This proposal represents a unique merger of behavioral, pharmacologic and nursing approaches towards improving the assessment and treatment of urinary incontinence in nursing homes (NHs). Despite the prevalence, adverse effects and substantial costs of incontinence in NHs, most incontinent NH residents do not undergo any type of diagnostic assessment, and are frequently managed by diapering or catheters. Both of these techniques have disadvantages; diapering is expensive and can foster dependency, and catheterization has been shown to be associated with substantial morbidity. Recent studies have documented that behavioral interventions such as prompted voiding can significantly reduce the frequency of incontinence among NH residents, and thus may be useful for many residents who are currently managed by diapering or catheters. The practicality and cost-effectiveness of behavioral interventions have, however, been questioned because they involve a substantial amount of NH staff time. This proposal is designed to determine whether the effectiveness of prompted voiding can be enhanced by either or a combination of two strategies: 1) identifying an assessment procedure that can be carried out by NH staff and enable them to target prompted voiding to incontinent residents who are most likely to benefit; and 2) adjunctive pharmacologic treatment for conditions commonly associated with incontinence in NHs-bacteriuria and detrusor hyperactivity. The study will involve 140 incontinent residents of several NHs over a 3-year period. Subjects will undergo an extensive evaluation of their incontinence including nursing and behavioral assessments, and both non-invasive and simplified urodynamic assessments of lower urinary tract function. Data from these assessments will be used as independent variables in multivariate analyses to identify factors that can be used by NH staff to predict responsiveness to treatment. The effects of eradicating bacteriuria on the frequency of incontinence will be systematically examined before prompted voiding is initiated by randomizing bacteriuric subjects to immediate vs delayed antimicrobial therapy, and making between and within group comparisons of incontinence frequency before and after therapy. The prompted voiding program will then be initiated for one week, which, based on previous studies, is a more than adequate time period to determine treatment responsiveness. Subjects who do not respond well to every 2-hour prompted voiding and who meet criteria for bladder relaxant drug therapy will then be entered into a 6-week double-blind placebo-controlled trial of oxybutynin, in order to determine if this drug enhances the effectiveness of prompted voiding in these selected residents. The proposed sample size will yield a power of at least .80 to detect clinically and statistically meaningful reductions in incontinence frequency with a two tailed alpha of .05. The outcomes of this project will be specific assessment and treatment strategies that will enable NH staff to efficiently target an effective behavioral intervention to residents most likely to benefit, as well as to identify residents who need more complex evaluations and other therapeutic approaches. These outcomes will be an important step towards improving the care of one of the conditions that currently contributes to the poor quality of care and poor quality of life for many NH residents.
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