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Age and Ageing Advance Access originally published online on November 21, 2007
Age and Ageing 2008 37(1):39-44; doi:10.1093/ageing/afm163
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

National audit of continence care for older people: management of urinary incontinence

Adrian Wagg1,, Jonathan Potter2, Penny Peel2, Penny Irwin2, Derek Lowe2 and Michael Pearson2

1 Geriatric Medicine, University College Hospital, 25 Grafton Way, London WC1E 6AU, UK
2 Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London NW1 4LE, UK

Address correspondence to: Adrian Wagg. Tel: 0207 380 9910; Fax: 0207 380 9652. Email: a.wagg{at}ucl.ac.uk


   Abstract
Top
 Abstract
Introduction
 Method
 Results
 Process of care
 Discussion
 Key points
 References
 
Introduction: the Department of Health report ‘Good practice in continence services’ highlights the need for proper assessment and management of urinary incontinence. The National Service Framework for Older People required service providers to establish integrated continence services by April 2004. A national audit was conducted to assess the quality of continence care for older people and whether these requirements have been met.

Method: the audit studied incontinent individuals of 65 years and over. Each site returned data on organisational structure and the process of 20 patients’ care. Data were submitted via the internet, and all were anonymous.

Results: the national audit was conducted across England, Wales and Northern Ireland. Data on the care of patients/residents with bladder problems were returned by 141/326 (43%) of primary care trusts (PCT), by 159/196 (81%) of secondary care trusts (involving 198 hospitals) and by 29/309 (9%) of invited care homes. In all 58% of PCT, 48% of hospitals and 74% of care homes reported that integrated continence services existed in their area. Whilst basic provision of care appeared to be in place, the audit identified deficiencies in the organisation of services, and in the assessment and management of urinary incontinence in the elderly.

Conclusion: the results of this audit indicate that the requirement for integrated continence services has not yet been met. Assessment and care by professionals directly looking after the older person were often lacking. There is an urgent need to re-establish the fundamentals of continence care into the practice of medical and nursing staff and action needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice.

Keywords: urinary incontinence, older people, audit, clinical effectiveness, elderly


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Process of care
 Discussion
 Key points
 References
 
Urinary incontinence (UI) is associated with a range of medical conditions, many of which are common with increasing age. UI affects some 20% of community dwelling older people and 30–60% of people in institutional care [1–4]. It remains an under-reported problem despite a significant impact on quality of life and associated morbidity [5, 6]. Many sufferers either do not present for care, cope in silence or do not receive effective treatment for their condition [7, 8].

Caring for a person with UI has an equally negative impact on quality of life of the carer [9], and UI may often precipitate a move to institutional care [10]. The costs to both health and social care services of providing care are considerable [11] so, there is a great opportunity for improving the lot of older people if UI can be better assessed and managed. The Department of Health report Good Practice in Continence Services (2000) recognised the need for proper assessment and management, identified a wide geographical variation in access to services and called for regular audit [12]. The National Service Framework for Older People (2001) required the establishment of integrated continence services for older people by April 2004 but allocated no resources to promote this objective [13]. Recent evidence suggests that there has been only limited action toward this end [14]

The Clinical Effectiveness and Evaluation Unit has developed measures for defining the quality of continence care and a comprehensive audit package to assess this across primary, secondary and care homes [3, 15–17]. The aims of this National audit were to describe the organisation and processes of care for older people with continence problems to describe variation in care and to produce data to enable the comparison of care between organisations.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Process of care
 Discussion
 Key points
 References
 
Audit tool development
Full details of the audit tool development have been published elsewhere [18]. Patients’ views on the quality of services added patient-defined standards [19]. The resulting package was piloted and modified [20].

Patient inclusion and data retrieval
Data were returned on 20 patients aged 65 and above with UI as defined by the clinical record in each participating site. In acute care hospitals, consecutive patients were identified from current inpatients. In primary care hospitals they came from the records of a single GP practice; data were obtained from any practice records and computer systems. In care homes, residents were identified and data obtained from the care home records.

