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Continence: A Matter
of Dignity
Causes, Signs and
Prevention
By
Marie Mangino, MSN, CRNP, GNP-BC
President, Vincent Healthcare, Inc.
Wendy W. Fox, MOT, OTR/L
Assistant Professor of Occupational Therapy
University of the Sciences, Philadelphia PA
Jennifer A. Reinhold, BA, PharmD, BCPS
Assistant Professor of Clinical Pharmacy
University of the Sciences in Philadelphia
Geriatric Education Center of Greater Philadelphia
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Acknowledgements
Appearing in Video:
Name
Appearing as
Bob Swensen……….Mr. Banks
Ruth Alpert…………Mrs. Banks
Susaye Lawson…… Susaye
Nate Lazowick…….Mr. Williams
Kevin Brown……… Carl, DCSW
Dinnie Childs………Piano Player
Clarese Herbert……Mr. William’s
friend
Man at Piano………Arjun Bhojwani
Nancy Web…………Mrs. Powell
Eric Stewart……….Mike, grandson
Ruth Livikoff………Ruth, DCSW
Name
Appearing as
Dick Brown………………Mr. Clark
Deanna Penn…………….Supervisor
Sangeeta Bhojwani…….Trainee
Roby Jacobs……………..Daughter
Charlene Duff……………Shopper,
Gift Shop
Sheila Mitchell-Ayers…Shopper,
Gift Shop
Marie Mangino………….Trainer, as
herself
Tanisha Jones……………Testimonial
Julie Cohlmer…………….Testimonial
Geriatric Education Center of Greater Philadelphia
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Special thanks to:
• Henrietta Roberts and Sandy Bailey, of
Stapeley in Germantown for coordination
of video shoot
• All the residents and staff of Stapeley in
Germantown, for their participation and
for permitting video production.
• Raybourn Rusk Productions
Geriatric Education Center of Greater Philadelphia
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Play video segment titled,
“01 Introduction.mpg”
Geriatric Education Center of Greater Philadelphia
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Urinary Incontinence (UI)
Defined
UI is simply defined as the
involuntary or inappropriate
loss of urine. In other words,
incontinence is urine loss
which happens when the
person doesn’t want it to or
doesn’t know it’s happening.
Geriatric Education Center of Greater Philadelphia
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Learning Objectives
At the end of this program you will be able to:
 List the common causes of urinary
incontinence (UI)
 Describe the potentially serious effects of
not treating UI
 Recognize signs of a urinary tract infection
 Discuss effective ways to prevent or reduce
episodes of UI
 Enhance the dignity of those in your care
Geriatric Education Center of Greater Philadelphia
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Prevalence of UI
 More
thank 13 million Americans
have UI
 85% of them are women
 37% of persons over 65 and living
in the community have UI
 53% of homebound have UI
 30-77% of NH residents have UI
In 8 of 10 cases symptoms can be improved
and in some cases function restored.
Geriatric Education Center of Greater Philadelphia
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The Facts about UI
Continence is normal;
Incontinence is not
 Normal aging does not cause
incontinence
 When continence is impaired,
many simple things can be done
to restore or improve function

Mrs. Mendoza
Geriatric Education Center of Greater Philadelphia
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Caring for UI is
Important Because:
 Untreated
or under-treated UI
can cause:



Skin breakdown and infection
Falls and injuries
Sleep disturbance
Mr. Phillips
Geriatric Education Center of Greater Philadelphia
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Caring for UI is
Important Because:
 Untreated
or under treated UI
can cause:



Depression/social withdrawal
Loss of dignity/lower quality of
life
UTIs (urinary tract infections) 
hospitalization  death
Geriatric Education Center of Greater Philadelphia
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Left Left
Kidney
Kidney
Right
Right
Kidney
Kidney
Ureters
Urethra
Structure of the
Urinary Tract System
Bladder
Bladder
Bladder
wall muscle
by Nicole Mangino
Nicole Mangino 2004
Geriatric Education Center of Greater Philadelphia
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Contributors to UI:
Age-Related Changes
 Overactive
bladder muscle
 Enlarged prostate (BPH)
 Atrophic vaginitis and
urethritis (occurs after
menopause)
 Reduced bladder capacity
 Increased post-void residual
(PVR)
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Contributors to UI:
Injury and Disease
 Diabetes
 Damage
to the:
 Brain
 Spinal
Cord
 Bladder
 Short
term use of an indwelling
catheter during acute illness
Mrs. Banks
Geriatric Education Center of Greater Philadelphia
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Contributors to UI:
Limitations in Function
 Ambulation
 Dressing
 Fear
of falling
 Choice
Mr. Williams
Geriatric Education Center of Greater Philadelphia
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Contributors to UI:
Dietary Factors
 Artificial
sweeteners
 Caffeine
 Alcohol
 Acidic Foods
Mrs. Powell
Geriatric Education Center of Greater Philadelphia
Contributors to UI:
Medications
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Anticholinergics : Can affect the
bladder’s ability to empty
 Diuretics (water pills): Cause extra
urine production
 Cold medicines: Can affect the
bladder’s ability to empty
 Pain medicines: Can cause
constipation and fecal impaction

