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Jan 29 2018 – Urinary Incontinence Case

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Download Document: Recommendations Jan 29 2018

Date: January 29 2018

PLEASE NOTE that Project ECHO® Care of the Elderly case recommendations do not create or otherwise    establish  a  provider-patient relationship between any   ECHO Care of the Elderly Hub team member/presenters and any patient whose case is being presented in a Project ECHO® setting.

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Case Synopsis:

60 year old female in CCC awaiting LTC home placement, with progressive MS, recent Rt. MCA ischemic stroke. New onset concerns with and perseverations over frequent urinary incontinence and toileting requests q15min.

Summary of Recommendations:

  1. Asses PVR, elderly have trouble emptying their bladder, particularly post stroke.
  2. Pharmacological: Tolterodine (long acting) not used as often, broken down in the liver.
    1. Consider discontinuing Tolterodine long acting
    2. Switch to Fesoterodine start with 4mg po daily.
    3. Can combine Fesoterodine with Mirabegron start with 25mg po daily and increase to 50mg based on pt efficacy and tolerability.
  3. Discussion with pharmacy, to get medication trial covered if required.
  4. Non-pharm/behavioural strategies:
    1. Trial individualize toileting schedule/timed voiding 2-3hrs.
      1. Gentle reminders to the client of her toileting schedule to act as a visual feedback.
      2. Transfer the client physically to the toilet according to the individualized toileting routine.
      3. Consider different visual cues of the toileting schedule, depending on cognition, ex. Indicator on the clock.
    2. No need for excessive fluid intake
    3. Pace fluid intake throughout the day
    4. Reduce fluid intake post 6/7pm
    5. Avoid caffeine products
    6. Avoid alcohol
    7. Manage constipation
  1. Consider reassessment of cognition, and trial of Anticholinesterase inhibitor if appropriate.
  2. Ensure barrier cream is being applied correctly and not uncomfortable for the client
  3. Additional activities to assist with distraction and boredom- such as wordsearches, colouring, conversation, music therapy, not just in the activity room but also on the unit or in her room.
  4. Psychosocial: re-engagement with son if appropriate.
  5. Further investigations: Urinary studies, cystoscopy
  6. Regular team meetings with interdisciplinary staff to ensure everyone is aware of the care plan, to reassure team and decrease care burden felt by the staff.