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8.7.1 Patient Education
For select cognitively intact older adults with fecal incontinence, education can be
offered to promote self-management, e.g., education about bowel function, reduc-
ing the risk of constipation and impaction through dietary and lifestyle measures,
and use of antimotility medications [2, 12]. Providing advice about skin care, odor
control, and use of continence aides, such as over-the-toilet chairs, is also important
[42]. For older adults with cognitive impairment, the attitude and management
methods adopted by care providers are critical in maintaining continence [2].
8.7.2 Management Compensating fortheConsequences
ofCognitive Impairment
Expert opinion supports the importance for older adults attempting to establish a
regular, predictable pattern of bowel evacuation [12]. Because peristaltic contrac-
tions of the colon, which are associated with defecation, increase in frequency fol-
lowing awakening from sleep and meals, the period after breakfast or another meal
may be an optimal time for scheduled defecation [12]. Assessing an individual’s
defecation pattern will inform this plan. It is suggested that an effective intervention
in managing fecal incontinence in cognitively impaired nursing home residents is
proximity to the toilet and the ability to recognize a toilet. This might involve
removing visual barriers to the toilet in the resident’s room and improving signpost-
ing both in the resident’s room and near the publicly available/shared toilets in the
nursing home. Examples of signposting include placing signs with unique bright
colors, pictures of a toilet, or the word, toilet, rather than restroom on the door to the
room with a toilet, and placing arrows on the oor that point to the location of the
toilet [43].
For some cognitively impaired nursing home residents, prompted toileting pro-
grams might be benecial. Prompted toileting involves asking, reminding, and
prompting the resident about going to the toilet on a regular schedule and giving
positive reinforcement when they do. Residents may simply need to be directed to
the toilet or reminded to defecate at regular intervals. Scheduled toileting involves
taking the resident to the toilet on a xed schedule and is recommended as a rst
• Behavioral therapies
– Pelvic oor muscle training
• These may be taught individually or in a group, which may increase
socialization
– Biofeedback therapy
– Neuromodulation, including electrical stimulation (ES) therapy
• Devices for fecal incontinence
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
164
approach for older adults with cognitive impairment. This intervention might also
be efcient in residents who “lack cortical control of the defecation process” but
tend to defecate formed stool following peristaltic movements [43].
8.7.3 Management Compensating fortheConsequences
ofFunctional Impairment
Expert opinion holds that it is important to ensure appropriate toilet facilities and
convenient access, especially for people with disabilities [12]. An environment with
physical or social obstacles may impair the ability to maintain continence. This is
particularly relevant to individuals who have physical or mental disorders.
Environmental obstacles include toilet facilities that are physically inaccessible, too
few or distant; they also include clothes that are difcult to manipulate in a hurry,
and a variety of other factors that vary with the abilities of the individual. The toilet
itself may be too high, leaving the feet dangling and thus making abdominal strain-
ing difcult. The toilet may also be too low, making sitting and rising difcult for
those with mobility difculties [12].
Effective bowel evacuation is helped by sitting well-supported, with feet slightly
raised upon a step stool if needed to enable appropriate use of abdominal effort, and
leaning forward slightly (the squat position). Horizontal grab rails assist pushing up
from a seated position, while vertical ones can enable pulling up. For lateral transfer
from a wheelchair, both seats need to be at the same height. Where it proves impos-
sible for an older adult to use the toilet, alternatives are commodes or temporary
non-ush chemical toilets [42]. If the nursing home resident is bed-bound, position-
ing them in a left-side lying position while bending their knees and moving the legs
towards the abdomen simulates the squat position.
8.7.4 Management ofFecal Incontinence Related toDiarrhea,
Constipation, andImpaction
Chapters 6 and 7 discuss interventions for fecal incontinence involving diet, uids,
and physical activity. For fecal incontinence due to diarrhea, loperamide may be
considered at a low dose (if infection and other causes have been excluded) [2].
