By Audrey Cochran
It happens all too often, a woman falls and fractures her hip in the middle of the night while hurrying to the bathroom. Or a family is worn out from changing wet beds or getting up several times each night to help grandmother to the bathroom, so into the nursing home she goes.
In 2004, a query appeared on the NAPGCM listserv about the best way to help an older man who may have been able to get by with one shift of in-home caregivers instead of two, if only he could sleep through the night instead of having to be helped to the bathroom every hour.
Looking through emails, which I saved because of my interest in the topic, were suggestions from other participants ranging from nighttime use of an external catheter attached to a urine drainage bag, which the client had already declined, placing three urinals on the rail of his hospital bed, or perhaps a funnel to a garden hose which drained into a plastic gas can.
Diagnosis:
In reading about this gentleman, my concern was getting a diagnosis and appropriate treatment. Managing frequent urination through an enlarged prostate is not about lining up urinals or attaching a hose. If the prostate is enlarged enough to cause partial obstruction and only high pressure overflow gets out, eventually pressures in the bladder force urine to back up into the kidneys and destroy them. If the obstruction is not reduced by medication or surgery, the problem will be solved when your client dies of kidney failure. One of the listserv members correctly pointed out the need for referral to an urologist.
The most common cause of incontinence is dehydration! Many people think if they drink less there will be less likely to leak, but actually they will leak more because of bladder irritation caused by the concentrated urine. Multiple studies of nursing homes show 60% of residents are dehydrated. No wonder residents have such a high rate of bladder infections, and often they are not treated unless they are exhibiting behavioral problems such as confusion. Many residents are unable to reach out and pour a glass of water from a heavy pitcher, especially if the pitcher is on a table behind them. Those with dementia, who respond automatically to visual cues, fail to see the pitcher so they do not think of drinking.
The second most common cause of poor bladder control in my private practice in a GYN office is constipation, and I suspect it is also true for nursing home residents. The mass of stool may prevent complete emptying of the bladder, leading to frequent bladder infections. It may also stimulate the bladder to empty before it reaches normal capacity. Even though doctors and other “experts” who have studied this phenomenon accept bowel movements between three times a day to once every three days as normal, I do not.
I show patients the “Bristol Stool Scale,” which can be found on the Internet, and ask them to point to the picture, which closely resembles what they see in the toilet. If they point to #1, which looks like “rabbit pellets” instead of a smooth banana (#4), then I suggest they take a plain magnesium tablet at dinnertime. The magnesium tablet has the added benefits of helping with sleep and providing the flexible matrix for bone reorganization, which occurs nightly.
(Please note magnesium is the food supplement found in the vitamin and mineral section of the drug store, not Milk of Magnesia that causes cramping and an unpredictable, rapid expulsion of feces. Magnesium is cheaper and far more effective than “stool softeners.” It is easier to swallow than bulking agents, and unlike the insoluble ones like Metamucil, does not cause gas. If one magnesium tablet with each evening meal makes no change within a week, I advise patients to double that, then if necessary add one with breakfast, and a week later add two. Only my patients on narcotics for intractable pain have found four per day necessary.
If the toilet contains ragged fragments or liquid (#6 or #7), the “diarrhea” actually could be encopresis caused by solid fecal matter blocking the rectum ,so only liquid stool higher up in the gut can be moved along by peristalsis, the rhythmic movement of the muscles in the large intestine.
Producing a large amount of urine at night may also be related to sleep apnea, especially in obese patients whose thick necks compress the trachea when they sleep on their back. Airway obstruction causes low oxygen and high carbon dioxide levels. This makes the heart send a signal to the kidneys to make more urine to get rid of fluid and relieve the pumping burden on the heart. Unrelieved, this condition can lead to heart attacks or eventually, heart failure. Get a doctor’s order for monitoring the oxygen level in the blood during sleep, which is done with a little device that clips on the end of the finger.
The challenge with some patients is keeping the device in place during sleep. One of my care management clients repeatedly pulled it off. It is possible to try an ace bandage wound around the hand and a large garden glove taped over that. If the oxygen level is low enough Medicare will pay for a C-PAP face mask and machine, which forces air into the lungs. The machine may need adjusting several times before the patient is comfortable and sleeps well.
Solutions and Resources:
The older we are, the more likely we are to develop urge incontinence. To an older person, a full bladder really is an emergency and should not be postponed until after meal trays are collected. This was the routine in one facility for which I provided training as part of a Plan of Correction mandated by the licensing body.
To calm down a twitchy bladder, there is a simple trick I teach all my patients and explain when I give talks on this subject. If repeated rapidly five or ten times, it causes the detrusor, the muscle inside the bladder wall, to reflexively relax, just like when the doctor taps your knee and your foot goes up. “But you have to do it very rapidly, like tapping your finger on the table (and I have them do that). Since those muscles go in circles like the muscles around your eyes, it’s sort of like winking. So let me see you wink your right eye, now wink your left eye, – now wink your anus.” They are startled by this unusual command, but comply. On my biofeedback machine they can see the electrical signals to those muscles die down. If an older patient doesn’t understand what I asked them to tighten, I say, “We make about a quart of gas a day. Which muscle would you tighten if you were about to pass gas at church and everyone was quiet just before the congregation started to pray?” That usually helps them understand. This will buy about a half hour, enough time to find a toilet and rearrange one’s clothing. A product, which can help, is a urinal attached to a drainage bag, which one of the listserv members suggested. It is available in male or female versions. One source of the “Advantage Urinal System” charges $430.73 for a case of 10 for the male version, and for a female slightly higher. Do the math to determine if that is more cost effective than having a caregiver at night.
If women require help in night-time toileting, they may feel more comfortable seated than using a urinal. If they can transfer independently to a bedside commode, that may solve the problem of nighttime staffing. If a woman can apply estrogen cream vaginally with an applicator, or to her inner labia twice a week (initially daily), that also plumps up the lining of the urethra so she doesn’t have to tighten her pelvic floor muscles so strongly in order to close against a sneeze or change in position. Estrogen cream applied topically does not pass through the liver then into the entire body, hence is less likely to cause breast cancer or cardiac problems.
At a specialty nursing conference in the late 90s I met Linda Asta, a nurse who developed The Feminal, a purple urinal contoured specially for the female anatomy, and a catheter guide women could use instead of struggling with a mirror. The latter probably would be more useful for a woman with M.S. than an elderly client with poor eyesight, severe arthritis, and memory problems.
Freshette often runs an ad in the Sierra Club magazine, because of the challenge women have when hiking on a trail miles from nowhere. Guys can slip behind a tree or bush every couple of hours and nobody is the wiser, but women have to squat and hope we don’t return to the group with splash marks in the dust on our hiking boots. Go to http://www.freshette.com/ and see their collapsible, portable funnel for women to slip inside the fly opening of their pants, after attaching a short tube. Freshette also makes a version with long tubing suitable for women confined to a wheelchair, or for whom transferring on and off a toilet is difficult.
“Old Folks In Wet Beds” was published in the British Medical Journal in 1962. There is no excuse for those conditions to exist today with all the research and technology of the intervening years.
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This article is reprinted with permission from Aginglife.org. As the preeminent resource for aging care, Advocare Care Management offers a range of services to address your unique needs and ensure the well-being of your loved ones.