Safety Tip: Management of Bladder Dysfunction and Fall Risk

Facts:

• Up to 60% of hospital patients and nursing home residents experience urinary incontinence (UI). UI is associated with increased the risk of falls (i.e., up to 50% of falls are elimination related).
• UI is an important risk factor for recurrent falls.
• UI prevalence is associated with immobility and medical co-morbidities, such as diabetes mellitus and dementia.

Fall Risk Factors

Urinary incontinence can contribute to fall risk in several ways:

• Incontinence episodes may lead to slips on wet floor surfaces.


• Urge incontinence (i.e., involuntary leakage accompanied by or immediately preceded by urgency) may increase risk when a patient hurries to the toilet to avoid wetting themselves.


• Incontinence can lead to episodes of dizziness (e.g., micturition syncope).


• Episodes of incontinence may be transitory (i.e., transient incontinence is present in up to 50% of patients) and often related to acute illness, such as urinary tract infections that can cause incontinence, delirium, drowsiness and hypotension.


• Medications used to treat incontinence (e.g. anticholinergics or alpha blockers) can cause postural hypotension.


• Nocturia (i.e., waking at night to void) can result in poor sleep, which is associated with increased fall risk.

Factors contributing to increased risk of falling include:

• Reduced mobility and balance (i.e., impaired ambulation and balance makes it difficult to reach the toilet and thereby increase the risk).


• Reduced dexterity (in manipulating undergarments etc.).


• Need for toileting assistance and impaired cognition (i.e., performing a secondary task, such as walking and concentrating on getting to the toilet, may be difficult)


• Need to use a walker (i.e., urinary incontinence is a significant risk factor for those who can’t stand without support).


• Increased episodes of nighttime incontinence.


• Urinary frequency and toileting (i.e., urinary frequency and the need for frequent assistance with toileting is much more of a fall risk factor than incontinence by itself).


• Environmental factors can also influence risk. For example, higher than the optimal toilet height (defined as 100% to 120% of the patient's lower leg length) can consequently increase difficulty toileting and risk of falls. Other environmental factors include signage for toilet facilities, distance to reach toilets, and availability of bedside commodes and urinals.

Strategies for Reducing Fall Risk

1. Identify and treat the cause of incontinence, including medication side effects. Patients may have more than one type of urinary incontinence. The goal of treating urinary incontinence is to improve the continence status of the patient by modifying those factors causing incontinence.


2. Identify and address co-morbid fall risk factors (e.g., gait and balance, transfer ability, reduced dexterity, etc.) which can impact upon toileting.


3. Ensure that caregiver staff are aware of the patient’s risk factors and needs.


4. Respond to toileting requests promptly, especially if the patient requires assistance to get to the toilet. Ensure that patients with impaired mobility can reach/use the nurse call bell; if not, consider asking patient if they need to go to the toilet and/or the use of a fall alarm to warn staff of unassisted transfers.


5. Locate patient near to the toilet if possible. Consider a bedside commode or urinal if the toilet is not close by.


6. Implement a toilet assistance program that best matches the patient’s needs and pattern of voiding. Common toileting programs to consider include: timed voiding (i.e., a fixed schedule of toileting); habit retraining (i.e., identifying a pattern of voiding and individualizing the toileting schedule); and prompted voiding (i.e., increasing a patient’s ability to discriminate their continence status and to respond appropriately) (Table 1).


7. Ensure that patient is wearing suitable clothes that can be easily removed or undone by self or staff and that patient wears footwear to reduce slipping in urine. Consider a non-slip mat on the floor beside the bed for patients who experience incontinence when transferring from bed.


8. Reduce caffeine and carbonated drinks intake to help decrease symptoms of urgency and frequency.


9. Keep the pathway to the toilet obstacle free and leave a nightlight on in the bedroom/bathroom at night.


10. Designate a continence specialist; this may be one way of ensuring that continence programs are maintained even in the face of high staff turnover.
    

Table 1