However, close monitoring for constipation and impaction is needed.
Goodman etal. [43] imply that management of constipation and impaction may
lead to improvement in fecal incontinence. This effect is explained by achieving
long-lasting and complete rectal emptying through the use of laxatives, which
would reduce the number of episodes of fecal incontinence. On the other hand, it is
also suggested that a preoccupation with constipation by nursing home care staff
may lead to an overuse of laxatives with resulting in loose stools and a higher risk
of fecal incontinence episodes. In residents identied with having constipation/
impaction with overow, effective bowel clearance might be effective in treating
fecal incontinence. Bowel clearance is best achieved by using a combination of
L. E. Blekken et al.
165
laxatives and enemas. After bowel clearance is achieved, the advanced practice
nurse should consider maintenance therapy with osmotic laxatives and dietary ber
intake. It is very important that the type and dosage of laxatives is titrated and indi-
vidualized and that the effect is closely monitored in each person [2]. In addition,
suppositories are useful in treating rectal outlet delay and preventing recurrent rectal
impaction with regular use [2].
8.8 Towards Dignity asaPrimary Goal ofContinence Care
Care personnel in nursing homes must ensure that assessment and management of
fecal incontinence are provided with compassion and respect for the resident’s dig-
nity [44, 45]. The stigma associated with fecal incontinence can cause care staff to
have dismissive or blaming reactions or show disgust, resulting in emotional dis-
tress of the incontinent older adult and interfering with appropriate care [44, 45].
The nursing home resident, their family caregivers, and nursing and medical staff
might be inuenced by the misperception that incontinence is part of the natural
aging process and therefore “nothing can be done about it” [2, 46]. In nursing homes
with a high prevalence of cognitive impairment, patients are even more dependent
on the care personnel to be aware of the problem and to be informed that fecal
incontinence can be managed in many patients and about the options of management.
In the guideline shown in Table8.2, dignity is proposed as an outcome for care.
Ostaszkiewicz [45] developed a framework to guide nurses in how to achieve the
goal of dignity in continence care. Dignity is dened as an inherent characteristic of
being human; it is subjectively felt as an attribute of the self and is manifest by
behaviors that demonstrate respect for self and others [45]. In a concept analysis,
Ostaszkiewicz etal. [50] identied key domains of dignity in relation to continence
care (see Box 8.2).
Box 8.2 Key Domains of Dignity in Relation to Continence Care
Respect
• Treating the person as an individual, not as an episode of care
• Ensuring the person’s body is kept clean
• Adopting a partnership approach that includes listening to and involving
family members, caregivers, and the person being cared for in continence
decisions
• Showing compassion
• Taking time to address the person’s need (not rushing care)
Empathy
• Conveying kindness, i.e., offering reassurance, showing tenderness and
compassion
• Being gentle, i.e., washing with care and using touch appropriately
• Acknowledging the impact of stigma
(continued)
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
166
Box 8.2 (continued)
