James Barrett

Treatment of urinary incontinence after stroke in adults

BACKGROUNDnUrinary incontinence can affect 40-60% of people admitted to hospital after a stroke, with 25% still having problems on hospital discharge and 15% remaining incontinent at one year.nnnOBJECTIVESnTo determine the optimal methods for treatment of urinary incontinence after stroke in adults.nnnSEARCH STRATEGYnWe searched the Cochrane Incontinence and Stroke Groups specialised registers (searched 15 March 2007 and 5 March 2007 respectively), CINAHL (January 1982 to January 2007), national and international trial databases for unpublished data, and the reference lists of relevant articles.nnnSELECTION CRITERIAnRandomised or quasi-randomised controlled trials evaluating the effects of interventions designed to promote continence in people after stroke.nnnDATA COLLECTION AND ANALYSISnData extraction and quality assessment were undertaken by two reviewers working independently. Disagreements were resolved by a third reviewer.nnnMAIN RESULTSnTwelve trials with a total of 724 participants were included in the review. Participants were from a mixture of settings, age groups and phases of stroke recovery. BEHAVIOURAL INTERVENTIONS: Three trials assessed behavioural interventions, such as timed voiding and pelvic floor muscle training. All had small sample sizes and confidence intervals were wide. SPECIALISED PROFESSIONAL INPUT INTERVENTIONS: Two trials assessed variants of professional input interventions. Results tended to favour the intervention groups: in a small trial in early rehabilitation, fewer people had incontinence at discharge from hospital after structured assessment and management than in a control group (1/21 vs. 10/13; RR 0.06, 95% CI 0.01 to 0.43); in the second trial, assessment and management by Continence Nurse Advisors was associated with fewer participants having urinary symptoms (48/89 vs. 38/54; RR 0.77, 95% CI 0.59 to 0.99) and statistically significantly more being satisfied with care. COMPLEMENTARY THERAPY INTERVENTIONS: Three small trials all reported fewer participants with incontinence after acupuncture therapy (overall RR 0.44; 95% 0.23 to 0.86), but there were particular concerns about study quality. PHARMACOTHERAPY AND HORMONAL INTERVENTIONS: There were three small trials that included groups allocated meclofenoxate, oxybutinin or oestrogen. There were no apparent differences other than in the trial of meclofenoxate where fewer participants had urinary symptoms in the active group than in the control group (9/40 vs. 27/40; RR 0.33, 95% CI 0.18 to 0.62).nnnAUTHORS CONCLUSIONSnData from the available trials are insufficient to guide continence care of adults after stroke. However, there was suggestive evidence that professional input through structured assessment and management of care and specialist continence nursing may reduce urinary incontinence and related symptoms after stroke. Better quality evidence is required of the range of interventions that have been suggested for continence care after stroke.

Intestinal permeability and orocaecal transit time in elderly patients with Parkinson's disease.

The aetiology of weight loss in patients with Parkinsons disease is likely to be multifactorial. We studied 15 patients with Parkinsons disease and 15 age- and sex-matched controls and looked for evidence of malabsorption due to small bowel bacterial overgrowth or alteration of intestinal permeability. There was a marked increase in orocaecal transit time in the patients with Parkinsons disease, although lactulose hydrogen breath testing did not show evidence of small bowel bacterial contamination. Intestinal permeability measured by the differential sugar absorption test was also deranged. There was reduced absorption of mannitol in patients with Parkinsons disease while lactulose absorption was similar in both groups, suggesting decreased non-mediated uptake across the enterocyte brush border membrane in patients with Parkinsons disease.

Anal function in geriatric patients with faecal incontinence.

