing lifestyle changes. Other changes include keeping a bladder diary to catalog fluid intake, voids, and leakage, and reducing caffeine intake (Domino, 2017, p. 535).

Pelvic floor muscle training with Kegel exercises: at least 8 contractions TID.

Second Line Treatments include surgery for mesh mid-urethral sling peri-urethral bulking agents (silicone polymers or collagen), and occlusive or supportive devices (super tampons, pessaries, and cones).

Third Line: Cymbalta, electrostimulation of pelvic floor muscles, percutaneous tibial nerve stimulation, and bladder augmentation. (Domino, 2017, p. 535)

Barriers to Lifestyle Changes

Losing weight may pose a challenge to some patients due to fear of leakage while exercising.

Other challenges include social isolation and depression.

Inability to care for oneself is often the precipitating factor in nursing home admissions, thus making exercise and diet regimens difficult for these patients to follow (Domino, 2017, p. 535).
Education
It is imperative to teach patients, family, caregivers, other healthcare providers (PT & OT), and the community that UI is NOT a normal part of aging and it is a treatable medical condition (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 103).

Behavioral therapy like Kegel exercises and self-catheterization can be discussed and taught in the primary care setting (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 103).

Instructions on proper fluid intake, limiting alcohol and caffeine, and proper perineal hygiene should also be given.

Discussion
Use the mnemonic devices DRIP and DIAPERS to differentiate between acute UI and persistent urinary incontinence.

Delirium
Restricted mobility
Infection
Pharmaceuticals, polyuria

Delirium
Infection, impaction, inflammation
Atrophic vaginitis
Psychological, pharmaceuticals, psychotropics
Restricted mobility
Stool impaction

Mnemonic devices obtained from: (Kennedy-Malone, Fletcher, & Martin-Plank, 2014, p. 101-102).

Discussion

Socioeconomic issues that may arise include patients who do not have access to care due to financial constraints or lack of insurance.

When communicating with patients about topics which may cause embarrassment, utilize open ended questions to gauge how the patient feels and let this steer the conversation.

It is important to provide culturally competent care to all patients. When treating patients of different cultures, let their preferences guide the discussion, and ask about their beliefs/wishes.

References

Domino, F. J. (2017). The 5 Minute Clinical Consult 2018 (26th ed.). Philadelphia, PA: Wolters Kluwer.

Kennedy-Malone, L., Fletcher, K. R., & Martin-Plank, L. (2014). Advanced Practice Nursing in the Care of Older Adults. Philadelphia, PA: .

Urinary Incontinence in Older Adults . (2017). Retrieved from https://www.nia.nih.gov/health/urinary-incontinence-older-adults

Geriatric Syndrome: Urinary Incontinence

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