Elder Incontinence

VIII. When is it time to consider nursing home placement? (3. selecting a facility) by C. D'Ambrosio, RN, PhD

Selecting a Long-Term Skilled Nursing Care Facility for your Elder

by Catherine D'Ambrosio, RN, PhD  dambrosi@uw.edu 

Choosing a nursing care facility that meets your needs, requirements, expectations, preferences and budget will require some research, some planning and some soul searching.  Having knowledge of your elder's actual financial assets will be essential to making some of the decisions.  Many elders wish to keep their finances private and return only vague, obtuse answers about their finances, such as "We have plenty of money dear." (which might they have assets amounting to $200 to $300), or "I don't know how I am going to afford anything." (with a financial portfolio worth tens of millions of dollars).   Most people fall somewhere in the middle.

I've organized this set of blogs (on nursing home placement decisions) around three questions most often asked of me by elders and their family caregivers who are considering relocation to a nursing care facility.

This entry addresses the third (III) question of how do we select the very best nursing care facility for our elder?  Questions I and II are addressed in separate blog entries (but are listed below along with their links).

I.              What are some of the signs that it may be time to being exploring nursing home placement?

II.            How much do nursing homes cost and who pays for nursing home care?

III.           We only have so much money, so how do we select the best nursing care facility for our elder?

1.    Location of the facility

2.    Cost of the facility

3.    Smell

4.    Ignore the décor, the chef, and any gourmet menu –until after you consider NURSING STAFFING RATIOS, and speak with a number of people.

5.    Nursing Staffing Ratios

6.    Interview the Nursing Staff

7.    Look around you and take note of whether elders are tied-up or restrained.  Ask the tour guide and the nurses about the facility’s policy on restraints.

8.    Talk to the Patients in the Facility

9.    Talk to Family Members of Patients in the Facility

10. Ask yourself some questions about your elder’s current condition

11. Some things I would like for you to know

 

This blog entry addresses the third question of:

III.  We only have so much money, so how do we select the best nursing care facility for our elder?

Choosing a nursing care facility that meets your needs, requirements, expectations, preferences and budget will require some research, some planning and even some soul searching. 

1.   Location of the Facility

The locations most ideal are near or easily accessed by family caregivers, friends, and relatives.  Elders who are well-tended by out-spoken advocates can sometimes be less vulnerable to neglect than elders who receive no or infrequent visitors and without an advocate.

Like real estate, there is location, location, and location to be considered.  Sometimes it is not enough to consider the city or town, but the neighborhood, and the location (such as a busy corner, a secluded park, or a river bank) within the neighborhood.

 

2.   Cost

You must consider how much your elder can afford to pay, and how much they are willing to allocate to their care in the nursing facility. 

Having knowledge of your elder's actual financial assets will be essential to making some of the decisions.  Many elders wish to keep their finances private and return only vague, obtuse answers about their finances, such as:

·         "We have plenty of money, dear." (which might mean they have assets amounting to $200 to $300), or

·         "I don't know how I am going to afford anything." (with a financial portfolio worth tens of millions of dollars).

·         I have worked with plenty of people at both ends of the spectrum and contorted perceptions.  Most people fall somewhere in the middle.

Knowing if and precisely how much any family, relatives or friends are willing to contribute to funding the elder’s long-term care will also need to be factored-in on the decision.

 

3.   Smell

The very first thing people notice when they enter a facility is the smell.  People are immediately turned-off by the overwhelming odor of urine and feces.  Any odor you once smell is unlikely to alter or diminish over time.  Your sensitivity to and awareness of this odor will however become less acute.

4.   Ignore the Décor

While sumptuous lobby décor and a gourmet chef and menu are doubtless appealing, even enticing, they are not the reason you are there.  Please try to ignore the décor in your initial assessment.  After you consider and make a decision based on #5 (below), then factor-in the lobby décor and the gourmet menu with the location, the cost, and the smell.

