**3. UI defined**

The term UI can be defined in multiple and diverse ways by different groups and individuals (Palmer, 1996). The International Continence Society (ICS) has defined UI as a condition of involuntary urine loss that is objectively demonstrable and is a social or hygienic problem (Thakar & Stanton, 2000). This definition implies that UI can have a detrimental effect on the lives of those experiencing the condition (Hunskaar & Vinsnes, 1991). The ICS is an international society for medical professionals, concerned with furthering education, scientific research, clinical practice and removing the stigma of incontinence (ICS, 2011). The ICS has developed definitions and terminology for researchers pertaining to UI types, assessment, and diagnosis in an attempt to standardize UI discourse. The ICS has a global health focus committed to improve the QoL for individuals affected by urinary, bowel, and pelvic floor disorders through education, research, and advocacy.

Another group to consider when defining UI is administrators and managers in LTC facilities. According to Palmer (1996), administrators in LTC may define UI with respect to controlling the economic expenditures that is required to manage the issue. Budgeting monies for UI products, linens, and staffing to manage toileting, soiling, and skin breakdown is of primary concern to LTC administrators and managers (MacDonald & Butler, 2007). In my previous experience as a Director, Resident Care and site manager in an

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

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).

The term UI can be defined in multiple and diverse ways by different groups and individuals (Palmer, 1996). The International Continence Society (ICS) has defined UI as a condition of involuntary urine loss that is objectively demonstrable and is a social or hygienic problem (Thakar & Stanton, 2000). This definition implies that UI can have a detrimental effect on the lives of those experiencing the condition (Hunskaar & Vinsnes, 1991). The ICS is an international society for medical professionals, concerned with furthering education, scientific research, clinical practice and removing the stigma of incontinence (ICS, 2011). The ICS has developed definitions and terminology for researchers pertaining to UI types, assessment, and diagnosis in an attempt to standardize UI discourse. The ICS has a global health focus committed to improve the QoL for individuals affected by urinary, bowel, and pelvic floor disorders through education, research, and advocacy.

Another group to consider when defining UI is administrators and managers in LTC facilities. According to Palmer (1996), administrators in LTC may define UI with respect to controlling the economic expenditures that is required to manage the issue. Budgeting monies for UI products, linens, and staffing to manage toileting, soiling, and skin breakdown is of primary concern to LTC administrators and managers (MacDonald & Butler, 2007). In my previous experience as a Director, Resident Care and site manager in an

(Beji et al., 2010).

**3. UI defined** 

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 impact on QoL.

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

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 requires timely attention and resources.

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

Elderly Women and Urinary Incontinence in Long-Term Care 93

Findings revealed that UI in women adversely affects QoL. Major differences were found when age and symptoms were analyzed such that women who had the urge to void identified symptoms associated with greater impairment than the symptoms defined by women who had stress incontinence. However, age had a greater influence on the impact of stress incontinence. Elderly women reported little effect of stress incontinence in terms of impairment while younger women believed stress incontinence had a significant effect on

Norton & Brubaker (2006) discussed UI in terms if being under-reported and under-treated. The authors cited that in women "urine storage and emptying is a complex coordination between the bladder and urethra, and disturbances in the system due to child birth, aging or other medical conditions can lead to urinary incontinence" (p.5). Further, that stress and urge UI, the two main types of UI in women, can be evaluated and clinically assessed by most primary physicians. They go on to discuss the pathophysiology, epidemiology, symptoms, signs, urodynamic diagnosis and treatment options for different types of UI in women. However, the authors do mention in the assessment and management of UI in primary care, the importance of acknowledging stigma or effect on QoL of the woman, and to initiate non-surgical options depending on the type of UI and overall goals for treatment. Lifford, et al. (2008) used a prospective study design to examine the epidemiology of UI in older women. The authors cited that "establishing the epidemiological of UI can aid in identification of populations at risk, and help to target medical screening, prevention, and treatment" (p.1191). The study setting was a Nurses' Health Study that was established in 1976 when 121,700 female registered nurses in 11 United States responded to a survey pertaining to their medical history and lifestyles. Between 2000 and 2002 women were requested to complete two questions to evaluate their frequency of UI experienced and extent of urine leakage. Then, the rates of UI incidents and progression or remission of UI were calculated, and estimated relative risks of UI and associated risk factors completed by logistic regression. Results indicated women with no urine leakage at baseline reported 9.2% experiencing leakage at least once a month after 2 years. The women experiencing leakage at least weekly had an incidence of 3.6% with stress UI being the greatest incidence followed by mixed and urge UI. Stress UI in the women was found to decrease with age, while urge and mixed UI increased with age. With regards to the prevalence UI in the year 2000, findings indicated that 32.1% of the women experiencing leakage once a month progressed to experiencing leakage at least once a week over follow-up. Furthermore, 8.9% of women with frequency leakage in 2000 indicated an improvement to monthly leakage or less, while 25 had experienced complete remission. Conclusions from the study revealed that the UI incidence is high in older women, with the progression from occasional to frequent leakage being very common, while urge UI increases with age and has limited effective treatment modalities. Therefore, it was proposed that more research on UI prevention in older women

the overall QoL.

needs to be conducted.

