Elder Incontinence and Mobility Assistance by Catherine D'Ambrosio, RN, PhD

dambrosi@uw.edu

As the lead family caregiver, one responsibility you have is to determine the precise and immediate cognitive and mobility assistance required by your elder. This blog entry discusses the mobility assistance determination.

Physically Helping Your Elder To and From the Toilet

Many elders require mobility assistance getting to and from the toilet.  Sometimes the help they need is entirely within the physical capabilities of available family caregivers.  Other times the elder's mobility needs are more intense than what can be managed by family caregivers who are immediately available.  And sometimes no one is reliably available to assist the elder with getting to and from the toilet, bed, and chair.

When assisting an elder with other activities of daily living (such as eating, bathing, grooming and dressing), any necessary assistance can generally be confined to specific times of the day, -and even scheduled on particular days.

Providing toileting assistance cannot however be reliably scheduled, appointed, or otherwise confined to particular times of day.  Toileting needs are generally unpredictable.  The urge to use the toilet can emerge suddenly and without warning virtually any time of the day or night.

The uncompromising urge to use the toilet can compel your elder to hasten their pace and increase their likelihood of falling -thereby sustaining injuries that can represent certain doom.  Some elders can never recover the function lost in a simple injury such as tripping over a throw rug while hurrying to the toilet. Ultimately when an elder's ability to manage their toileting needs is compromised, so is their ability to remain in their own home.

This blog entry is designed to improve your awareness of your elder's immediate mobility needs and provides some guidelines for adapting their home and your care to improve their safety.

Using a form of Prompted Voiding* a behavioral modification technique (reference Schnelle, Ouslander, Hu) where toileting is offered either hourly or every two hours can improve your elder’s continence and reduce the number of unexpected interruptions in a caregiver's day.  Please see my blog entry entitled Preventing Incontinent Episodes and Keeping Your Hands Clean for detailed description of the prompted voiding technique and the blog entry entitled Adapting the Prompted Voiding Technique to Your Elder's Needs and Your Capabilities for adapting the prompted voiding technique to your elder's immediate needs.

Some of the guidelines may seem obvious, but in my 20 years of experience consulting with elders and their family caregivers, it is often the most obvious issues that are ignored and become problematic.

Providing optimal mobility assistance to a frail elder is not an intuitive process for all family caregivers.  Many family caregivers are overwhelmed when confronted with decisions regarding how to best assist their elder to the toilet.

 

A.   First, in order to provide your elder with safe and effective mobility assistance to and from the toilet, you need to figure-out two things:

1. What kind of mobility assistance does your elder require?  I have classified mobility assistance into 5 groups:
1. Independent (no physical assistance required)
2. stand-by assistance (not actually touching the elder while in transit, but remaining within arm’s reach of the elder)
3. balance assistance (in constant physical contact with elder, but not bearing any of their weight)
4. weight-bearing assistance (bearing some of the elder’s weight –not lifting)
5. mechanical lift (using a mechanical lift is often appropriate under the following circumstances:
1. the elder is not capable of bearing any of their own weight, or
2. the elder’s weight-bearing need exceeds the weight-bearing capacity of available caregivers).  Within this group there is wide variation ranging (for example) from a 90 pound elder with a 25% (22.5 pound) weight-bearing need whose family caregiver is a 100 pound elder with arthritis, degenerative joint disease, and cardiomyopathy to a 400 pound elder who has a 50% (~200 pound) weight-bearing need and has three caregivers available to assist with transfers.

 

2. Intensity of assistance:  How many people are necessary to provide this mobility assistance (can range between 0 and 3 persons).  (Please note:  I have yet to meet anyone who has three people who are constantly ready, willing and able to help them to the toilet.)

Determining the precise technique most appropriate and intensity required to safely assist your elder to and from the toilet can be a complex process.  I cannot see you or your elder, so I cannot determine or otherwise tell you precisely what would be the most appropriate type or intensity of assistance.

The type (independent, stand-by assist, balance assist, weight-bearing assist, or mechanical lift) and intensity of assistance (ranging between 0 and 3 people), although generally consistent for a particular elder, is often not static.  Sometimes the type or intensity of assistance required will vary depending on the time of day.  Fatigue (for example) often intensifies the assistance necessary. 

Many things can alter or change your elder’s mobility assistance needs, including:

Ø  A health incident (ranging from a cold or flu to a stroke or a heart attack)

Ø  Balance

Ø  Mobility

Ø  Flexibility

Ø  the presence of pain

Ø  medications

Ø  many others besides

Therefore, consulting with a registered nurse who specializes in Gerontological Nursing, elder rehabilitation and mobility assistance can be a worthwhile investment.  Such a nursing care consultation will not alter your elder's ongoing needs.  What a nursing care consultation *can* do is serve to improve the accuracy, efficiency and effectiveness of the ongoing care you provide to your elder.

