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2000 Nursing Home Ombudsman Agency of the Bluegrass, Inc.

Urinary incontinence, the inability to control the bladder, is one of the most common reasons people are placed in nursing homes. More than 50 percent of Kentucky nursing home residents are incontinent. Incontinence causes many problems, including skin rashes, pressure sores, falls, isolation, and psychological harm. In the past, treatment of incontinent residents was often limited to constant changing of diapers, pads and bedding. However, new studies show that incontinence is not a normal part of aging and is often reversible. This Info Sheet discusses care options for incontinence, including residents' rights to choice of incontinency care products such as cloth and disposable diapers.

Care Options

As a result of growing knowledge about incontinence, federal rules require screening and assessment for urinary incontinence and a plan of care for each resident found to have the condition. The first step in treating incontinence is determining its cause. Incontinence may be caused by physical or mental disorders or by decreased mobility. Some common causes or types of incontinence are described below:

Lack of Toilet Access -- Many residents need help in getting to the toilet; regular staff assistance is necessary. This may mean helping residents to the toilet or providing a bedside commode, urinal, or a room or a bed that is closer to the bathroom. Residents in wheelchairs should have access to barrier-free bathrooms.

Immobility -- Residents who are immobile may have control of their bladder but be unable to reach the toilet. Improving the resident's ability in walking, transferring and toileting will often reduce incontinence.

Dexterity -- Some residents may not be able to adjust their clothing to use the toilet. Special clothing or staff assistance may be needed to help overcome this problem.

Depression -- Severe depression can reduce a resident's desire to stay dry. Treating the depression may resolve this problem. In the meantime, the nursing home should encourage depressed residents to use the toilet as needed.

Disorientation -- Some residents are no longer aware of their surroundings or no longer sense their own needs. Scheduled toileting--reminding and assisting a resident to toilet on a regular basis--may overcome this problem.

Medications -- Many medications can affect the bladder and cause incontinence. Residents on diuretics, for example, may need to toilet frequently after taking the drug. Changing administration of the drug from the evening to the morning may help a resident remain continent through the night. Some medications help relax the bladder and are used to treat incontinence.

Diet -- Some types of food products, such as caffeine and alcohol, irritate the bladder. Reducing or eliminating their use may be helpful.

Medical Problems -- Conditions such as congestive heart failure, urinary tract infection, fecal impaction, and pedal edema may contribute to incontinence. Treatment of these conditions will improve both incontinence and functional status.

Fluid Intake -- Do not decrease fluids. Adequate fluids--four to six glasses of juice or water daily--are needed for the bladder to operate properly. Exceptions exist for residents whose medical condition requires fluid restrictions. Decreasing fluid intake before bedtime will help reduce night-time toileting.

Urge Incontinence -- Residents with this common condition may feel the need to urinate but be unable to suppress the need long enough to reach the toilet. A scheduled toileting routine can address this problem.

Stress or Overflow Incontinence -- Stress incontinence, often triggered by coughing, laughing, or sneezing, results in small amounts of leakage between toileting times. Inability to completely empty the bladder is a symptom of overflow incontinence. The resident's physician can help identify treatments for these conditions.

It is a good idea to check with the nursing home's director of nursing and the resident's attending physician for information about assessment and treatment of incontinence.

Managing Incontinence

If the treatments and environmental modification do not prevent episodes of incontinence, some type of absorbent clothing will be needed. Cloth or disposable diapers, sometimes called adult briefs, are most often used for this purpose. Regardless of which product is used, it is important that the resident be kept clean and dry and that diapers, clothing and bedding be changed as often as needed. Use of a catheter to manage incontinence is not recommended unless absolutely necessary. Catheters cause discomfort and increase the risk of infection, bladder stones and cancer.


Cloth v. Disposable Diapers

Residents of Kentucky nursing homes do not automatically have the right to choose the type of incontinency product used in their care. If you are paying privately for your nursing home care, your home may charge you extra for the product you select. If Medicaid is paying for your care, the nursing home cannot charge you for either cloth or disposable briefs (diapers). Medicaid rules state:

1. The nursing home must not charge you for cloth or disposable briefs,

2. The nursing home must not limit the number used; this should be based on your need.

3. The nursing home is not required to supply more than one brand of each type of brief.

4. If you want a different brand, you may purchase it yourself.

Some factors to consider when making the choice between cloth and disposable diapers include dignity, health considerations, and environmental impact. For some residents, cloth diapers may be more comfortable and less prone to contribute to irritation from rash. Others may need a more absorbent product and find disposable diapers able to fit that need. Residents should determine what product will best meet their needs and ask the nursing home to honor their choice.

What Can You Do If Choice Is Not Provided?

If you feel that you are not being offered a choice of incontinency product, or if you are unsure as to the best choice for you, you may consider speaking with the Director of Nursing during a care plan meeting or at any other time. Explain your preferences. If choice is not offered, you may contact the Nursing Home Ombudsman Agency office for further assistance.

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