**5. The burdens of UI on QoL of elderly women** 

UI imposes devastating psychosocial, physical and economical burdens for elderly women (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). Elderly women's

to combine the cost factors related to the management of UI in long- term care, with the fiscal and human burden (cost) to women experiencing UI, to determine appropriate practices. What it means to experience UI and the impact on QoL, given the associated management strategies imposed on elderly women within LTC, is a critical concern for the delivery of holistic and individual continence care. Knowledge about the impact of UI on an individual's sense of self, and how that translates to the delivery of continence care has received minimal attention in the research literature. The need for healthcare providers to become more knowledgeable about the issues that effect the delivery of care related to UI requires an in depth analysis beyond budget consideration, to acknowledge the overall burden to elderly women experiencing UI in LTC. Thus, it is suggested by the author that UI may be viewed from a broader perspective encompassing the social, physical, economic, cultural, and political contexts rather than focusing primarily on a narrow perspective that can further lead to the medicalization of UI.

### **4. Medicalization of UI**

UI has been associated with several disease processes and is reported to be one of the major causes of admission to long- term care facilities (Beji et al., 2010; Bradway et al., 2010; Coward et al., 1995; Du Moulinet al., 2009; Edwards, 2001; MacDonald & Butler, 2007; Norton & Brubaker, 2006; Thom et al, 1997). Yet, there is minimal research regarding the psychosocial impact of UI on elderly women. UI creates a multidimensional healthcare problem, which has become medicalized as evidenced by the predominance of diagnostic and treatment regimes. Further, UI is often associated with co-morbidity and invasive procedures such as urodynamic studies, catheterizations and pelvic examinations, particularly in the elderly (Norton & Brubaker, 2006; Resnick, 1992). However, for over twenty years, literature has suggested that incontinence in the elderly is curable with medical and/or surgical interventions (Resnick). The elderly population may be a more vulnerable group relative to the fear of impending surgery or invasive diagnostic treatments that require hospitalization (Mitteness, 1990), which consequently poses a threat to maintaining independence. Being independent and able to control UI is of vital importance to elderly women's perception of themselves (Birgersson et. al, 1993). The following are some examples of research demonstrating the medicalization of UI.

Thom et al. (1997) in a review of 5,986 medical records of men and women aged 65 years and older examined the associations between medically diagnosed UI and factors such as; risk of several disease conditions, hospitalizations, nursing home admissions and mortality. Results indicated that the risk of hospitalization was 30% higher for women. There was also an increased risk of UI with a diagnosis of Parkinson's disease, dementia, stroke, depression and congestive heart failure for both women and men. In addition, the likelihood of nursing home admission secondary to UI was twice as high for women while the risk of mortality was a not significant. These results demonstrate a medical approach to institutionalized care when managing UI, which is more likely to impact women.

Hunskaar and Vinsnes (1991) used the Sickness Impact Profile (SIP) questionnaire to assess the QoL of women with UI according to age, symptom group, volume of urinary leakage, and duration of incontinence. Thirty-six women between 40-60 years and forty women aged 70 years or more were randomly selected from a medical clinic. Women were categorized into two subgroups, either urge to void or stress incontinence, as defined by the SIP.

to combine the cost factors related to the management of UI in long- term care, with the fiscal and human burden (cost) to women experiencing UI, to determine appropriate practices. What it means to experience UI and the impact on QoL, given the associated management strategies imposed on elderly women within LTC, is a critical concern for the delivery of holistic and individual continence care. Knowledge about the impact of UI on an individual's sense of self, and how that translates to the delivery of continence care has received minimal attention in the research literature. The need for healthcare providers to become more knowledgeable about the issues that effect the delivery of care related to UI requires an in depth analysis beyond budget consideration, to acknowledge the overall burden to elderly women experiencing UI in LTC. Thus, it is suggested by the author that UI may be viewed from a broader perspective encompassing the social, physical, economic, cultural, and political contexts rather than focusing primarily on a narrow perspective that

UI has been associated with several disease processes and is reported to be one of the major causes of admission to long- term care facilities (Beji et al., 2010; Bradway et al., 2010; Coward et al., 1995; Du Moulinet al., 2009; Edwards, 2001; MacDonald & Butler, 2007; Norton & Brubaker, 2006; Thom et al, 1997). Yet, there is minimal research regarding the psychosocial impact of UI on elderly women. UI creates a multidimensional healthcare problem, which has become medicalized as evidenced by the predominance of diagnostic and treatment regimes. Further, UI is often associated with co-morbidity and invasive procedures such as urodynamic studies, catheterizations and pelvic examinations, particularly in the elderly (Norton & Brubaker, 2006; Resnick, 1992). However, for over twenty years, literature has suggested that incontinence in the elderly is curable with medical and/or surgical interventions (Resnick). The elderly population may be a more vulnerable group relative to the fear of impending surgery or invasive diagnostic treatments that require hospitalization (Mitteness, 1990), which consequently poses a threat to maintaining independence. Being independent and able to control UI is of vital importance to elderly women's perception of themselves (Birgersson et. al, 1993). The following are

Thom et al. (1997) in a review of 5,986 medical records of men and women aged 65 years and older examined the associations between medically diagnosed UI and factors such as; risk of several disease conditions, hospitalizations, nursing home admissions and mortality. Results indicated that the risk of hospitalization was 30% higher for women. There was also an increased risk of UI with a diagnosis of Parkinson's disease, dementia, stroke, depression and congestive heart failure for both women and men. In addition, the likelihood of nursing home admission secondary to UI was twice as high for women while the risk of mortality was a not significant. These results demonstrate a medical approach to institutionalized care

Hunskaar and Vinsnes (1991) used the Sickness Impact Profile (SIP) questionnaire to assess the QoL of women with UI according to age, symptom group, volume of urinary leakage, and duration of incontinence. Thirty-six women between 40-60 years and forty women aged 70 years or more were randomly selected from a medical clinic. Women were categorized into two subgroups, either urge to void or stress incontinence, as defined by the SIP.

some examples of research demonstrating the medicalization of UI.

when managing UI, which is more likely to impact women.

can further lead to the medicalization of UI.