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Contributors to UI
Hydration & Physical
Conditions
 Not
enough fluid
 Too much fluid
 Fecal impaction
 Acute confusion
 Too much alcohol or caffeine
 Infections/Medical illness
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UTI Symptoms in the
Older Adult
 Increased
frequency
 Increased urgency
 New or increased UI
 Urine odor or cloudiness
 Blood in the urine
 Fever or chills
 Change in mental status
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Acute Changes in
Mental Status that may
indicate UTI
 Sleepiness
 Irritability
or agitation
 Lethargy
 New
or increased
confusion
Mr. Green
Geriatric Education Center of Greater Philadelphia
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Things You Can Do for
Older Adults with UI
 Keep
a log of UI
events
 Monitor toileting
Geriatric Education Center of Greater Philadelphia
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Things You Can Do for
Older Adults with UI
 Determine
frequency
of need
 Develop a schedule
and assist to toilet
 Consider recent
medication change
Geriatric Education Center of Greater Philadelphia
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Play video segment titled,
“02 Mrs. Banks.mpg”
Geriatric Education Center of Greater Philadelphia
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Things You can Do:
Scheduling
Log actual number of
“accidents” or “urinations”
 Based on log results - develop
schedule
 Establishing and following a
schedule can give a person
confidence to do other things
 Prompt and assist
 Praise the effort

Geriatric Education Center of Greater Philadelphia
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Things You Can Do
Encourage change in diet
(gradually reducing and then
eliminating caffeine, alcohol,
sweeteners and acidic foods)
 Avoid over the counter
medications that can cause
constipation or make
continence more difficult

Geriatric Education Center of Greater Philadelphia
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Things You Can Do

Assist as needed to:
 Get to the bathroom or commode
safely
 Remove clothing
 Make urinals (male and female)
available as well as bed pans
 Position urinal or bedpan
 Assist w/ pericare and appropriate
products and redressing
Geriatric Education Center of Greater Philadelphia
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Play video segment titled,
“03 Mr. Williams.mpg”
Geriatric Education Center of Greater Philadelphia
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Mr. Williams’
Challenge
 Arthritis
 Personal
embarrassment
 Effect on family
 Clothing with elastic
or Velcro closures
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Things You Can Do
• Establish safe bathroom setup
– Use of grab bars and/or a raised
toilet seat, 3-in-1 commode
– Observe for good hygiene
– Assist if needed with hygiene
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Things You Can Do
 Make
urinals available
 Prompt (suggest, encourage
and remind) to toilet
 Compliment effort and success
 Change if incontinent
Mr. Samson
Geriatric Education Center of Greater Philadelphia
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Things You Can Do “JIC”
• For outings….Be prepared!
– Take a “JIC” bag – Just In Case
•
•
•
•
•
•
Extra set of clothes
Incontinence products (briefs, liners, underwear)
Gloves, moist wipes, hand sanitizer
Absorbent pads to protect furniture
Air deodorizer
Plastic bag
• Being prepared reduces anxiety for
both the client and the caregiver!
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Skin Care
To prevent skin breakdown:




Work towards improved
continence
Promptly change absorbent
undergarments and clean
perineum and buttocks
Use a skin barrier
Promptly report any change
in skin
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Product Use for UI


Least restrictive
Most dignified
Individual product preference
 Proper fit
 Regular underwear w/ liner
 Pull-up
 Brief (adult absorbent product)
 Proper fit ensures best protection
and is most cost effective!