 

5.   Nursing Care Staffing Ratios

Ask to see the facility’s actual patient care nursing staffing ratios for both the facility and for the unit where your elder would be placed. 

A.   This is not the number of RN’s, LPN’s and CNA's employed by the facility, divided by the number of patients, because

                                              i.        Many nurses and nursing assistants work part-time.

                                            ii.        Many nurses and nursing assistants work per diem (on-call).

                                           iii.        Nurses do not work 24/7.  They work approximately 40 hours per week, and they take vacations and sometimes get ill and take sick days.

                                           iv.        Many of the RNs employed by nursing homes perform management, staffing, planning, marketing, and administrative functions, and do not provide patient care.

                                            v.        Facilities often employ many RNs are to do only paperwork, to fill-out Medicare, Medicaid and insurance forms necessary for reimbursement, often on patients they have never taken care of

 

B.   Look at the facility’s actual –not their planned or optimal staffing ratios. 

                                              i.        What are the patient care staffing ratios today? (remembering to subtract the number of nurses and nursing assistants who did not show-up today.

                                            ii.        What were the patient care staffing ratios yesterday?

                                           iii.        What were the staffing ratios last week, last month, and last year?

                                           iv.        Fill-out the chart (below) for each shift (days, evenings and nights).  Expect that day shift staffing ratios will be higher than evenings, and evening staffing ratios higher than night shift staffing ratios.  Weekend staffing ratios are often lower than weekday staffing ratios.

 

C.   Make sure you know and understand the facility staffing ratios and how that breaks-out for each unit on each shift, including weekends and holidays.  Some units such as Medicare Skilled Nursing and Rehabilitation units often have higher staffing ratios than other units that are not mandated to comply with Medicare’s more stringent requirements. 

 

D.   Awards are interesting but sometimes of little or no consequence.  All too often awards for “Best Nursing Home in the World” or whatever, are meaningless marketing tools. 

 

E.   In addition to focusing on the patient care staffing ratios, inquire and request specific information about the degrees and certifications of the registered nursing staff, and training seminars attended by the nursing assistants.  Ask questions including:

                              i.                How many Master’s prepared nurses are on-staff at this facility? 

                            ii.                How many Master’s of nursing consult with the facility?  When?  How often?  What do they do?  What training education and training seminars do they provide to the nursing staff?

                           iii.                How many patient care nurses employed by the facility have bachelor’s degrees in nursing (BSN)?

                           iv.                How many nurses in the facility have a wound, ostomy, or continence care certification?  How often do they provide inservices (training seminars) to the other nurses and the LPNs and nursing assistants?

                            v.                How many nurses in the facility have other certifications –such as Gerontological nursing?

                           vi.                How often are nursing assistants required to attend education and training seminars on provision of basic nursing care? 

                          vii.                What types of training seminars are offered to the facility’s nursing assistants?  -or are basic nursing care seminars even offered at the facility?

 

6.   Interview the patient care RNs, LPNs, and nursing assistants

Optimally –if you can, take the opportunity to speak to the nurses and nursing assistants individually -away from the marketing director or facility tour guide. 

Or, if you have a friend, neighbor or relative who is residing in this particular facility, visit them and talk to the nurses and nursing assistants who come to your friend’s or relative’s room to care for them. 

If you are a gregarious or more sociable soul, offer to meet and host a nurse for coffee in the cafeteria or a local coffee shop. 

When you speak with the nurses and nursing assistants, ask them:

A.   How many patients do you have today?

 

B.   If you are speaking with an RN, ask:

 

                              i.        How many LPNs (licensed practical nurses) and CNAs (certified nursing assistants) do you have assigned to you?

                            ii.        What do your duties include?

                           iii.        Do you provide any direct patient care?

                           iv.        What is the most number of patients you’ve ever been assigned in this facility?  How often does this happen (being assigned so many patients)?