**4. Medicalization of UI** 

Findings revealed that UI in women adversely affects QoL. Major differences were found when age and symptoms were analyzed such that women who had the urge to void identified symptoms associated with greater impairment than the symptoms defined by women who had stress incontinence. However, age had a greater influence on the impact of stress incontinence. Elderly women reported little effect of stress incontinence in terms of impairment while younger women believed stress incontinence had a significant effect on the overall QoL.

Norton & Brubaker (2006) discussed UI in terms if being under-reported and under-treated. The authors cited that in women "urine storage and emptying is a complex coordination between the bladder and urethra, and disturbances in the system due to child birth, aging or other medical conditions can lead to urinary incontinence" (p.5). Further, that stress and urge UI, the two main types of UI in women, can be evaluated and clinically assessed by most primary physicians. They go on to discuss the pathophysiology, epidemiology, symptoms, signs, urodynamic diagnosis and treatment options for different types of UI in women. However, the authors do mention in the assessment and management of UI in primary care, the importance of acknowledging stigma or effect on QoL of the woman, and to initiate non-surgical options depending on the type of UI and overall goals for treatment.

Lifford, et al. (2008) used a prospective study design to examine the epidemiology of UI in older women. The authors cited that "establishing the epidemiological of UI can aid in identification of populations at risk, and help to target medical screening, prevention, and treatment" (p.1191). The study setting was a Nurses' Health Study that was established in 1976 when 121,700 female registered nurses in 11 United States responded to a survey pertaining to their medical history and lifestyles. Between 2000 and 2002 women were requested to complete two questions to evaluate their frequency of UI experienced and extent of urine leakage. Then, the rates of UI incidents and progression or remission of UI were calculated, and estimated relative risks of UI and associated risk factors completed by logistic regression. Results indicated women with no urine leakage at baseline reported 9.2% experiencing leakage at least once a month after 2 years. The women experiencing leakage at least weekly had an incidence of 3.6% with stress UI being the greatest incidence followed by mixed and urge UI. Stress UI in the women was found to decrease with age, while urge and mixed UI increased with age. With regards to the prevalence UI in the year 2000, findings indicated that 32.1% of the women experiencing leakage once a month progressed to experiencing leakage at least once a week over follow-up. Furthermore, 8.9% of women with frequency leakage in 2000 indicated an improvement to monthly leakage or less, while 25 had experienced complete remission. Conclusions from the study revealed that the UI incidence is high in older women, with the progression from occasional to frequent leakage being very common, while urge UI increases with age and has limited effective treatment modalities. Therefore, it was proposed that more research on UI prevention in older women needs to be conducted.

#### **5. The burdens of UI on QoL of elderly women**

UI imposes devastating psychosocial, physical and economical burdens for elderly women (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). Elderly women's

Elderly Women and Urinary Incontinence in Long-Term Care 95

Rolls (1997) explored the night time sleeping patterns of 18 residents living in a nursing home and the factors that impacted on sleep. Findings indicated that factors such as; environmental noise, lights, staff conversation, performance of routine incontinence care, and repositioning of residents who were immobile were major contributors to sleep disruption. Consequently, individualized incontinence care routines were considered as critical to promote sleep. In addition, Rolls (1997) asserted that residents experience more agitation during the day if awaken by night staff to perform incontinence care and repositioning. Thus, a lack of sleep due to the changing of incontinence products at night is

DuBeau et al. (2006) conducted a retrospective quantitative study using a Minimum Data Set (MDS) database involving 5 states (Kanas, Maine, Mississippi, New York and South Dakota) in the USA from 1994-1996. The purpose of the study was to determine whether nursing home residents with UI experienced worse QoL than continent residents, whether the relationship between QoL differs across cognitive and functional impairment, and to determine whether a change in continence status is associated with a change in QoL. The participants were aged 65 years and older. QoL was measured according to the MDS derived social engagement scale. Findings reported that UI was significantly associated with worse QoL in residents experiencing moderate cognitive and functional impairment, and new or worsening UI experienced over a 6 month period was associated with worse QoL. The authors suggested that this research evidence supports strong rationale for targeting interventions and strategies for those residents experiencing UI, while presenting an

Howard & Steggall (2010) in a descriptive literature review explored the relationship between UI, QoL and barriers to help-seeking behaviour in women. The authors indicated that factors such as severity of UI, type of UI, age, and actual QoL scores seemed to contribute to how UI impacts women's QoL. Reliable evidence concluded that increased severity of UI is as a predictor of impact on QoL (Huang et al., 2006; Yu et al., 2003). Yet, with increasing age the prevalence and severity of UI increases, but in younger women the impact of UI on QoL was found to be more significant than in their older counterparts (Monz et al., 2007). The major cue for seeking help for UI appears to have been the QoL score itself. This is supported by Yu et al. (2003) in their findings that indicated that QoL and women's perceptions of whether they viewed UI as a disease or not, were factors that

Not only do elderly women experience psychosocial impacts of UI, but the importance of physical and economic burdens that UI can impose should not be overlooked. UI predisposes elderly women to physical side effects such as rashes, dermatitis, skin infections, decubitus ulcers, and urinary tract infections (Du Moulin et al., 2009; Getliffe et al., 2007; Goldstein et al, 1992; Nix & Haugen, 2010; Schnelle, 1991). There is also an increased risk of falls associated with UI in the elderly, due to wet and slippery floors from dribbling and impaired mobility due to wearing bulky or poor fitting incontinence products (Hu, 1990; Loughrey, 1999; Parker, 2007). This was evidenced in my own nursing practice in LTC. Incidents of residents falling occurred while toileting by slipping on their own incontinent products or urine. For some, the outcome was traumatic requiring treatment

a burden affecting the QoL of individuals living in LTC.

incentive to improving continence care.

affected women's help-seeking behaviour.