The association of faecal incontinence with constipation and confusion in the elderly is well recognised but the anal function of faecally incontinent geriatric patients is poorly understood. Anal studies were therefore performed on 99 geriatric patients (49 with faecal incontinence, 19 continent patients with faecal impaction and 31 geriatric control patients with normal bowel habit) and 57 younger healthy control patients. An age related reduction in anal squeeze pressure but not resting pressure was identified. A reduction in anal resting pressure was detected in the faecally incontinent geriatric patients but squeeze pressure did not differ significantly from that found in the other geriatric patients. Anal sensation was impaired in the faecally incontinent patients. No difference was found between the groups as measured by pudendal nerve terminal motor latency. Gross neuropathy of the distal part of the pudendal nerve does not account for the observed external anal sphincter weakness in geriatric patients or for their faecal incontinence. Internal anal sphincter dysfunction is an important factor in faecal incontinence in the elderly.

Systematic review of the management of incontinence and promotion of continence in older people in care homes: Descriptive studies with urinary incontinence as primary focus

Aim This is a review of descriptive studies with incontinence as the primary focus in older people in care homes. Background Incontinence is prevalent among residents of care home populations. Data sources MEDLINE and CINAHL were searched from 1996 to 2007 using the highly sensitive search strings of the Cochrane Incontinence Review Group for urinary and faecal incontinence including all research designs. Search strings were modified to enhance selectiveness for care homes and older people and exclude studies involving surgical or pharmacological interventions. Searching of reference sections from identified studies was also used to supplement electronic searches. The Cochrane Library was searched for relevant systematic reviews to locate relevant studies from those included or excluded from reviews. The search was limited to English-language publications. Methods A systematic review of studies on the management of incontinence, promotion of continence or maintenance of continence in care homes was conducted in 2007–2009. This is a report of descriptive studies. Results Ten studies were identified that reported on prevalence and incidence of incontinence (urinary with or without faecal), policies, assessment, documentation, management or economic evaluation of its management. Use of incontinence pads and toileting programmes comprised the most common management approaches used. No studies were identified that attempted to maintain continence of residents in care homes. Conclusions Studies on maintaining continence and identifying components of toileting programmes that are successful in managing or preventing incontinence and promoting continence in residents of care home populations along with their economic evaluation are warranted.

Bladder and bowel problems after stroke

The purpose of this review is to explore the evidence currently available and to identify the framework within which to consider bladder and bowel emptying problems following a stroke. The author was a member of the Intercollegiate Working Party for Stroke Continence Subgroup that reviewed the evidence for the National Guidelines. The review is based on the author’s personal knowledge of published and unpublished work. References in large textbooks and in the landmark papers were checked and a Medline search was performed using the terms stroke , cerebrovascular disease , incontinence and constipation .

The COSTAR wheelchair study: a two-centre pilot study of self-propulsion in a wheelchair in early stroke rehabilitation

Objective: It is uncertain whether self-propulsion in a wheelchair should be encouraged or discouraged in the early stages of stroke rehabilitation. Design: A two-centre pilot study to assess the feasibility of performing a multicentre randomized controlled trial on this subject. Setting: Clatterbridge and Aintree Stroke Rehabilitation Units, Merseyside, UK. Subjects: Forty early stroke patients (mean age 67 years) in whom it was uncertain whether self-propulsion in a wheelchair should be encouraged were studied. Intervention: A central randomization service at Newcastle University was used to determine the policy about wheelchair provision and use for each patient. They were allocated to either an ‘encouraged to self-propel’ or a ‘discouraged from self-propulsion group’. Outcome measures used: Independent outcome assessment was performed by postal questionnaire and telephone interview using the Barthel ADL Scale, Nottingham Extended ADL Scales and the shortened General Health Questionnaire (GHQ-12) at 3 and 12 months. Patients length of stay and their Ashworth tone score were also measured either at three months or when they were discharged from hospital. Results: After considerable preparation time it was possible to conduct a trial on self-propulsion in early stroke rehabilitation in the two-pilot centres. No major differences were found between the pilot groups for any of the outcome measures. Conclusions: A multicentre randomized controlled trial to assess this question is feasible but further work is being conducted before proceeding, to satisfy the concerns expressed to our group regarding the appropriateness of the intervention and the outcome measures. Address for correspondence: JA Barrett, Clatterbridge Hospital, Wirral, Merseyside CH69 4JY, UK. e-mail: jabarrett@clatterbridgesru.freeserve.co.uk

