Continence Care

The reasons elderly go into care are self-neglect, incontinence and dementia. Some estimates are that up to 6 million people in the UK are affected by incontinence.



Incontinence is not a disease, but more a symptom of other problems to be tackled with differing methods and advice. It is defined as an inability to control the bladder (urinary incontinence) or the leakage of bowel motions (faecal incontinence).



It is not certain that the teenage and middle age years are followed by incontinence in old age. Not everyone is affected; I have cared for senior citizens who have reached beyond 100 years who are unaffected. It is estimated that 5 out of 6 older people never have a problem with bladder control. However, in care homes 1 in 2 do have a problem. Ageing does not cause incontinence, but bowel and bladder weakness is more common as we become older. It is a growing problem because we are living longer and awareness is more heightened. Some believe it could become an epidemic.



Urinary incontinence is most common in women, usually divided into four groups – stress incontinence with weak muscles, possibly due to menopause, causing leakage when sneezing or lifting, urge incontinence, possibly caused by infection, overflow incontinence, due to a full bladder resulting in bed wetting, functional incontinence with difficulty walking or undoing clothing quickly enough.



Although there is growing public awareness of incontinence it can still lead to personal embarrassment and social isolation which can lead to depression. How often have we heard of mobile elderly who do not take their ‘water pills’ when going on a coach trip for fear of not getting to the toilet in time. Many, many times I have experienced elderly ladies within care who are so upset and ashamed because they are incontinent and think they are the only ones in the home who are. There are instances of hiding wet or soiled clothing through embarrassment. "…Getting people to talk about incontinence can be a problem in itself because it is seen as taboo…." (1)



At home incontinence often goes unreported because it is believed by the family to be a normal consequence of ageing, it is seen as an embarrassment and there is a low expectation of the benefits of treatment.



The NHS directs its resources, not to the treatment of incontinence, but to the management of incontinence. Specialist continence teams attached to PCT’s and co-operative local joint ventures with local authorities, Community Health Partnerships and local health boards give advice.



Treatments of incontinence are behavioural (bladder retraining, pelvic muscle exercise and scheduled toilet prompting), drug treatment with possibly associated side effects, surgery, catheterisation with the risk of infections, and pads and protective garments.



Continence advisors – the front line, and often referred to as the "pants and pads brigade" - are stretched to cover the rising demand but are well placed with good organisations to extend their roles to other disciplines as, for example, the interaction of continence and dementia. Their role is, however, circumscribed by the budgetary requirements of PCT’s and the NHS.



Government policy of the Department of Health under the previous Labour administration had been to encourage mergers in the number of PCT’s which determine priorities in their areas, and the formation of procurement groups of PCT’s. At the same time health initiatives in tendering for products purchased by the NHS have sought to bring down costs. The tender for one well-known brand already selling to the NHS and PCT’s was alleged to be 20% higher than the next highest bidder and this brand was rejected. The PCT’s can still place continence contracts with their individual suppliers. The government has tried to remove barriers to entry to new competitors of the big pad suppliers by making new brands available through the NHS and encouraging separation, and therefore the pricing, of the elements of the service (delivery costs and technical advice and support as opposed to the actual product costs). At the same time NHS Logistics introduced a home delivery service for continence products, direct from the manufacturers to the client of the PCT. Further, the Government signed a contract with DHL to manage NHS Logistics, now called NHS Supply Chain, for ten years. Novation, a US healthcare supplier, was advisor to DHL in these earlier arrangements but has now ceased.



Current Government policy is to substitute GP buying consortia for PCT’s and make responsibility more local. Plus ça change..!!



The market for absorbent disposables in continence in the NHS is about £50 million plus, which gives scope for large savings for the PCT’s of 30%. According to one PCT 5% of the population requires pads at a cost of 85p per head of population, nationally equating to £51 million. Medication costs for an individual are £30 per month and for pads £5 per week.(2)



This article has embraced the social stigma of incontinence, the types of incontinence and assistance available from the continence nurses and the role of the continence advisor within ever changing structures of the NHS. My background is in care and developing products to improve care, particularly in residential homes. I have views ‘from the coalface’ on the impact of continence care in the homes.



There is pressure on care home staff not only to improve the physical well-being of the residents but also to deal with the consequences to the home of incontinent residents, many with dementia. The care staff numbers need to rise to cope with the increased demands of caring for residents now often living well into their late nineties. Early discharge from hospitals increases the burden of care. One hears of new care homes being built with insufficient facilities to deal with the disposal of the increased number of pads.