**5.1 Physical and economic burdens of UI** 

emotional health can be negatively affected by experiencing UI (Gallagher, 1998; Howard & Steggall, 2010; McDermott, 2010). The following are some studies that will demonstrate the burdens of UI on the QoL of elderly women. Gallagher (1998) used a descriptive correlation research design to explore the relationship between urogenital distress and the psychosocial impact of UI in elderly women living in apartment complexes in Toledo, Ohio. The sample was comprised of 17 women over the age of 60 who experienced UI at least once a week. Findings indicated that there was a strong relationship between urogenital distress and the psychosocial impact of UI in elderly women. The author further reported that UI negatively impacted physical, social and emotional aspects of health. These findings are consistent with other studies that have identified factors that support a negative effect of UI. Another example, a quantitative study by Norton (1982) focused on the degree and extent of restrictions imposed by UI, using a sample of 55 women aged 22-78 who attended a urodynamic clinic. Results from the study demonstrated that incontinence did have farreaching psychosocial effects and contributed to women feeling anxious, embarrassed and unwilling to participate in a wide range of activities. To what extent age impacted on these restrictions and the psychosocial effects of UI was unclear given the wide variance in ages in this sample.

Whyman et al. (1987) measured the psychosocial impact of UI on 69 women living in the community, aged 55 and older using the Incontinence Impact Questionnaire (IIQ).The IIQ consisted of 26 items which asked women to rate the extent to which urine leakage affected their activities of daily living, social interactions and perceptions of self. Findings revealed that incontinence affects primarily women's perceptions of self. Daily activities most affected occurred when the availability of restrooms was unknown, and when women were unfamiliar with surroundings or engaged in physical recreation.

To acquire an understanding of older women's experience of UI in the community, Dowd (1991) interviewed seven women aged 58-79. Findings suggested that older women's experiences with UI posed a threat to their self-esteem. In addition, these older women employed a number of self-care strategies to control and normalize their UI into daily routines, thus maintaining their self-esteem and dignity. Although this study did address the psychosocial impact of UI in older women, the author neglects to identify or discuss the actual types of self-care strategies the women used to maintain self-esteem.

Sandvik et al. (1993) in a study of 187 women aged 19-91, investigated the psychosocial consequences of UI using a 38 item questionnaire mapping demographic data, medial history and toileting habits. Findings cited that 80% of the women interviewed considered UI to be more than a minor problem. The effect of age on these findings was not reported, which is a major limitation in interpreting the findings. These researchers defined three major concepts relating to the psychosocial impact of UI, mental distress, practical inconveniences, and social restrictions. Mental distress caused by UI included, fear of smelling, fear of discovery, feelings of despair, feeling dirty, feeling of inferiority, lack of self confidence, fear of being alone, loss of joy, and shame. Practical inconveniences caused by UI included smell, disturbed sleep, skin irritation, extra laundry, and added expenses. For women living in long- term care the "practical inconveniences" of smell and skin irritations are potential psychological burdens when attending socials, visiting with friends and families, or eating in the dining room. The social restrictions caused by UI included; lifting, laughing, travelling, dancing, shopping, wearing desired clothes, and entertaining guests.

emotional health can be negatively affected by experiencing UI (Gallagher, 1998; Howard & Steggall, 2010; McDermott, 2010). The following are some studies that will demonstrate the burdens of UI on the QoL of elderly women. Gallagher (1998) used a descriptive correlation research design to explore the relationship between urogenital distress and the psychosocial impact of UI in elderly women living in apartment complexes in Toledo, Ohio. The sample was comprised of 17 women over the age of 60 who experienced UI at least once a week. Findings indicated that there was a strong relationship between urogenital distress and the psychosocial impact of UI in elderly women. The author further reported that UI negatively impacted physical, social and emotional aspects of health. These findings are consistent with other studies that have identified factors that support a negative effect of UI. Another example, a quantitative study by Norton (1982) focused on the degree and extent of restrictions imposed by UI, using a sample of 55 women aged 22-78 who attended a urodynamic clinic. Results from the study demonstrated that incontinence did have farreaching psychosocial effects and contributed to women feeling anxious, embarrassed and unwilling to participate in a wide range of activities. To what extent age impacted on these restrictions and the psychosocial effects of UI was unclear given the wide variance in ages in

Whyman et al. (1987) measured the psychosocial impact of UI on 69 women living in the community, aged 55 and older using the Incontinence Impact Questionnaire (IIQ).The IIQ consisted of 26 items which asked women to rate the extent to which urine leakage affected their activities of daily living, social interactions and perceptions of self. Findings revealed that incontinence affects primarily women's perceptions of self. Daily activities most affected occurred when the availability of restrooms was unknown, and when women were

