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© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_7
7
Management ofFecal Incontinence
inFrail Older Adults Living
intheCommunity
TamaraDickinson andKathleenF.Hunter
Abstract
Most older adults live in the community either alone or in a family arrangement.
Community- living older adults are diverse, and the health status of some is char-
acterized by complexity related to having multiple comorbidities and possibly
frailty. Assessment and management of fecal incontinence in community-living
older adults with health-related complexity may be enhanced using a complexity
framework that accounts for social, environmental, and political contextual fac-
tors as well as health/medical concerns. This framework should also consider the
concepts of frailty. This chapter will explain common problems that contribute to
fecal incontinence in these older adults, such as impaction with overow, consti-
pation, diarrhea, and mild to moderate cognitive impairment. It will address spe-
cial considerations that the advanced practice nurse must take into account,
including hearing and vision impairment, physical limitations, the physical envi-
ronment and toilet access in the home, diet and hydration, and the role of the
caregiver. The chapter will then discuss appropriate management interventions.
Interventions highlight the importance of a holistic approach, client and care-
giver engagement and education, and referral to other health care professionals
and community services.
T. Dickinson (*)
UT Southwestern Medical Center, Dallas, TX, USA
e-mail: tamara.dickinson@utsouthwestern.edu
K. F. Hunter
Professor Emeritus, University of Alberta, Edmonton, AB, Canada
e-mail: kathleen.hunter@ualberta.ca
128
7.1 Introduction
The demographic shift and population ageing in most countries of the world are
well recognized. However, the tremendous diversity in aging is not always appreci-
ated, with variation in physical and cognitive function among individuals of similar
ages. Worldwide, older people live in the community in their homes on their own,
with a spouse or other family members, rather than in long-term care facilities or
nursing homes. Living in the community in an extended family arrangement is more
common in some traditional cultures, although this pattern is changing [1].
Just as there is diversity in ageing, there is diversity among older adults regarding
etiology of fecal incontinence, ranging from acquired neurological disease (e.g.,
Parkinson’s, multiple sclerosis), life-long congenital conditions, and, for women,
childbirth years earlier resulting in pelvic oor issues and dysfunction. This chapter
focuses on advanced practice nursing management of common types of problems
that could lead to fecal incontinence in community-living older adults whose health
status has complexity due to multiple comorbidities and who could potentially
be frail.
7.2 The Concept ofFrailty
Some view aging from a decit perspective, a period of decline and dependency,
while others advocate for a perspective of active and successful aging that chal-
lenges stereotypes [1]. With greater recognition and appreciation of the heterogene-
ity in ageing, being able to distinguish the frail from the non-frail has become an
important concept for advanced practice nurses and other health care professionals
to take into consideration for the planning and delivery of health services. While
many denitions of frailty exist, generally, there is agreement that it involves a loss
of physiologic reserve capacity and loss of the ability to resist the effects of stress-
ors. Frailty is a multidimensional concept with physical, psychological, and social
dimensions, not just a biological or physiological state [2]. While frailty is complex,
it is not static, and there is potential for improvement or worsening through modify-
ing inuencing factors and putting interventions in place [3]. However, complex
interventions in community-living older adults have been shown to increase inde-
pendence, reduce mortality, and improve cognition, thereby reducing the incidence
of frailty [3]. Nurses have a unique opportunity to be the primary lead in developing
these multidisciplinary care interventions.
Similar to estimates of fecal incontinence in community-living older persons, the
prevalence of frailty among this population varies by country and denition used.
Frailty is a concept of signicant public health importance, particularly in this age-
ing world population. A meta-analysis of >120,000 persons from 28 countries by
Ofori-Asenso etal. [4] estimated the incidence of frailty at 43.4 cases per 1000 and
the incidence of prefrailty at 150.6 per 1000 persons. The risk of frailty rises with
increasing age and varies by sex, diagnostic criteria, and country income level [4].
Frailty in older adults is associated more with falls, delirium, and incident disability,
T. Dickinson and K. F. Hunter
129
which in turn makes them frequent users of the healthcare system with higher rates
of institutionalization and mortality [4]. The potential of frailty and prefrailty in the
community-living older adult makes interventions and a universally accepted de-
nition in our increasing ageing population a considerable public health concern.