Trust
• Establishing a trusting relationship before care happens
• Knowing and understanding the person’s biography and preadmission his-
tory, understanding the person’s inner experience
• Understanding the person’s unique behaviors
• Knowing the person’s values and beliefs
• Gathering the person’s narrative to develop an individualized continence
care plan
• Responding to the person’s continence care needs promptly
• Ensuring the person feels emotionally and physically safe in continence
care interactions
Privacy
• Closing doors, closing curtains
• Ensuring incontinence products remain hidden so they are not visible
to others
• Concealing the person’s incontinence from others
• Being discreet
Autonomy
• Providing individualized care that includes offering the person a choice
and supporting them to make decisions about the gender of the carer, toi-
leting preferences, and choice of products
Communication
• Managing one’s emotional responses and body language
• Speaking in a calm, soft tone
• Noticing verbal and nonverbal cues
• Using touch appropriately
• Using appropriate language
• Adopting a friendly and gentle attitude
• Maintain a sense of calm and normality about the situation
• Minimizing the socially taboo nature of the problem in the context of
the setting
• Using humor judiciously
• Maintaining eye contact
L. E. Blekken et al.
167
Table 8.2 Example of a guideline on diagnostic assessment and management of fecal inconti-
nence [41, 43, 45, 47, 48, 49]
Nursing diagnosis—fecal
incontinence or risk of fecal
incontinence Management to consider
Potential causes/risk factors to
consider
• Constipation
• Impaction
• Chronic diarrhea
• Acute diarrhea
• Incomplete emptying of the bowel
• Loss of rectal sphincter control
• Impaired reservoir capacity
• Prior rectal surgery
• Impaired cognition/dementia, but
with cortical control of the
defecation process (e.g., cannot
remember where the WC is).
• Advanced dementia with no
control of the defecation process
• Stress
• Apathy/depression
• Toileting self-care decit
• Impaired mobility
• Inactivity
• Frailty
• Upper motor nerve damage
• Lower motor nerve damage
• Inadequate toileting (privacy,
timeliness, position for
defecation)
• Medication
• Laxative abuse/misuse
• Environmental factors
(e.g., inaccessible bathroom)
• Inadequate dietary habits
• Insufcient intake of dietary ber
• Insufcient intake of uids
• Enquire (resident/proxy) about beliefs, goals, and
preferences for continence care
• Discuss management options and expected results with
the resident
• Teach residents about specic foods that are assistive in
promoting bowel regularity
• Provide foods that are assistive in promoting bowel
regularity
• Avoid foods that can cause diarrhea
• Implement scheduled−/prompted toileting program, as
appropriate
• Administer bowel record/bowel diary
• Implement a program for physical activity, as
appropriate
• Facilitate personal rituals
• Ensure proper seating on the toilet/on the bedpan
• Offer toileting assistance, as appropriate
• Manual removal of stool bulbs from the rectum
• Perform rectal examination, as appropriate
• Monitor for adequate bowel evacuation
• Monitor bowel movements, including frequency,
consistency, shape, volume, and color, as appropriate
• Monitor diet and uid requirements
• Monitor bowel sounds
• Monitor for signs and symptoms of diarrhea,
constipation, and impaction
• Administer laxatives, as appropriate
• Monitor for adverse effects of medication
administration
• Monitor perianal skin for the development of pressure
ulcers and infection
• Wash the perineal area with soap and water and dry it
thoroughly after each stool
• Provide proper skin creams in the perineal area.
• Ensure privacy
• Keep bed and clothing clean.
• Manage incontinence pad, as needed
• Manage anal plug, as needed
Patient outcomes to consider
• Independent continence (person has never been incontinent or continent as a result of treatment)
• Controlled continence (continent with an intervention, e.g., behavioral treatment, toileting
assistance)
• Contained continence (incontinence that is contained by incontinence products)
• Recognition/use of the toilet
• Minimization of leakage/improvement of symptoms
• Skin integrity
• Comfort
• Minimization of distress
• Dignity
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
168
8.9 Disparities inCare
In studies of nursing homes in the US, Bliss and colleagues observed racial and ethnic
disparities in the management of incontinence (including fecal and urinary inconti-
nence) as well as its prevention. For nursing home admissions who were Hispanic,
disparities were found in time to cure of incontinence [51]. For Black or African
American nursing home residents, there were signicant disparities in receiving man-
agement of dual incontinence that developed after admission [52] as well as in the
prevention of incontinence [47]. Recommendations for eliminating disparities in
incontinence care include developing an organizational culture and model of care
committed to equity [53, 54]. This development would include becoming aware of
any disparities, implementing interventions for improvement that engage staff at all
levels and are based on resident needs, and benchmarking and communicating prog-
ress. Achieving equity in nursing home care is consistent with the goal of providing
care that maintains residents’ dignity and of the practice of the advanced prac-
tice nurse.
