Incontinence and Mood in Long-Term Care

Abstract

Objectives: This study determined the effects of discomfort due to urinary incontinence on behavioural and emotive states within the long-term care setting.
Design: Retrospective, cross-sectional study.
Setting: Three long-term care facilities.
Participants: Data from 295 long-term care residents were gathered during 1999-2000.
Measurements: Long-term care clients were assessed using the Minimum Data Set 2.0.
Results: Predictors of disruptive behaviour included male sex, diagnosed dementia, diagnosed depression, impaired cognition, and level of urinary incontinence. Predictors of depressed mood included diagnosed depression and impaired cognition. An interaction of type by use of briefs was significant. Close examination of the interaction revealed a greater number of residents using reusable briefs displayed disruptive behaviour; similar results were also found with respect to depressed mood. Unlike the home that used disposable briefs, more residents in homes using reusable briefs showed depressed mood. There was no significant effect of briefs on mood in the home that used disposable briefs. Conclusions: Long-term care facilities that use reusable briefs may reduce disruptive behaviour and depressed mood by employing disposable briefs.
Key Words: disruptive behaviour, incontinence, long-term care

Introduction

As measured by the Minimum Data Set 2.0 (MDS 2.0), disruptive behavior by long-term care residents includes verbal or physical aggression towards other residents or staff, socially inappropriate behavior, and attempts to resist care. Risk factors for disruptive behaviour include impaired cognition,1,2,3 impaired physical functioning,1,4,5 mood disorder,3 urinary incontinence,4,5 and older age.5 Sloane et al.6 examined verbally disruptive behaviour and concluded that it “arises largely in people with cognitive impairment and generally reflects an underlying need or discomfort” (p. 675). The same is likely to be true for other forms of disruptive behaviour and adverse mood.

Sources of unmet need and discomfort in long-term care include problems arising from urinary incontinence. Urinary incontinence is a frequent problem in this population with prevalence rates of between 61-80%.7 Because incontinent residents frequently have impaired cognition as well as physical deficiencies, such residents may be unable to articulate the needs and discomfort that accompany incontinence.

The most common procedure to manage urinary incontinence is the use of adult briefs. When used properly adult briefs help to minimize problems that include spills, aversive odour, and skin disorder. The two main types of brief are disposable and reusable. Claims made in favour of disposable briefs include superior absorbance, leakage prevention and comfort,8 and residents may prefer them to reusable briefs.9 Incontinence may also contribute to concomitant skin disorders that include rashes and ulcers.10,11,12 Because at least two studies reported more frequent skin disorder with disposable than reusable briefs,11,12 it is possible that soreness because of concomitant skin disorder may add to discomfort.

If discomfort does affect behavioral and emotive states, as Sloane et al.6 contend, it is reasonable to hypothesize that such states should vary with type of brief and concomitant skin disorder. Discomfort because of wetness should be higher in residents using reusable rather than disposable briefs, and discomfort because of soreness should be higher in residents with skin disorder. The purpose of this research was to test these hypotheses using data from the Minimum Data Set 2.0 (MDS 2.0) by comparisons across homes that routinely used either disposable or reusable briefs.

Methods

Participants

The participants were aged 65 years or older and residents of three long-term care facilities in the same city in Ontario. One home used only disposable briefs. The other two homes used reusable briefs as routine practice except for a small minority of residents (<5%) of one home that used disposable briefs at the request of their families. After exclusion of comatose residents and those using catheters, the total sample consisted of 295 residents (208 women and 87 men, mean age = 81.4). The home that used only disposable briefs had 70 residents (45 women and 25 men, mean age = 84.55). The homes using reusable briefs as routine practice respectively had 101 residents (80 women and 21 men, mean age = 82.34) and 124 residents (83 women and 41 men, mean age = 82.34).

Measures

All the measures except the type of brief routinely used in the homes were from the MDS 2.0. The MDS 2.0 is a comprehensive assessment tool mandated for use in all licensed nursing homes in the USA since 1991 and administered with generally high inter-rater reliabilities by trained assessors.13 The measure of disruptive behavior was a reliable eight-item index described by Stones et al.,3 that measures physical and verbal abuse by residents, socially inappropriate behavior, and care resistance during the week before assessment. The measure of mood was the Depression Rating Scale (MDSDRS) that showed acceptable reliability and validity in previous research. The MDSDRS contains items on negative statements, persistent anger, unrealistic fears, repetitive health complaints, repetitive anxious complaints, sad facial expression, and tearfulness in the 30 days preceding assessment, with a cut-off of three points for depressed mood. Other indexes from the MDS 2.0 included demographics (age, sex), diagnosis of mental state (dementia, depression), functional capability (activities of daily living short scale, Lawton’s index of cognitive impairment,15 urinary incontinence, skin disorders associated with urinary incontinence (rashes, ulcers), and use of briefs in the previous 14 days. The other measure used in analysis was the type of brief routinely used in the home (disposable versus reusable).

