**1. Introduction**

88 Urinary Incontinence

WHO/FIMS (1995). Committee on Physical Activity for Health: Exercise for health. *Bullettin* 

135-136, ISSN: 0042-9686.

*of the World Health Organization: The International Journal of Public Health,* Vol. 73, pp.

The prevalence of urinary incontinence (UI), although difficult to define due to underreporting, is estimated to affect over 13 million Americans, and greater than 50% of residents residing in long-term care (LTC) facilities (Bennet, 2008; Earthy & Nativ, 2009; Parker, 2007). It has been estimated that the cost of UI in Canadian LTC facilities is approximately \$3000.00 to \$10,000.00 per year for each resident experiencing UI (Earthy & Nativ, 2009). The Canadian Continence Foundation (2005) reported that one in four middleaged and older women are affected by UI. By the year 2050, the number of women likely to experience UI will increase by 46% (Romanzi, 2010). The increasing prevalence of UI in long term-care facilities from 55% to 65% over the past 10 years is alarming, and requires careful consideration by healthcare providers and policy-makers (MacDonald & Butler, 2007; Sahyoun, et al., 2001).

UI is a multidimensional healthcare issue that should be viewed from various perspectives and contexts, as a condition requiring operational, clinical, strategic, and interdisciplinary focus (Klusch, 2003). However, the current state of the knowledge maintains that much of the existing literature continues to explore UI from the contexts of the medicalization of UI, the physical and economic burdens of UI, the marginalization of elderly women experiencing UI in long- term care, and healthcare providers' attitudes, approaches, and strategies to managing UI in LTC. There were few references found that discussed how elderly women managed their UI, and the effects of UI on the quality of life (QoL) from the women's lived experiences. To date the psychosocial effects of urinary incontinence for elderly women has received minimal attention in the current research literature. Physiological complications and the implications for symptom management of UI are the predominant research issues being addressed. The following chapter presents an account of the current state of knowledge with each of the aforementioned topics discussed in relation to elderly women in LTC. The chapter will begin by defining UI, and end with a necessary discussion of healthcare practices, education, and research related to elderly women and UI in LTC.

#### **2. Background**

UI is a prevalent health issue adversely affecting the quality of life, well-being and psychosocial aspects of elderly women's lives residing in LTC (Bradway et al., 2010;

Elderly Women and Urinary Incontinence in Long-Term Care 91

urban, LTC setting in Eastern Nova Scotia, Canada, discussions of UI frequently occurred in relation to the economic burden of managing the problem. Procedures and strategies were designed to maintain costs of products used for UI, with little consideration given to comfort or appropriateness of interventions from the resident's perspective or the overall

Some healthcare providers and caregivers in LTC may define UI in terms of the demanding workload and the timely investments dedicated to physical management of changing incontinent products, voiding schedules, and soiled linens and clothing changes (Brink, 1990, Palmer, 1996). Furthermore, UI maybe viewed by some healthcare professionals as low on the priority list of healthcare needs, and not a prudent expenditure of precious time and energy (Bayliss & Salter, 2004). In an attempt to reduce or eliminate UI, it has been documented that some healthcare providers and caregivers in LTC spend productive time implementing fluid management strategies and double incontinent products worn in an attempt to deal with the issue of UI (Brink, 1990). Physicians on the other hand, may define UI in regards to assessment, diagnosis, medical and/or surgical technologies and management, and pharmacological treatments (Day et al, 2010). This definition incorporates the philosophy of controlling and/or curing UI for those individuals experiencing the condition and tends to medicalize UI. Conversely, elderly women experiencing UI in LTC may subjectively define UI with respect to psychological, social, economic or physical implications and contexts (DuBeau et al., 2006; Getliffe et al., 2007; Hagglund & Ahlstrom, 2007; Howard & Steggall, 2010; Lifford et al, 2008; MacDonald & Butler, 2007; McDermott, 2010; Norton & Brubaker, 2006; Palmer, 1996; Parker, 2007; Wilson, 2003; Zeznock et al, 2010). The loss of bodily control, decrease in activities of daily living, social isolation, skin infections and dermatitis, falls, cost of incontinent products, and embarrassment maybe considered important in a UI definition to elderly women (MacDonald & Butler, 2007; McDermott, 2010; Nix & Haugen, 2010; Palmer, 2008; Parker, 2007; Stewart, 2010; Wilson, 2003). Also, it has been well documented in the literature that elderly women experience feelings of being less attractive and different from others resulting in shame, depression, and loss of self-confidence and inferiority, which must be considered when defining UI from the individuals perspective (Gallagher, 1998; Goldstein et al., 1992; Grimgy et al., 1993; Lifford

The diversity in definitions, terminology, and perspectives pertaining to UI can lead to confusion and ambiguity about the health issue, which in turn impacts upon UI care. The lack of common, cohesive and holistic definitions and terminology relating to UI makes it difficult for healthcare professionals, caregivers, researchers, educators and those experiencing UI to communicate and conceptualize issues, solutions, and interventions (Palmer, 1996; Zeznock et al, 2010). Moreover, clear, common, and cohesive UI definitions and terminology could provide individuals with an opportunity to give voice and meaning to their experiences of living with UI, and subsequently influence their care (Hagglund & Ahlstrom, 2007). Thus, myths and ideas of UI being a normal part of ageing could be dispelled, while increasing the possibility of making UI an important healthcare issue that

The author suggests that definitions and terminology about UI may be expanded to encompass the social determinants of health and the broader impact of cultural, political, and economic contexts that influence individuals' experiences with UI. There is also a need

impact on QoL.

et al, 2008; Palmer, 2008; Hunskaar & Vinsnes, 1991).

requires timely attention and resources.

Howard & Steggall, 2010; Palmer, 2008). UI has been documented as a primary reason for institutionalization and admission to LTC facilities, and documented to negatively impact social, sexual, and physical activities of elderly women (Lifford et al., 2008; Stewart, 2010; Wilson, 2003). Yet, UI has been acknowledged as an inconvenience, rather than being a health issue requiring adequate healthcare resources (Hu, 1990; MacDonald & Butler, 2007; Norton & Brubaker, 2006). Given that, UI is not life threatening to women, often results in UI care not being viewed as a priority, therefore, it is repeatedly under-reported, undertreated, and often mismanaged (McDermott, 2010 Norton & Brubaker, 2006). UI has been labelled a "silent epidemic" and a worldwide health issue that commonly affects women (Beji et al., 2010).

Although UI has devastating physical and psychological effects on individuals, family, friends, and caregivers (McDermott, 2010; Wilson, 2003), society continues to stigmatize and associate UI with as inevitable component of ageing that is considered normal, and effortlessly managed (Bennet, 2008; Bradway et al., 2010). As suggested in the literature, this stigma has the potential to isolate women and render them silent about their experiencing of UI, hence, women accept UI as being a normal part of life (Borrie et al., 2002, Howard & Steggall, 2010; MacDonald & Butler, 2007; Robinson, 2000). This in turn, potentially may prevent women from accessing supportive healthcare services and seeking appropriate measures to assist in the prevention or management of UI (Bennet, 2008; Parker, 2007; Hagglund & Ahlstrom, 2007). The stigma of UI is further compounded by some healthcare professional trivializing UI in comparison to other healthcare issues and "by incorrectly describing it as a non-hierarchical index of functional status" (Wilson, 2003, p.752). While frequently cited as the primary reason for admission of elderly women to LTC, the impacts of UI are continually misunderstood, downplayed, under-reported, under-treated, silenced and not well defined (Borrie et al., 2002; Norton & Brubaker, 2006; Zeznock et al., 2009).
