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7.4.3 Mild-Moderate Cognitive Impairment
Cognitive impairment may not necessarily meet criteria for diagnosis of dementia,
but can result from any neurological impairments that occur as a result of brain
damage/injury or disease. In addition to those with mild cognitive impairment,
worldwide, the majority of older people who have dementia live in the community.
Dementia is a broad term that encompasses a variety of conditions that affect brain
function and can include Alzheimer’s disease, vascular dementia, Lewy Body
dementia, Huntington’s disease, Creutzfeldt-Jacob disease, and HIV-related demen-
tia [14]. It has been estimated that 53% of people with dementia have incontinence,
yet incontinence only affects approximately 13–15% of the community-living pop-
ulation without dementia [14]. Burholt etal. [15] found that up to 34% of people
living with dementia had issues with toileting and that without appropriate conti-
nence assessments and interventions, incontinence can lead to institutional place-
ment. People with cognitive difculties may experience challenges that lead to fecal
incontinence, such as:
• Visuospatial problems in nding the toilet. These visual disturbances and dis-
orientation can be reduced by using plain colors to identify and differentiate
between the toilet and other bathroom furniture. For example, a black toilet
seat on a white toilet can make the toilet easier to see. Mirrors can also con-
fuse people with dementia, as they may think there is someone else in the
bathroom.
• Agnosia (difculty with object recognition). Clear visible signs with a picture can
aid people to identify the toilet, as well as leaving the toilet door open when
not in use.
• Apraxia (difculty performing toileting tasks, e.g., wiping/cleaning, dressing).
Consider altering clothing, for example, increasing the length of the opening and
replacing zips and buttons with Velcro (hook and loop fastening) to make clothes
quick and easy to remove, or adding loops of thread to a zipper to aid opening
and closure.
7.5 Special Considerations forAssessment andDiagnosis
The goals and outcomes of addressing fecal incontinence in community-living older
adults should focus on maximizing function and independence. Thus, assessment of
fecal incontinence in this population by the advanced practice nurse should include the
standard elements of assessment outlined in Chap. 5, as well as strategies to assess hear-
ing and vision, physical/cognitive function, the physical environment and access to a
toilet in the home, diet and hydration, and the role of the caregiver/care partner in conti-
nence (see Box 7.3). These aspects correspond with the complexity of the patient with
regards to mental health, social capital, medical and physical health, health and social
experiences in the context of the physical environment of the home, and the sociopoliti-
cal context of available assistance through formal and informal caregivers [4, 8].
7 Management ofFecal Incontinence inFrail Older Adults Living intheCommunity
134
7.5.1 Hearing andVision
Sensory loss, and particularly dual sensory loss, is associated with functional
impairment in older people. Guthrie and colleagues [16] reported that among older
persons living in the community and receiving home care, those with dual sensory
loss were more likely to have impairments in many aspects of functional ability,
including bladder and bowel incontinence, than those without hearing and vision
decits. Sensory loss can adversely affect independent waynding and communica-
tion of toileting needs. Otoscopic examination of the ear canal to assess for abnor-
malities and cerumen impaction, along with a screening test for auditory acuity,
such as the Whispered Voice test [17], can provide the advanced practice nurse with
insight into hearing impairment. To screen for visual impairment, an ophthalmo-
scope examination and screening of visual acuity using the Snellen chart and visual
elds testing [17] can be undertaken.
7.5.2 Physical andCognitive Function
Both basic activities of daily living (e.g., meal preparation, shopping, managing
money, transportation) and instrumental activities of daily living (e.g., bathing,
dressing, eating, toileting, transferring) should be assessed using a standardized
assessment tool. Physical ability as well as cognitive ability affect performance.
People with mild cognitive impairment often have difculty with instrumental
activities of daily living but their ability to perform basic activities of daily liv-
ing remains intact [18]. Those living with dementia have increasing difculty
with both basic and instrumental activities of daily living, requiring assistance
and support. Common assessment tools for basic activities of daily living
include the modied Barthel Index [19] and Katz Index [20]. Examples of
instruments for assessing instrumental activities of daily living include the
Lawton Scale [21].