Procedure

Trained assessors collected the data as part of a provincewide Resident Assessment Instrument Health Infomatics Project (RAIHIP) during 1999-2000.

Results

The dependent measures had adequate alpha coefficient reliabilities of .84 for the disruptive behavior measure and .72 for the mood measure. The percentage of residents showing any evidence of disruptive behavior was 49.2%, and 20.4% of residents scored above the cut-off for depression on the mood measure. Other frequency estimates included 38.6% of residents with a diagnosis of dementia and 15.9% with diagnosed depression; 30.8% fully continent and 46.4% incontinent on a daily basis; 22.9% with a rash and 11.5% with any stage of ulcer. Comparison across the homes differentiated according to the type of brief in routine use showed no significant differences in demographics, diagnosed dementia, diagnosed depression, activities of daily living, cognitive impairment, urinary incontinence, and ulcers. The only significant differences were higher frequencies of brief use (i.e., 67.1% versus 47.1%; x2[1]=8.58, p<.005) and rashes (i.e., 48.6% versus 13.8%; x2[1]=37.62, p<.001) in the home that used disposable briefs. The main analyses used hierarchical logistic regression to predict any disruptive behavior and scores above the cut-off on the mood measure. The predictors entered at the first step were age, sex, diagnosed dementia and depression, activities of daily living, cognitive impairment, urinary incontinence, presence of rashes and ulcers, type of brief used in the home, and use of brief in the 14 days before assessment. Age, activities of daily living, cognitive impairment, and urinary incontinence were continuous variable and the remainder binary variables. The second step added the interaction between type and use of brief to the predictor array only if it contributed significantly to the prediction model.

The interaction of type by use of briefs was significant in both analyses. The other significant coefficients are shown in Table 1 as follows: the predictors of disruptive behavior included male sex, diagnosed dementia, diagnosed depression, impaired cognition, and level of urinary incontinence; the predictors of depressed mood included diagnosed depression and impaired cognition.

Further analyses to clarify the significant interactions used crosstabs. Figure 1 shows the interactive effects of type by use of briefs on disruptive behavior. Disruptive behavior was highest in residents with reusable briefs, with the relationship between disruptive behavior and briefs significant only in the homes that routinely used reusable briefs (x2[1]=36.55, p<.001). The interaction was similar with respect to depressed mood. More residents with than without briefs showed depressed mood in the homes that used reusable briefs (30.2% versus 11%; x2[1]=12.75, p<.001), with no significant effect of briefs on mood in the home that used disposable briefs.

Discussion

This study compared a home that used only disposable briefs with homes that used reusable briefs exclusively or for more than 95% of residents. Trained assessors completed measures from the MDS 2.0 that had adequate reliability in the present and previous studies. Although limitations to the design include the cross-sectional comparison across homes that may differ in ways beyond the scope of the measures taken, there was no evidence of differences across the homes with respect to distributions on age sex, diagnosed dementia, diagnosed depression, activities of daily living, cognitive impairment, urinary incontinence, and frequency of ulcers. The only univariate differences between homes were a higher use of briefs in the home using disposable briefs – an interpretation of this finding is that the greater convenience of disposable briefs contributed to a more frequent usage – and a higher frequency of rashes that was probably contingent on the use of disposable briefs.

Consequently, these findings suggest that the homes were comparable except for effects associated with type of brief.

The hypotheses for the study were that wetness and soreness associated with urinary incontinence might be sources of discomfort that affect disruptive behavior and depressed mood. The findings failed to support the soreness hypothesis with no evidence for relationships of the dependent variables with skin disorder. This null finding might simply reflect the effective management of skin disorder to mitigate soreness or that soreness has minimal effects on behavior and mood. The findings did support the wetness hypothesis with higher frequencies of disruptive behavior and depressed mood in residents wearing briefs only in the homes that used reusable briefs. Support for this hypothesis rests on the claim that reusable briefs are less efficient in wetness absorption and leakage prevention than disposable briefs.8 Alternative interpretations – that relate the frequency of usage of the different types of brief to the dependent variables – appear untenable because the significant effect was the interaction between type and use of brief with the component terms being nonsignificant. The other measures found to be significant predictors of disruptive behavior (i.e., male sex, cognitive deficiency, diagnosed depression, urinary incontinence) and depressed mood (i.e., cognitive impairment, diagnosed depression) are consistent with reports previously cited in this article.

The implications of the findings are of possible reductions to disruptive behavior and depressed mood through the substitution of reusable briefs by disposable briefs. Disruptive behavior by residents not only adds to the burden experienced by their peers and staff but also detracts considerably from the time available to staff to provide good quality care. Although the costs of disposable versus reusable briefs was outside the scope of this article, future research might consider inclusive costs that account for effects on disruptive behavior and depressed mood.