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153
© 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_8
8
Management ofFecal Incontinence
inOlder Adults inNursing Homes
LeneElisabethBlekken, SusanSaga
,
andDonnaZ.Bliss
Abstract
Of all the health challenges that older adults face, fecal incontinence is one of the
most dreaded. Fecal incontinence can lead to feelings of shame and embarrass-
ment, and a downward spiral of psychological distress, dependency, and poor
health. Fecal incontinence is often a reason for needing nursing home care.
Nursing home residents are among the most fragile older adults. Among this
group, there are often problems of defecation, such as constipation, diarrhea, and
fecal incontinence. Fecal incontinence is a complex problem. The most impor-
tant risk factors are functional incapacity, reduced cognitive function and mobil-
ity, diarrhea, constipation/impaction, stroke, some neurological diseases,
diabetes, and comorbidity in general. Loose stool as well as hard stool can be
related to fecal incontinence. Urgency associated with bowel movements and
weak pelvic oor muscles are also factors. It is therefore necessary to have a
comprehensive person-centered approach for fecal incontinence management,
addressing the potential role of co-morbid disease and current medications, func-
tional and cognitive impairment, and the degree of bother to the person. An envi-
L. E. Blekken · S. Saga
Norwegian University of Science and Technology, Department of Public Health and Nursing,
Trondheim, Norway
e-mail: lene.blekken@ntnu.no; susan.saga@ntnu.no
D. Z. Bliss (*)
University of Minnesota School of Nursing, Minneapolis, MN, USA
e-mail: bliss@umn.edu
Chapter authors from the rst edition of this book:
Anne G. Vinsnes, Professor Emerita, Department of Public Health and Nursing, Norwegian
University of Science and Technology (NTNU), Trondheim, Norway: Kari H. Gjeilo, Associate
Professor, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
154
ronment with physical or social obstacles may impair a person’s ability to
maintain continence, and adjustments may be needed. This is particularly rele-
vant to individuals who have physical or mental disorders. Nurses must have
high knowledge and advanced skills when it comes to meeting nursing home
residents’ needs for assessment and management. The level of knowledge and
engagement among health personnel on the value of good bowel care is often
low. There is, at present, relatively limited evidence from high-quality experi-
mental trials for many fecal incontinence interventions in this population. Good
care quality enables nursing home care personnel to approach managing fecal
incontinence compassionately while maintaining the dignity of the resident.
8.1 Introduction
Of all the health challenges frail elderly face, fecal incontinence is one of the most
dreaded; it is a major assault to psychosocial as well as physiologic well-being.
Care requires systematic interventions on multiple levels to assure that staff provide
individualized, evidence-based care. Clinical improvement efforts aimed at improv-
ing care of older adults with fecal incontinence must be systematic and evaluated.
8.2 Older Adults Residing inNursing Homes
With life expectancy lengthening, the percentage of people who will require care in
long-term care facilities will increase in the coming decades. Depending on the care
needs of the older person, there are several options for residential nursing care, and
various terms have been used to describe this care setting, including nursing homes,
long-term care, aged residential care, assisted living, etc. Residential nursing care
facilities provide a range of health and personal care services; skilled nursing care
facilities focus more on medical care than most assisted care facilities [1]. In this
chapter, we will use the term nursing home. Nursing home residents are the most
fragile of the older people; they often have advanced chronic illnesses, multiple
diagnoses, are using many different medications, and they have high dependency
due to possible cognitive impairment and a low level of function according to the
activities of daily living in general. Hence, nursing home residents are a group of
highly dependent older adults. Among this group, there are often problems con-
nected with defecation, such as constipation, diarrhea, and fecal incontinence. It is
therefore necessary to have a broad approach to fecal incontinence in nursing
homes. Nurses must have high knowledge and advanced skills when it comes to
meeting frail older adults’ needs for assessment, care, and treatment.
