AC FFC Tidbit of the Week for May 22, 2022: Proactive Toileting with Older Adults

Hospitalized older adults may experience intermittent incontinence, even if they are typically continent at home. This can be due to delirium, infection, and changes in their daily routine. One of the most effective and beneficial strategies for managing intermittent incontinence is to try proactive toileting during the day.

  • Proactive toileting means that staff direct and assist patients to the commode or toilet routinely throughout the day, without waiting for patients to request to go. Patients who have dementia or other cognitive impairment may not be able to verbalize that they need to use the bathroom but will go when you help them. Many patients, when given the opportunity to visit the commode or toilet routinely, will achieve daytime continence.  A suggested schedule for offering the toilet is: upon waking up in the morning, before and after meals, and prior to bedtime. 

Sometimes, in place of proactive toileting, patients are given external catheters. These are appropriate in certain situations but should be used sparingly and cautiously. 

  • External urinary catheters are sometimes used as an alternative to indwelling urinary catheterization as they are non-invasive, do not require a provider order, and have been shown to reduce risk of catheter associated urinary tract infections. They are intended to be used for patients who are already incontinent and have poor mobility related to surgeries or end-of-life care.
  • When external catheters are used with people who are continent, not only can it feel like an indignity, but their use also reinforces individuals to be incontinent. In contrast, the use of bedpans does not reinforce incontinent behaviors and requires some movement on the part of the patient. And as we know, movement for hospitalized patients is good!
  • In most cases, they should be limited to overnight use for incontinent patients, when patients are sleeping in bed.
  • While external catheters can help reduce the risk of UTI’s that occur with indwelling catheters, they should NOT be used if the patient has urinary retention or skin breakdown.
  • They should also not be used for the sake of convenience (even if a patient requests it!), to avoid the need to get a patient out of bed and walk to the bathroom. If you or your team is considering using one with a patient, be certain that it is for an appropriate reason and all other alternatives have been explored. An external catheter is a tether to the bed, which can hinder our efforts to promote out of bed activity as well as present a fall risk if a patient tries to get up or loses lower and core muscle strength due to inactivity.
  • Prolonged bedrest and lack of mobility present major health risks to patients, especially older adults, as we’ve discussed in other tidbits. The benefits of external catheters can often be outweighed by the risk of immobility and decreased function. Assisting a patient to use the bathroom may take some extra time, but it is also an opportunity to help the patient mobilize, do range of motion exercises, maintain dignity, and avoid the risk of skin breakdown that comes with catheter use.

Talk about proactive toileting with your team this week and choose a patient or two to start with. Have a great week!

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