Evidence-based implementation practice to reduce urinary incontinence among older women
Author: Sunu Alice Cherian
Ageing is inevitable and comes with numerous changes and associated challenges. Urinary incontinence (UI) is one such challenge that affects millions of older women worldwide. Incontinence is a symptom, not a disease in itself, although it has a significant impact on a person’s life.
Understanding urinary incontinence
UI is the involuntary leakage of urine that leads to embarrassment, reduced participation in social functions, decreased quality of life, and increased healthcare costs due to allied complications. It increases with age and is also higher in women than men. Common causes include relaxation of pelvic musculature, disruption of cerebral and nervous system control, and disturbance of bladder musculature.
The prevalence of UI varies widely depending on the population studied, the definition used and the method of assessment. Population studies of older Indian women from different parts of India show a prevalence in the range of 14.8% to 43.1%. There is limited information available to determine whether the embarrassment of UI among Indian women is more than in other communities. However, it is thought to be a significant health problem in the Indian community and can lead to embarrassment and curtailment of daily and social activities.
There are health equity concerns caused by UI in relation to access to knowledge and education, lack of access to healthcare and cultural barriers to seeking help, insurance coverage, and embarrassment. Addressing these disparities and promoting greater access to education, healthcare, and culturally sensitive care for all women is important.
According to the North American Nursing Diagnosis Association International (NANDA-I), UI can take different forms:
- stress incontinence: loss of urine with increased abdominal pressure
- reflex incontinence: involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached
- urge incontinence: involuntary passage of urine soon after a strong urge to void
- functional incontinence: involuntary, unpredictable passage of urine
- total incontinence: continuous and unpredictable loss of urine.
Evidence-based management strategies
Evidence-based management strategies can help these women regain control over their lives, boost their self-esteem and improve their overall well-being. One of the most effective evidence-based management strategies for UI in older women is pelvic floor muscle training (PFMT) or Kegel exercises. The primary goal of PFMT is to strengthen the pelvic floor muscles, improve muscle tone, and enhance the ability to control urinary continence.
The National Institute of Health and Care Excellence (NICE) clinical guidelines recommend supervised PFMT for at least three months as first-line therapy for women with stress urinary incontinence (SUI) or mixed urinary incontinence (MUI), including older people. This approach involves at least eight contractions performed three times per day. The effectiveness of PFMT lies in its ability to:
- reduce frequency and severity: PFMT can significantly reduce the frequency and severity of UI episodes, allowing older women to regain control over their bladder
- improve quality of life: with fewer episodes of incontinence, women experience an improvement in their overall quality of life, which can lead to increased self-esteem and confidence
- reduce the need for other interventions: PFMT often eliminates the need for other interventions, such as medications or surgery, making it a non-invasive and cost-effective approach.
A best-practice implementation project on PFMT for UI, using the JBI evidence implementation framework, was conducted at a long-term care facility for older women in Kerala. The JBI implementation approach is grounded in the audit, feedback and reaudit process, along with a structured approach to the identification and management of barriers to compliance with recommended clinical practices.
Aligned with the audit criteria based on a JBI evidence summary for urinary incontinence in older adults: pelvic floor muscle training, the participants had to perform PFMT three times a day, three times a week, for three months. It included six criteria:
1. older women with SUI or MUI are prescribed PFMT as their initial treatment
2. PFMT performed under the supervision of an experienced therapist (a specially trained nurse)
3. home-based PFMT in addition to the supervised session
4. PFMT is performed three times per day
5. PFMT is performed at least three times per week
6. PFMT is performed for at least three months’ duration
A baseline and follow-up audit after three and six months were conducted. The baseline audit showed that PFMT was not practiced by any of the participants, hence there was no compliance with any of the six audit criteria.
The comparison of the baseline audit with the first follow-up (after three months) and second follow-up (after six months) showed 100% compliance in the first, second, third and sixth criteria. It showed a compliance of 70% and 60% with the fourth and fifth criteria, respectively.
The results were promising, with a significant improvement in UI observed among those who practiced PFMT. This project not only demonstrates the effectiveness of evidence-based management, but also highlights the importance of education and awareness in empowering older women to take control of their urinary health.
Key message:
- Evidence-based management strategies, like PFMT, offer hope and a path to improvement in UI.
- Implementing strategies and raising awareness in older women can help them regain their confidence, improve their well-being, and lead more fulfilling lives.
Authors
Sunu Alice Cherian1,2, Terese SIC3,4, Saritha Susan Vargese2,5
1. Pushpagiri College of Dental Sciences, Kerala, India
2. Pushpagiri Center for Evidence Based Practice, Kerala, India.
3. St. James College of Nursing, Kerala, India
4. Pushpagiri Center for Evidence-Based Practice, Kerala, India
5. Believers Church Medical College, Kerala, India
Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.