Fecal incontinence is prevalent among the group of elderly residents in nursing
homes [2, 3]. Approximately 30% of the older individuals admitted to nursing
homes in the United States (US) had fecal incontinence [3, 4], which indicated that
fecal incontinence is an independent risk factor for admission to an aged residential
care facility, increasing the odds of admission by 27%. A systematic review of 23
studies of nursing homes in a variety of countries found that the median prevalence
(as reported by the studies) of fecal incontinence was 42.8% [5]. Subsequent
L. E. Blekken et al.
155
ndings in Japanese nursing homes supported this prevalence [6]. Among cogni-
tively impaired older residents living in long-term care facilities in East Asia, a
prevalence of fecal incontinence between 4.0% in Taiwan and 57.0% in Korea was
reported [7]. In terms of incidence, of incontinence in nursing homes, Bliss etal. [8]
reported that up to 30% of older individuals admitted to a US nursing home who
were not incontinent developed incontinence within 6 months.
Fecal incontinence among the frail elderly is usually a result of many interacting
risk factors that include age-related physical changes, comorbidity, multiple phar-
macological treatments, and physical and cognitive impairment [2, 5]. For many of
these complexly ill residents, families are an important source of support. Previous
research has conrmed that family members continued their involvement and sense
of responsibility for care as their elder moved to and remained in a nursing home.
However, family members’ expectations for care were rarely met in full [9].
8.3 Clinical Setting
Future demographic changes portend future pressure to expand nursing home care
while maintaining high care standards with limited resources. Fecal incontinence
leads to a high direct and indirect economic burden to the health-care system, and is
an important cause of institutionalization of older people [2]. Quality has at least
two components that should be addressed: quality of care and quality of life, both of
which can be transformed, either positively or negatively, by nursing care [9].
Nursing home care continues to be necessary for those individuals who are no
longer able to live at home comfortably or safely. With the shifting demography
towards an ageing population, nursing homes will continue to be an essential ser-
vice provided to individuals for the near future. Nursing homes provide a total ser-
vice, including advanced healthcare, housing, and social care. Nursing home staff
are challenged to meet the dual demands of providing a home for residents while
managing chronic and acute medical problems [10]. Internationally recognized
standards emphasize patient safety, excellence in care, and patient satisfaction in
nursing home care of older people. National quality standards for nursing home care
in several countries include a range of domains relevant to nursing care quality [11].
Also, in providing care, nursing home staff must be mindful that fecal incontinence
is related to feelings of shame and embarrassment [12] and is associated with
reduced quality of life, and poor self-health perceptions [2].
8.4 Risk Factors forFecal Incontinence inNursing
Home Residents
8.4.1 Age andGender
Age has been conrmed as a risk factor for fecal incontinence in many population-
based studies [2]. Normal anorectal physiologic function is complex and relies on
several different functions, including anatomic and neurologic factors. Norton etal.
[13] found the results from physiological studies on the ageing bowel to vary due to
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
156
(a) a variety of different techniques used in measuring anorectal function, (b)
unclear denition of the normative range of manometric measures for older people,
(c) poor matching between cases and controls of clinical factors which may affect
gut function (e.g., level of mobility), or inadequate clinical information and (d) usu-
ally small subject numbers. However, studies on healthy older adults report that the
anorectal function is characterized by a tendency towards an age-related reduction
in internal anal sphincter tone (basal pressure) after the age of 70years in both gen-
ders, but to a greater degree in women. There also seems to be a decline in external
anal sphincter tone (squeeze pressure), in women after the age of 70, and in men
from the age of 90years. There seems to be an age-related increase in anorectal
sensitivity thresholds and a reduced rectal compliance. However, rectal motility
seems to be well preserved [13]. Overall, the physiological data suggest that fecal
incontinence should not be considered an inevitable consequence of aging alone [2].
