Faecal incontinence, constipation and laxative use: Epidemiology and development of an implementation strategy for improving incontinence care in nursing homes

Abstract

Background: Faecal incontinence (FI) and constipation affects a significant amount of the nursing home (NH) patients. In addition, many of the patients use laxatives regularly. Both faecal incontinence and constipation are bothersome conditions associated with increased risk of morbidity and reduced quality of life. There is a lack of studies investigating bowel problems among NH patients using validated and comprehensive instruments able to capture the complexity in NH patients. The level of awareness among health care staff regarding assessment and treatment options for FI seems limited. Aim: The aim of this thesis was to investigate prevalence and associations of faecal incontinence, constipation and laxative use among NH patients using the standardized and comprehensive Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). Secondly, the aim was to develop an implementation strategy for change in FI care in order to achieve a reduction in FI prevalence rates among patients. Results: Study I and II had a cross-sectional design including 261 patients in NHs in one Norwegian municipality. Study I showed prevalence rate of FI was 42.1 % or 54 %, depending on the chosen cut-off on the scale measuring FI in interRAI LTCF. In order to get some additional information on FI St. Mark’s Incontinence score was used, resulting in a prevalence rate of 70.1 %. This illustrates the importance of using clear definitions together with standardized instruments when investigating FI. Deficiencies in ADL, cognitive impairment, urinary incontinence and diarrhea were identified as risk factors, and involvement in activities and instability in health/frailty were identified as protective factors. In study II the prevalence of constipation was 23.4 % and 67.1 % of the patients used laxatives regularly. Balance problems, urinary incontinence, hypothyroidism, and Parkinson’s disease were identified as risk factors for constipation. Risk factors for laxative use were reduced ability to communicate and number of drugs other than laxatives, while anti-dementia drugs and being involved in activities were protective factors. Analyses using mixed effects models showed that most of the total variance in prevalence rates of faecal incontinence (88 %), constipation (90.3 %) and laxative use (97 %), was due to differences in individual patient characteristics, not variance between NH units. Study III was a pilot study preceding a cluster-randomized controlled trial (C-RCT). The pilot was designed as a three armed external pilot study investigating feasibility, acceptability, and adherence of two educational programmes for care staff concerning NH patients’ FI. Data was collected at baseline (t0) and after 3 months (t1). The study included patients (t0 n = 62, t1 n = 57) and registered nurses (t0 n = 7, t1 n = 7) in NHs. Quantitative data was analysed by descriptive statistics. Qualitative data from one focus group interview and four individual interviews were analysed by qualitative content analyses. The pilot study found the planned C-RCT to be feasible with one major and some minor modification. The major modification was the necessity to reduce the main study from a three-armed design to a two-armed design. Important barriers identified were sub-optimal use of skill-mix, problems of communicating assessments and care plans, and isolated RNs with an indistinct nurse identity. Paper IV is the protocol describing the C-RCT evaluating a multifaceted educational programme for care staff on assessment and treatment of patients’ FI. Conclusion: Prevalence of FI, constipation and laxative use are confirmed high. Variance in prevalence rates is mainly explained by different patient characteristics/ health deficiencies. Hence, individualized care matching the patients’ deficiencies might be a key to managing bowel problems. There is a need for studies evaluating interventions targeting bowel problems in NHs. Further, there is a need for studies evaluating different implementation strategies. The interRAI LTCF is a useful instrument by its combination of a comprehensive range of individual items and scales that make it possible to capture a holistic picture of the complex NH patient, allowing for comparison of immediate and long-term change in patients across settings