The effect of government cost containment policies and under-estimation of individual needs by continence advisors means that care homes retain pads after a resident dies whilst PCT’s require return of full packs by families of an incontinence sufferer at home who has passed away. What happens if a resident of a care home uses more disposable pads per week than the advisor’s recommendation……? We are very dependent on good communication between nurse and care home when assessing the individual for continence care; there is often the wrong choice of disposable pad for the needs of a particular resident because of lack of communication and under-estimation of requirements because of financial pressure.



One very exhausted mother telephoned to say that only two washable bed pad (‘kylies’) every six months were supplied to her strapping teenage son with a high level of incontinence living at home and she struggles to turn round these two bed pads. She is not guided as to what is available to purchase privately at a realistic price, rather than the often grossly inflated prices and inadequate size of many washable bed pads. MEDORIS has endeavoured to provide a high quality washable bed pad of a sensible size at an excellent price – now recognised by the NHS with MEDORIS’s inclusion on the NHS Home Delivery Service.



We have noticed our internet-based sales have risen considerably, which may be an indication that the public are nolonger exclusively turning to the NHS for supply of washable bed pads.



Prejudices and prior experience determine care home policies. Some homes pad up for night time, others prefer washable bed pads, some do both. Some believe in many pad changes during the night, and research shows that there is no evidence that frequent changes lead to sleep deprivation. Some believe in strict toileting programs during the day – not always achievable with the increased pressure on care staff’s time and staff shortages – with the ongoing problem of cleaning up after ‘accidents’ and keeping the home smelling pleasant. Again, how often is there no chair protection in place which, even with the new wipe-able fabrics, means that after a short time the chairs become impregnated with urine however well they are washed. How much easier to have in place seat pads that blend in with the décor of the home on all chairs (and not just discriminating against the ones who have an incontinence problem) which can be easily laundered overnight if required…. and do not look like "the person who sits in this chair is incontinent…." MEDORIS has an anti-slip seat pad with bed pad technology.



What can we do to improve the well being and dignity of the incontinent? What can be done to help the carer concentrate on the care rather than the effect of incontinence in the home surroundings?.



Care home staff and families need help in dealing with the common issues of incontinence – wet nightwear which is very difficult to remove, washable bed pads which are too small and not sufficiently absorbent, clothing which is hard to remove quickly. MEDORIS has endeavoured to solve these problems with a wide range of washable bed pads, including bed pads for a double bed where the partner is not incontinent but the individual wants the reassurance of a bed pad. The MEDORIS absorbent easy-on nightwear with its unique award-winning popper system for continence care, easy care comfortable open back skirts where the individual can sit directly on a seat pad, are all time saving products for discreet continence care.



The dignified and gentle prevention of continually taking off clothes and pads, with its often accompanied pad shredding and smearing, in cases of dementia and learning disabilities can be helped with the use of comfortable 100% cotton absorbent all-in-one nightwear and easy care all-in-one daywear which looks like separate trousers and top – both available from MEDORIS.



A Canadian study indicates "…the prevalence of urinary and faecal incontinence increases with age, institutionalisation, failing mental powers, and loss of mobility. Severe dementia and immobility are the factors most strongly associated with incontinence…" (3)



As the baby boom generation reaches the last quarter of their lives are we facing a rapid growth in incontinence….?



Brenda Currill, a carer and Director of Medoris, a supplier of incontinence products to the NHS.





(1) Quoted by Sue Brown, Nottingham Continence Advisory Service

(2) Quoted by Dr Judith Wardle of the Continence Foundation in Caring Business – April 2007

(3) Quoted from "Analysis of urinary and faecal incontinence" Ian McDowell, University of Ottowa 1998







Useful References:

The Merck Manual of Geriatrics

The Continence Foundation

NICE Clinical Guideline 40 – October 2006

South Warwickshire Integrated Continence Services – September 2005

Continence Advisory Service – Nottingham

Bolton PCT Services - Continence

www.incontact.org

www.promocon.co.uk

Specialist care products for the elderly, people with disabilities and children suffering with learning disability and mobility problems, helping individuals and their carers with products aimed at making elderly care and disability care manageable, including elderly care products, disabled aids, and products for pressure care, incontinence and special needs and mobility accessibility products.