Continence And Stroke

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Continence And Stroke

• Central South Regional Stroke Program
• September 2007
• Funded by the Ministry of Health and Long Term
  Care

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Session Overview

• The types of stroke.
• The common changes that result from stroke.
• The link between stroke and continence
• The types of incontinence.
• Strategies to support a residents success in
  being continent.

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What is a Stroke

• An interruption of the supply of blood and oxygen
  to an area of the brain.
• This causes the brain cells in an area to die,
  and reduces the brain function in that area.
• The area of the body controlled by the damaged
  area in unable to function properly.
• There are two types of stroke.

• http//www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/s
  troke-vasculaire_e.htmlef

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What is a Stroke?
A stroke can happen when a blood clot blocks a
blood vessel in the brain. 80 of strokes are
this type.
A Guide to Understanding Stroke, Heart and Stroke
Foundation of Canada, 1996
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What is a Stroke?

• A stroke can also happen when a blood vessel
  breaks and results in bleeding in the brain.
• 20 of strokes are this type.

A Guide to Understanding Stroke, Heart and Stroke
Foundation of Canada, 1996
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Risk factors you can do something about

• Being overweight
• Excessive alcohol use
• Physical inactivity
• Smoking

• High blood pressure
• High blood cholesterol
• Heart disease
• Diabetes

Pearson et.al., (2002) AHA Guidelines for
Primary Prevention of Cardiovascular Disease and
Stroke 2002 Update Consensus Panel Guide to
Comprehensive Risk Reduction for Adult Patients
Without Coronary or Other Atherosclerotic
Vascular Diseases Circulation, 106, 388-391.
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What does a resident who has had a stroke look
like in LTC?
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What are some of the losses due to stroke?

• paralysis or weakness on one side of the body
• vision problems
• trouble speaking or understanding language

http//www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/s
troke-vasculaire_e.htmlef
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What are some of the losses due to stroke?

• inability to recognize or use familiar objects
• tiredness
• depression

http//www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/s
troke-vasculaire_e.htmlef
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What are some of the losses due to stroke?

• exaggerated or inappropriate emotional responses
  
• difficulty learning and remembering new
  information and
• changes in personality.

http//www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/s
troke-vasculaire_e.htmlef
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Stroke Statistics

• There are between 40,000 and 50,000 strokes
  survivors in Canada each year.
• 10 (4-5,000) of strokes survivors each year
  require long-term care.
• 40 (16-20,000) of strokes survivors each year
  are left with a moderate to severe impairment.

http//ww2.heartandstroke.ca/Page.asp?PageID33Ar
ticleID1078SrcnewsFromSubCategory
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• Stroke can cause a loss of bowel and bladder
  control.

http//www.medicine.mcgill.ca/Strokengine/module_u
i_intro-en.html
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Urinary Incontinence is common in stroke

• 40-60 of stroke survivors are incontinent after
  having their stroke.

Thomas LH, Barrett J, Cross S, French B, Leathley
M, Sutton C, Watkins C. Prevention and treatment
of urinary incontinenceafter stroke in adults.
Cochrane Database of Systematic Reviews 2005,
Issue 3.
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• Over time bladder continence can improve.

Thomas LH, Barrett J, Cross S, French B, Leathley
M, Sutton C, Watkins C. Prevention and treatment
of urinary incontinence after stroke in adults.
Cochrane Database of Systematic Reviews 2005,
Issue 3.
15
There may be improvement in their bladder/bowel
function Upon discharge from hospital 25 of
stroke survivors are incontinent 1 year 15 of
stroke survivors are incontinent
Thomas LH, Barrett J, Cross S, French B, Leathley
M, Sutton C, Watkins C. Prevention and treatment
of urinary incontinence after stroke in adults.
Cochrane Database of Systematic Reviews 2005,
Issue 3.
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Types of Incontinence

• Physical incontinence
• Functional incontinence

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Physical Incontinence

• Urinary Frequency
• Urgency (sudden compelling desire to pass urine
  which is difficult to defer)
• Urge Incontinence (involuntary leakage)

Thomas LH, Barrett J, Cross S, French B, Leathley
M, Sutton C, Watkins C. Prevention and treatment
of urinary incontinence after stroke in adults.
Cochrane Database of Systematic Reviews 2005,
Issue 3.
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Functional Incontinence

• Patient has either decreased mental ability or
  decreased physical ability and is unable to make
  it to the bathroom in time.