Box 7.3 Special Considerations for Assessment and Diagnosis for Frail Older
Adults in the Community
• Demographic considerations: age, gender, ethnicity, education, and frailty
• Mental health concerns (such as depression) and dementia
• Social capital, including social support, caregiver presence and strain,
socioeconomic status, relationships, and leisure activities
• Medical and physical health considerations, including the impact of mul-
tiple chronic conditions impacting fecal incontinence
• Health and social experience considerations such as healthcare utilization
and access, quality of life, self-management support, and healthcare sys-
tem navigation
T. Dickinson and K. F. Hunter
135
There are many cognitive screening and assessment tools. The Montreal
Cognitive Assessment (MOCA) is useful for screening for both mild cognitive
impairment and dementia, and was designed to take only 10min to administer [22].
This tool is easily accessible to clinicians through the website (https://www.moca.
org) and has been translated into many languages.
7.5.3 Physical Environment andAccess toToilet intheHome
Easy access to the toilet is important for those with mobility limitations, and addi-
tional equipment such as a commode or raised toilet seat may be needed. Wheelchair
accessibility to the toilet may also be important in supporting continence and maxi-
mizing independent function. The advanced practice nurse can consult with an
Occupational Therapist in cases where specialty equipment or home modications
are needed.
7.5.4 Diet andHydration
Due to the increased risk of poor nutrition and dehydration in frail older individuals,
attention to dietary and uid intake is needed. Whenever possible, the older person
should be engaged in completing their own diet and uid diary, with caregiver assis-
tance only when needed (see Chap. 5).
7.5.5 Role oftheCaregiver
The family caregiver may have an important role in promoting and maintaining
continence in the frail older person. When assessing how toileting is approached in
the home, the advanced practice nurse needs to include how the family care
approaches assisting with managing any episodes of fecal incontinence. Fecal
incontinence can add to caregiver burden and is a risk for admitting the family mem-
ber to a nursing home [23]. It can also increase the workload for formal caregiving
services. Even patients who are fairly independent in living in the community may
receive periodic assistance from family members with daily care. Family caregivers
of individuals with cognitive limitations have identied numerous aspects about
managing fecal incontinence for which they need teaching and guidance [24], but
guidelines for educating these caregivers are lacking [14, 25]. Challenges in conti-
nence care for people with dementia living at home include perceptions about
dementia, availability of support, nancial costs, and emotions such as shame on the
part of the person with dementia and their caregiver.
To promote successful outcomes, the advanced practice nurse can inquire if the
patient wishes to have a family member/or other caregiver present during the nurs-
ing assessment visit and subsequent follow up appointments. Mullins etal. [26]
reported that distant relatives or friends (versus immediate family members) who
7 Management ofFecal Incontinence inFrail Older Adults Living intheCommunity
136
assist an individual to manage fecal incontinence are often overlooked and excluded
from clinic visits. These caregivers believe their participation in the plan of care
may be benecial. Often, it is these individuals who are going to be toileting their
family member/care recipient, reminding them to toilet, implementing any treat-
ments, changing their products, and helping with any environmental challenges.
Bringing the family member/caregiver into the nursing assessment visit and subse-
quent follow-up appointments will help them feel included in the plan of care and
contribute to the success of the management plan for fecal incontinence.
It can be very frustrating for the caregiver to manage an individual with fecal
incontinence as the patient will often use inappropriate places to defecate, refuse to
be wiped or cleaned, and react aggressively to the offer of help, especially those
with dementia. Also, the caregivers are often uncomfortable handling feces.
Caregivers have suggested there is a need for healthcare professionals to have a bet-
ter understanding of treating patients in the community with issues related to conti-
nence care [3]. Santini etal. [27] found that in some parts of Europe, the main
provider, both from a psychological and practical point of view, was the family. In
other countries, the family provided mainly emotional support, and the formal care
sector delivered the practical needs [27]. Some countries may have better support
services and more specialized health care professionals to treat fecal incontinence.