Recruitment of sites
The audit included England, Wales, Northern Ireland and the Channel Islands. Primary care trusts (PCTs)/Local Health Boards were identified and each was asked to identify one of their GP practices for the audit. Totally, 326 invitations were sent, of which 179 registered an interest to participate. All acute care National Health Service Trusts were identified and of 196 invited to participate 175 registered to do so. Major care home providers were invited with a target total of 100 homes; 309 invitations were sent and 85 registered. Regional workshops were held for training with the audit tool prior to data collection.

Data were submitted via the Internet to a secure web site, and all were anonymous. Help buttons were provided online alongside the questions and an extensive printed help booklet was also issued to participants. Each participating site was asked to use another auditor to independently audit their first five cases to conduct a reliability study (results not presented here).

Data were expressed in percentage and absolute terms and where data were not applicable the denominator was adjusted accordingly. Missing data were regarded in the negative. The input method guaranteed that missing data levels (i.e. ‘blank’ entries) were very low (less than 1%). Analyses were performed using SPSS v11.5.

No ethical committee permission was sought for this clinical effectiveness work which involved no intervention. Data transfer was in accordance with standards of practice laid out by the Patient Information Advisory Group.


   Results
Top
 Abstract
 Introduction
 Method
 Results
Process of care
 Discussion
 Key points
 References
 
In all, 138 primary care sites, 195 hospitals and 27 care homes returned data, these included information on 2,717 primary care, 3,683 hospital and 488 care home patients and residents.

Organisation of care
Fifty eight percent of PCTs (79/137), 48% (94/195) of hospitals and 74% (20/27) of care homes (CHs) reported that integrated services existed in their area, but in only 67% (53) of PCTs, 53% (50) of hospitals and 50% (10) of CHs did that integrated service have a designated lead clinician. Seventy-five percent of PCTs, 90% of hospitals and 100% of CHs had a policy of routinely asking patients about bladder problems, but fewer of them guaranteed an assessment should a problem be found. Of the hospital based services only 32% had a written policy for managing continence, 49% had a structured training programme and 35% performed regular audit.

Specialist assessments were performed by staff trained to carry out abdominal, vaginal and rectal examinations in only 54% of cases. The number of specialist continence advisors is summarised in Table 1.


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  		Table 1. Numbers of continence advisors available to sites

 
Where a written policy for continence care existed, services reported that products were supplied on the basis of clinical need rather than cost in 88% (71/81) of PCTs, 76% (48/63) of hospitals and 86% (19/22) of CHs. In 84% (108/128) of PCTs, 53% (86/163) of hospitals and 76% (19/25) of CH patients' views were sought in selecting the range of products supplied. Despite this there was evidence of rationing in both PCT (104/129) sites and CH (19/25) sites, this practice being less common in hospitals (39/166 sites). The median number of products supplied per patient per day in each sector was four.

Patients surveyed
Patients/residents were older in hospitals (mean 82, SD 8 years) and in CHs (mean 86, SD 8 years) than in PCTs (mean 80, SD 8 years). The majority of the sample for which data were available had significant levels of cognitive and functional impairment (Figure 1). Seven percent (196) of PCT patients, 2% (61) of hospital patients and 2% (99) of CH residents had no reported associated co-morbidity. The distribution of continence-associated co-morbidities is shown in Table 2.


Figure 1
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  		Figure 1. Proportion of cognitive and functional impairment by care setting.

