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In a study conducted in 14 nursing homes, we collected independent data that showed that the only two currently used MDS incontinence quality indicators (QIs)-"prevalence of incontinence" and "prevalence of incontinence without a toileting plan"-do not reflect real differences in the quality of incontinence care provided to residents. None of the facilities, for example, evaluated residents' responsiveness to toileting assistance (see Step 2 for instructions on how to do this). Residents who received toileting assistance were comparatively less cognitively and physically impaired, which suggests that staff used invalid resident characteristics to determine who received services. Although facilities with better scores on both MDS incontinence QIs were more likely to document in medical records that residents received toileting assistance, there was no difference between homes in resident reports of the assistance they actually received. Across all facilities, participants capable of accurately reporting care activity said they received an average of 1.8 toileting assists per day (range 1.6-2.0), which is insufficient to improve urinary incontinence. There also were no differences in reports of received assistance between residents noted in the MDS as being on scheduled toileting and those who were not. This finding points to disturbing discrepancies between care documented and care actually provided.
The short answer is no. In the only study of its kind, we attempted a nighttime toileting assistance program with 61 incontinent nursing home residents. Wetness rates remained relatively high at night-49%--while appropriate toileting rates were low-18%. Ideally, wetness rates should drop below 20% and appropriate toileting rates should be above 66%. Even residents who responded well to daytime prompted voiding showed poor results at night. Prompted voiding is effective with most residents between 7am and 10pm. However, there are some residents who want to use the toilet during the night, and who can maintain dryness if given assistance.
Based on these findings, we recommend that nighttime incontinence care be individualized, with the goals of minimizing sleep disruption and protecting at-risk residents from skin problems (and falls related to independent toileting attempts). Prompted voiding and other toileting assistance interventions should be reserved for those residents who are bothered by nighttime incontinence and who demonstrate, through a two- or three-night trial, their willingness to toilet at night. (See Step 2 for procedures for conducting prompted voiding trials.)
In a related study, our research staff individualized nighttime incontinence care by conducting hourly rounds in four nursing homes and providing incontinence care only if participating residents were found awake during the round. Residents at low risk for skin problems were allowed to sleep for as many as four consecutive hourly checks, but were awakened on the fifth hourly check if still asleep. Residents at high risk for skin problems were allowed to sleep for only two consecutive hourly checks and awakened on the third hourly check if still asleep. There were no adverse, intervention-related changes in skin health or most other risk factors associated with skin. The intervention also proved no more labor intensive to provide than usual care.
We also recommend a noise and light abatement program to facilitate nighttime sleep. These programs feature common sense procedures such as closing doors to residents' rooms, fixing squeaky or otherwise noisy equipment (e.g., rolling carts), turning off unattended TVs and radios, not using overhead intercom systems for staff communication, and using table lamps instead of overhead lights when providing incontinence care
To find out, we surveyed three groups of respondents: frail older adults, family members of nursing home residents, and long-term-care nursing staff. Among all respondents, 85% "definitely" or "probably" preferred incontinence briefs, and 77% "definitely" or "probably" preferred prompted voiding to indwelling catheterization. There were, however, differences among the respondent groups. Nurses preferred prompted voiding to incontinence briefs more than did older adults or family members. Older adults, compared with family and nurse respondents, more strongly preferred medications to incontinence briefs. In open-ended responses, older adults (nine of them nursing home residents and 70 residential care residents) said they would choose a treatment based in part upon criteria of feeling dry, being natural, not causing embarrassment, being easy, and not resulting in dependence. The comments also indicated that older adults and families did not believe nursing home staff would provide prompted voiding often enough to improve continence (see Step 3 for time-saving strategies that help maintain prompted voiding programs). Because of the divergence of opinions among different proxy respondents, we recommend that, when possible, nursing home residents be asked first for their treatment preference.
No. Restricting fluids in an attempt to improve continence is potentially harmful to a resident's health. Studies show that the majority of nursing home residents are at high risk for dehydration, a condition associated with numerous adverse clinical outcomes for residents, including the ultimate: death (5).
Experts recommend that nursing home staff offer all residents extra fluids between meals, as many as 4-8 times a day (5). Incontinent residents may be more likely to drink more if they know they can count on help to the toilet. For this reason, we believe the start of a prompted voiding program is an ideal time to begin offering extra fluids to residents (see our introduction to this training module). Consider offering residents beverages to drink before or after assisting them to the toilet.
For more information about strategies to increase residents' fluid intake, visit our training module on weight loss prevention, especially the FAQs.
Possibly, but only if prompted voiding is combined with interventions that increase mobility/exercise and prompt residents to drink more. When this type of integrated intervention is implemented, there is evidence that there will be a major increase in how often residents have a bowel movement in the toilet and a decrease in the frequency of incontinent bowel movements. Our training module on mobility decline prevention describes such an intervention. Constipation, however, remains a problem. Other intervention components will likely have to be included in a comprehensive program to improve constipation. Improving food intake and controlling medications with constipative side effects are two treatments that should supplement prompted voiding