Colonic function in general, and fecal incontinence specically, appears to be
more inuenced by factors associated with aging than by aging itself [2]. Gender is
normally an issue when discussing fecal incontinence since female gender is associ-
ated with a higher prevalence due to pregnancies and obstetric injuries [14].
However, among older people residing in nursing homes, a systematic review [5]
found no signicant associations between gender and fecal incontinence in six of
the 23 included studies, 1 study found increased risk between female gender and
fecal incontinence [15] and two studies found a signicant correlation between
male gender and fecal incontinence [16, 17]. A more recent study from over 2500
residents in nursing homes in Japan found that fecal incontinence was more preva-
lent in men than women, approximately 48.8% and 40.7% respectively [6].
8.4.2 Stool Consistency
Stool consistency is an important factor associated with fecal incontinence. Loose
stool as well as hard stool can be related to fecal incontinence [2, 5]. Potential revers-
ible causes of loose stool may include excessive laxative use, lactose intolerance,
drug-related side effects, and bacterial overgrowth [2]. In the elderly, chronic consti-
pation can lead to fecal impaction. Although a denition of fecal impaction is elu-
sive, it usually refers to the accumulation of hard feces in the rectum and colon that
the person cannot evacuate alone [18]. Liquid stools from the proximal colon can
bypass the impacted stool, causing overow incontinence, often mistaken for diar-
rhea [2]. The research on prevalence and risk factors of impaction is very limited, but
indirect data suggest that it is highly prevalent among frail older people in nursing
homes [18]. One study investigating prevalence and risk factors for impaction in
nursing home residents found a prevalence of 28% with a frequency labeling of
impaction as a record of at least two episodes of impaction in the last year, and 47%
with a frequency labeling of at least one impaction episode in the last year. The same
study found a prevalence of 7% based on a rectal examination performed by a physi-
cian when the physician described the feces as hard and impacted. They also found
that the prevalence of fecal incontinence was 16% among residents without a history
of fecal impaction, and 28% among those with a history of fecal impaction [18].
L. E. Blekken et al.
157
8.4.3 Urgency
Urgency associated with bowel movements is also an important factor related to
fecal incontinence [2]. Many studies do not evaluate urgency as an independent risk
factor. However, among the studies that evaluated a sense of urgency associated
with bowel movements, urgency is consistently and strongly related to fecal incon-
tinence [2]. Other bowel-related disorders, such as hemorrhoids, posterior vaginal
prolapse, irritable bowel syndrome, or complications of prior surgery and child-
birth, can contribute to fecal incontinence in older adults who otherwise would be
continent. This might especially become a problem when functional status, mobil-
ity, and cognition become impaired. Hence, a focused history in older people with
fecal incontinence inquires about bowel-related disorders, obstetric and gynecologi-
cal history, and surgery [2].
8.4.4 Comorbidities
In residents living in nursing homes, some diseases seem to increase the risk of fecal
incontinence. An environment with physical or social obstacles may further impair
the ability to maintain continence. This is particularly relevant to individuals who
have physical or mental disorders. Akpan etal. [19] found that comorbidity in gen-
eral was associated with fecal incontinence. In male nursing home residents, Aslan
etal. [15] found diabetes mellitus to be associated with fecal incontinence, possibly
due to impaired rectal sensitivity and sphincter weakness. Neurological diseases
associated with fecal incontinence in nursing home residents include neurological
disease in general [20], cognitive impairment/dementia [5], and stroke [15, 21].
Regarding stroke, epidemiological studies suggest that fecal incontinence is associ-
ated more with disability-related factors (e.g., locomotion, other functional impair-
ment) than stroke-related factors (e.g., severity, lesion location) [2]. In addition,
poor mobility and an increase in dependency in activities of daily living are shown
to be risk factors [5], after controlling for other variables [15, 17, 20, 22–24]. In
nursing home residents, fecal incontinence often co-exists with urinary inconti-
nence [2].
