Quality indicators for the management of urinary incontinence in vulnerable community-dwelling elders.

The prevalence of urinary incontinence in noninstitutionalized persons older than 60 years of age is 15% to 35%; of these, 25% to 30% have frequent episodes of urinary incontinence (1). The significance of urinary incontinence may vary from minimal to severe, with extreme activity limitation and social isolation. For example, several reports have linked urinary incontinence in community-dwelling elders with falls and depression (2, 3). Urinary incontinence also imposes significant psychosocial distress on family, friends, and caregivers (1). Urinary incontinence is even more prevalent in the nursing home than in the community. In nursing homes, however, urinary incontinence is known to be very treatable with assisted toileting programs (4). Nursing home residents are older and frailer than community-dwelling elders and have caregivers available 24 hours per day. As a result, major differences exist in how incontinence can be assessed and treated in the nursing home compared with the community. This paper describes incontinence quality indicators that can be applied to vulnerable community-dwelling elders who may be treated across the spectrum of care, from primary care physicians to surgical specialists. Methods The methods for developing these quality indicators, including literature review and expert panel consideration, are detailed in a preceding paper (5). For urinary incontinence, the structured literature review identified 4153 titles, from which abstracts and articles relevant to this report were identified. On the basis of the literature and the authors' expertise, 16 potential quality indicators were proposed. Results Of the 16 potential quality indicators, 9 were judged valid by the expert panel (see the quality indicators), 2 were merged into other indicators, and 5 were not accepted. The panel also suggested an additional indicator. The literature reviews that support each of the indicators judged to be valid by the expert panel process are summarized below. Quality Indicators 1 and 2 Initial Evaluation: Detection of Incontinence ALL vulnerable elders should have documentation of the presence or absence of urinary incontinence during the initial evaluation. ALL vulnerable elders should have annual documentation of the presence or absence of urinary incontinence BECAUSE urinary incontinence is prevalent in older adults, has a high psychological impact, is often neglected, is associated with a large practice variation, has a high monetary cost, and is reasonably responsive to directed treatment. Supporting Evidence. Despite the high prevalence of urinary incontinence and its influence on both mood and functional status, primary care providers do not consistently inquire about it and patients do not report it. Patients frequently are embarrassed, consider it to be an inevitable fact of aging, or have low expectations for treatment (1). Because providers often lack knowledge about the evaluation and management of urinary incontinence, they fail to elicit its presence (1). Older geriatric patients, and male patients in general, are even less likely to be screened for urinary incontinence than are younger geriatric patients and women (6). This discrepancy leads to substantial variation in the identification, assessment, and management of urinary incontinence. While no direct evidence shows that routine inquiry about urinary incontinence will lead to increased detection and treatment or improved outcomes, achieving these goals is likely to be more difficult without increased vigilance on the part of the health care provider. No data support or refute the interval at which inquiry should be performed. Quality Indicators 3, 4, and 5: Targeted Evaluation Targeted History IF a vulnerable elder has new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a targeted history should be obtained that documents each of the following: 1) characteristics of voiding, 2) ability to get to the toilet, 3) previous treatment for urinary incontinence, 4) importance of the problem to the patient, and 5) mental status BECAUSE this information is necessary for the appropriate diagnosis and treatment of urinary incontinence. Targeted Physical Examination IF a vulnerable elder has new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a targeted physical examination should be performed that documents 1) a rectal examination and 2) a genital system examination (including a pelvic examination for women) BECAUSE information obtained from these examinations is necessary for the appropriate diagnosis and treatment of urinary incontinence. Diagnostic Tests IF a vulnerable elder has new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a dipstick urinalysis and post-void residual should be obtained BECAUSE information obtained from these studies is necessary for the appropriate diagnosis and treatment of urinary incontinence. Supporting Evidence. These indicators are based on clinical practice algorithms that are advocated by the Agency for Health Care Policy and Research (AHCPR) (now the Agency for Healthcare Research and Quality) and others (1, 7, 8). They are the product of expert consensus but have not been tested prospectively. Few prospective studies of clinical algorithms for urinary incontinence in older adult patients have been conducted or published, and those that have been published focused on diagnostic accuracy rather than treatment outcomes. With aging, the pathophysiology of urinary incontinence becomes more complex and often has more than one contributory cause (9). Urodynamic testing detects abnormalities even in healthy, asymptomatic older adults (10, 11). Therefore, a focused evaluation is necessary to determine the relevant diagnosis. Although the clinical history of urinary incontinence may be nonspecific, it is often valuable. Most patients with stress incontinence symptoms have true stress urinary incontinence, and many persons with symptoms of urgency or urge urinary incontinence have detrusor instability (1215). Likewise, the physical examination may help identify the cause of urinary incontinence. The goals of physical examination also include identifying other medical conditions, such as reversible factors that may trigger or contribute to urinary incontinence, and assessing pelvic floor deficits that may warrant surgical correction. No studies were identified that directly assessed the utility of physical examination in the evaluation of urinary incontinence. However, several studies have identified reversible causes of urinary incontinence as a result of evaluations that included a physical examination. In one study evaluating the cause of urinary incontinence in 100 women referred to an incontinence clinic (mean age, 74.6 years), 17 patients had a urinary tract infection and 8 patients had fecal impaction, both of which are easily treatable causes of urinary incontinence (16). The fact that infection was identified in so many residents supports the importance of screening for symptoms of infection, such as a burning sensation. In a study of institutionalized and noninstitutionalized persons (mean age, 80.2 years) referred to an incontinence clinic for persistent urinary incontinence, 7 of 264 (3%) had reversible causes identified and successfully treated after a history, physical examination, and limited laboratory testing (17). Evaluation of reversible causes should screen for medications that can affect urine production or bladder or sphincter function (for example, diuretics, anticholinergic medications, opiates, and -adrenergic medications). Despite the value of the history and the examination, signs and symptoms of urinary retention may be unreliable in elderly persons (1719). Unsuspected obstruction or underactive detrusor are not uncommon, and the high prevalence of detrusor hyperactivity with impaired bladder contractility involving risk for retention with medication or impaction makes monitoring for urinary retention in these patients especially important (9, 20). An elevated amount of post-void residual urine is especially common in older patients. In one study, post-void residual urine exceeding 100 mL was found in 28% of both men and women older than 65 years of age who had urinary incontinence and were referred to a urology clinic (21). Pelvic ultrasonography or straight catheterization may be used to measure the post-void residual urine content, but ultrasonography is safer in elderly men. Quality Indicator 6 Discuss Treatment Options for Urinary Incontinence IF a vulnerable elder has new urinary incontinence or urinary incontinence at the time of a new evaluation, THEN treatment options should be discussed BECAUSE urinary incontinence frequently remains untreated despite the availability of many effective treatment options. Supporting Evidence. Absorbent pads and garments are too often used as a first-line treatment for urinary incontinence (1). The widespread use of these products is reflected in the growth of the market for disposable pads and adult diapers from $99 million in 1972 to $496 million in 1987 (1). One practice guideline recommends the use of such absorbent products only as an adjunct to other therapy during the evaluation period and for long-term care of patients with chronic intractable urinary incontinence (1). However, diapers should not be the first-line treatment for incontinence, and vulnerable elders with incontinence should be made aware of alternative treatments. The treatment options that might be discussed include pharmacologic treatments, electrical stimulation, and behavioral therapy. The effectiveness and relative lack of side effects of pharmacologic treatments have been documented for most types of incontinence (2225). The evidence for efficacy of behavioral