INCONTINENCE.
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To avoid this, only ‘acceptable’ voiding is allowed so a given individual must be able to identify an acceptable place and get there safely. Advancing age and increasing disability can lower the threshold for control but incontinence is not an inevitable outcome of ageing.
Incontinence is an involuntary loss of urine or faeces in an inappropriate place. This implies that there were no physical or psychological barriers preventing access to an acceptable place but despite this the person excreted inappropriately. This necessitates a thorough investigation as many causes of involuntary loss of control are amenable to medical and surgical management.
These are dependent upon a host of factors such as age, sex, social class, society, nationality and present circumstances. The driver of a hansom cab is allowed by law to urinate against the rear offside wheel of his cab. This law has never been repealed, but putting it to the test would probably result in an arrest for obscene behaviour in a public place. Peasant farmers squat down in fields around the world, but Oxford Street (which was once a field) is certainly not now acceptable; society here has decreed the use of private lavatories or public conveniences.
Most people have no problem in identifying acceptable places. Difficulties arise, how-ever, when one is unaware of the location. This can happen to anyone in a strange town or building and is a plight experienced by people with dementia; they know they should get to an acceptable place but they cannot find it. If directed, continence results; if not, the near-est suitable alternative (bin or sink) is used rather than be wet.
There is no difference in behaviour between the demented patient and someone unable to find a toilet who urinates in the bushes or up against a Wall. In hospitals the lack of suitable toilets is a common cause of loss of continence. Patients may be aware of the need to go, of where to go and of acceptable alternatives (commodes) but are unable to get to them in time.
Some patients are placed on incontinence pads in bed, psychologically inviting loss of control. The necessity to get up at night to urinate increases with advancing age. High beds, night sedatives, cot-sides and shortage of help combine to prevent patients from getting to the toilet. It is essential that commodes and toilets be near the beds and chairs of elderly patients.
GETTING THERE
Psychological barriers
The indignity of being inadequately clothed (split-back nightdresses, pyiama bottoms that fall down) means that many people are incontinent rather than shame themselves crossing a semi-public Ward area ‘naked’. Loss of mobility This is the commonest cause of difficulty both in the community and in institutions. Most public conveniences were designed for the physically able.
There are few with access and facilities for the disabled. People taking diuretics or those with bladder or bowel control difficulties often have to plan routes on the basis of available toilet facilities; more commonly they become house bound. There is no need for architects and town planners to experience being old, a test dose of a fast-acting diuretic taken in the middle of a shopping precinct should concentrate the mind!
Location of toilet
An outside toilet requires that to be continent one must get outside (whatever the weather) or use another receptacle. Toilets upstairs depend on good physical mobility. Thus many elderly people who are ill at home have been ‘incontinent’ before they enter hospital, their illness preventing them from reaching the toilet. The loss of control is due to illness and associated immobility, not their age. A bedside commode may have enabled them to remain continent.
How they are treated in hospital will influence whether incontinence becomes an established pattern or not.
Ward toilets
The majority of hospital wards have too few toilets, often providing only two for 20-30 people. If we really expected people to be continent we would provide (as in hotels) a lavatory for each patient next to the bed. Most patients have to walk long distances then wait, Toilet doors are often heavy and the space may not permit a wheel chair or walking frame. Unless specifically designed, the seat will be too low, with no hand rails and toilet paper on a roll.
Try going to the toilet using only one hand, balancing on one leg and get a few pieces of paper off the roll at a time (this is often a situation stroke patients find themselves in).
Bad design Many hospitals are still equipped with old-fashioned high beds so that nearly all elderly patients need assistance to get in and out. If someone does try to get out unaided they either fall or sides are put up. If the bed is adjustable and set correctly most patients can get out unaided and cot-sides are certainly unnecessary.
Use of bed pans
The gymnastic prowess necessary to straddle a bed pan and maintain balance and position on it is difficult and exhausting for most elderly patients. The sheer act becomes one of dread and putting off its use can lead to retention and constipation with later face all incontinence due to overflow (spurious diarrhoea). A bedside mmmnde is easier to use.
Chairs
The correct chair is one that a person can get out of easily. Properly dressed (With underclothes), sitting in a chair of the correct height with a walking frame nearby, the majority of elderly patients can get to the toilet independently. They cannot do this if the chair is too high or too low, if they are trapped by a fixed table or if they feel inadequately dressed or cannot reach their walking frame.
Mercyvill.