There are two competing models of frailty and multiple approaches to measure
the phenomena. The rst of the denitions is the phenotype model, exemplied by
the work of Fried and colleagues [2]. It is based on physiological indicators includ-
ing unintended loss of weight, reduced muscle strength and gait speed, and low
energy expenditure. The second is the cumulated decits model, described by
Rockwood and Mitnitski [5]. This model takes into account physical health, mental
health, and psychosocial status, noting frailty to be highly age-associated and reec-
tive of multisystem change. This group has developed a clinically friendly tool, the
Clinical Frailty Scale, based on a tness-frailty model that emphasizes function and
acknowledges the diversity among older adults. The assessor can also take into
account the presence of dementia, which may interfere with the person’s ability to
remain continent independently. Frailty, along with multimorbidity, leads to
complexity.
7.3 Frailty andMultimorbidity Leading toComplex
Community-Living Older Adults
Frailty and multimorbidity are complex syndromes that often coexist. For older
adults with frailty and fecal incontinence, where empirical evidence regarding com-
plex interventions is lacking, employing a framework to guide assessment and inter-
vention selection is even more important and useful [6, 7]. Lemke etal. [7] propose
the use of a population segmentation framework to classify healthcare needs across
the life span and, through their work, developed a patient need group framework to
document a range of both clinical and resource endpoints. Vetrano etal. [8] found in
their systematic review and meta-analysis that the prevalence of multimorbidity in
frailty was around 16%. They also showed a non-conclusive association between
multimorbidity and frailty. As we know, during ageing, biological decits and
chronic diseases can accumulate, so does this biologically predispose the older
community-living adult to frailty? Further understanding the correlations between
the two has the potential to further assist health care providers in understanding the
ageing processes and build better care pathways. Vetrano etal. [8] also found that 7
out of 10 frail adults had complex multimorbid chronic health concerns, while only
1in 5 patients with multimorbid chronic health issues exhibited frailty, making the
community-dwelling population prevalence with both 6%. Healthcare providers,
particularly the advanced practice nurse, have the potential to gain a greater under-
standing of population-based needs based on the concepts of multimorbidity and
frailty. They may also use population-based needs and non-biologic determinants of
health to increase knowledge of risk [9]. Within these complex syndromes, there
should also be a commitment to ethical care. Box 7.1 describes a framework for
ethical care [10].
7 Management ofFecal Incontinence inFrail Older Adults Living intheCommunity
130
Fig. 7.1 Socioeconomic structures—intersecting levels of analysis [10]
Box 7.1 Framework for Ethics of Care [10]
• The Ethics of Care framework emphasizes that care must be provided in
ways that meet each person’s specic needs, within the contexts in which
their care is delivered.
• Elder care is primarily home-based or institutional, but the availability of
knowledgeable and competent caregivers, educational aids, incontinence
products, and infrastructure that supports the delivery of proper continence
care vary widely depending on systems of care, geography, and cul-
tural norms.
• Care practices are shaped by the socioeconomic structure in which the care
is delivered. This expands the ethical responsibility of good care to include
not only healthcare professionals but also policymakers, hospitals, and
home care administrators.
The relationship of socioeconomic factor levels on the health of frail older adults
is illustrated in Fig.7.1.
T. Dickinson and K. F. Hunter
131
7.4 Common Problems Contributing toFecal Incontinence
inFrail Older Adults intheCommunity
7.4.1 Overflow Fecal Incontinence
There are a variety of problems that contribute to fecal incontinence in frail older
adults living in the community (see Box 7.2).
Overow incontinence is often secondary to fecal impaction and rectal loading
that results from causes such as constipation. It is estimated that 6.5% of older
adults have functional constipation, and one in ve over the age of 65years has fecal
incontinence [6, 11]. The management of fecal impaction in older adults living in
nursing homes is addressed in Chap. 8. For older adults living in the community, the
contributing factors for fecal incontinence caused by constipation and fecal impac-
tion or rectal loading are multifactorial, including: polypharmacy, dehydration,
reduced dietary ber, multiple comorbidities, decreased mobility, and physiologic
changes. Complete rectal clearance may be difcult to attain in the frail elderly
population but is needed to avoid overow incontinence [6, 11].