Availability of family and other support services within a health care system needs
to be taken into consideration [10].
Caregivers can nd that dealing with how to manage fecal incontinence can be
overwhelming. Lack of understanding and education on the topic makes it frustrat-
ing for them. Sometimes, just listening to the family member/ caregiver and provid-
ing simple advice or helping to refer them to a multidisciplinary team can be
extremely effective. Crocker etal. [18] found that care and support are often inad-
equate or inappropriate for community-living individuals suffering from
incontinence.
For clients with a chronic condition and varied levels of independence, informal
caregivers may have been participating in their care for years before the onset of
fecal incontinence. The caregivers may be involved with assisting the patient in
mobilizing, transferring, and toileting before being seen by a healthcare profes-
sional. This makes them very capable, and they should not be underestimated in
their importance and value in care planning. The caregiver may help with toileting
records and bowel diaries and describe activities that may have precipitated fecal
incontinence episodes. This information will benet the provider with a more accu-
rate diagnosis. However, considering and respecting the patient’s privacy, level of
independence, and perspective is essential. The advanced practice nurse should
develop the tact and communication that facilitate a satisfactory encounter with
these patients and caregivers.
There are barriers to communicating with healthcare professionals as well as
varying levels of health literacy about incontinence among different types of infor-
mal caregivers of individuals. Specialist continence nurses have an important role in
improving health literacy about incontinence and its management for informal care-
givers [15]. Interventions must be tailored to the caregiving situation to improve the
T. Dickinson and K. F. Hunter
137
continence care of those receiving care. Educating both the patient and their care-
giver will improve treatment outcomes, provide accurate measurability, and pro-
mote successful communication.
7.6 Initial Interventions ofManagement
The advanced nursing practice approach to the management of fecal incontinence in
older adults with frailty and multiple chronic conditions living in the community
requires a comprehensive approach. This approach must attend to the multiple
dimensions of complexity, frailty, and ethics that inuence patient and advanced
practice nurse goals, the selection of appropriate interventions, and patient out-
comes [4, 8].
7.6.1 Specific Considerations
The advanced nursing practice approach to the management of fecal incontinence in
older, frail adults living in the community requires specic considerations beyond
those addressed in Chap. 6 regarding younger adults. These specic considerations
can be categorized by the ve health dimensions of the complexity framework
(demographics, mental health, social capital, medical and physical health, health
and social experiences) and the sociopolitical and physical context [4, 8] (see
Box 7.4).
7.6.1.1 Demographic Considerations
Interventions for older adults with fecal incontinence will necessarily vary based on
their age, gender, ethnicity, education, and frailty [18]. For example, interventions
must be tailored to accommodate different age-related changes by gender, such as
pelvic organ prolapse in older women. Furthermore, culturally sensitive care extends
to interventions for fecal incontinence, such as ensuring the availability of educa-
tional materials in multiple languages. See, for example, the patient education pub-
lications available on the Australian Continence Foundation in 30 different written
languages [28].
7.6.1.2 Mental Health Considerations
Approaching fecal incontinence in community-living older adults must attend to
mental health. People with fecal incontinence describe feelings of worthlessness,
poor mood, and low self-esteem [6]. Introducing any strategies that require a self-
management component, where the patient is implementing and monitoring their
response to behavioral changes, will not be successful unless underlying depression
is identied and treated [29]. Depression is also common in older adults managing
multiple chronic conditions and experiencing functional decline and frailty [18].
Additionally, older adults with fecal incontinence may be experiencing cognitive
changes, including dementia, as these conditions tend to occur together. Thus,
7 Management ofFecal Incontinence inFrail Older Adults Living intheCommunity
138
optimizing cognitive function in persons with dementia has the potential to improve
fecal incontinence.
