Age and Ageing Advance Access originally published online on March 22, 2007
Age and Ageing 2007 36(3):239-240; doi:10.1093/ageing/afm008
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Faecal incontinence
Faecal incontinence can be a disaster for patients and their carers and may be e final straw for admission to long-term care. Studies have reported wide variation in prevalence rates, from up to 13% for minor incontinence in the community, to up to 95% in nursing homes [1]. It is also widely considered to be a hidden problem, with possibly only 1 in 8 older people in the community seeking help for the problem [2].The overall management is complicated by multi-factorial causes especially in the frail elderly. There is a wealth of clinical experience but a lack of trial evidence when it comes to effective management [2]. What is agreed is that constipation and faecal impaction can be caused by many factors including immobility, frailty, medication, movement disorders such as Parkinson's disease, poor dietary and fluid intake and dementia. In any one individual, a number of these factors will inter-relate at any one time. Less common causes include primary neurological disorders such as spinal cord injury, diseases of the ano-rectum (e.g. after hysterectomy), and the end stage of severe cognitive impairment. The importance of gastrointestinal problems leading to loose stools should not be overlooked, with one reported series suggesting that up to 44% of episodes of faecal incontinence in nursing home residents were related to diarrhoea-type illness [3].
Multi-factorial patho-physiological causes indicate that management should involve multi-disciplinary assessment, comprehensive medical assessment (always including rectal examination), and then multi-factorial interventions. Indeed, it is also crucial to involve the patient in considering all aspects of management. A study of interviews conducted on people with bowel problems emphasised the important issues of patient dignity and nursing care (in particular, using a toilet as opposed to a commode), access to specialist continence advisory services, bowel assessment by a trained practitioner, the importance of fluid intake, and the need for education for all those involved, to help them deal competently and sensitively with the issue [2].
Thus, the evidence suggests that this is a common problem which is poorly reported, and is often inadequately assessed and managed. Yet there are multi-factorial interventions that help management, for example the draft recommendations of the National Institute for Health and Clinical Excellence (NICE) [4]. Most agree that change can be very difficult to achieve in any healthcare system. Indeed, Don Berwick's ‘first law of improvement’ is that ‘every system is perfectly designed to achieve exactly the result it gets’ [5]. Without redesigning the system there will be no change in the outcomes of care. The first step is to raise concern and show evidence of the need for improvement, sometimes referred to as the ‘tension’ that is needed for change.
The British Geriatrics Society in a partnership with Age Concern, the Department of Geriatric Medicine, Cardiff University, Carers UK, Continence Foundation, Help the Aged, In Contact and the Royal College of Nursing, recently started a campaign to improve the dignity of old people, starting with the act of going to the toilet and aiming to give people back control over this most private of functions [6]. The campaign is setting clear standards in order to help stimulate local improvements and to influence national policy and campaigning. Such work will support the recommendation on faecal incontinence from NICE to be published in full in June 2007 [4]. These draft guidelines recommend that people who have faecal incontinence should have their care managed by healthcare professionals with the relevant skills, training and experience, and who also work within an integrated continence service as set out in the national service framework for older people.
But change does not just happen because of well-written guidelines or even by raising ‘the tension’ for change. The model of improvement adopted by the Institute for Healthcare Improvement asks three questions: What are we trying to accomplish? How will we know that a change is an improvement? And what changes can we make that will result in an improvement? The Plan-Do-Study-Act four-stage model of change and improvement is increasingly well understood in the UK, each cycle consisting of: planning, doing, studying, acting and then planning again. Thus, improving the quality of healthcare requires robust, reproducible measurements of relevant outcomes as well as process and structures. Surprisingly, for a country with a comprehensive healthcare status, there is a lack of such data compared with, for example, the USA and this has hampered real improvement in quality [7]. A notable exception has been the work of the Royal College of Physicians Clinical Effectiveness and Evaluation Unit (CEEU), with work on the management of Myocardial Infarction and the National Sentinel Audit Programme on Stroke. These programmes build on evidence-based standards followed by a voluntary buy-in of all organisations involved in the delivery of that service. Comparative audit data fed back to organisations becomes a powerful driver for change and is demonstrated by the stroke audit which is now in its fifth round [8].
Thus, the first national audit of faecal incontinence in older people in the UK reported in this copy of the journal is a crucial next step in producing change and improvement in the management of this distressing problem [9]. This paper reports part of the national audit of continence care for older people commissioned by the Healthcare Commission. Of course it raises concerns. While 81% of secondary care trusts were involved, it was very disappointing that only 9% of care homes participated, particularly as they have such a high prevalence of faecal incontinence. The proportion of organisations reporting integrated continence services is certainly encouraging, but their reported very high level of awareness of the importance of privacy and dignity does not appear to accord with the recorded experience of older people in institutional environments. The lack of basic assessment, and documentation of that assessment, even in those organisations most motivated to make a return on the audit suggests that there is much room for improvement.
The importance of this audit must not be underestimated. Faecal incontinence is a distressingly common problem in old age, particularly for the frail elderly. All involved in managing such patients need to strive to improve their performance. Hard data is crucial to improving quality of care, and the next steps must be to build on this first audit so that it becomes a part of the everyday quality environment for older people.
Consultant Geriatrician, Queen Mary's Hospital, Sidcup, Kent DA14 6LT, UK
Email: dblack{at}kssdeanery.ac.uk
References
- Potter J, Wagg A. Management of bowel problems in older people: an update. Clin Med (2005) 5:289–95.[ISI][Medline]
- Potter J, Norton C, Cottenden A. Bowel Care in Older People. Clinical Effectiveness and Evaluation Unit (2002) London: Royal College of Physicians. Research and practice.
- Chassagne P, Landrin I, Neveu C, Czernichow P, Buvaniche M, Doucet J. Fecal incontinence in the institutionalised elderly: incidence, risk factors, and prognosis. Am J Med (1999) 106:185–90.[CrossRef][ISI][Medline]
- Faecal Incontinence. NICE draft guidelines (2006) Last accessed 28 Dec. www.nice.org.uk/page.aspx?o=389312.
- Berwick DM. A primer on leading the improvement of systems. BMJ (1996) 312:619–22.
[Free Full Text] - Morris J, Barrett J. BGS Dignity Campaign. (2006) London: BGS Newsletter.
- Tomson CRV, Berwick DM. What can the UK learn from the USA about improving the quality and safety of healthcare? Clin Med (2006) 6:551–8.[ISI][Medline]
- The Royal College of Physicians. Stroke Programme. (2006) Last accessed 28 December. www.rcplondon.ac.uk/college/ceeu/ceeu_stroke_home.htm.
- Potter J, Peel P, Mian S, et al. National audit of continence care for older people: management of faecal incontinence. Age Ageing (2007) 36:268–73.
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