                            v.        What is the least number of patients you’ve ever been assigned in this facility?  How often does this happen?

                           vi.        How many patients do you think would be optimal –for you to care for at one time?

Compare the RN’s optimal numbers with the actual number of patients she’s caring for.  How substantial is the difference?

C.   If it is an LPN you are speaking with, ask:

                              i.        How many CNAs do you have assigned to you?

                            ii.        What do your duties include?

                           iii.        What is the most number of patients you’ve ever been assigned in this facility?  How often does this happen (being assigned so many patients)?

                           iv.        What is the least number of patients you’ve ever been assigned in this facility?

                            v.        How many patients do you think would be optimal –for you to care for at one time?

                           vi.        Compare the actual numbers with the stated optimal numbers.

 

D.   If you are speaking with a CNA, ask:

                              i.        How many of your (X –number of patients) are physically and cognitively independent?  (expect this number to be none to exceedingly few in a skilled nursing care facility)

                            ii.        How many of your patients are in a completely dependent or a vegetative state?  (hopefully this number is as low as the independent number, with most of the patients ranging somewhere between these two extremes)

                           iii.        What do your duties include?

                           iv.        How many of your (X –number of patients) required the assistance of more than one nursing assistant?

                            v.        What is the most number of patients you’ve ever been assigned in this facility?  How often does this happen (being assigned so many patients)?

                           vi.        What is the least number of patients you’ve ever been assigned in this facility?  How often does this happen?

                         vii.        How many patients do you think would be optimal –for you to care for at one time?

Ø  Compare the CNA’s optimal numbers with the actual number of patients for whom she is currently providing care.  How substantial is the difference?

Recommendations for interviewing nursing home staff 

Highlight and print several copies of the questions listed below.  Take them with you to the nursing home and fill them out as you speak with each nurse and nursing assistant.  

Fill-out a separate form for each person you speak with.  

Compare what the marketing director says about the nursing staffing ratios (the number of patients assigned to each nurse or nursing assistant) with the numbers the nurses and nursing assistants give you.

 

Date __________  Time of day:  ________________

 

Name of Facility: __________________________________________

 

Name & Title of the person you’re speaking to:  ___________________

 

Location in the facility:  ___________________________________

------------------------------------------------------------------------------------------------

 

1.     How many patients are you assigned to take care of today?_______

 

2.     Can you please tell me what is a normal or average assignment (how many patients each) for RN’s, LPN’s, and Nursing Assistants here (in this facility)?:

Weekday	Day Shift	Evening Shift	Night Shift
RN’s
LPN’s
Nursing Assistants

 

Weekend	Day Shift	Evening Shift	Night Shift
RN’s
LPN’s
Nursing Assistants

 

3.    What is the worst staffing ratio you’ve ever seen here?

Worst Time	Day Shift	Evening Shift	Night Shift
RN’s
LPN’s
Nursing Assistants

 

How did this happen? (i.e., a blizzard or a hurricane) ___________

 

How often do these sorts of (worst) staffing ratios happen (in your experience)? 

E.   TOILETING

Ask any of the RNs, LPNs or CNAs the following questions.  They should know the answers.  More than half of all patients or residents in skilled nursing care facilities suffer from incontinence.

                                    i.    How many of your patients toilet themselves independently?

                                  ii.    How many of your patients require cognitive prompts to toilet themselves?

                                 iii.    How many of your patients require physical assistance to toilet themselves?

                                 iv.    How many of your patients are completely incontinent, diapered and dependent on the nursing assistants for diaper changes?

·         How often are diapered and incontinent patients cleaned and changed?

                                  v.    How many of your patients require the physical assistance of more than one person to toilet themselves?

                                 vi.    How many of your (X number of) patients receive *Prompted Voiding?

                                vii.    Can you please tell me about how you provide *prompted voiding*, and how often?  Please note the following:

·         Providing prompted voiding every hour (while awake) is optimal, but every two hours while awake is also effective and quite acceptable;

·         Providing prompted voiding to support the existing toileting capabilities takes three times as long as diapering the elder in a dependent position.