Because many people cannot afford or access a nursing care consultation, I want to help you figure-out what kind of help your elder may need.  Ask yourself and your elder the following questions, then observe your elder’s movement in the following circumstances:

Ø  How does your elder currently get themselves from one place to another? 

Ø  Does your elder use a cane, a walker, a wheelchair, or other mobility assistance device to move about in their home?

Ø  If your elder uses a walker or a wheelchair, does it easily fit all along the paths your elder takes from one location to another?

Ø  Is your elder certain of how to use their current mobility assistance device?  (Proper use of a mobility assistance device –while not terribly complicated, is not generally intuitive either.  Improper use of mobility assistance device can easily result in devastating injuries.  It is important to seek and obtain information on the proper methods of using your current mechanical assist device.)

Ø  Can your elder go from a lying to a sitting position without any help from anyone?

Ø  Can your elder swivel their legs off the bed without any help from anyone?

Ø  Can your elder go from a sitting to a standing position without any help from anyone?

Ø  Can your elder pivot (turn-around) without any help from anyone?

Ø  Can your elder go from a standing to a sitting position without falling and without any help from anyone?

Ø  Can your elder get into and out of their bed without needing help from anyone?

Ø  Can your elder get on and off the toilet without needing help from anyone?

Ø  Can your elder effectively wipe themselves after toileting without help?

 

B.   Next (second),you need to determine whether (or not) the required number of people necessary to provide mobility assistance to your elder are:

1. reliably available
2. physically capable of providing the required assistance
3. actually *willing* to assist the elder with their toileting needs.

So if your elder is completely alone every day and night and is unable to get themselves out of bed, to the chair or to the toilet without the assistance of another person, then perhaps it is time to consider relocating your elder to your home, another family member's home, having a family member move-in with the elder to assist them with toileting, or relocating your elder to a nursing care facility.

 

C.   Next, assess the path your elder most commonly takes to and from the toilet.  Take a careful look at your elder's most common locations including their bed, their kitchen chair, their favorite living room chair or sofa, their favorite spot on the front porch, et cetera and the path your elder most commonly takes between their favorite or most common locations.  Ask yourself the following questions:

Ø  Does any of the furniture need to be moved?

Ø  Can any of the furniture be moved or rearranged? 

Ø  Are there sturdy grab-bars directly adjacent to your elder’s bed, toilet, kitchen chair, and living room chair?

Ø  Has your elder recently suffered a fall or other injury while moving from one location (i.e., bed, chair, toilet) to another?

Ø  Are you concerned that your elder is likely to fall or sustain an injury while moving-about?

Ø  Has your elder’s mobility (their ability to move about in their house) changed recently?

 

 

D.   Fourth, modify the path your elder most commonly takes to and from the toilet.  Take a careful look at your elder's most common locations including their bed, their kitchen chair, their favorite living room chair or sofa, their favorite spot on the front porch, etc.

 

Consider the appropriateness of the following:

1. Obtaining a bedside commode and place it in a convenient location near your elder's bed.  Keep in mind that the bedside commode will need to be emptied and cleaned at least daily -without fail.  It is also a good idea to keep toilet paper near the commode.

 

2. Install an adaptation on the toilet with arm rests and an elevated seat.  Make sure any adaptations are secure and cannot be pulled from the wall.

 

3. Install hand-grip bars on the walls adjacent to favored sitting places and along the walls leading to and from the toilet.

 

4. Remove ALL throw rugs and clutter along the paths between the bed, favorite sitting places, and the toilet.

 

5. Consult with nursing, physical and occupational therapists (as access dictates) to determine whether your elder needs, or would otherwise benefit from a mobility assistance device such as a cane or a walker.

Insurance coverage of these modifications and appliances will vary.  Unfortunately insurance coverage is based primarily upon allopathically (MD) diagnosed conditions -rather than upon your elder's precise nursing care needs.  There is some variability among insurance plans but often coverage is dependent upon the temerity and tenacity of the elder's advocate.

Nursing care consultations are not generally covered by insurers. 

Ongoing, chronic (sometimes called custodial) nursing care -is generally NOT covered by Medicare or other insurers. 

Medicaid does cover chronic long-term nursing care –but only after the elder has been legally declared financially indigent.  Please see my blog on Costs of Long-Term Care.

If your elder:

• cannot reliably and independently balance or bear all of their own weight -with or without a mechanical assist device (such as a cane or a walker), OR
• does not have constant and continuous access to sufficient numbers of family caregivers who are willing, able, and immediately available to provide toileting assistance, OR
• the financial means to pay for private duty nursing care,

then your elder's ability to remain alone in their own home is in immediate jeopardy.  Please see my blog on Incontinence -When is it time to consider nursing home placement? 

Posted at 15:53 in Elder Incontinence, Family Caregiving | Permalink

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