Prompted voiding treatment of urinary incontinence in nursing home patients. A behavior management approach for nursing home staff.

This study evaluated a treatment procedure in which 126 incontinent nursing home patients were checked on an hourly basis, asked if they needed toileting assistance (prompted), and socially reinforced for appropriate toileting. Urodynamic analysis (including cystometrogram), provocative stress test, and behavioral assessment revealed that the nursing home patients were severely debilitated, with 65% demonstrating bladder abnormalities, 87% incapable of independent toileting, and 25% failing to score on the Mini-Mental Status Exam (average score, 8.0). The treatment procedures were evaluated with a multiple baseline design in which subjects were randomly divided into immediate or delayed treatment groups after a baseline observation period. During treatment, the frequency of incontinence per 12 hours changed from a baseline average of 3.85 to a treatment average of 1.91. Three behavioral measures that can be easily collected by nursing staff significantly predicted continence levels during treatment (multiple R, 0.79) and change in incontinence during treatment (multiple R, 0.64). These prognostic criteria offer nursing staff a cost-effective method for selecting the most responsive patients for prompted-voiding treatment.

Behavioral management in the inpatient geriatric population.

Urinary incontinence is a reversible problem in many nursing home patients. The types of patients that respond to nursing management procedures have been identified in this article. Specific diagnostic and rehabilitative assessments, as well as treatment procedures, have been described in a fashion that makes them usable by most nursing professionals in long-term care facilities. Two key issues remain to be addressed. The foremost issue is that, once patients are taught to request toileting assistance, the challenge remains to motivate staff to render that assistance over long periods of time. Second, a number of patients with urologic conditions (most notably, high residual urine volumes and low bladder capacities) do not respond well to nursing management. The type of medical or nursing treatment best suited for these patients has not yet been resolved. Nevertheless, this article has detailed techniques that positively affect incontinence in nursing home patients. Nursing implementation of prompted voiding can dramatically improve continence within the geriatric inpatient population.

Reduction of urinary incontinence in nursing homes: does it reduce or increase costs?

Labor and supply costs associated with the care of urinary incontinent patients in three nursing homes were measured. First, normal nursing home changing patterns and their associated costs were measured. Second, the costs were documented when patients were checked by research staff and changed on an hourly basis as needed. Nursing home staff changed patients significantly less frequently than patient voiding as detected by the hourly checking system. Thus, cost of incontinence during the hourly checking condition ($3.35) per 12-hour patient-day was significantly higher than the cost normally incurred in nursing homes ($1.52) per 12-hour patient-day. The cost of an incontinence rehabilitation program, which significantly reduced incontinence episodes, was contrasted to the cost of incontinence as measured under both of the previous conditions. The rehabilitation program produced significant labor and supply savings only when compared with the hourly checking and changing system. Maintaining patients in a more continent condition costs significantly more than the direct incontinence cost normally incurred by the nursing home. Quality of life and other second-order benefits must be considered if continence rehabilitation is to be judged cost-effective.

Behavioral covariation in the treatment of chronic pain.

The successful use of operant procedures to alter behaviors associated with various medical conditions suggests that such behaviors may be learned and that the principles of learning may be applied not only to treatment but also to the study of the pathogenesis of illness behavior. The present study, conducted within an ongoing neuromuscular research project, assessed the covariation of behaviors associated with chronic pain within and across behavioral and drug approaches to treatment. Problems of screaming and five other behaviors (including self-reports of pain) were measured across conditions of varying behavioral contingencies (noncontingent reinforcement vs the removal of reinforcement contingent upon screaming) and varying administration (time since medication and dosage) of Parsidol during attempts to treat the muscle pain of a 24-year-old male with a severe, chronic neuromuscular disorder diagnosed as dystonia musculorum deformans (DMD). Results indicated that: (a) pain behaviors covaried during behavioral and drug conditions even though the behavioral intervention only targeted screaming; (b) effects were greater on nontargeted behaviors during periods that followed rather than preceded drug administration; (c) in contrast to behavioral observation data, physiological measures of neuromuscular activity (EMG) did not differ across conditions. These results suggest that functional response-response relationships exist in patients as the result of their illness experience.

Management of geriatric incontinence in nursing homes.

A behavioral management system designed to reduce urinary incontinence was evaluated in two nursing homes with a pretest-posttest control group design with repeated measures. The primary components of the system were prompting and contingent social approval/disapproval which required approximately 2.5 minutes per patient per hour to administer. The frequency of correct toileting for experimental subjects increased by approximately 45%. The experimental groups were significantly different from the control groups on both incontinence and correct toileting measures. The results are discussed in view of the management issues inherent in nursing home settings.