8.4.5 Functional Fecal Incontinence
In addition to the risk factors and potential causes presented above, a very important
aspect in this group is the concept of functional fecal incontinence, dened by
mobility problems, toileting self-care decit, or cognitive problems or restraints that
restrict accessibility to the toilet, despite normal bowel sensation and capacity [2,
25]. In a large study of more than 39,000 patients in nursing homes in 27 states in
the US, Bliss etal. [26] observed that 24.6% of residents developed dual inconti-
nence during their nursing home stay. Of these, 35.5% of residents had urinary
incontinence only at admission, developing fecal incontinence after admission.
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
158
Functional limitations in activities of daily living were a signicant independent
predictor of developing dual incontinence, as were older age, having more comor-
bidities, and worse cognitive function [26].
Since most of the residents in nursing homes are dependent on care, personnel
for prevention and management of fecal incontinence and care personnel need to
be aware of the problem and know what the best practice for this group is. The
value of good bowel care needs to be emphasized since individualized continence
care might be the key in preventing and treating the condition. However, the level
of knowledge among care personnel on the value of good bowel care, including
appropriate assessment and treatment options, seems limited [10, 12, 27–29], and
nursing students do not always receive adequate education about bowel manage-
ment or incontinence care [30]. Hence, the use of incontinence pads is the most
common management for fecal incontinence in long-term care settings [25, 31,
32]. Harrington etal. [33] found that only 3.7% of nursing home residents with
fecal incontinence were offered a bowel-training program (diet, uid, regular
schedules).
8.5 Evidence Based onManagement inNursing
Home Residents
There is at present a relatively limited evidence base for interventions for fecal
incontinence in nursing home residents from high-quality experimental trials [12].
However, expert consensus recommends conservative interventions, singly or in
combination, for most patients with fecal incontinence as rst-line management,
including frail older adults in nursing homes. Conservative management is dened
as a non-operative intervention designed to improve fecal incontinence or prevent
deterioration. It includes pharmacological treatments [12]. Treatment of fecal
incontinence in older adults living in nursing homes may require treatment of con-
stipation and fecal impaction as well; yet, there are few studies about the treatment
and prevention of constipation and fecal impaction in this population [2].
Ouslander etal. [34] investigated the effect of prompted voiding on fecal incon-
tinence in nursing home residents. Results showed no signicant change in the fre-
quency of incontinent bowel movements. There was, however, an increase in the
number of continent bowel movements.
Chassagne etal. [35] studied the effect of lactulose alone (group I) compared to
lactulose together with daily suppositories and weekly tap water enemas (group II)
for reducing fecal incontinence episodes in older nursing home residents. There was
no signicant difference in fecal incontinence between the groups. In a subgroup
analysis, the patients in group II who achieved complete rectal emptying had fewer
fecal incontinence episodes.
Schnelle etal. [36] studied the effect of a three-month multicomponent interven-
tion for improving fecal incontinence and constipation in nursing home residents.
L. E. Blekken et al.
159
The intervention group received toileting assistance and exercise. In addition, to
increase nursing home residents’ caloric intake, patients were offered a choice of
food and uids several times a day between meals. The intervention was compared
to a usual care control group. The intervention group had improvements in bowel
movement frequency and the percentage of bowel movements in the toilet, but not
fewer episodes of fecal incontinence.
Goodman etal. [37] tested the effect of a clinical benchmarking tool to improve
bowel-related care in frail older people living in nursing homes. The study did not
demonstrate a signicant reduction in bowel-related problems. However, one care
home experienced a reduction in episodes of avoidable fecal incontinence.
A Cochrane review [38] investigated and compared the effects of biofeedback,
pelvic oor exercises, electrical stimulation, and sacral nerve stimulation in adults.
