More than 25 million Americans experience continence problems, according to the National Association for Continence (NAFC). Although it is more prevalent among older adults, incontinence is not a normal part of aging. Many cases of incontinence can be easily treated, but afflicted senior patients are often too embarrassed to address the condition.
Incontinence is a widespread problem among seniors, which may contribute to the number of people who think it is normal and decide not to treat it. When coupled with embarrassment in seeking help, ignoring the issue can lead to serious consequences ranging from social isolation to life-threatening falls. In fact, getting out of bed to go to the bathroom is a leading cause of falls, and one study found that urinary incontinence increased the risk of falling in patients with dementia. Incontinence can also contribute to health problems such as bladder and urinary tract infections as well as skin problems. Seniors and their caregivers bear the cost of supplies to cope with incontinence, which can become expensive.
The NAFC reports that 75 to 80 percent of those affected by urinary incontinence (UI) are women. Childbirth, menopause, and other factors can make women more prone to the condition. Many sufferers of UI have more than one form of it. There are four general types:
This is an activity-related incontinence that occurs when the bladder leaks under pressure. It is often noticed after a high-impact exercise or after a simple act physical act such as sneezing. While stress incontinence is the most common form of UI among younger women, it may also occur during menopause. Men sometimes develop stress incontinence from prostate enlargement or prostate cancer treatment.
Some people may experience the urge to urinate suddenly and with a full bladder. Sometimes referred to as an overactive bladder, urge incontinence is more common among people with neurological damage resulting from a stroke, multiple sclerosis, Parkinson’s or Alzheimer’s disease, or diabetes.
Also called chronic urinary retention, overflow incontinence is when a full bladder leaks small amounts of urine. It can result from two possible causes: an obstructed urinary tract due to constipation or an enlarged prostate, or a bladder that has lost its ability to contract adequately due to nerve damage from conditions such as diabetes or stroke.
Functional incontinence primarily affects older adults who cannot make it to the bathroom in time due to a condition that slows down their movement, such as an arthritic knee or COPD.
The cause of UI is often easy to trace, as it is typically a symptom or complication of another issue. UI type and severity can be diagnosed in several ways. A patient’s medical history, physical exam, laboratory tests of both urine and blood, and in some cases imaging techniques are usually enough to detect the causes of most cases of UI. The patient may be asked to maintain a daily bladder diary that notes when he urinated, how much, what he ate or drank, and in which physical activities he engaged.
A senior’s healthcare practitioner can usually diagnose and treat most instances of UI based on their underlying cause(s). Patients requiring more extensive diagnostics and treatments may be referred to an urologist or other specialist. Treatments range from behavioral training to medication, medical devices, and surgery. Ultimately, the UI is either cured or the patient learns how to manage it.
Understanding what activities may be harming a senior’s body and having her eliminate them is often enough to resolve a UI. Some of the more important lifestyle changes include:
- Avoiding constipation
- Reducing caffeine consumption
- Losing weight
- Stopping smoking
- Eliminating alcohol
- Becoming more physically active
Bladder control training
Training the pelvic floor muscles that control the ability to stop urinating can greatly improve bladder function. Performing pelvic floor exercises can benefit both women and men.
Sensors placed on the patient’s body send neurological and muscular responses to the need to urinate to a computer that displays these responses as graph lines on a screen. Over the course of treatment, a patient can use these graphs to utilize his muscles to better control his bladder.
Medications may be prescribed if behavioral methods alone are inadequate. Medications effective for urge incontinence include solifenacin, trospium chloride, or an oxybutynin patch. Women might be prescribed a low dose of topical estrogen, while tamsulosin may be given to men to relax prostate muscles. A medication management system may help seniors remember to take the right dose at the right time.
Urethral inserts for treating stress incontinence are helpful for some women, and they are easily inserted and removed as needed. Another option for women is a device called a pessary, which supports the bladder; it is removed every two to three months. Stress incontinence in men can be treated with the implantation of a manually controlled artificial urinary device.