·         Special training on provision of prompted voiding is required.  Prompted voiding is not terribly complicated, but it is not intuitive either.

·         Be mindful of what is within the realm of physical possibility and the time constraints of caring for multiple patients.

                              viii.     Do you provide *prompted voiding* to patients who require more than one nursing assistant to physically assist them to and from the toilet?

·         Be mindful that dedicating the time and expertise of more than one highly trained nursing assistant to support the toileting continence of one single patient is a very time-consuming, labor-itensive process, and thus very expensive to provide.

·         Do the math.  If the CNAs each have 8, 10, or 15 patients, they will not have the time to reliably provide *prompted voiding* to even one patient, much less more than one patient, or for patients who require the assistance of more than one nursing assistant.  This does not mean the nursing assistants don’t try or that they wouldn’t like to provide this intensive level of care, but they simply won’t have the time to dedicate so much time to the toileting continence of one single patient.

·         Compare the answers given by the different people you speak with.

·         Confrontation is not your purpose.

·         You are not there to prosecute the nurses and nursing assistants for doing their job the best they can, or for dealing with their assignment and the staffing ratios as they are.

·         You are asking these questions in order to gather information and decide whether placing your dear one in their care is a good idea.

                                 ix.    Have you attended any special conferences or training seminars on mobility assistance, cognitive prompting, and toileting care?

                                  x.    How often do you attend training seminars on toileting care?

 

* prompted voiding references:  Schnell, Ouslander, Hu

 

F.    Eating

                                    i.    How many of your patients feed themselves independently?

                                  ii.    How many require some assistance with eating, but are not entirely dependent?

                                 iii.    How many of your patients are entirely dependent in order to eat?

                                 iv.    Do you feed your patients who require assistance, or does your facility have a “feeding team”?

 

G.  Bathing, Grooming and Dressing

                                    i.    How many people do you have to (or have you given) a bath, or assisted with bathing today?

                                  ii.    If the nursing assistant answers zero, ask whether the facility employs bathing teams.

                                 iii.    How much time do you generally spend assisting each patient with their bathing (or showering), grooming, and dressing?

                                 iv.    How often are patients bathed or showered on your unit?

                                  v.    Do you get everyone up and dressed every day?

·         If not, why not?

·         Under what circumstances? (answers you might expect include when an elder:

Ø   is ill, or

Ø  recuperating from an illness and simply too weak, or

Ø  requests to remain in bed, or

Ø  refuses to get out of bed.)

                                 vi.    How many of your patients move-about independently –with or without any mechanical assist devices (such as a cane or a walker)?

                                vii.    How many of your patients require two or more people to transfer and assist them from one place to another (i.e., from the bed to the chair, from the chair to the toilet)?

                              viii.    How many of your patients require the use of a mechanical lift to transfer them from one place to another?

 

7.   Look around you and take note:

A.  Are any of the patients tied to their beds?  (you might notice straps hanging from the side of the bed)

B.  Are any of the patients tied to their chair or wheelchair?

C.  Are any of the patients restrained to their chair with a lap table secured to their chair?

D.  In total, how many patients do you see restrained?

E.  Ask the nurses and your tour guide about the facility’s policy towards restraints.

 

8.   Talk to the patients. 

    A.  How do they like the facility?

    B.  How do they feel about their nursing care?

    C.  It can be advantageous to already know someone –even distantly- -whom you can speak with and ask about the facility.  Sometimes however people want to say only good things about the facility for fear of casting themselves or the nurses –whom they maybe attached to- in a bad light.

 

9.    Talk to the Family Members of patients in the facility.  Ask them:

    A.  What do they think of the nursing care provided to their elder?

    B.  Do they feel the facility has worked to improve their elder’s health, function, and / or quality of life?

    C.  Do they regret having placed their elder in this facility?

 

10.       Ask yourself some questions about your elder’s current condition:

Ø How many people does it currently take to get your elder out of bed, and to and from:

Ø    the toilet?