The limited number of identied trials, together with methodological weaknesses of
many, did not allow for denite conclusions, but there are indications that biofeed-
back and electrical stimulation may enhance the outcome of treatment compared to
electrical stimulation alone or exercises alone. Exercise appears to be less effective
than an implanted sacral nerve stimulator. While evidence for biofeedback treat-
ment for improving fecal incontinence in older adults with cognitive impairment or
physical limitations was not found, there is no reason nursing home residents with
fecal incontinence may not benet from biofeedback and exercises if they can
comply [2].
If associated with loose stools, the anti-motility drug, loperamide, may reduce
the frequency of fecal incontinence (if infection and other causes have been
excluded), but should be used with caution in nursing home residents so as not to
result in constipation [2].
Overall, it is recognized that in many people, the symptom of fecal incontinence
is the result of a complex combination of disordered anatomy and physiology, stool
consistency and gut motility, emotional and psychological status, and restricted
access to toilet facilities, amongst other factors [12]. In nursing home residents,
assessment of fecal incontinence is further complicated due to functional and cogni-
tive decline, making the residents less able to express their needs and more depen-
dent on caregivers for their bowel management program. There is no reason to
expect that interventions, which have proven efcacy in the community-dwelling
elderly, should not also be effective in frail older people living in a nursing home.
Clinicians must, however, consider the practicality and potential benets and risks
of employing any single intervention in this population.
Effective management to meet the goals of care to maintain continence should be
possible for most frail older people [2]. Frail older people often require a different
approach, addressing the potential role of co-morbid disease, current medications,
and functional and cognitive impairment in fecal incontinence. Because risk factors
and/or causes of fecal incontinence in this group are multifactorial, a multi-
component assessment and individualized interventions are necessary to appropri-
ately treat the condition.
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
160
8.6 Special Considerations: Physical Examination, Health
Assessment, andSymptom Assessment forOlder Adults
inNursing Homes
An active case nding for fecal incontinence should be done in all frail older adults
[2, 39], and even more so in residents living in nursing homes due to a higher degree
of frailty, a high prevalence of severe functional and cognitive impairment in this
population. As noted earlier in this chapter, treatment of fecal incontinence in this
group often needs to involve treatment of constipation and fecal impaction [2].
In the process of diagnosing and deciding management, a thorough assessment
is crucial because of the complexity of interdependent factors associated with fecal
incontinence. It is important to capture the holistic picture of the frail older person.
When diagnosing fecal incontinence in residents in nursing homes, it is essential to
assess what might be the most probable causes in the individual older person. This
is an important key in matching the treatment to the person. Hence, the assessment
should include:
• Comorbid conditions and medications that could cause or worsen fecal inconti-
nence [2]. In addition to chronic medical conditions in general, the most impor-
tant comorbid conditions associated with fecal incontinence are neurological
diseases, depression, and dementia [2]. A vast number of drugs have direct or
indirect effects on the gastrointestinal system, tending to cause constipation,
diarrhea, or both in different people [2]. In addition, anti-anginal and antihyper-
tensive medications may reduce sphincter tone, while ferrous sulphate or antac-
ids may provoke diarrhea [39].
• Functional and cognitive assessment (mobility, transfers, manual dexterity,
dressing and undressing ability, ability to toilet), and screening for depression.
This will assist in diagnosing and informing individual care needs related to
bowel management [2, 40].
• Evaluation of age-related reduction in internal and external sphincter function
and a digital examination to identify rectal stool impaction causing overow. In
addition, patients who are unaware of the presence of a large fecal bolus in the
rectum may have rectal dyschezia and should be considered at risk of recurrent
impaction with overow [2].
• Evaluation of bowel “alarm” symptoms: rectal bleeding, positive blood screen-
ing from stool studies, obstructive symptoms, recent onset of constipation or
diarrhea, weight loss, and a change in stool form/consistency. These symptoms
need more extensive evaluation. In addition to assessing according to the condi-
tions mentioned above, the advanced practice continence nurse must conduct a
thorough bowel assessment (see Table8.1 for an exemplar guideline for bowel
assessment).
