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Behavioral intervention associated with modest improvement in daytime continence for nursing home residents, systematic review shows

Tuesday, December 16 2008 | Comments

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What's This? Prompted voiding, a behavioral intervention for treating urinary incontinence (UI) that consists of caregivers querying and checking residents for wetness, providing toileting prompts, and offering positive feedback for dryness and appropriate toileting requests, is an effective intervention for treating UI among nursing home residents, concludes a new analysis of existing trials.

To assess the safety and efficacy of interventions commonly used in nursing homes, the researchers conducted a systematic review of randomized, controlled trials published from January 1985 through May 2008. Trials were eligible if participants were residents of nursing homes or other long-term care institutions. The team identified 14 studies with a total of 1,161 participants for inclusion in the analysis. Most of the participants were women.

In addition to prompted voiding, interventions considered in the studies were antimuscarinic drugs, oral estrogen plus progesterone, and other behavioral interventions (ie, habit retraining, timed voiding). Some trials also considered the impact of specialized exercise programs including functional incidental training (FIT), a program in which strength and endurance exercises are integrated into a daytime prompted voiding routine.

Data pooling was not possible because of the heterogeneity of the patients, interventions, and outcomes.

Five trials compared the efficacy of a toileting behavioral program with that of usual care for nursing home residents with UI, with results showing that behavioral interventions were consistently associated with improved continence as compared with usual care.

For example, a 1989 study by Schnelle et al. compared daytime prompted voiding with usual care during 5-day and 10-day periods. Prompted voiding reduced the percentage of incontinent wet checks as compared with usual care (18% vs 35%, respectively; P<.001) and increased the appropriate toileting ratio (59% vs 17%, respectively, P<.001). Similarly, a 1992 study by Surdy reported that 24-hour prompted voiding resulted in a reduced rate of incontinent wet checks after 7 weeks of treatment as compared with usual care (13% vs 46%, respectively; P<.001).

Three clinical trials assessed the efficacy of prompted voiding in conjunction with FIT. In these trials, nursing home residents who received FIT showed greater improvement in urinary continence than did residents who received usual care. Researchers did not find, however, that the combined FIT/prompted voiding intervention enhanced outcomes compared with prompted voiding alone.

Pharmacologic interventions resulted in small and inconsistent effects, according to the authors, though they noted that the trials included in the analysis provided limited data regarding the efficacy and adverse effects of pharmacological treatments. Limited evidence suggests that antimuscarinic drugs may reduce UI episodes among nursing home residents who are not responsive to prompted voiding.

The researchers conducting the analysis noted that trials considered were generally small in sample size, short in duration, and in some cases, were methodologically weak.

"Most evidence supports the efficacy of prompted voiding in reducing daytime UI," the authors commented.

Future studies regarding antimuscarinic drugs should be "well-designed randomized controlled clinical trials," they added. (Fink HA, et al. Mayo Clin Proc 2008;83:1332-1343.)

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