 


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  		Table 2. Distribution of co-morbidity

 

   Process of care
Top
 Abstract
 Introduction
 Method
 Results
 Process of care
Discussion
 Key points
 References
 
A continence history was documented in 73% (1984/2,717) of PCT patients, 70% (344/488) of CH and 45% (1,651/3,682) of hospital patients. The most common lower urinary tract symptoms documented were: in PCTs—urgency (43%, 1,158/2,717), urgency incontinence (42%, 1,143/2,717) and stress incontinence (40%, 1,094/2,717); in hospitals—urinary frequency (22%, 806/3,682), nocturnal frequency (22%, 799/3,682) and nocturnal enuresis (21%, 774/3,682); and in CHs—nocturnal enuresis (43%, 211/488), nocturnal frequency (33%, 162/488) and urinary frequency (32%, 156/488). Permanent catheters were present in 17% (618/3,682) of hospital patients, 13% (62/488) of CH residents and 3% (87/2,717) of PCT patients. Among 2,176 PCT patients with documentation of symptoms, 36% (788) had a diagnosis of stress incontinence (SUI), 42% (904) had urgency incontinence (UUI) and 19% (404) had mixed urinary incontinence (MUI). Among 1,746 secondary care patients with documentation 18% (314) had a diagnosis of UUI, 12% (204) had SUI and 8% (132) had MUI.

Details of assessment and management of UI are shown in Table 3.


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  		Table 3. Assessment and care

 
It was found that 89% (435) of CH residents had a documented care plan, compared with 51% (1,398) of PCT and 41% (1,513) of hospital patients. In all 94% (1,416) of hospital patients and 82% (356) of care home residents had been reviewed within the last 6 months, though longer review times were evident in PCT patients. Where appropriate 46% (1,112/2,443) of PCT patients, 21% (528/2,508) of hospital patients and 41% (122/299) of CH residents had a documented discussion about the cause and treatment of their incontinence.


   Discussion
Top
 Abstract
 Introduction
 Method
 Results
 Process of care
 Discussion
Key points
 References
 
This is the largest and widest study of continence care in the United Kingdom and provides a picture that reflects the current state of services and care in primary and hospital care. Given the different considerations which affect the three different settings, the level of engagement with this first round of national audit was encouraging.

Hospitals
Most hospitals were able to complete the audit and an impressive 81% returned good data. Cases were identified by audit departments and clinical staff with an interest in continence care. Cases should have been consecutive, but this may not have been as rigidly applied as intended. Some sites reported difficulty in accessing records and may therefore have submitted a small sample of patients that was not truly representative of their normal case mix. The sample in hospitals was, for the most part, drawn from inpatients under the care of geriatricians—this introduces some bias, to what extent fitter, although incontinent, older people might populate other wards is not known, but our results should be viewed in this light. Nevertheless, the data are likely to be generally representative of care in this sector.

Primary care
Primary care participation was good; this may reflect the budgetary importance of continence and the fact that Continence Advisors were the professional group most motivated to carry out the audit. However, only one practice per PCT was nominated to take part and it may not be possible for the results to be generalised across the whole area. A high proportion of primary care sites returned data via their continence services and thus these results may therefore not represent the experience of the ‘average’ GP patient. Using the GP record as a source for patient notes proved difficult as there was often no mention of continence status; linking these records to those held by district nursing, product supply databases or continence service records was then necessary, but again difficult.

Care homes
It was particularly difficult to recruit care homes, and those that were recruited had difficulties with data collection. This highlighted the challenge of carrying out audit in settings where resources, staffing and culture do not routinely support it. A lack of access to a single central set of records, limited information technology and staff shortage was often cited as a contributing difficulty. Many homes noted that continence status was assessed prior to admission and that the role of care home staff was to enact a management plan rather than repeat the assessment process. It is also likely that only enthusiastic care homes took part and thus the ability to draw conclusions regarding care in that sector is severely limited.

The reported organisation of services suggests a good basic provision of care, particularly within primary care. Sectors ranged from 48 to 74% in reporting access to an integrated service but many had missing elements, suggesting that the perception of integration was optimistic and varied depending upon the perspective of the reporting site. The lack of a designated lead in most services is a specific barrier to development and quality improvement. The ultimate goal contained in the NSF for Older People has not been met.

