Urinary incontinence treatment preferences in long-term care

OBJECTIVE: To elicit preferences for different urinary incontinence (UI) treatments in long-term care (LTC) from groups likely to serve as proxy decision makers for LTC residents. DESIGN: A descriptive, comparative study of preference for UI treatments of frail older adults, family members of nursing home (NH) residents, and LTC nursing staff. Surveys were mailed to families and self-administered by staff. Older adults were interviewed. SETTING: Four LTC facilities and two residential-care facilities in Los Angeles. PARTICIPANTS: Four hundred and three family members of incontinent NH residents were mailed surveys. Sixty-six nursing staff caring for these incontinent residents and 79 older adult residents of care facilities (nine cognitively intact NH respondents and 70 residential care residents) answered surveys, MEASUREMENTS: Preference rankings between seven paired combinations of five different UI treatments were measured on an 11-point visual analog scale, with the verbal anchors "definitely prefer" this treatment, "probably prefer" this treatment, and "uncertain." Respondents gave open-ended comments as well. RESULTS: Forty-two percent of family members (171/ 403) returned the mailed survey. Of all respondents, 85% "definitely" or "probably" preferred diapers, and 77% "definitely" or "probably" preferred prompted voiding (PV) to indwelling catheterization. Respondent groups occasionally differed significantly in their preferences. In choosing between treatment pairs using a visual analogue scale, nurses preferred PV to diapers significantly more than did older adults or families (both of whom preferred diapers) (F (2,295) = 13.11, P < .0001). Older adults, compared with family and nurse respondents, showed a significantly stronger preference for medications over diapers (F (2,296) = 41.54, P < .0001). In open-ended re sponses, older adults stated that they would choose a UI treatment based in part upon criteria of feeling dry, being natural, not causing embarrassment, being easy, and not resulting in dependence. Nurses said that they would base their choice of UI treatment upon increasing self-esteem and avoiding infection. CONCLUSIONS: Although there was wide variation within and between groups about preferred UI treatment, most respondents preferred noninvasive strategies (diapers and PV) to invasive strategies (indwelling catheters and electrical stimulation). Older adults preferred to a greater degree medications and electrical stimulation, therapies directed at the underlying cause of UI. Despite data documenting that diapering is a less time intensive way to manage UI and that toileting programs are difficult to maintain in LTC, nurses viewed PV as "natural" and strongly preferred it to diapering. Several family members and older adults viewed PV as "embarrassing" and "fostering dependence." These data highlight the need to elicit preferences for UI treatment among LTC residents and their families.