L. E. Blekken et al.
161
Table 8.1 Exemplar guideline for bowel assessment [41]
The assessment leads to a determination of onset, cause, and type of fecal incontinence,
frequency of episodes, and any related change in bowel function or stool consistency. In older
people, the causes are often multiple. The assessment lays the foundation for a nursing
diagnosis and choice of interventions
Frequency of defecation before moving
to the nursing home:
□ Several times a day
□ Every day
□ Between 3 and 6 times a week
□ Less than 3 times a week
□ Do not know
Excessive straining during
defecation:
□ Ye s
□ No
Frequency of defecation (the last 7 days):
□ Several times a day
□ Every day
□ Between 3 and 6 times a week
□ Less than 3 times a week
Any changes in the defecation pattern
in the last 7 days:
□ Ye s
□ No
Stool color:
□ Brown
□ Red
□ Pale, white, or clay-colored
□ Green
□ Yellow
Frequency of incontinence episodes:
□ Never
□ Less than once a month
□ A few times a month
□ A few times a week
□ Every day/or night
Stool consistency (normally):
□ Separate, hard lumps, as nuts
□ Sausage-like, but lumpy
□ Like a sausage, smooth and soft
□ Fluffy pieces with ragged edges, a mushy stool
□Watery, no solid pieces
Does it happen at night (defecation/
incontinence episodes):
□ Ye s
□ No
Pain/discomfort before, during, or after defecation
□ Ye s
□ No
Continent for urine:
□ Ye s
□ No
□ The patient has a catheter
Blood in the stool:
□ Ye s
□ No
If necessary, do a digital rectal
examination to evaluate:
□ Sore/cracks around the anus
□ Hemorrhoids
□ Impaction
□ Rectal prolapse
□ Reduced internal/external
sphincter tone
□ Others
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
162
8.7 Fecal Incontinence Management
andExpected Outcomes
The extent of the investigation and management should consider the degree of
bother to the frail older person, the goals for care, whether the person can adhere
to the intervention due to, e.g., cognitive or functional impairment, and the over-
all prognosis and life expectancy. As residents in nursing homes are, to a large
degree, dependent on care personnel to carry out the interventions, the advanced
practice nurse needs to consider what is possible for care personnel to accom-
plish. In some frail older adults, the only possible intervention may be contain-
ment of incontinence, management with absorbent products. This is especially
true for people with minimal mobility (requiring assistance of ≥2 people to
transfer), advanced dementia (unable to state their name), and/or nocturnal fecal
incontinence [2, 42].
Even if there are very few studies investigating management of fecal inconti-
nence in the nursing home population, interventions which have proven efcacy in
adults and in community-dwelling older adults, may also be effective in frail older
people in nursing homes [2]. Accordingly, see Chaps. 6 and 7 for more information
about these management interventions. Special considerations for managing fecal
incontinence in older adults in nursing homes are noted in Box 8.1.
Box 8.1 Special Considerations for Management of Fecal Incontinence in Older
Adults in Nursing Homes
• Diet modications
– In nursing home residents, the risk of malnutrition should be closely
monitored when modifying diets
– Supplement of dietary ber to improve/rm stool consistency
– Fiber supplements should be prepared with adequate uid for safe swal-
lowing; intake of additional ber should be accompanied by sufcient
intake of liquids to prevent constipation
• Increased mobility
– Therapy for increasing mobility may be combined with a plan for estab-
lishing a bowel routine or with a toileting plan
• Consequences of polypharmacy
• Establishment of regular bowel habits
– The advanced practice nurse can work with nursing home staff to
develop a person-centered toileting program as needed
• Taking control and practical coping strategies
– Strategies should be tailored/modied for a nursing home setting; for
example, providing cleansing wipes in rooms within stalls where toilets
are located may be possible rather than expecting residents to carry/
prepare their own
L. E. Blekken et al.