Ø    the dining room or kitchen table?

Ø    the living room chair or sofa?

Ø    the rocker on the front porch?

 

Ø Know that if your elder requires assistance from more than one person for mobility, that your elder’s mobility will likely diminish after admission to the skilled nursing care facility –unless of course you are able to afford to place your elder into a uber luxury skilled nursing care facility with very high nursing staffing ratios.

 

11.       Some things I would like for you to know:

A.    Most elders who are physically and cognitively independent now live in retirement communities or Assisted Living Facilities where:

                              i.        They do not have to pay as much as skilled nursing facilities cost.

                            ii.        They do not have to share a bedroom and a bathroom with a virtual stranger whose habits (such as watching television 24/7, or frequently filling the room with their visitors).

B.   Odds are that in facilities with very low staffing ratios, a frail elder’s existing function (unless independent) will likely be allowed to deteriorate to a dependent state.

C.   Caring for a dependent elder is much easier to manage and less time-consuming than to care for and promote the highest level of function possible among elders who are struggling to maintain their function and independence –because such elders tend to move very slowly.

D.      Some States do not specify minimum nursing staffing ratios for non-Medicare funded beds.  This means that:

                             i.        each RN could potentially have as many as 90 patients –far too many to provide or even to competently supervise minimal nursing care.

                           ii.        Each LPN could potentially have as many as 50 patients to whom she is passing medications, far more than is safely or optimally handled.

                          iii.        Each CNA could potentially have as many as 15 patients.  Such an enormous number of patients is far too many for a single nursing assistant to provide even minimal care.

 

E.    Just because your elder is in a skilled nursing care facility does not render them invulnerable to neglect and its potentially devastating effects on their health, function, independence, and quality of life.

 

F.   Some skilled nursing facilities provide “assembly line” nursing care where, for example:

                              i.    One team of nursing assistants (sometimes) called “feeders” feed all elders who are dependent upon or require assistance from others for eating.  Elders are typically fed in the common dining room where the feeding team members often move from one patient to another.

                            ii.    Another team of nursing assistants (sometimes) called “showers” wear shower thongs on their feet and shower each patient in-turn.

                           iii.    Another team of nursing assistants (sometimes) called “beds” change all the bed linens in the facility.

                           iv.    The remaining nursing assistants take elders to and from the toilet, clean-up incontinent messes, and perform any other duties assigned such as taking and recording temperatures, blood pressures, heart rates and respiratory rates..

 

G.    Ask the facility director or marketing representative about what kind of nursing is practiced in the facility (i.e., team, assembly line, primary nursing, etc.).  Although primary nursing (where the same nurses and nursing assistants are assigned to particular elders) is an optimal ideal, it may be impractical –even logistically impossible in situations where staffing ratios cannot support it (primary nursing care). 

 

Team nursing and assembly line nursing, while typically never optimal, maybe the most efficient way (particularly in facilities with very low staffing ratios) to ensure each patient receives a bath, timely assistance with meals, and reliably toileted or diapered on a regular basis.

 

H.   There is not a cardinal right or wrong type of nursing (i.e., primary nursing, team nursing, or assembly line nursing) for a facility to practice.  What matters most is the level and quality of nursing care provided to the elders in the facility.  Having very low staffing ratios is not a crime.  It is simply less than optimal and as such, can in many circumstances, be reasonably expected to result in less than optimal outcomes for many of the recipients of the care.

 

Overview of this Blog on Family Caregiving and Incontinence by Catherine D'Ambrosio, RN, PhD

Family Caregiving and Incontinence -Blog Overview

by Catherine D'Ambrosio, RN, PhD         dambrosi@uw.edu 

It is important to note that incontinence is NOT a normal part of aging.  All incontinence needs to be evaluated by a qualified health practitioner.