To acquire an understanding of older women's experience of UI in the community, Dowd (1991) interviewed seven women aged 58-79. Findings suggested that older women's experiences with UI posed a threat to their self-esteem. In addition, these older women employed a number of self-care strategies to control and normalize their UI into daily routines, thus maintaining their self-esteem and dignity. Although this study did address the psychosocial impact of UI in older women, the author neglects to identify or discuss the

Sandvik et al. (1993) in a study of 187 women aged 19-91, investigated the psychosocial consequences of UI using a 38 item questionnaire mapping demographic data, medial history and toileting habits. Findings cited that 80% of the women interviewed considered UI to be more than a minor problem. The effect of age on these findings was not reported, which is a major limitation in interpreting the findings. These researchers defined three major concepts relating to the psychosocial impact of UI, mental distress, practical inconveniences, and social restrictions. Mental distress caused by UI included, fear of smelling, fear of discovery, feelings of despair, feeling dirty, feeling of inferiority, lack of self confidence, fear of being alone, loss of joy, and shame. Practical inconveniences caused by UI included smell, disturbed sleep, skin irritation, extra laundry, and added expenses. For women living in long- term care the "practical inconveniences" of smell and skin irritations are potential psychological burdens when attending socials, visiting with friends and families, or eating in the dining room. The social restrictions caused by UI included; lifting, laughing, travelling, dancing, shopping, wearing desired clothes, and entertaining guests.

unfamiliar with surroundings or engaged in physical recreation.

actual types of self-care strategies the women used to maintain self-esteem.

this sample.

Rolls (1997) explored the night time sleeping patterns of 18 residents living in a nursing home and the factors that impacted on sleep. Findings indicated that factors such as; environmental noise, lights, staff conversation, performance of routine incontinence care, and repositioning of residents who were immobile were major contributors to sleep disruption. Consequently, individualized incontinence care routines were considered as critical to promote sleep. In addition, Rolls (1997) asserted that residents experience more agitation during the day if awaken by night staff to perform incontinence care and repositioning. Thus, a lack of sleep due to the changing of incontinence products at night is a burden affecting the QoL of individuals living in LTC.

DuBeau et al. (2006) conducted a retrospective quantitative study using a Minimum Data Set (MDS) database involving 5 states (Kanas, Maine, Mississippi, New York and South Dakota) in the USA from 1994-1996. The purpose of the study was to determine whether nursing home residents with UI experienced worse QoL than continent residents, whether the relationship between QoL differs across cognitive and functional impairment, and to determine whether a change in continence status is associated with a change in QoL. The participants were aged 65 years and older. QoL was measured according to the MDS derived social engagement scale. Findings reported that UI was significantly associated with worse QoL in residents experiencing moderate cognitive and functional impairment, and new or worsening UI experienced over a 6 month period was associated with worse QoL. The authors suggested that this research evidence supports strong rationale for targeting interventions and strategies for those residents experiencing UI, while presenting an incentive to improving continence care.

Howard & Steggall (2010) in a descriptive literature review explored the relationship between UI, QoL and barriers to help-seeking behaviour in women. The authors indicated that factors such as severity of UI, type of UI, age, and actual QoL scores seemed to contribute to how UI impacts women's QoL. Reliable evidence concluded that increased severity of UI is as a predictor of impact on QoL (Huang et al., 2006; Yu et al., 2003). Yet, with increasing age the prevalence and severity of UI increases, but in younger women the impact of UI on QoL was found to be more significant than in their older counterparts (Monz et al., 2007). The major cue for seeking help for UI appears to have been the QoL score itself. This is supported by Yu et al. (2003) in their findings that indicated that QoL and women's perceptions of whether they viewed UI as a disease or not, were factors that affected women's help-seeking behaviour.

#### **5.1 Physical and economic burdens of UI**

Not only do elderly women experience psychosocial impacts of UI, but the importance of physical and economic burdens that UI can impose should not be overlooked. UI predisposes elderly women to physical side effects such as rashes, dermatitis, skin infections, decubitus ulcers, and urinary tract infections (Du Moulin et al., 2009; Getliffe et al., 2007; Goldstein et al, 1992; Nix & Haugen, 2010; Schnelle, 1991). There is also an increased risk of falls associated with UI in the elderly, due to wet and slippery floors from dribbling and impaired mobility due to wearing bulky or poor fitting incontinence products (Hu, 1990; Loughrey, 1999; Parker, 2007). This was evidenced in my own nursing practice in LTC. Incidents of residents falling occurred while toileting by slipping on their own incontinent products or urine. For some, the outcome was traumatic requiring treatment