Approximately 18 million Americans have fecal incontinence (FI), according to the National Institute of Diabetes and Digestive and Kidney Diseases. Seniors with FI may be unaware of its causes or of how it can be treated.
Causes of FI
The most common causes of FI include:
- Inactivity, which can cause excess stool to accumulate
- Stress, especially when severe and persistent
- Diarrhea, which is more difficult for the rectum to hold
- Brain damage, trauma, stroke, and certain diseases that may interfere with the neural responses needed for proper bowel movement
- Surgery, chronic bowel inflammation, or radiation treatments
- Hemorrhoids and rectal prolapse
- Damage to the muscles or nerves from trauma or surgery
- Dyssynergic defecation, a type of constipation and a learned muscle behavior that inhibits proper elimination
Diagnosing a senior’s FI begins with the primary healthcare provider obtaining a thorough patient history and performing a medical examination. Blood, urine, and stool samples are then collected and sent for lab analysis. The patient may also be asked to maintain a daily diary recording when bowel movements occurred, how frequently and completely, and his diet and activity. This information helps the primary physician determine if she can treat the cause or if she should refer the senior to a specialist such as a proctologist or gastroenterologist. Additional diagnostic tools include:
- Anorectal ultrasonography, which employs a camera to examine the rectum
- Anal manometry, which inserts a balloon in the rectum to see how well it contains pressure
- Flexible sigmoidoscopy, which uses a camera to explore the rectum and lower colon
- Defecography, which uses X-rays to view how well the rectum functions
- MRI, which provides detailed images of the entire pelvic area
- Colonoscopy, which explores the rectum and colon
As with UI, much of the causal factors behind FI are treatable; some can even be cured with a combination of therapies. Diet is the first issue addressed, as certain foods can either exacerbate or help control fecal incontinence. For example, foods high in fiber, such as fruit, can help ease both constipation and diarrhea. Some fruits, however — including pears, peaches, and apples — may exacerbate constipation. Drinking plenty of water throughout the day can also help relieve constipation. Foods and beverages that may worsen constipation include:
- Carbonated beverages
- Diet drinks and candy made with sweeteners such as fructose and sorbitol
- Milk and other dairy products
- Foods high in fat
- Spicy or greasy foods
- Smoked or cured meats
Medications typically employed for FI are those that aid the elimination process. Polyethylene glycol 3350 (MiraLAX), available over-the-counter, is often effective in controlling constipation, especially when used routinely. Psyllium, such as Metamucil, is also available without a prescription. A physician might prescribe loperamide (Imodium) to treat diarrhea. Healthcare providers should supervise the use of any of these products.
Bowel training is often an effective adjunct therapy that involves a senior training herself to use the restroom at the same time each day. The same pelvic floor exercises used to treat UI may also be used to treat FI. When combined with biofeedback, these therapies may help seniors relearn how to effectively control their elimination process.
Surgery is often considered a last resort for treating FI. Common surgical procedures include:
- Sphincteroplasty to repair a trauma-damaged sphincter muscle
- Insertion of an artificial anal sphincter balloon that the patient manually operates
- Colonostomy to divert the bowel to eliminate in an external bag
- Neuromodulation to electrically stimulate the nerves that control the rectum and anus
Many seniors live with treatable continence issues that they may believe are normal because of their age. You may be in a position to help seniors understand these conditions in such a way that they may seek additional information — and treatment — from their healthcare providers.
Beyond referring patients to their practitioners and providing resource information, such as from Voices for PFD, you can offer tips for managing these conditions. It is especially important for seniors with continence issues to understand their increased risk of falls. They may want to seek out fall prevention advice and reliable fall detection technologies that can call for help no matter their location.
If you know a senior patient who would benefit from information about medical alert devices, refer your patients to Philips Lifeline.