8.10 Multidisciplinary Cooperation andContinuity ofCare
In addition to the greater emphasis that needs to be placed on systematic and effec-
tive management of fecal incontinence by the advanced practice nurse, there is also
an accompanying need for multidisciplinary cooperation and sound communication
between members in the multidisciplinary team involved in the assessment and
treatment of the resident’s bowel problems [2]. Most residents in nursing homes
have several complex and interdependent health problems, where fecal incontinence
may be one of them. Therefore, it may be worth considering whether there is a need
for a comprehensive geriatric assessment (CGA). Comprehensive geriatric assess-
ment is dened as a multidisciplinary diagnostic and treatment process that identi-
es medical, psychosocial, and functional limitations of a frail older adult to develop
a coordinated plan to maximize overall healthy aging [55]. CGA is based on the
premise that a systematic evaluation of frail, older adults by a team of health profes-
sionals may identify a variety of treatable health problems and lead to better health
outcomes. The best evidence for CGA is based on identifying appropriate residents,
which means excluding those who are too well or too sick to derive benet. The
medical assessment of the nursing home resident may be conducted by an advanced
practice nurse, including a selected brief initial assessment or screens for some
dimensions. These may be augmented with more in-depth evaluations by additional
professionals.Table 8.2 shows an example of a fecal incontinence guideline facili-
tating an in-depth assessment and management of fecal incontinence in nursing
home residents. The guideline facilitates an individualized assessment, and the
goals for management also need to be individualized. For example, the guideline
may facilitate the individualized nursing diagnosis: Fecal incontinence related to
loose stools, possibly due to excessive laxatives, urgency, and reduced mobility. The
guideline suggests several interventions related to this diagnosis, e.g., offer toilet
assistance as appropriate and administer laxatives as appropriate. The meaning of
L. E. Blekken et al.
169
“appropriate” is for an individual older adult requires knowledge, clinical reasoning
skills among care staff, and contextually situated decision-making.
8.11 Educating andEngaging Nursing Home Staff
Nursing staff in nursing homes may lack knowledge about incontinence assessment
and best practice intervention strategies [2, 46]. There may be a need for the
advanced practice nurse to assist with implementing staff education and a change in
practice to improve care related to fecal incontinence. However, translating evi-
dence-based practices into policies and procedures in nursing homes and other care
settings can be a challenge [56]. Even though research-based evidence is not con-
clusive, implementation science research suggests that the most effective method
for changing the behavior of health care staff in nursing homes involves multifac-
eted teaching strategies and resources, such as toolkits, combined with individual or
small group training and feedback [57, 58]. Key staff outcomes are increased
knowledge, change of attitude towards believing that fecal incontinence is not an
inevitable consequence of aging and can be treated, condence in incontinence care,
and work satisfaction [43]. Box 8.3 shows an example of a multifaceted education
program for implementing change for fecal incontinence care in a nursing home,
developed and evaluated by Blekken etal. [59, 60].