Elderly Women and Urinary Incontinence in Long-Term Care 97

gender bias and ageism, which contributes to a lack of health maintenance services for older women. The present healthcare system reinforces this attitude by the lack of interest and resources for speciality practices in geriatrics (Wilson, 2003). Some healthcare providers diminish the significance of UI (Wilson, 2003) and some healthcare providers are seen as being unhelpful (Bradway, 2004), which in turn impacts upon women's seeking help for UI. UI is often found to be ignored by some healthcare providers due to their lack of education or expertise to address the healthcare issue, which are limiting factors negatively impacting service development and delivery (Getliffe & Dolman, 2007; Zeznock et al., 2009). Ignoring UI and negative demeaning attitudes towards the elderly, and the withholding treatments based on biased judgements and prognoses for the elderly are pervasive among some healthcare professionals and policy decision-makers (Mardon et al., 2006; Sharpe, 1995). The use of "baby talk" to elderly women by nursing staff in long- term care facilities reaffirms the negative perceptions of the elderly person's functional ability, perpetuating "women to women ageism" (Bernard, 1998; Sharpe, 1995). Bernard (1998) found that some healthcare providers, including nurses, possess more ageism attitudes than the population at large, a situation which dramatically impacts on the marginalization of elderly women. For elderly women, healthcare providers' stereotypical beliefs about aging increase the probability that their concerns will be devalued (Sharpe, 1995; Wilson, 2003). For that reason, elderly women may hesitate to discuss their UI with physicians, nurses, and other healthcare providers who possess ageist and sexist attitudes. Further, UI is considered to be a social taboo and stigmatizing, which is often another reason for women to not seek healthcare or delay in seeking healthcare services for their UI (Hagglund et al, 2003; Howard & Steggall, 2010). Walters et al. (2001) cited that withdrawal, resignation and low expectations were found to be dominant reasons for women not seeking assistance for their UI. Further, Horrocks et al. (2004) in a grounded theory study of twenty participants over 65 years old added that reasons for not seeking help for UI were independent management of UI, reactions to incontinence and attitudes to ageing and health. When individuals did seek help for incontinence the themes

Tauton et al. (2005) found that the attitudes of some healthcare providers' negatively impacted incontinence care, as they viewed UI as being time consuming and sometimes frustrating. Subsequently, patients were passively managed instead of being actively treated for UI. This is consistent with MacDonald & Butler (2007) who noted that the attitudes of staff providing care directly to women with UI in long-term care affected their UI experience, particularly when the staff were busy. This is supported by one woman in the study mentioning that her experience with UI in LTC was influenced directly by how busy the staff were when she rang to be toileted. Walters et al. (2001) acknowledged that even when some elderly do consult with healthcare providers there are high rates of unmet needs experienced. It was also found that healthcare providers often do not inquire about UI, even

Zeznock et al. (2009) in a qualitative descriptive study of 17 women living with UI in Alaska found that although most women did seek out healthcare providers' their encounters with healthcare providers were varied with both negative and positive experiences. Many of the women in the study viewed encounters with healthcare providers as being a significant factor in their experiences of living with UI, particularly if those encounters were negative. Negative encounters with healthcare providers precluded women from seeking future

media influences and contact with primary care emerged.

when individuals are at high risk (Du Moulin et al., 2009).

and/or hospitalization for lacerations and fractures. This proved to be an enormous physical burden for the elderly and the healthcare system, despite being preventable with proper supervision and appropriate symptom management of UI.

UI imposes tremendous economic burdens on individuals and their families. UI is one of the primary reasons for breakdown in care giving relationships for the elderly, and often results in nursing home placement (Du Moulin et al., 2009; Coward et al., 1995; Hu, 1990). Given our aging population and longer life expectancy of women, it is the aging woman who will be at the greatest risk for requiring additional care for UI, and the potential increased for associated nursing home placement to long- term care facilities (Sharpe, 1995; Stewart, 2010; Wilson, 2003).

Over a twenty years ago Hu, (1990) asserted that there are costs associated with routine incontinence care included; labour, supplies, and laundry in LTC facilities. The burden of managing UI in long- term care been estimated to be more than 3 billion dollars annually in the USA (Wilson, 2003). In Canada, the average cost for supplies and nursing care for a senior with UI residing in LTC is between \$3,000-\$10,000 per year (Earthy & Nativ, 2009). Budget conscious administrators provide residents with the most cost-effective incontinence products, supplies, and staffing. Therefore, elderly women in long- term care facilities incur a personal cost for buying preferred incontinence products, and personal hygiene items to hide embarrassing odour associated with UI (Getliffe et al., 2007; Stewart, 2010). In turn, these disposalable incontinence and personal hygiene products are considered a burden for the environment, and may not be permitted for use in health related facilities and long -term care agencies (MacDonald & Butler, 2007). Moreover, scent-free policies instituted in many LTC facilities compounds the issue of elderly women attempting to hide embarrassing odours associated with being incontinent.

UI has pyschosocial, physical, and economic burdens which impact on elderly women in today's society as evidenced in the literature (Beji et al, 2010; Borrie et al, 2002; Coward et al., 1995; Dowd, 1991; Earthy & Nativ, 2009; Goldstein, 1992; Gallagher, 1998; Hu, 1990; Lifford et al, 2008; MacDonald & Butler, 2007; McDermott, 2010; Norton, 1982; Parker, 2007; Resnick, 1997; Sandvik et al., 1993; Schnelle, 1991; Simons, 1985; Wilson, 2003; ). Research is required that explores how elderly women's perceive the impact of this event on their overall QoL and sense of well-being. For healthcare providers working in long- term care to be instrumental in reducing the economic, physical, and psychosocial burden of UI they need to consider the perception of the residents and plan incontinence care in a way that promotes QoL and assists in decreasing the marginalization of elderly women experiencing UI.