In general
The reported availability of specialist continence advisors represents approximately one continence advisor per 40,000 population over 65 years or about 8,400 men and women with UI. This seems too few personnel to provide an adequate service for so many, particularly given the variable remit of existing advisors, the majority of whom will cover bladder and bowel care for the entire population. Department of Health guidance unfortunately makes no firm recommendation on staffing levels upon which to base these figures.

All settings reported a very high level of regard for privacy and dignity in relation to continence care. This is a particularly important observation given the sensitivities of bladder and bowel management and the importance given to privacy and dignity in the NSF follow-up document ‘A new ambition for old age’ [21]. There is concern that the impression of care providers may not be shared by older people themselves [22]. There may be institutionalised ‘blindness’ to deficiencies and an acceptance of a level of privacy and dignity, which might not meet the true wishes of older people.

These real-life, cross-sectional data illustrate the real nature of UI in the elderly in terms of medical co-morbidity; cognitive and functional impairment. The audited sample revealed a high distribution of functional and cognitive impairment, the ‘fittest’ patients being in the primary care group as might be expected. The small number of patients with available AMTS or Barthel scores was not reported in our results, which therefore underestimate the true level of associated functional or cognitive impairment.

Most sectors claimed to ask routinely about bladder problems but unfortunately, in many sites, elicitation of a positive response to the question did not guarantee an assessment of the problem and audit of the process of care gave further cause for concern. A history was seldom taken in hospital, suggesting that continence is not a priority in acute care. A bladder diary, an essential component of the assessment, was seldom used in primary care, where one might expect its uptake to be high. Likewise, a review of medication was seldom performed. Although recommended as part of the specialist assessment, a rectal examination is infrequently done. Very few people underwent an assessment of post-micturition residual urine as part of their evaluation. Although there are no published data which support the routine performance of this procedure in women, it is well established that in men the presence or absence of symptoms do not predict finding of a significant residual, requiring this part of the examination.

Importantly, a clear cause of incontinence was documented in only 25–63% of cases. Without a known cause, evidence-based, effective treatment could not be provided.

Given the reported levels of training in assessment and management across all sites, there appears to be a disparity between education, training and practice. This is not uncommon, but does not serve patients well.

Management plans where they existed, all too often, relied on containment. There was also ample evidence of rationing of continence products despite ‘free pads’ being available to those in care homes. This is consistent with previous work which suggests that the NHS provides only a third of the pad requirement associated with UI [23]. Patients within the hospitals appeared to have unfettered access to pads and products, perhaps reflecting the different budgetary pressures but encouraging indiscriminate usage.

There may have been marked differences in how a patient's incontinence was managed in practice and that which was documented. It is unlikely however, that key elements of the examination are routinely not documented and thus the audit is likely to reflect actual practice in these areas.

This audit demonstrates that the requirement for integrated continence services contained within the National Service Framework for Older People has not yet been met. Action still needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice. Many services appeared to be reliant upon the input from specialist continence advisors at the expense of basic assessment and care undertaken by clinical staff. Regardless of the organisation of care, these data illustrated an urgent need to re-establish the fundamentals of continence care within the daily practice of medical and nursing staff looking after patients.

The cost of continence care is high, whether measured in health care or financial terms. Services which deliver high quality evidence-based care should be able to manage and thus reduce the associated morbidity and ensure that financial costs are based on cost-effective decisions. If specialist continence services are to cater to the needs of all people with continence problems then there is a large resource problem, particularly in the light of current financial pressure which has resulted in a withdrawal of continence care in some areas of the country.


   Key points
Top
 Abstract
 Introduction
 Method
 Results
 Process of care
 Discussion
 Key points
References
 

  • Assessment and management of older people is under-assessed and under-treated.
  • There is an over-reliance on containment as the sole source of management of the condition.
  • The rectal examination is seldom undertaken as part of the assessment of urinary incontinence.
  • There is a great opportunity to improve the treatment and lot of older people with bladder problems.