Box 8.3 An Exemplar Educational Program with an Intervention Period of
3 Months for Fecal Incontinence in a Nursing Home
• Initial workshop [61] (7h)
– 3h theoretical introduction targeting knowledge, attitudes, and skills
Example content
• Anatomy and physiology of the bowel in general and on the
aging bowel
• Risk factors for incontinence in nursing home residents
• Difference between fecal incontinence, diarrhea, and constipation
• Discussion about attitudes, stigma, and shame related to fecal
incontinence
• Skills for assessing and managing fecal incontinence
– 3.5h case-based discussions using the fecal incontinence guideline (see
Tables 8.1 and 8.2)
• Recruitment of a local opinion leader [62] responsible for:
– Motivating and engaging care staff in general between outreach
meetings
– Facilitating adherence to the program together with the care manager
• Six 1.5h educational outreach meetings [61] focusing on:
– Empowering care staff in critical and clinical reasoning on managing
fecal incontinence
– Facilitating nursing home-specic strategies to ensure continuity of care
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
170
The effect of the implementation strategy in Box 8.3 was evaluated by a cluster-
randomized trial involving 20 nursing home wards. The primary outcome was the
frequency of fecal incontinence episodes in residents. Two of the secondary outcomes
were change in knowledge among registered nurses and change in documented care
for fecal incontinence by health care staff in the electronic patient record as individu-
alized care plans. The trial is nished, but the results are not published. However,
analyses indicate no signicant effect on the frequency of fecal incontinence in resi-
dents. Why this implementation strategy did not work as hypothesized is up for dis-
cussion. Two potential reasons are that an intervention period of 3months is too short
for the whole care staff in a complex organizational setting to change practice in fecal
incontinence care and for the residents to respond to the treatment. Another reason
might be the problem of continuity of care. Even though thorough assessments and
individualized care plans were developed, these authors do not know whether all care
staff on all shifts followed the instructions. Third, the interventions focused only on
the residents with fecal incontinence. Maybe it would have been wise to also focus on
the prevention of fecal incontinence in residents still continent. In addition, even
though the intervention focused some degree on attitudes and education, the investiga-
tors did not focus on the concepts of dignity, empathy, therapeutic communication,
and the acknowledgement of stigma and person-centered care. According to the
Dignity of Continence Care Framework, this might be essential in the process of fos-
tering change of care in nursing homes in addition to educating staff [45].
Improving the provision of continence care by nurses needs to be multipronged
and include strategies other than education and increasing nurse knowledge. Hunter
and Wagg [63] recommended ways to increase nurses’ engagement with continence
care that seem appropriate for various care settings from the community clinics to
nursing homes. These strategies include articulation and stratication of nursing
responsibilities among general nurses, advanced practice nurses, and continence
specialist nurses, as all nurses do not have the same expertise. Other strategies to
improve nurse engagement were to develop and utilize clinical guidelines for conti-
nence care and to enable patients to have direct access to specialized, comprehen-
sive nursing services for continence care.
8.12 Person-Centered Care
Goodman etal. [43] have explored theory and research on the possible effect of
person-centered care on the management of fecal incontinence. The FINCH pro-
gram theories are derived from a comprehensive realist synthesis of what type of
continence care works for older adults with dementia in nursing homes [43]. The
theory encapsulates the person-centered care approach in that a person’s needs,
wants, and abilities, specically in relation to toileting and continence, will prevent
and/or reduce reversible fecal incontinence. Although Goodman et al. [43] found
extensive literature on person-centered care in nursing homes, very little of it pro-
vided details about how care should be delivered and about what kind of outcomes
were likely to be achieved.
L. E. Blekken et al.
171
Musa [64] tested the FINCH program theories by developing a complex inter-
vention for the management of fecal incontinence in older adults with dementia in
nursing homes. Musa [64] also tested the feasibility and potential efcacy of the
intervention. The overall aim of the PhD project was to determine whether it was
feasible to develop a fecal incontinence intervention for care home residents living
with dementia, and whether such an intervention could reduce the frequency of
fecal incontinence episodes. Even though the intervention led to increased staff
knowledge and condence in bowel care, the results showed no reduction in fecal
incontinence at the nursing home unit level. However, at the individual resident
level, ve residents (out of 16) with fewer comorbidities who were receiving fewer
medications had some reduction in the overall frequency of fecal incontinence epi-
sodes. From the FINCH program study, Musa [64] concluded that incorporating
person-centered care into nursing home routines is difcult.
It is reasonable to believe that if person-centeredness and emotional bonds
between caregivers and residents are discouraged by the nursing home setting and
managers, burnout among staff occurs more frequently, leading to absence, higher
turnover, and a task-oriented approach resulting in low-quality fecal incontinence
care. On the other hand, when interactions and the formation of bonds with resi-
dents are valued, staff might develop a person-centered working style and focus on
residents as individuals with different needs and preferences [43], leading to indi-
vidualized strategies to optimize the resident’s autonomy and continence [45].