7.6.1.3 Social Capital Considerations
The advanced practice nursing approach to fecal incontinence must consider the
older adult’s social capital [30]. Social capital refers to the older adult’s social sup-
port, caregiver presence and strain, socioeconomic status, relationships, and leisure
activities [30]. In relation to interventions for fecal incontinence, care for fecal
incontinence that considers the older adult’s social capital by the advanced practice
nurse would be inclusive and responsive to the caregiver’s understanding and needs.
In the home environment, this could involve education and support to formal care-
givers, such as personal support workers, to assist in meal preparation or toileting
assistance. Informal caregiver needs and burden must be managed by the advanced
practice nurse as informal caregivers are providing the majority of instrumental sup-
port for older adults with personal care needs, in particular for persons with demen-
tia [31]. Additionally, the advanced practice nurse needs to consider the
environmental safety of the home, particularly related to bathroom accessibility.
The nancial resources of the older adult are an important aspect in planning the
intervention, as many older adults are living on xed incomes [32]. Internationally,
there is variable governmental funding for conservative treatment of fecal inconti-
nence (e.g., medications) and incontinence products.
7.6.1.4 Medical andPhysical Health Considerations
Consideration of medical and physical health is integral to the treatment of fecal
incontinence, but for older adults, the impact and interplay of multiple chronic con-
ditions need to be addressed [4] as the following examples illustrate. Patients with
chronic diarrhea could be related to poorly controlled diabetes, for example, and
further aggravated by impaired rectal sensitivity and rectal weakness associated
with diabetes in older adults [6, 11]. Older adults who have had a stroke will also
likely experience decits in activities of daily living and cognition, which could
contribute to the development of fecal incontinence [6, 18, 27]. Thus, interventions
to promote function in this population have the potential to improve fecal inconti-
nence [33]. Conversely, interventions to improve mobility and, thereby, daily func-
tion could be challenging in the presence of painful arthritis, so individualization of
interventions is critical. Constipation-induced fecal incontinence has particular
importance and urgency for treatment in older adults with Parkinson’s disease, as it
can negatively affect the absorption of anti-Parkinsonian medications [33].
7.6.1.5 Health andSocial Experience Considerations
Health and social experiences that inuence patient complexity include healthcare
utilization and access, quality of life, self-management support, and healthcare
system navigation. The use of home health care services alone is an indicator of
complexity. For example, older adults receiving home care services have a higher
prevalence of fecal incontinence—ranging from 9 to 13% depending on the
study—than those who live independently [34]. Also in the home care context,
T. Dickinson and K. F. Hunter
139
activities of daily living ability and cognitive function are more important predic-
tors of fecal incontinence than would be seen in independently living older adults
[18]. Experiences of health care are also affected by the complexity of the system
itself for older adults. Older adults with multiple chronic conditions routinely
require care from multiple providers in different settings, for example, primary
and specialist care in both community and hospital settings [4]. The advanced
practice nurse has the requisite skill set to lead and coordinate a team approach to
treat fecal incontinence across these types of complex networks of health care
providers.
7.7 Other Interventions
7.7.1 Address Reversible Causes
With the special considerations in mind, the advanced practice nurse must rst
address any reversible cause of fecal incontinence in the older adult.
7.7.1.1 Medications
As discussed earlier, the advanced practice nurse caring for an older adult with fecal
incontinence needs to conduct a medication review and assess polypharmacy. The
advanced practice nurse must consider if a “prescribing cascade” was involved in
the development of fecal incontinence [35]. For example, a narcotic could have
been prescribed for pain, which resulted in constipation, which was treated with
sennosides, but the sennosides caused diarrhea and fecal incontinence, so loper-
amide was added, which could worsen constipation [35]. De-prescribing medica-
tions is an intervention [8].
7.7.1.2 Toilet Access andAbilities
Based on the assessment of the home environment, functional ability, and presence
of caregiver support, a determination must be made in regards to whether the fecal
incontinence is related to not accessing the toilet promptly [18]. If so, the advanced
practice nurse can intervene to discuss strategies such as prompting defecation,
timed defecation, advising adaptive, easily removable clothing, and using adaptive
devices to get on and off the toilet easily (e.g., grab bars).