Family caregivers provide the bulk of long term care to American elders.  The care required is becoming increasingly complex and the duration of time the care is needed is often indefinite, lasting a decade or more. Family caregivers must typically provide this (sometimes advanced and complex nursing) care to their elders without support or guidance from professional nurses.  Physicians -while accessible, are not typically brimming with help or support to guide your family caregiving efforts to support your elder's toileting continence.

Incontinence is the single biggest reason family caregivers decide to place their elder in an institution. Many family members want to avoid nursing home placement of their elder -at all costs. Many families cannot afford to place their elder in a nursing home and do not yet qualify for Medicaid.  Many other families cannot find an acceptable facility -one they would be willing to trust.  Still others cannot find an available bed in their (geographic) location.

I have been a registered nurse since 1983.  I have advanced degrees in nursing (Bachelor of Science in Nursing, Master of Science in Nursing, and a Doctorate of Philosophy (PhD) in Nursing).  This blog and its entries are dedicated to the needs of family caregivers who are confronting and dealing with the complex nursing care issues around incontinence in their elderly family member.  

This blog site will address 9 areas around incontinence care, including:

1. Detailed steps to preventing incontinence episodes through the use of a behavioral technique called "Prompted Voiding" (referencing: Schnelle, Ouslander, Hu, et al).
2. Specific ways you can individualize "Prompted Voiding" to your elder's individual needs and your specific capabilities.
3. Provides guidelines for identifying what kind of cognitive and mobility assistance your elder might require to support their toileting continence.
4. Safety Issues:  Provides tips for minimizing the probability your elder will fall on their way to the toilet or be rendered helpless or incommunicado if they do fall.
5. Steps you can take to minimize the impact of incontinent episodes on you, your elder, and the entire family.
6. Provides tips and guidelines for *Building a Family Caregiving Team* to help you provide the care your elder requires.  Caregiving can be an incredibly isolating experience.  The caregiver is vulnerable to neglecting their own needs and becoming disabled themselves, even dying.  Building a team of people to help you can be the key to your survival through this ordeal.
7. Strategies for addressing common interpersonal problems that often accompany incontinence, including:  frustration, anger, rage, violence (either to or from the elder), emotional abuse, neglect (of yourself or your elder -or both), social isolation, and depression.
8. Tips on knowing when it is time to consider institutionalization (nursing home placement) of your elder.  What are the signs and what are the factors you might want to consider.
9. I will also review what I see as the inevitable solution to the problem of incontinence care and family caregiving:  Personal Nursing Care Robots designed to assist elders to maintain the highest level of toileting function and independence possible -in the privacy of their own home, allowing elders to age with grace and dignity -without bankrupting themselves, their family, or future generations of tax payers.

Welcome to my blog!  I look forward to hearing your feedback about what you find helpful and areas where you disagree.  

Many thanks for stopping-by.  I wish you the very best of luck and love in providing care to your elder.  I sincerely hope the information in this blog is helpful to you!

Kind regards,

Catherine

We Need Elder Care Robots Now by Catherine D'Ambrosio, RN, PhD

We Need Elder Care Robots Now

by Catherine D'Ambrosio, RN, PhD       dambrosi@uw.edu 

The old man sits in his living room chair weeping bitter tears.  His pants are soiled with urine and feces, oozing through his clothes and into the upholstery.  His daughter will not arrive to help him out of his chair and filthy clothes until she gets off work, four hours from now.  The old man knows his daughter will be disgusted when she arrives.  She had plans to go out this evening.  Instead she will be helping him get showered, picking the clumps of feces from inside his clothes, doing laundry, and trying to scrub the excrement out of the upholstered chair.  It is already the third time this week.