Geriatric Education Center of Greater Philadelphia
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Things You Can Do
• Simple clothing changes
make toileting a lot easier!
– Velcro closures on
shirts/pants/shoes makes
on/off less effortful
– Elastic waistbands and roomier
fit ease up/down of pants
– Add rings onto zippers
Geriatric Education Center of Greater Philadelphia
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Final Case Scenario
•
•
Ms. Hill has rheumatoid
arthritis with severe deformities
of her hands
She has difficulty with such
things as door knobs and
buttons on her clothes
Mrs. Hill
Geriatric Education Center of Greater Philadelphia
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Learning Objectives
Review
Can you now:





List the common causes of urinary
incontinence (UI)
Describe the potentially serious effects of
not treating UI
Recognize signs of a urinary tract infection
Discuss effective ways to prevent or reduce
episodes of UI
List ways to enhance the dignity of those in
your care
Geriatric Education Center of Greater Philadelphia
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Special Thanks To:
Christine Bradway, PhD, CRNP,
FAAN
Associate Professor of
Gerontologic Nursing
University of Pennsylvania
School of Nursing
Mary Ann Forciea, MD
Clinical Associate Professor of Medicine
Director, Primary Care Services
University of Pennsylvania Health Systems
Nicole Mangino
Illustrator
Geriatric Education Center of Greater Philadelphia
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References and Resources
• American Medical Directors Association. (2012). Urinary
Incontinence in the Long Term Care Setting Clinical Practice
Guideline. Columbia, MD: AMDA.
• DuBeau, C.E., Kuchel, G.A., Johnson.T., Palmer, M.H.,
Wagg, A. Incontinence in the frail elderly. In Abrams, P,
Cardozo, L, Khoury, S, Wein, A. (2009). 4th International
Consultation on Incontinence. Health Publication Ltd. 9631024.
•DuBeau CE, Simon SE, Morris JN. The effect of urinary
incontinence on quality of life in older nursing home
residents. J Am Geriatr Soc 2006;54:1325-33.
•Fink HA, Taylor BC, Tacklind JW, Rutks IR, Wilt TJ.
Treatment interventions in nursing home residents with
urinary incontinence: a systematic review of randomized
trials. Mayo Clin Proc 2008;83:1332-43
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References and Resources
•
Genao, L. & Buhr, G.T. Urinary tract infections in
older adults residing in long-term care facilities.
Annals of Long-Term Care: Clinical Care and Aging.
2012;20(4):33-38.
•
Hagglund, D. (2010). A systematic literature review of
incontinence care for persons with dementia: the
research evidence. Journal of Clinical Nursing.
2010;19,303-312.
•
Kraus SR. Bavendam T. Brake T. Griebling TL.
Vulnerable elderly patients and overactive bladder
syndrome. Drugs & Aging. 2010; 27(9):697-713.
Geriatric Education Center of Greater Philadelphia
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References and Resources
•
Landefeld CS, Bowers BJ, Feld AD, et al. National
Institutes of Health state-of-the-science conference
statement: prevention of fecal and urinary incontinence in
adults. Ann Intern Med 2008;148:449-58.
•
Lee, S.Y., Phanumus D. & Fields S.D. Urinary
incontinence: a primary care guide to managing acute and
chronic symptoms in older adults. Geriatrics 2000; 55(11):
65-72.
Matthews, S.J. & Lancaster, J.W. Urinary tract infections
in the elderly population. The American Journal of
Geriatric Pharmacotherapy 2011; 9: 286-309.
•
•
Newman, D.K., & Wein, A.J. Managing and treating
urinary incontinence. 2nd ed. 2009; Baltimore, MD:
Health Professions Press.
Geriatric Education Center of Greater Philadelphia
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References and Resources
•
Offermans, MP, Du Moulin MF, Hamers JP, Dassen T,
Halfens RJ. Prevalence of urinary incontinence and
associated risk factors in nursing home residents: a
systematic review. Neurourol Urodyn 2009;28:288-94.
•
Saliba D, Solomon D. Rubenstein L. Young R. Schnelle J.
Roth C. Wenger N. Feasibility of quality indicators for the
management of geriatric syndromes in nursing home
residents. Journal of the American Medical Directors
Association 2005; 6(3 Suppl):S50-9, 2005.
Geriatric Education Center of Greater Philadelphia
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References and Resources
Web sites:
Collaborative to Support Urinary Incontinence and
Women’s Health www.stressUI.org
National Association for Continence: www.nafc.org
Australian Government Department of Health and Aging
http://www.bladderbowel.gov.au/all/bladderproblem
s.htm
National Kidney and Urologic Diseases Information
Clearing House
http://kidney.niddk.nih.gov/index.aspx
Geriatric Education Center of Greater Philadelphia