Ostaszkiewicz [45] also highlights the importance of meeting the older person’s
values when providing continence care. In a literature review, Göransson etal. [65]
examined the question: What values are of importance in relation to toileting and
containment care? Based on the ndings, they developed the conceptual construct
“The art of connectedness.” Achieving connectedness meant that continence care
given to an older adult had to be co-created, personalized, and reective of the value
to the older adult. Goodman etal. [43] also refer to a study with promising results
investigating the effect of a combination of person-centered care and a standardized
package of care. The underlying mechanism may have been that staff were more
likely to promote bowel health when the individual needs of the resident were sys-
tematically considered and linked to a standardized checklist. The guideline used by
Blekken etal. [41] is an example of a standardized checklist that can be used in
implementing change processes together with concepts of person-centered care.
8.13 Ongoing Management andReassessment
Optimal fecal incontinence management is possible with the approaches described
in this chapter. If initial management fails to achieve the desired goals, the next
steps are reassessment and treatment of contributing comorbidity and/or functional
impairment. If frail older adults have either other signicant symptoms (e.g., pain or
other bowel “alarm” symptoms as described above) or other complicated comor-
bidities that the primary care clinician cannot address, referral to a specialist should
be considered. Referral should also be considered if the response to initial
8 Management ofFecal Incontinence inOlder Adults inNursing Homes
172
management is insufcient. The type of referral will depend on local resources and
reason for referral: colorectal surgeons, gastroenterologists, physiotherapists (func-
tional and cognitive impairment), and continence nurse specialists. Referral deci-
sions should consider goals of care, the older adult’s desire for additional and
perhaps more invasive therapy, quality of life, and estimated remaining life
expectancy.
Box 8.4 presents a case study illustrating a plan of care for a resident with fecal
incontinence in a nursing home after the staff completed an educational program
aimed at improving their ability to better manage fecal incontinence.
Box 8.4 Case Study
Nurses in a nursing home participated in an education and engagement pro-
gram about best practice fecal incontinence care and how interventions can be
effective in reducing fecal incontinence. The program involved learning, dis-
cussion, and practice in performing a thorough and holistic assessment of
residents, including bowel function in general and fecal incontinence in par-
ticular. The nurses were coached to use their assessment ndings along with
risk factors and possible causes of fecal incontinence to develop intervention
plans that were person-centered and feasible. Below is a case study of a resi-
dent and their continence plan.
Mrs. Anderson is a 94-year-old woman who was admitted to a nursing
home after living independently in her own home for a few years after her
husband died. Mrs. Anderson had become more frail needing assistance with
activities of daily living and taking her medications for hypertension and
depression, and has some mild cognitive impairment and fecal incontinence.
The staff did an assessment of Mrs. Anderson’s bowel elimination patterns,
including fecal incontinence episodes, diet intake, mobility, and social activi-
ties and interactions. Mrs. Anderson was not always able to notify the staff
when she needed to use the toilet with enough time to avoid an incontinence
episode. She also did not “make it” to the toilet on her own in time to avoid
leakage, as she was unsteady in her walking and sometimes got confused
about the location of the room with the toilet. Mrs. Anderson’s diet intake was
low, and she had frequent small amounts of stool. She also did not socialize
with others at meal times since she was new to the community.
The nursing staff’s plan of care utilized a toileting program with staff assis-
tance based on their assessment. The staff explained the signs used to identify
the rooms with toilets and the way to get there to Mrs. Anderson. Physical
therapists started her on an exercise regimen to increase her strength and dex-
terity and provided her with a walker to help stabilize her mobility. Her meals
were adjusted to include foods and supplements containing extra protein and
calories, and a ber supplement in the form of cookie wafers aimed at bulking
(continued)
L. E. Blekken et al.