Every day millions of elders are suffering in situations like this.  We can expect it to get worse as more of us are able to live through and despite illnesses, diseases and injuries, successfully surviving beyond our ability to independently care for ourselves.  Very few people can afford consistent access to decent, basic nursing care that helps them to maintain their function, mobility and toileting continence.  Fewer still are comfortable accepting help with toileting.  It is embarrassing and demoralizing to be dependent upon other people to help with this very private function.

Conversely, attending to another person's toileting needs as a primary and consistent responsibility is beneath most people.  Assisting elders to maintain toileting continence is messy, smelly, labor-intensive, repetitive, underappreciated, and ultimately unpredictable.  Even people desperately in need of a job can find that assisting other people with their toileting needs is degrading and demoralizing.  The caregivers -whether they are family members or paid caregivers are going to want and need to seek a higher function, to serve a higher purpose than tending to the toileting needs of another person.

Nearly half of all American elders over the age of 75 years require basic nursing care assistance with activities of daily living (eating, bathing, grooming, dressing, toileting and mobility).  Most elders cannot however afford to pay for this basic nursing care.  As a consequence elders are becoming ever more reliant upon family caregivers who themselves must then balance their work requirements, relationships, child-rearing responsibilities, social life and sleep with the need of their elderly family members.  As a result of these and many other factors, increasing numbers of elders are vulnerable to neglect of their basic nursing care needs -and the terrible consequences upon their health, function, independence, dignity and self-respect.

Unlike many other professions, no significant amount of automation has ever occurred to reduce the cost of or improve the efficiency of basic nursing care delivery.  This e-book:

1. describes the problems encountered by elders and their family caregivers who are trying to maintain continence in the privacy of their own homes, and 
2. explicates the inevitable solution:  Personal Nursing Care Robots.

Family Caregiving and Toileting Assistance: Answering Some Questions by Catherine D'Ambrosio, RN, PhD

Questions on Family Caregiving and Toileting Assistance

by Catherine D'Ambrosio, RN, PhD      dambrosi@uw.edu 

Supporting an elderly family member's toileting continence is a very important responsibility.  It is also however labor-intensive, time consuming, unpredictable, -and sometimes thankless, unpleasant, irritating, provocative, and even dangerous.  Maintaining continence is essential to your elder's self-esteem, pride, and dignity.  Preventing incontinence is also imperative to your elder's healthy, well-bing and their ability to stay in their own home.  Incontinence that cannot be self-managed is the single biggest reason for institutionalization (nursing home placement) of elders.

Is incontinence a normal part of aging?

No.  Although the risk of incontinence increases with advancing age, incontinence is NOT a normal part of the aging process.  Any incontinence should be evaluated by a qualified professional -optimally by a board-certified urologist- -prior to purchasing large quantities of incontinence undergarments.  Some people suffer from multiple forms of incontinence.  Some incontinence problems can be resolved with surgery.  Other types can be effectively treated or reduced in frequency and severity with daily medication.  Other types of incontinence can be effectively managed through the use of behavior modification.

What causes incontinence?

Many things can cause or precipitate incontinence (ranging from infection and dehydration to a prolapsed bladder, enlarged prostate, and detrusor (bladder) muscle instability).  Some medical and surgical treatments can resolve the incontinence entirely.  Other medical and surgical treatments can only lessen the severity of incontinence for some individuals under particular circumstances. 

Some types of incontinence are caused by mobility and / or cognitive impairments (problems).  Other types of incontinence are made worse by mobility and / or cognitive impairments.  Incontinence that is caused by -or made worse by cognitive or mobility impairments are called "functional incontinence".

So while your elder:

1. may have a normal bladder, or
2. may have had a bladder surgery to correct a problem that was causing incontinent episodes, or 
3. maybe getting medication that might lessen the severity of their incontinence, 

the incontinence may still be a problem.

WE HAD THE PROBLEM FIXED WITH SURGERY AND TREATED WITH MEDICATION EVERY DAY.  SO WHY IS MY ELDER STILL INCONTINENT?

