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Continence Strategies: Towards Independence in the Elderly. Karina So Clinical Nurse Consultant Urology / Continence Management Concord Hospital. Practical strategies. Curative therapy for mild SI Symptom management for SI & UI Containment for severe and permanent Urinary incontinence - PowerPoint PPT Presentation
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Continence Strategies: Towards Independence in the Elderly
Karina SoClinical Nurse Consultant
Urology / Continence ManagementConcord Hospital
Practical strategies
• Curative therapy for mild SI• Symptom management for SI & UI• Containment for severe and permanent
Urinary incontinence • Nocturnal incontinence• Risk management on IDC/SPC/CISCUrge incontinence is associated with a
modest increase in falls.Chiarelli et. Al.(2008) Urinary incontinence is associated with an increase in falls: a systematic review” Australia
Journal of Physiotherapy 55: 89-95
Common Continence Problems in the elderly population
• Stress incontinence (SI)
• Urge incontinence (UI)
• Mixed incontinence
• Overflow incontinence
• Functional incontinence
Drugs that can cause urinary incontinenceAgent Mechanism of Action Type of Incontinence
AntihypertensivePrazosin, Labetolol Sphincter relaxation
Stress Incontinence
Bladder relaxantAnticholinergics
Tricyclic Antidepressants
Promote incomplete emptying
Overflow
Incontinence
Bladder StimulantCaffeine, Cholinergics
Enhance detrusor instability
Urge Incontinence
SedativeAntihistamines,antidepressants antipsychotics,Tranquilisers, Hypnotics
Reduce awareness of bladder sensation
Urge incontinence
Miscellaneous Alcohol
loop diuretics
Lithium
Lower inhibition
Increase bladder filling, Polydipsia
Urge incontinence
Stress Incontinence (SI)• Mild SI - Curative therapy
– Pelvic Floor Muscle Exercises– Behavioural modification– Review medication(s)– Healthy diet & maintain healthy wt.– Regulate fluid intake & healthy bowel habit
Real-time Ultrasound Scan
• Patient can watch pelvic floor muscles contract and relax as you retrain them (visual feedback on performance).
• It is a tool to encourage compliance.
• It does not measure PFM strength.
Moderate SI
Symptom management– Mild SI care path– Intravaginal device – pessary ring,
tampon, Contiform device.– Selection of continence products
uridome
Symptom management SI
• Contiform!
• Penile clamp should be released every one to two hours to empty the bladder and prevent damage.
Severe and permanent SI
Supportive care/ Risk Management – Containment– Social continence– Prevent skin problems, UTIs, odour control– Government Continence Aids schemes
• PADP • CAAS/CAPS• DVA – gold card
Management of Urge Incontinence
• Regulate fluid intake:amount,type, time.• Bladder training strategies +/- medication• Clothing- reduce layers, zipper/belt• Medications – dose, time, route.• Healthy diet, healthy bowel.• Selection of appropriate continence aids• Assess eligibility for Government
schemes:PADP / CAAS/ DVA
Bladder Training therapyFor mild-moderate sensory and motor
urgency.
• Deferment strategies (take control)– Pelvic floor muscle contractions– Talk to your bladder– Tactile sensation/pressure– Distraction (think hard)
• Identify Optimal voiding time
• Frequency, volume & urgency diary
Drugs used to treat OABAnticholinergics/Antimuscurinic
• Propantheline (Pro-banthine 15 - 30mg q.i.d.)
• Oxybutynin (Ditropan 5mg up to q.i.d.)– Oxytrol transdermal patch (3.9mg twice a week)
• Tolterodine (Detrusitol 1 - 2mg b.i.d.)
• Darifenacin (Enablex)
• Solifenacin (Vesicare 5 – 10mg daily)
Nocturnal incontinence
Booster padPull up pants
Stricture therapy – patient specific
• Identify the optimal time for urethral dilatation before a reduction in urine flow.
• Select the size and type of firm catheter.
• Educate and support patient to perform regular self dilatation.
Coude tip firm nelaton catheter
Management of Acute Urinary Retention
• Decompress the bladder using 100% silicone catheter size 14/16
• Select the most appropriate drainage device – bag / valve
• Educate patient & carer on IDC care
Catheter size Balloon Size
12 FG
14 FG
16 FG
18 FG
20 FG
22 FG
24 FG
• 3 ml• 5 ml• 10 ml• 20 ml• 30 ml• 60 ml
Colour code
Catheter valve & leg bag
Management of Chronic Urinary Retention
• Prevent recurrent symptomatic UTI• Identify high risk cases for urosepsis and prepare
care plan– Use antibacterial soap for daily hygiene– If possible, high fluid intake > 2 litre/day– Prevent and correct constipation– Avoid trauma during catheter replacement procedure– Use catheter fixation device to avoid traction– Frequency of IDC or SPC replacement is individualised.– Periodic Urology review
Neurogenic bladder
CISC +/-
Anticholinergic
Medication
Queen Square Bladder Stimulator $75
Management of CISC• Reduce Symptomatic UTI –
assess CISC technique,
frequency of CISC, equipment care,
single use versus reusable catheter.
• Educate patient on monitoring of residual volume – bladder diary.
• Periodic urology review.
Class of laxatives/time to effect
Bulk forming agents Oral, 48-72 hrs.
Osmotic agents
(sorbitol, lactulose,glyerol)
Oral, 24-72 hrs.
Osmotic agents
(Macrogol or saline laxatives)
Oral, 0.5 – 3 hrs.
Stool softeners Oral, 24 -72 hrs.
Stimulant Oral, 6- 12 hrs.
Government Continence Aids Schemes
• NSW Health – Enable Health– PADP
• Federal Government Schemes – CAAS– CAPS from July 2010– DVA for veterans with gold card
PADP Transition to Enable Health
• Website: www.health.nsw.gov.au/health-public-affairs/factsheets
• One centralised body
• Office is based in Parramatta
• Transfer of PADP data in stages
Continence Aids Assistance Scheme (CAAS)
• CAAS is an Australian Government scheme offering assistance to eligible people who have permanent and severe incontinence.
• The scheme covers children aged 5 to 15 years, and adults over 64 years with permanent incontinence due to neurological conditions (Cat.A).
• The scheme also includes all causes of permanent incontinence, not just neurological causes, for those people who hold a pensioner concession card and their dependents (Cat.B).
• Website: www.intouchdirect.com.au
• The National Continence Helpline 1800 330 066
Continence Aids Payment Scheme (CAPS)
As of July 2010 …..• Clients can receive a one off payment of up
to $489.95 to purchase their own products.• Can nominate the payment goes to an
agency/ supplier.• CAPS payment is exempted as income.• Contact Medicare Australia Office for
information 132 011
Role of Medicare Australia
As of July 2010..• Respond to enquires about CAPS.• Receive and process CAPS applications.• Make payments directly into a CAPS client’s
nominated bank account or nominated provider’s account.
• Send statements regarding the payment to clients.
• Supply CAPS Application form
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