In previously continent adults, aged 70 or older, use of urinary catheters or diapers while in hospital increases the risk of new urinary incontinence
- Correspondence to Ella McLafferty
School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee DD1 4JH, UK;
Implications for nursing practice of this research
■ The rationale for the use of all continence containment products should be documented in the nursing notes.
■ The use of reliable and valid urinary continence assessment measures are crucial in the identification of risk factors predisposing to the development of urinary incontinence in older people.
■ Implementing urinary continence promotion strategies to prevent the development of new onset urinary incontinence (UI) in hospitalised older people should be incorporated into nursing practice.
Implications for nursing research in light of this study
■ There is a need for further exploration of the reasons for the continued use of containment products in hospitalised older people.
■ Further research into the triggers that predispose UI in older people while in hospital is required.
■ There is a need for continued exploration of urinary continence promotion strategies that will prevent the development of UI in hospitalised older people.
The focus of this study is on whether the introduction of incontinence aids in hospitalised older people is associated with the development of new UI. Zisberg et al state in the introduction that between 10% and 21% of older people will develop new UI while in hospital. They also identify that urinary catheters and incontinence pads may be overused or used inappropriately. The authors state that the relationship between the introduction of incontinence pads and urinary catheters in previously continent adults and new UI has not been tested before.
The purpose of this study was to assess whether the development of new UI in older people occurred when they were using incontinence pads, urinary catheters or were independently toileting. Participants (n=325) from five medical wards in a teaching hospital in Israel were eligible for inclusion in the study. Patients were interviewed within 48 h of admission. Up to two follow-up interviews were conducted, but there is no indication when they took place. The Barthel index evaluated the level of dependence or independence. Data were collected relating to patient demographics, age, illness severity and living conditions, as well as the reasons recorded in the patient's notes for urinary catheterization. Urinary continence was assessed by the following question: ‘Did you have any trouble controlling your bladder; do you lose urine when you do not want to?’ There is no indication that this question was tested for comprehension among older people. Use of continence aids and UI were assessed according to the participants' report during each interview.
Data were analysed to identify differences between containment products and new UI status. Evidence of known risk factors was assessed to determine whether they were related to continence status during hospitalisation. Multivariate logistic regressions were made to examine the association between the use of incontinence aids versus self-toileting and new UI.
Of 352 participants, 60 (17%) developed UI during their hospital stay. The participants most likely to develop UI included those who were 2 years older, had lower cognitive status, higher illness severity score, had a 2 day longer median stay and higher rates of dependency in their activities of daily living at baseline. A total of 26 patients out of 267 participants who toileted independently developed new UI. Twenty-one participants out of 58 participants wearing incontinence pads developed new UI, and 13 participants from 27 with urinary catheters developed new UI.
The strength of this study lays in the fact that Zisberg et al identified the numbers of hospitalised older people who developed new onset UI and whether they were using containment aids or self-toileting. The numbers of older people developing UI in this study reflect current research. They also identified that medical or nursing notes do not always record a rationale for the insertion of urinary catheters. However, what is interesting about the findings is that, of 58 patients who were wearing pads, only 21 patients developed new UI. This study would have been strengthened if data were collected from nursing staff about why patients were given pads if they were continent. Once patients start using pads, it is very difficult to withdraw them again as they feel a sense of security when they are wearing them. They may also request pads due to the fear of UI. Reasons for only 12 cases out of the 27 urinary catheterisations were recorded in the notes. Consequently, we do not know why the other patients were catheterised. Studies have identified that urinary catheters are overused or used for convenience of the nursing staff rather than necessity.1
The authors acknowledge that no information was collected about the nature and severity of new onset UI for older people. However, in the acute ward settings, older people can be labelled as having UI after one episode of urine loss.2 Objective data to confirm whether patients were continent of urine on admission to hospital would have added to the rigour of the study. Many older people are adept at managing their UI without help as they are aware of the stigma of being unable to control body functions. They also fear the reactions of others, including health professionals.3 In addition to investigating the use of continence aids to contain the UI, tools are required to aid nurses to identify risk factors that predispose toward UI. The development of relevant continence promotion strategies is vital to reduce the burden of UI for older people.