• Polypharmacy. Medications can contribute to constipation in older adults (e.g.,
anticholinergics, opioids, tricyclic antidepressants, calcium channel blockers,
calcium supplements, high-dose laxatives [11, 12]. Medications can also contrib-
ute to diarrhea/loose stool in older adults (such as antibiotics, proton pump inhib-
itors, allopurinol, selective serotonin reuptake inhibitors, angiotensin II receptor
blockers, psycholeptics (e.g., anxiolytics, antipsychotics) [11, 12]. Polypharmacy
should be assessed by the advanced practice nurse when evaluating fecal incon-
tinence in the frail older adult. The advanced practice nurse also needs to assess
whether the self-administration of antimotility agents to prevent loose overow
bowel movements associated with rectal loading or fecal impaction is followed
by laxative medications to treat the resultant worsening of constipation and/or
impaction. This can create a cycle of over-the-counter symptom relief medica-
tion use without addressing the underlying cause of constipation.
• Dehydration due to decreased uid intake. Low uid intake is often self-induced
to reduce the number of trips to the toilet, but also sometimes enforced due to a
Box 7.2 Common Problems Contributing to Fecal Incontinence in Frail Older
Adults in the Community
• Overow from constipation or fecal impaction
• Adverse side effects of medications
• Polypharmacy due to the relief of cyclical symptoms
• Inadequate uid and diet/ber intake
• Effects of multiple comorbidities
• Reduced sensorimotor function
7 Management ofFecal Incontinence inFrail Older Adults Living intheCommunity
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lack of caregivers to assist with drinking. Those living alone at home may be at
higher risk.
• Reduced dietary ber intake. Poor teeth and ill-tting dentures can lead older
people to choose a diet with reduced dietary ber. Taste also changes with ageing
creating dietary changes and new likes and dislikes. This can go along with a
decreasing ability to prepare meals for themselves and result in an increased use
of convenience foods that lack adequate ber and further the risk of impaction.
• Multiple chronic conditions. Older people often have multiple chronic condi-
tions, including dementia or cognitive impairment, metabolic disorders (e.g.,
hypothyroidism), anatomical defects (such as pelvic organ prolapse or intussus-
ception), neuropathy (e.g., diabetes mellitus), or neurological disease (such as
multiple sclerosis, stroke, or Parkinson’s disease).
• Decreased mobility. Decreased mobility reduces colonic mass movement [6,
11], thereby increasing transit times. Reduced mobility also makes transferring
to the toilet more difcult, resulting in the use of bedpans or bedside com-
modes, and consequently, correct anatomical positioning for defecation does
not occur.
• Physiological changes. In the elderly, smooth muscle and colonic neuron func-
tion is usually preserved, but there is decreased cholinergic function and unop-
posed nitrergic relaxation that is believed to contribute to colonic motor
dysfunction [11]. Increased age is associated with decreased colonic and rectal
sensation, along with decreased rectal tone, lax perineum, and decreased squeeze
pressures [11].
7.4.2 Diarrhea
Diarrhea is dened as the passage of loose or liquid stool and can often result in
fecal incontinence. The causes of diarrhea vary and can range from infection (e.g.,
Salmonella and Clostridium difcile), which was assigned to a new genus and is
now called Clostridioides difcile [13] (C. difcile), inammation (e.g., colitis and
diverticulitis), and medications such as laxatives, antibiotics, tube feeding, and con-
stipation/impaction with overow. Polypharmacy and interactions with the health
care system put older adults more at risk for an infective process that would alter
stool consistency [6]. Patients with fecal incontinence may inaccurately report diar-
rhea rather than fecal incontinence as the presenting problem due to embarrassment,
which can mislead the healthcare practitioner to mislabel the diarrhea as the pri-
mary cause. It is very important to get an accurate measure of the degree of loose-
ness of the stool, as the denition of diarrhea can vary from person to person. A
stool consistency chart is a very useful aid in this situation for the client or caregiver
to use at home (see Chap. 5 for examples).
T. Dickinson and K. F. Hunter