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New Guidance for Ethical Urinary Incontinence Care for Older Adults

An International Continence Society working group led by UCSF urologist Anne M. Suskind, MD, MS, FACS, FPM-RS, recently published a white paper that provides an ethical framework for caring for older adults with urinary incontinence.

Suskind, chief of Neurourology and Female Pelvic Medicine and Reconstructive Surgery at UCSF, studies special considerations in treating older adults, particularly those with frailty and dementia. “I’m passionate about these vulnerable populations, which are certainly growing as people live longer,” she said. 

Factors to guide ethical care for urinary incontinence

“I chaired this international, multidisciplinary group of experts, including nurses, geriatricians, urologists and social scientists,” Suskind said. “We delved into specific ethical considerations for these unique populations that don’t necessarily get a lot of attention. There wasn’t anything in the literature like this.”

Suskind and the working group developed guidance that reflects the perspectives of patients, caregivers and health care professionals: 

  • Health systems should create environments that support ethical continence care. It is essential to provide care to meet each person’s needs within the home or institutional environment. The availability of knowledgeable caregivers and the infrastructure to support effective continence care varies widely. Health care professionals, policymakers and hospital and home-care administrators share responsibility for ethical continence care delivery practices. 
  • All older adults should be treated with dignity. Special consideration is needed when caring for those with cognitive impairment or frailty. Effective verbal and nonverbal communication are required. “It’s important to maintain dignity as much as possible, which sounds simple but is somewhat revolutionary,” Suskind said.
  • The health care team should elicit the patient’s goals of care. For patients who cannot make decisions on their own, providers will need to work with a surrogate decision-maker to determine a treatment plan that best aligns with the patient’s goals and values.
  • Advanced communication methods should be used in intimate continence care interactions. This is especially important when cognitive conditions involve aggressive behavior.
  • Treatment should be aligned with goals of care. Treatment plans need to be discussed and updated regularly as patients’ needs and conditions change.
  • The health care team should consider the potential burden of treatment, based on multimorbidity, frailty, and physical and cognitive impairments. Health care professionals also need to be aware of possible biases related to ageism. Patient- and context-sensitive care plans are essential for a holistic approach in treating older adults with urinary incontinence.

Many factors drive patient outcomes

Suskind also led an outcomes study comparing nursing home residents and community-residing older adults who had surgery for bladder and bowel dysfunction. The study found that nursing home residents had a higher risk of complications and mortality.

“There truly is something beyond comorbidity and age that’s driving these poor outcomes,” Suskind said. “We believe frailty is a component, but it’s probably multifaceted.

“The big-picture message of my work is bringing awareness to special considerations in treating older adults, particularly with quality-of-life issues related to urinary incontinence,” she added. “It’s so important to look holistically at individual patients.”


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UCSF Urology Practice
Phone: (415) 353-2200 | Fax: (415) 353-2641
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UCSF Women’s Center for Bladder & Pelvic Health
Phone: (415) 353-2200 | Fax: (415) 353-2641
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