Continence management, including toilet assistance, is a major cause of caregiver burnout. Severe dementia and immobility are the factors most strongly associated with incontinence in seniors in long-term care.

An early assessment and diagnosis of incontinence could identify and correct incontinence in instances where it is reversible. Early assessment and diagnosis also allow prompt introduction of treatments, strategies and products to manage incontinence.

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Things You Should Know

• Incontinence is not an automatic part of aging
• Incontinence can be treated
• Incontinence can be the final burden that forces some informal caregivers to place their care recipient in long-term care

Clearing up misconceptions about incontinence

• Incontinence is not a disease. It is a symptom of other problems, such as weakened pelvic muscles, neurological disease, injury, impaired mobility, constipation and dehydration. Incontinence can also occur as a side effect of medication or surgery.
• Incontinence may result from some of the diseases and impairments that come with increasing age.
• Treatments and management strategies for incontinence may be successful, particularly with early assessment and diagnosis of incontinence. Depending on the reason for incontinence, it may even be reversible or cured.

Types, causes, and treatments of urinary incontinence in adults

There are four main types of urinary incontinence: urge incontinence, stress incontinence, overflow incontinence and functional incontinence. Mixed incontinence occurs when a person has two or more types of urinary incontinence.

Causes

• urinary tract infections
• changes in the bladder's ability to contract
• neurological disorders: stroke, Parkinson's Disease, brain tumours, multiple sclerosis, spinal cord injury.

Treatments

• behavioural treatments, such as bladder training/retraining, pelvic muscle exercises and biofeedback
• drugs

Stress Incontinence
Stress incontinence is the involuntary loss of small amounts of urine when a person sneezes, coughs, laughs, bends, lifts heavy objects, jogs or performs other physical activities that increase the pressure on the bladder. Stress incontinence occurs mostly in women. It is also present in about one third of all incontinent seniors.

Causes

• weakened support for the pelvic muscles
• weakness in the sphincter (the muscles that expand and contract to release urine through the urethra)

Overflow Incontinence
Overflow incontinence occurs when urine leaks frequently, even though the person feels no urge to urinate. Overflow incontinence accounts for about 10-15% of urinary incontinence.

Causes

• obstruction in the bladder
• medications
• vonstipation
• neurological disorders
• illness
• medical conditions, such as an enlarged prostate gland or a collapsed uterus
• surgery

Treatments

• drugs
• surgery
• dietary changes

Functional Incontinence
Functional incontinence is incontinence that is totally unrelated to the state of a person's urinary tract. This type of incontinence is usually diagnosed by excluding all other causes. Functional incontinence accounts for 25% of incontinence in the residents of long-term care institutions.

Causes

• severe loss of physical and cognitive function
• restricted mobility
• vision, hearing, speech loss
• inability to communicate

Treatments

• no specific treatment
• a variety of continence management aids and devices may have to be employed

Bladder and bowel control is dependent on having a properly functioning bladder, urethra, bowel and digestive system; a sound neurological system; efficient urine and stool production and elimination; and the desire and capability to go to the toilet alone or with personal assistance. A change in one or more of these factors could result in incontinence. Incontinence may also be caused or aggravated by medications, illness or environmental factors, such as the location of the bathroom.

• Sudden changes in bladder or bowel habits
  Sudden changes: increased frequency, increased urgency and pain may indicate transient or short-term incontinence. The incontinence may be a result of infection, especially urinary tract infections; injury, such as a hip fracture; surgery, particularly prostate surgery; chronic illness, such as diabetes and heart disease. Or it may be a bad reaction to medication.

• Persistent changes in bladder or bowel habits
  Straining to urinate, urinating in trickles and spurts, producing a weak stream of urine, not emptying the bladder completely and dribbling are symptoms of incontinence that may be caused by an obstruction in the bladder, medications, constipation and neurological disorders. "Accidents" or urine loss when a person laughs, coughs, sneezes or engages in physical activity may be related to pelvic or sphincter muscle weakness.

• Urine Retention
  Urine retention occurs when a large amount of urine stays in the bladder after a person has urinated. This build-up of urine can put a person at increased risk for urinary tract infections. Urine retention occurs in over half of all elderly people who have just had surgery for a fractured hip or stroke. It can also be a side effect of illness or medication.

• Excessive production of urine
  Diuretics: foods and medications that cause the body to shed water may increase a person's frequency and urgency to urinate and lead to incontinence.

  Caffeine: found in coffee, tea, cola, cocoa, beer, chocolate and soft drinks is a known diuretic.

  Several medications have a diuretic effect. Illnesses, such as diabetes and heart disease may cause people to urinate excessively or build up large amounts of urine in the bladder.

• Bladder or urinary tract infection/cystitis
  Irritation from a bladder or urinary tract infection can cause or aggravate incontinence.

• Constipation
  Constipation is a major cause of urinary incontinence in elderly people. A bowel filled with stool can block the flow of urine or cause urine to stay in the bladder. People with constipation may also exhibit bowel incontinence.

• Dehydration
  Dark, strong-smelling urine can be a sign of dehydration. If a person is not getting enough liquids (about six cups) daily, the urine may become so concentrated that it irritates the bladder and lays the groundwork for bladder or urinary tract infections. Signs of dehydration include having a dry mouth, cracked lips, or sunken eyes.

• Restricted mobility/physical disability/access
  Restricted mobility and immobility may make it difficult or impossible for people to control their bladder or bowels or get to the bathroom in time. Mobility restrictions caused by illnesses, such as arthritis or Parkinson's Disease can prevent people from undoing their own clothing. Poor eyesight, speech, hearing and other communication problems may affect a person's ability to seek help from a caregiver. The location or ease of access to the bathroom may hinder a person from using the toilet effectively.

• Cognitive impairment
  Confusion may occur as a side-effect of medication. Neurological disorders such as Parkinson's Disease, stroke, and spinal cord injury may affect the brain so that it does not give a person enough warning time to get to the toilet before the bladder or bowel is emptied. Brain tumours may affect people's ability to empty their bladder or bowels without help. People in the early stages of Alzheimer Disease and other dementia may forget where the bathroom is or how to use it. In the middle and later stages of dementia, people lose the interest and ability to look after themselves and forget how to urinate or move their bowels.

• may reduce the body's sensitivity to sensation, so that a person cannot sense a full bladder
• taking sedatives at night may result in bed wetting
• sedatives such as flurazepam and diazepam may build up in the bloodstream and cause confusion

• prescription drugs and over-the-counter drugs commonly taken for insomnia, itchy skin and dizziness may have side-effects that include urine retention, increased urine frequency and overflow incontinence

• may cause urine retention and overflow incontinence in men with enlarged prostate

• Can reduce contractions in the bladder and occasionally cause urine retention leading to overflow incontinence

Source: "Incontinence: Silent No More,"Seniors Info Exchange, Fall 1999, Vol. 8, No. 1, Health Canada

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