Turhan et.al., Impact of stroke etiology, lesion
location and aging on post-stroke urinary
incontinence as a predictor of functional
recovery, International Journal of Rehabilitation
Research 2006, Vol 29 No 4
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To remain continent a resident must

• Know they have to void
• Communicate their need to a caregiver
• Be motivated

Brittain et.al., (1998) Stroke and Incontinence,
Stroke, 29, 524-528
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To remain continent a resident must

• Be able to
• bear weight
• assist in transferring to a toilet or commode
• or use an appropriate appliance
• Delay voiding until the appropriate time
• Initiate voiding voluntarily

Brittain et.al., (1998) Stroke and Incontinence,
Stroke, 29, 524-528
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Impact of Stroke on Continence Care

• Inaccurate interpretation of messages and
  sensations from the brain to the bladder.
• Decreased thinking abilities (insight, impulse
  control)
• Decreased functional ability

Brittain et.al., (1998) Stroke and Incontinence,
Stroke, 29, 524-528
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Stroke and Incontinence Link

• Frequent coughing (difficulty swallowing)
• Problems speaking (aphasia)

Brittain et.al., (1998) Stroke and Incontinence,
Stroke, 29, 524-528
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Other Causes of Incontinence

• Fecal impaction
• Drug therapy
• Diuretics
• Poor diabetes control
• Urinary tract infections
• Low estrogen levels in women
• Pre-morbid conditions

Brittain et.al., (1998) Stroke and Incontinence,
Stroke, 29, 524-528
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Incontinence Strategies

• Use of individualized assessment and goal setting
  (Thomas LH, Barrett J, Cross S, French B,
  Leathley M, Sutton C, Watkins C. Prevention and
  treatment of urinary incontinence after stroke in
  adults. Cochrane Database of Systematic Reviews
  2005, Issue 3.)
• Scheduled toileting before/after meals, q2h, and
  prn (MOHLTC standard) (Ostaszkiewicz J, Johnston
  L, Roe B. Timed voiding for the management of
  urinary incontinence in adults. Cochrane Database
  of Systematic Reviews 2004, Issue 1.)
• Adequate fluid intake 1500ml/day (MOHLTC
  standard)
• Making sure the resident is close to a washroom

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Incontinence Strategies

• Adaptable clothing
• Communication resident can tell you what they
  need
• Adaptive devices commode, grab bars, use of
  urinals, bed pans

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Incontinence Strategies

• Use incontinent products when needed
• Encourage independence and self-care
• Environment prompting
• Privacy
• Dementia care strategies responsive behaviour
  strategies, PIECES

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Allie

• Allie has been recently admitted to Cozy Acres
  with a diagnosis of stroke. This is the first
  time that you have worked with Allie and have not
  been able to review her chart. The RN lets you
  know that Allie is incontinent. Allie is able to
  walk with assistance but she has fallen before.
  Allie needs you to help her with washing and
  getting dressed. Allie needs assistance
  ambulating to the washroom and removing her
  clothing. Allie is unable to tell you that she
  needs to use the toilet, however she is able to
  accurately report Y/N responses. Allie often
  identifies when she needs to be changed by
  moaning or gesturing to staff.

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Allie

• What are two possible losses that Allie has
  experienced as a result of her stroke that may be
  affecting her incontinence.
• What can you do about this situation?

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Next Steps

• You are the eyes, ears and voice of your home.
• Be aware of the diagnosis of your residents.
• Take this stroke information and use it with the
  residents that you work with.
• Share this stroke information and care strategies
  with other staff.
• Follow-up in 2 months with the homes best
  practice champions.

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More Information

• Acute Changes and Stroke
• Continence and Stroke
• Dementia and Stroke
• Falls and Stroke
• Pain and Stroke

Please contact Rebecca Fleck or Kim
Young Community and Long Term Care
Specialist Central South Regional Stroke
Program 905-521-2100 x 44127
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Acknowledgements

• Best Practices long term care advisory group
• Best Practices long term care evaluation group
• Best Practice Continence Working Group, Haldimand
  Norfolk
• Charmaine Martin, Hamilton Health Sciences, Acute
  Care Nurse Practitioner
• Mary-Lou van der Horst, Regional Best Practice
  Coordinator Long-Term Care Central South Region
• Wendy MacDougal, Regional Best Practice
  Coordinator Long-Term Care Central West.
• Central South Regional Stroke Program
• Maryann Watts, Hamilton Health Sciences, Clinical
  Manager Neuro-ambulatory Centre
• Melanie Fall Stratton, Regional Stroke Program,
  Program Manager,
• Kim Young, Regional Stroke Program, Community and
  Long-term Care Specialist
• Rhonda McNIcoll-Whiteman, Hamilton Health
  Sciences, Stroke Best Practice Co-ordinator
• Lisa Colizza, Regional Stroke Program, Regional
  Stroke Development Specialist
• Nancy van Essen, Regional Stroke Program, Stroke
  Rehabilitation Coordinator
• Carol Pereira, Regional Stroke Program, LTC
  Project Coordinator

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