Systematic review of care intervention studies for the management of incontinence and promotion of continence in older people in care homes with urinary incontinence as the primary focus (1966-2010)

The aim of this paper was to compare published studies of care interventions for the management and promotion of continence, with urinary incontinence as the primary focus, in older care home residents. Incontinence is a prevalent and serious problem amongst older people in care homes, with an increasing international focus. MEDLINE and CINAHL searches via OVID (January 1966 to May 2010) were carried out, with studies limited to English language publications only. Included in this search were studies investigating urinary and fecal incontinence in people aged 65u2003years or older in care homes. Studies on surgical or pharmacological interventions or fecal incontinence alone were excluded. A total of 33 interventional studies were identified. Toileting programs and incontinence pads are the mainstays of treatment, with some studies implying significant economic and labor costs. Drug therapy as an adjunct to toileting programs has so far shown only moderate benefits. Combined physical therapy/behavioral therapies have shown effective short‐term improvements. Adaptations to physical environment and staff training techniques might also be paramount. Exercise and Functional Incidental Training programs, although expensive, might provide additional benefit by reducing wetness rates and improving appropriate toileting rates. Combined complex behavioral interventions are now a common feature and their effectiveness for the management of urinary incontinence should be determined in future studies. Studies including long‐term effectiveness on maintaining continence with full economic evaluation are also warranted in this population. Geriatr Gerontol Int 2012; 12: ••–••.

Systematic review of descriptive studies that investigated associated factors with the management of incontinence in older people in care homes

BACKGROUNDnIncontinence is prevalent among older populations and residents in care homes.nnnAIM AND OBJECTIVESnThis paper is a review of descriptive studies that investigated associated factors related to managing urinary incontinence in older people in care homes. A systematic literature review was undertaken. MEDLINE and CINHAL were searched from 1996-2010 using the Cochrane Incontinence Review Group search strings for urinary and faecal incontinence including all research designs.nnnRESULTSnSixteen studies were identified that reported on associated factors related to comorbidities, management preferences, policies, staff views and knowledge or methodological studies. Non-invasive methods involving toileting and use of pads were common management approaches. No studies aimed at maintaining continence were identified.nnnCONCLUSIONSnFactors associated with incontinence need to also be considered when planning and managing care for individuals, and developing and designing systems of care within care homes. Further study in care home populations to change or inform practice and provide effective care is warranted. Preventive studies that maintain continence are required.nnnIMPLICATIONS FOR PRACTICEnOlder people and their families should be involved with decisions regarding their preferred care, goals, management and outcomes for managing incontinence, promoting or maintaining continence.

Systemic lupus erythematosus presenting with cardiac tamponade

A previously well 36 year old man presented with cardiac tamponade as the initial manifestation of systemic lupus erythematosus. This diagnosis should, therefore, be considered not only in cases of pericarditis but also in those of tamponade.

Systematic review of descriptive studies that investigated associated factors with the management of incontinence in older people in care homes.

BACKGROUNDnIncontinence is prevalent among older populations and residents in care homes.nnnAIM AND OBJECTIVESnThis paper is a review of descriptive studies that investigated associated factors related to managing urinary incontinence in older people in care homes. A systematic literature review was undertaken. MEDLINE and CINHAL were searched from 1996-2010 using the Cochrane Incontinence Review Group search strings for urinary and faecal incontinence including all research designs.nnnRESULTSnSixteen studies were identified that reported on associated factors related to comorbidities, management preferences, policies, staff views and knowledge or methodological studies. Non-invasive methods involving toileting and use of pads were common management approaches. No studies aimed at maintaining continence were identified.nnnCONCLUSIONSnFactors associated with incontinence need to also be considered when planning and managing care for individuals, and developing and designing systems of care within care homes. Further study in care home populations to change or inform practice and provide effective care is warranted. Preventive studies that maintain continence are required.nnnIMPLICATIONS FOR PRACTICEnOlder people and their families should be involved with decisions regarding their preferred care, goals, management and outcomes for managing incontinence, promoting or maintaining continence.