#### **5.2 The marginalization of elderly women**

Western society focuses on youthfulness as evidenced in media images of anti-ageing cosmetics, wrinkle-smoothing creams and hair dyes (Bernard, 1998). Historically, elderly women have rarely been portrayed as attractive females, and were commonly viewed as asexual or incapable of sexual expression (Steinke, 1988). Sexual behaviour was believed to be inappropriate, hence taboo for older adults (Smedley, 1991). Consequently, gender and age have continued to marginalize elderly women in our society. Ageism creates a negative attitude towards the elderly, while reinforcing social oppression (Bernard, 1998). Blair and White (1998) suggested that compelling evidence exists concerning stereotyping related to

and/or hospitalization for lacerations and fractures. This proved to be an enormous physical burden for the elderly and the healthcare system, despite being preventable with

UI imposes tremendous economic burdens on individuals and their families. UI is one of the primary reasons for breakdown in care giving relationships for the elderly, and often results in nursing home placement (Du Moulin et al., 2009; Coward et al., 1995; Hu, 1990). Given our aging population and longer life expectancy of women, it is the aging woman who will be at the greatest risk for requiring additional care for UI, and the potential increased for associated nursing home placement to long- term care facilities (Sharpe, 1995; Stewart, 2010;

Over a twenty years ago Hu, (1990) asserted that there are costs associated with routine incontinence care included; labour, supplies, and laundry in LTC facilities. The burden of managing UI in long- term care been estimated to be more than 3 billion dollars annually in the USA (Wilson, 2003). In Canada, the average cost for supplies and nursing care for a senior with UI residing in LTC is between \$3,000-\$10,000 per year (Earthy & Nativ, 2009). Budget conscious administrators provide residents with the most cost-effective incontinence products, supplies, and staffing. Therefore, elderly women in long- term care facilities incur a personal cost for buying preferred incontinence products, and personal hygiene items to hide embarrassing odour associated with UI (Getliffe et al., 2007; Stewart, 2010). In turn, these disposalable incontinence and personal hygiene products are considered a burden for the environment, and may not be permitted for use in health related facilities and long -term care agencies (MacDonald & Butler, 2007). Moreover, scent-free policies instituted in many LTC facilities compounds the issue of elderly women attempting to hide embarrassing

UI has pyschosocial, physical, and economic burdens which impact on elderly women in today's society as evidenced in the literature (Beji et al, 2010; Borrie et al, 2002; Coward et al., 1995; Dowd, 1991; Earthy & Nativ, 2009; Goldstein, 1992; Gallagher, 1998; Hu, 1990; Lifford et al, 2008; MacDonald & Butler, 2007; McDermott, 2010; Norton, 1982; Parker, 2007; Resnick, 1997; Sandvik et al., 1993; Schnelle, 1991; Simons, 1985; Wilson, 2003; ). Research is required that explores how elderly women's perceive the impact of this event on their overall QoL and sense of well-being. For healthcare providers working in long- term care to be instrumental in reducing the economic, physical, and psychosocial burden of UI they need to consider the perception of the residents and plan incontinence care in a way that promotes QoL and assists

Western society focuses on youthfulness as evidenced in media images of anti-ageing cosmetics, wrinkle-smoothing creams and hair dyes (Bernard, 1998). Historically, elderly women have rarely been portrayed as attractive females, and were commonly viewed as asexual or incapable of sexual expression (Steinke, 1988). Sexual behaviour was believed to be inappropriate, hence taboo for older adults (Smedley, 1991). Consequently, gender and age have continued to marginalize elderly women in our society. Ageism creates a negative attitude towards the elderly, while reinforcing social oppression (Bernard, 1998). Blair and White (1998) suggested that compelling evidence exists concerning stereotyping related to

in decreasing the marginalization of elderly women experiencing UI.

proper supervision and appropriate symptom management of UI.

Wilson, 2003).

odours associated with being incontinent.

**5.2 The marginalization of elderly women** 

gender bias and ageism, which contributes to a lack of health maintenance services for older women. The present healthcare system reinforces this attitude by the lack of interest and resources for speciality practices in geriatrics (Wilson, 2003). Some healthcare providers diminish the significance of UI (Wilson, 2003) and some healthcare providers are seen as being unhelpful (Bradway, 2004), which in turn impacts upon women's seeking help for UI. UI is often found to be ignored by some healthcare providers due to their lack of education or expertise to address the healthcare issue, which are limiting factors negatively impacting service development and delivery (Getliffe & Dolman, 2007; Zeznock et al., 2009). Ignoring UI and negative demeaning attitudes towards the elderly, and the withholding treatments based on biased judgements and prognoses for the elderly are pervasive among some healthcare professionals and policy decision-makers (Mardon et al., 2006; Sharpe, 1995). The use of "baby talk" to elderly women by nursing staff in long- term care facilities reaffirms the negative perceptions of the elderly person's functional ability, perpetuating "women to women ageism" (Bernard, 1998; Sharpe, 1995). Bernard (1998) found that some healthcare providers, including nurses, possess more ageism attitudes than the population at large, a situation which dramatically impacts on the marginalization of elderly women. For elderly women, healthcare providers' stereotypical beliefs about aging increase the probability that their concerns will be devalued (Sharpe, 1995; Wilson, 2003). For that reason, elderly women may hesitate to discuss their UI with physicians, nurses, and other healthcare providers who possess ageist and sexist attitudes. Further, UI is considered to be a social taboo and stigmatizing, which is often another reason for women to not seek healthcare or delay in seeking healthcare services for their UI (Hagglund et al, 2003; Howard & Steggall, 2010). Walters et al. (2001) cited that withdrawal, resignation and low expectations were found to be dominant reasons for women not seeking assistance for their UI. Further, Horrocks et al. (2004) in a grounded theory study of twenty participants over 65 years old added that reasons for not seeking help for UI were independent management of UI, reactions to incontinence and attitudes to ageing and health. When individuals did seek help for incontinence the themes media influences and contact with primary care emerged.