7.7.1.3 Infection
Diarrhea associated with C. difcile infection can result in fecal incontinence and is
discussed more in Chap. 10. Although more common in individuals in institutional
settings (such as hospitals and nursing homes), community-acquired C. difcile
infection now accounts for 35–48% of C. difcile infection diagnoses [36, 37]. The
advanced practice nurse should determine if the older adult is being treated with
antibiotics or was recently hospitalized and treated for Clostridium difcile infec-
tion during their hospital stay. Older adults are at risk of a C. difcile recurrence [37,
38]. There is good evidence that some probiotics (such as Lactobacillus rhamnosus
7 Management ofFecal Incontinence inFrail Older Adults Living intheCommunity
140
GG) [38] and Saccharomyces boulardii [37, 38] can decrease the incidence of anti-
biotic-associated C. difcile infection diarrhea.
7.7.1.4 Rectal Loading/Fecal Impaction
As impaction can be a common and reversible cause of fecal incontinence in older
adults, the advanced practice nurse should include this management in their treat-
ment plan [39]. Treatment for rectal loading and fecal impaction in an institutional
setting, such as a nursing home, is addressed in Chap. 8. In the community environ-
ment, if the older adult requires support, the advanced practice nurse can coordinate
home care nursing support to administer and monitor outcomes, as jurisdictional
services and funding permit. Older adults with multiple chronic conditions and
frailty frequently experience constipation [40]. Clinical experience with older adults
has revealed that constipation has the real potential to translate into impaction and
fecal incontinence. Thus, the prevention and management of constipation is a proac-
tive advanced practice nurse intervention in preventing this condition from worsen-
ing into episodes of fecal incontinence in community-based frail older adults (see
Chap. 6).
7.7.1.5 Dietary andFluid Intake
The maintenance of adequate hydration and dietary ber intake is critical to pre-
vent constipation [39–41]. As many older adults are unable to consume enough
food to increase their dietary ber intake sufciently, dietary ber supplements can
be useful. The addition of a ber supplement, such as psyllium, is an initial conser-
vative strategy [42–45] (see Fig.7.2). Psyllium supplementation can bulk up stool
with residual ber that is not fermented by colonic bacteria and by drawing uid
into the intestine, thus stimulating defecation and softening hard stool [11]. Dietary
ber supplements must be accompanied by adequate uid intake, or they can alter
stool consistency, making stool more difcult to pass. For older adults, eating
meals and snacks at regular times promotes bowel regularity [40]. Troubleshooting
Fig. 7.2 Management
pyramid for the treatment
of constipation in older
adults. (Adapted from Liu
[46] and Wagg etal. [47])
T. Dickinson and K. F. Hunter
141
how to achieve these goals is part of the advanced practice nurse role. Income,
energy level, function, and tolerance are all factors for a frail older adult in enact-
ing these self-care activities. The advanced practice nurse can connect clients to
community support services, such as subsidized home delivery meal programs
(i.e., Meals on Wheels) or food banks. They can also initiate referrals to home sup-
port services and develop meal plans for the personal support workers to prepare
with or for the client.
7.7.1.6 Exercise
Regular activity through exercise is a foundational component of constipation
treatments as it is believed to improve peristalsis and colonic transit time [18].
Also, any activity to improve mobility will improve fecal continence by prevent-
ing functional decline and subsequent incontinence. The advanced practice nurse
might suggest walking as a treatment for constipation based on the client’s ability
and energy levels [48]. Walking for 15–20min once or twice a day or 30–60min
daily or three to ve times per week is optimal [40, 48]. For older adults with
more limited mobility or energy resources, ambulating at least 50feet twice a day
is recommended [44]. These recommendations are based on expert clinical opin-
ion [48].
