Hypothesis / aims of study
The incidence rate of urinary incontinence (UI) among elderly people living in Japanese institutions is 26.9%. The actual cause of UI is not yet identified. However, incontinence caused by dementia is common among patients in geriatric facilities (Bando et al., 1998). To provide individualized urinary care to institutionalized elderly patients, the type of UI should be first classified. Some medications for UI may cause cognitive decline caused by side effects that may reduce cognitive function, and this has been a cause of concern. Therefore, the urinary function of elderly patients with UI and their bladder function must be evaluated (Yoshida, 2004; Ueyama, 2011). These actions can prevent unnecessary drug therapy. UI involves voiding dysfunction. Further, it is associated with personal and environmental factors. However, these notions are currently overlooked (Kamei, 1996).
Functional urinary incontinence (FUI) is defined as UI that occurs despite normal urinary function. It is caused by physical, motor, or cognitive function decline. Only a few studies have examined the effect of individualized urinary care on UI and cognitive function in institutionalized elderly patients with FUI.
The current study aimed to determine the association between individualized bladder management and UI and cognitive function improvement in elderly patients with FUI.
Study design, materials and methods
Study design
This was a 6-month prospective pilot study.
Informed consent
The research purpose was explained to the participants, and a verbal and written informed consent was obtained. The participants were also informed that they were free to withdraw from the study at any time during and that such withdrawal is not a disadvantage to them.
Study participants
There were 121 residents with FUI and cognitive impairment, 24 of whom had been hospitalized for at least 6 months.
The exclusion criteria were as follows:
・Patients who presented with evident organic disorders of the bladder or urethra.
・Those who are bedridden.
・Those who presented with diabetes mellitus and hypertension or those taking sleeping pills.
・Those who presented with malignant diseases.
・Those who required end-of-life care.
・Those who presented with severe cognitive decline (Mini-Mental State Examination [MMSE] score of <10).
・Those who could not provide consent to the survey.
Research period
The current study was conducted from September 1, 2016, to March 31, 2022.
Study methods
First, bladder function assessment (voiding diary, urination) was performed at admission and at 6 months after. Second, cognitive assessment was conducted at admission and at 6 months after using the MMSE. Third, urinary management was implemented (care process).
Urinary guidance based on the patient’s will (urination intention and motivation) and individual urination patterns
First, bladder function assessment (specialist visit and treatment based on voiding diary and residual urine measurement) was performed. Second, urinalysis was conducted to confirm conditions including urinary tract infection and to identify the appropriate treatment if necessary. Third, monthly conferences of nurses and caregivers should be held. Fourth, awareness-raising activities for nurses and caregivers (praise and support for the staff by nurse managers as appropriate) must be implemented. Fifth, nursing and caregiver awareness activities (praise and support for the staff by nurse managers, as appropriate) should be implemented. Sixth, monthly conferences of nurses and caregivers should be held.
Definition of terms
UI was defined as complaint of any involuntary leakage of urine (International Continence Society, 2002).
Assessment tool
The MMSE was used to evaluate cognitive function (suspected dementia: ≤ 21/30 points, suspected mild cognitive impairment: 22–26/30 points).
Statistical analysis
All survey data were summarized, tabulated, and analyzed. After checking for normal distribution, all tests were two-tailed, and a p value of <0.05 indicated a statistically significant difference. Statistical analysis was performed using the Statistical Package for the Social Sciences software v. 28.0.1 (IBM Inc., Armonk, the USA). The time of enrollment was used as the baseline. The postintervention period was defined as 6 months after enrollment. Data at baseline and the postintervention period were compared. The paired t-tests were used to assess quantitative data. The primary outcome was the difference between the mean MMSE score at baseline and the postintervention period.
Results
The mean age of the patients (n = 24) at baseline was 89.7 (± 6.8) years. In total, 10 were men and 14 women. The pre-existing medical conditions included dementia (n = 18), cerebrovascular disease (n = 5), and musculoskeletal disease (n = 13) (with overlap).
The mean MMSE score for cognitive function was 16 (± 5.5), and the mean Functional Independence Measure score was 63.1 (± 26.5). All patients were urinating in their diapers.
At 6 months after admission, 12 patients were included in the without UI group and 1 (1 male and 6 females) in the UI group. The without UI group had a significantly lower mean score for the level of care required than the UI group (1.71 [± 1.11] vs 3.29 [± 0.95], p = 0.04).
Meanwhile, the MMSE score for cognitive function after urinary care significantly improved, with a mean score of 16.43 (± 6.05) at baseline and 18.57 (± 5.65) at 6 months in the without UI group (p = 0.01).
The UI group presented with a trend toward improvement, with a mean score of 15.57 (± 7.48) at baseline and 16.29 (± 7.27) at 6 months (p = 0.34).
Interpretation of results
The prevalence rate of UI among institutionalized residents is 43%–77% (median: 58%). Dementia and cognitive function are associated with UI (Offermans, 2009). In addition, the incidence rate of UI increases with greater severe cognitive decline (Taniguchi, 1993).
In elderly individuals with preserved bladder function, cognitive function could improve by providing drinking instructions and toileting guidance based on the patient’s micturition patterns and signs and urinary complaints. Facilities should prioritize the treatment and management of mild UI cases. The ongoing involvement of nursing staff is essential in the diagnosis and management of these cases. The main factors inhibiting urination are the function of the left elbow and knee joint, communication of urination based on movement, verbal communication of urination, pain (an individual ability factor), being in an inappropriate position (an environmental factors), negative attitudes toward urination assistance, and desire for social participation (an emotional reaction). Hence, it is important to provide urinary guidance according to each person’s urination pattern and to understand the person’s personality, values, and personal relationships with those who care for him or her (Hirazakura, 2009; Yura, 2008; Ichikawa, 2003).
It is also useful to hold regular conferences, and nurses must work with caregivers in a coordinating role to promote care. We believe that the urinary care provided by these nurses, which include urinary care several times a day, was effective in improving not only UI but also cognitive function.