Tauton et al. (2005) found that the attitudes of some healthcare providers' negatively impacted incontinence care, as they viewed UI as being time consuming and sometimes frustrating. Subsequently, patients were passively managed instead of being actively treated for UI. This is consistent with MacDonald & Butler (2007) who noted that the attitudes of staff providing care directly to women with UI in long-term care affected their UI experience, particularly when the staff were busy. This is supported by one woman in the study mentioning that her experience with UI in LTC was influenced directly by how busy the staff were when she rang to be toileted. Walters et al. (2001) acknowledged that even when some elderly do consult with healthcare providers there are high rates of unmet needs experienced. It was also found that healthcare providers often do not inquire about UI, even when individuals are at high risk (Du Moulin et al., 2009).

Zeznock et al. (2009) in a qualitative descriptive study of 17 women living with UI in Alaska found that although most women did seek out healthcare providers' their encounters with healthcare providers were varied with both negative and positive experiences. Many of the women in the study viewed encounters with healthcare providers as being a significant factor in their experiences of living with UI, particularly if those encounters were negative. Negative encounters with healthcare providers precluded women from seeking future

Elderly Women and Urinary Incontinence in Long-Term Care 99

(Herzog et al., 1989). Physicians perceived UI as a nursing task and often avoid dealing with the issue, thus ignoring the effect of UI on self-esteem of elderly women, while nurses often inappropriately focused on the management of soiling rather than on the management of incontinence (Mitteness, 1990). Staff in nursing homes reported finding UI care frustrating, time-consuming and aesthetically unpleasant, leading to staff burnout, and poor morale (Yu & Kaltreider, 1987). Notably, if caregivers view UI negatively, rather than a QoL concern, elderly women who are physically and psychologically devastated by the effects of UI are

A study conducted by Birgersson et al. (1993) of six elderly women with a mean age of 80.5 years, living in a Swedish nursing home, identified that a decrease in self-esteem was closely linked with the manner in which nurses assisted them in changing their incontinence products. Elderly women were in a state of vulnerability regarding their intrinsic value and autonomy as a result of having UI and wearing an incontinence product. These authors send a powerful message to healthcare providers concerning UI in elderly women. The need to treat women who have UI with respect, support, and include them in decisions-making and

The implementation of fluid management and voiding schedules are strategies employed by some nursing staff in LTC as an attempt to reduce or eliminate UI (Brink, 1990). Nursing staff will often restrict fluids in the evening in order to reduce night-time toileting or wetting (Brink, 1990). However, imposing such a strategy as a policy for all residents is excessive and places individuals at risk for dehydration. The goal for creating such a policy raises the question of quality of care. By trying to control UI in elderly women, nursing staff may, in fact, be attempting to minimize their workload associated with UI. Little data was found to

Routine voiding schedules are considered habit training procedures that will avoid incontinence by having the resident empty their bladder regularly (Earthy & Nativ, 2009; Klusch, 2003). Voiding schedules are usually indicated for many residents living in LTC, yet too often voiding schedules become a regular regime to control incontinence (Palmer, 2008; Resnick 1992). Imposing such a strategy on a competent elderly woman, capable of making informed decisions regarding her UI has ramifications for self-esteem and QoL. A simple request to go to the washroom to void could be denied by the staff, because it is not her scheduled bathroom time. Additionally, these women who do not need to void, are forced to toilet. If voiding schedules are to assist residents in maintaining comfort and decreasing the number of incontinent episodes, they must be individualized (Birgersson et al., 1993). By providing individualized care, nurses may enable elderly women experiencing UI to

Freundl and Dugan (1992) examined the relationships between attitudes, knowledge, and institutional culture in relation to management of UI in the elderly. The Incontinence Stress Questionnaire-Staff Reaction (ISQ-SR) was used to measure staff attitudes towards UI in the elderly. The participants were 336 nursing personnel from 16 different LTC agencies accrued by convenience sampling. Prevalence of UI was calculated at 72%, however written protocols were not always apparent. Also, over 50% of the agencies acknowledged to using catheters as a management strategy for UI, and almost all of the agencies used incontinence products. With regards to education, findings indicated that few of the agencies reported

document the outcome of these shortages on overall care and resident's well-being.

increase their autonomy and self-esteem and ultimately their QoL.

rendered helpless (Mitteness, 1990).

choices regarding their UI is essential.

healthcare pertaining to their incontinence. Likewise, Hagglund and Ahlstrom (2007) in a phenomenological hermeneutic approach interviewed 14 women with UI in Sweden. One of the findings pointed out that some women had experienced a less satisfying encounter when they sought help for their UI. In some instances, women felt that they were treated nonchalantly by healthcare providers, and were not being taken seriously. Also, some women felt that they were wounded by the manner in which they were treated by some healthcare providers, but they did have a respectful experience when they accessed another healthcare provider.

Yet, some healthcare providers have found have to positively influence those experiencing UI (Borrie et al., 2002; MacDonald & Butler, 2007). One example is Borrie et al (2002) , who reported the use of specialized nurses (nurse continence advisors) with education and training in managing UI to positively impacted UI care, and reduced the incidence of UI, and use of incontinence pads in Ontario, Canada. The nurse continence advisors used behavioural interventions and lifestyle counselling, which proved to be a cost- effective management strategy consistent with recommendations and guidelines of the Canadian Continence Association. Given the shifting of demographics of our population, the extent to which healthcare providers' attitudes and behaviours exists in the delivery of care to the elderly, and specifically to women, requires close scrutiny and careful examination by healthcare providers and the public.