7.7.1.7 Pharmacological Treatment ofConstipation
Constipation cannot always be effectively treated with uid, ber, and tness, par-
ticularly in older adults with polypharmacy or chronic conditions that cause consti-
pation. In these situations, the advanced practice nurse must consider the addition of
laxatives. Osmotic laxatives, which also draw uid into the stool, are the next line
of treatment and should also be accompanied by adequate uid intake. The product
choice depends on client preference and reimbursement rules of different private
and public drug benet plans. Finally, stimulant laxatives and enemas are reserved
for occasional use or “rescue” if the regular treatment is intermittently not effective
[11]. If constipation does not positively respond to conservative interventions, refer-
ral to a gastrointestinal specialist for further workup and appropriate treatment is
recommended [45]. Refer to Fig.7.2 for a management pyramid for the treatment of
constipation in older adults. Although commonly prescribed for older adults, the use
of surfactant is not recommended due to a lack of high-quality evidence of its effec-
tiveness [11].
7.7.1.8 Hemorrhoids
Hemorrhoids are caused by chronic straining due to hard stool and constipation, and
are also associated with fecal incontinence in older adults [33]. While the advanced
practice nurse is working with the client on treating and resolving constipation, the
pain and swelling of hemorrhoids must also be addressed. Clients should be advised
to cleanse hemorrhoids gently with moistened wipes that do not contain perfume or
alcohol, or a cotton pad dampened with Witch Hazel. Topical treatments that can be
purchased over-the-counter, containing lidocaine and hydrocortisone, can also be
recommended for short-term use.
7 Management ofFecal Incontinence inFrail Older Adults Living intheCommunity
142
7.7.1.9 Rectocele
A rectocele is the herniation or bulging of the posterior vaginal wall from the rectum
pushing anteriorly into the vagina [49]. Rectoceles are associated with fecal incon-
tinence in older women [6] and can contribute to constipation and an incomplete
evacuation of the bowel. The best treatment for a rectocele is prevention of hard
stool and straining to have a bowel movement, which can worsen the degree of pro-
lapse. The advanced practice nurse can also instruct the client on techniques, such
as using the rst and second ngers together as a brace to support the rectocele
external to the vagina when bearing down. Alternatively, the advanced practice
nurse can instruct the client to insert her nger into the vagina to exert pressure on
the back wall to facilitate bowel emptying. These techniques rely on clinical exper-
tise. For some clients, with some types of rectocele, there is some evidence that a
pessary could provide the necessary support [50]. For older women, the success of
a pessary is enhanced when local hormone replacement therapy is used to treat vagi-
nal atrophic changes [50].
7.7.1.10 Abdominal Massage
For older adults with fecal incontinence related to constipation, self-massage of the
abdomen, which involves applying rm pressure in the direction of stool movement,
could facilitate movement of stool through the bowel [33]. Although there are no
empirical studies with an older adult population, some evidence exists that this is
effective for younger adults with multiple sclerosis. Having multiple techniques to
try to improve bowel function can bolster clients’ feelings of self-efcacy and is
worth consideration by the advanced practice nurse with willing clients.
7.7.2 Establishing Regular Bowel Habits
The advanced practice nurse works with the client to establish a regular bowel elim-
ination pattern [33] (see Chap. 6). One strategy is to take advantage of the gastro-
colic reex and resulting increased peristalsis that often occurs after the rst meal
of the day (but can occur after a later meal) and to plan for defecation at this time
[39, 40]. The advanced practice nurse should work with the client in assessing their
usual bowel elimination schedule. Troubleshooting and planning related to the cli-
ent’s regular schedule in order to account for disruptions, such as doctor’s appoint-
ments or visits from community health care providers, may also be needed.
7.7.2.1 Positioning ontheToilet
Comfort and position on the toilet is a component of establishing regular bowel
habits for the older adult [33]. Adaptive aids in the home, such as a raised toilet seat
or poorly tting over-the-seat commode, may make sitting comfortably and prop-
erly on the toilet a challenge. Refer to Fig.7.3 for the correct position to sit on the
toilet to effectively evacuate the bowels. This image is also a helpful teaching tool.
As can be seen in the images, if a raised toilet seat is in place, assuming the squat
position is not possible. In this case, the advanced practice nurse would suggest that
T. Dickinson and K. F. Hunter