Incontinence is often still a problem after surgery and despite being on incontinence medication because your elder may have "functional incontinence" (a nursing care issue) on top of their medically or surgically-treatable incontinence.

Functional incontinence is defined as incontinence caused by physical access or mobility problems, or cognitive impairments -such as stroke or dementia that prevent or impinge upon an individual's ability to get to the toilet and use it appropriately in a timely manner.  Functional incontinence can exist independently, worsen the effects of other forms of incontinence, or continue to persevere after other forms of incontinence have been effectively treated.

Being diagnosed with something like "detrusor muscle instability" and treated with incontinence medication, or having the prostate removed or prolapsed bladder repaired isn't going to affect your elder's ability to get up out of bed and safely get to the toilet.  Likewise, if your elder is confused -because for example, they are suffering from some form of dementia, the incontinence medication is not going to help your elder figure-out how to resolve the sensation of a full bladder.  The incontinence medication doesn't help your elder figure-out what steps they need to take when they feel the urge to urinate or have a bowel movement.

Once an elder requires routine assistance with toileting, they have only FOUR options for obtaining toileting assistance:

1. Obtain toileting assistance from family caregivers.
2. Hire and pay nursing assistants (out of pocket money) to provide toileting assistance.
3. Leave their home and enter an institution -such as a nursing home.
4. Suffer the deleterious (bad) effects of neglect.

Because most elders desire to remain in their own homes and cannot afford to pay for private duty care, by the time they need assistance with toileting, elders are entirely dependent upon their family caregivers. Family caregivers are often carrying many heavy loads and managing a wide range of responsibilities including:

1. raising their children,
2. managing work responsibilities,
3. maintaining spousal relationships,
4. managing their household, and
5. often tending to the needs of more than one elder
6. routinely spending time commuting between their obligations and responsibilities

Determining how best to help your elder to and from the toilet can be a very complicated process -but if it is done correctly- -can make life easier for all parties and postpone or even prevent your elder's need to ever be institutionalized.

There are two areas where your elder may need your assistance to maintain their functional toileting continence: Cognition and Mobility.  An elder's physical mobility needs and their cognitive prompting needs around toileting cannot necessarily be predicted by or from each other.  So while some elders require detailed cognitive prompting and minimal physical mobility assistance, other elders require minimal cognitive prompting and intensive physical mobility assistance to get to the toilet.  Other elders require both detailed cognitive prompting and intensive physical mobility assistance to get to the toilet.  The easiest elders to assist are often (but not always) elders who require minimal prompting and minimal physical mobility assistance.

Cognitive Assistance:

There is a wide range of cognitive assistance your elder may need in order to support and maintain their toileting continence.  Too little cognitive guidance can be confusing and frustrating for all parties.  Too much (cognitive guidance) can be labor-intensive and time-consuming for you (as the family caregiver), and irritating and even provocative for your elder.  

Determining the optimal level of cognitive support can be a tricky business and the amount can vary a bit depending on the time of day and other factors.  A substantial change in the amount of cognitive prompting required for a successful toileting episode can be an early indication of bigger problems (such as delirium) that need to be addressed. 

1. Some elders need only the question:  "Do you need to go to the toilet?" and require no further cognitive prompting.  They know exactly what needs to be done to get to the toilet.  They still may need physical assistance, but you won't need to narrate each step.
2. Some elders may need additional prompting after the initial question of "Do you need to go to the toilet?"  Such as:  

• "Stand-up." 
• "Walk this way."  
• "Step-up here."
• "Watch your step here."
• "Turn around."
• "Pull your pants down."
• "Pull your underwear down."
• "Sit-down."
• "Its OK to go now."
• "Are you finished?"
• "Wipe yourself"
• "Pull your pants-up", etc.

3.  Others require even more intensive prompting with continuous feedback and redirection.

Cognitive prompting can be the most challenging component of assisting the elder to the toilet, requiring time, kindness, patience,