   Conflicts of interest
 
None


   Acknowledgements
 
To the Continence Working Party, for their support and guidance

To all those nationally who gave time and energy in submitting data to the audit.


   References
Top
 Abstract
 Introduction
 Method
 Results
 Process of care
 Discussion
 Key points
 References
 

  1. Thomas TM, Plymat KR, Blannin J, et al. Prevalence of urinary incontinence. Br Med J (1980) 281:1243–45.[Abstract/Free Full Text]
  2. Perry S, Shaw C, Assassa P, et al. An epidemiological study to establish the prevalence of urinary symptoms and felt need in the community: The Leicestershire MRC Incontinence Study. J Public Health Med (2000) 22:427–34.[Abstract/Free Full Text]
  3. Royal College of Physicians. Incontinence: Causes, Management and Provision of Services. (1995) London: The Royal College of Physicians.
  4. Peet SM, Castleden SM, McGrother CW. Prevalence of urinary and faecal incontinence in hospitals and residential and nursing homes for older people. Br Med J (1995) 311:1063–4.[Free Full Text]
  5. Dugan E, Roberts CP, Cohen SJ, et al. Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians. J Am Geriatr Soc (2001) 49:462–5.[CrossRef][Web of Science][Medline]
  6. Wagg AS, Malone-Lee JG. Urinary incontinence in the elderly. Br J Urol (1998) 82(Suppl. 1):11–7.[Web of Science][Medline]
  7. Teunissen TA, de Jonge A, van Weel C, et al. Treating urinary incontinence in the elderly–conservative therapies that work: a systematic review. J Fam Pract (2004) 53:25–32.[Web of Science][Medline]
  8. Burgio K, Locher JL, Goode PS. Combined behavioural and drug therapy for urge incontinence in older women. J Am Geriatr Soc (2000) 48:370–4.[Web of Science][Medline]
  9. Cassells C, Watt E. The impact of incontinence on older spousal caregivers. J Adv Nurs (2003) 42:607–16.[CrossRef][Web of Science][Medline]
  10. Thom DH, Haan MN, vanden Eeden SK. Medically recognised urinary incontinence and risks of hospitalisation, nursing home admission and mortality. Age Ageing (1997) 26:367–74.[Abstract/Free Full Text]
  11. Making the Case for Investment in an Integrated Continence Service. (2000) London: The Continence Foundation.
  12. Department of Health. Good Practice in Continence Services. (2000) London: HMSO.
  13. Department of Health. National Service Framework for Older People. (2001) London: HMSO.
  14. Thomas S. Is Policy Translated into Action? A Report by the Royal College of Nursing Continence care Forum and the Continence Foundation. (2003) London: Continence Foundation.
  15. Royal College of Physicians. Promoting Continence. Clinical audit Scheme for the Management of Urinary and Faecal Incontinence. (1998) London: Royal College of Physicians.
  16. Royal College of Physicians of London. The CARE Scheme–Continuous Assessment, Review and Evaluation. Clinical Audit of Long-Term Care of Elderly People. (1999) 2nd edition. Prepared by Professor John Brocklehurst and Dr Edward Dickinson.
  17. Georgiou A, Potter JM, Brocklehurst J, et al. Measuring the quality of continence care in long term care facilities: an analysis of outcome indicators. Age Ageing (2001) 30:63–6.[Abstract/Free Full Text]
  18. Mian S, Wagg A, Potter J, et al. National audit of continence care for older people: resources and method. J Eval Clin Pract (2005) 11:533–43.[CrossRef][Web of Science][Medline]
  19. Wagg A, Billings J. Involving older users of continence services in developing standards of care: Differences and similarities between professional and user's views. (2004) In: Proceedings of the International Continence Society Meeting, Paris.
  20. Wagg A, Mian S, Lowe D, et al. The national audit of continence care for older people: results of a pilot study. J Eval Clin Pract (2005) 11:525–32.[CrossRef][Web of Science][Medline]
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Received 19 November 2006; accepted in revised form 19 June 2007.


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