Proposal
PROPOSED TITLE: The Prevalence of Urinary Incontinence among Elderly in HK Old Age Homes
ABSTRACT
The research entitled The Prevalence of Urinary Incontinence among the Elderly in Hong Kong Old Age Homes is a study to determine the rate of incidence of urinary incontinence among the elderly in Hong Kong. This study aims to increase the awareness of the people regarding urinary incontinence that it can be treated and can even be prevented. The study will also determine the risk factors associated with urinary incontinence and determine the probability of the condition being curable. As the research will be conducted in Hong Kong old age Homes the study will also identify the primary reasons why the elderly people are being left in retirement homes.
INTRODUCTION
The (2003) defines urinary incontinence as the individual complaint of involuntary leakage of urine. In most areas, urinary incontinence has been considered as one of the primary economic and health problem. This condition generally affects the social, psychological, physical and economic aspect not only of the affected individuals but also their families. In addition, this health condition leads to significant economic burden on both social and health services (2004).
In general there are four types of urinary incontinence: stress incontinence, urge incontinence, overflow incontinence and functional incontinence. Each of these types of urinary incontinence differs primarily in terms of their symptoms and causes. The pathogenesis of urinary incontinence is frequently multi-factorial. In most cases, this involves various conditions on the neurological, behavioral, urologic, psychological, functional and gynecologic aspects. Hence, evaluation and care should be based on these possible factors. Among others, treating reversible conditions should be the focus of treatment. Though urinary incontinence cannot be fully cured by treating these factors, the burden caused by this condition can be reduced significantly. Most importantly, addressing these factors can result to significant progress to the patients’ quality life and overall functioning (1995).
Urinary incontinence has reached the attention of several healthcare institutions worldwide due to its increasing prevalence among the elderly. In nursing home facilities, although prevalence rates vary, the rates are considerably high. In some studies, the prevalence of urinary incontinence ranges from 12 to 15 percent. Other studies however, claimed a prevalence rate as high as thirty percent (1990; 1986). In addition to nursing homes, acute hospitals have also observed the increasing prevalence of urinary incontinence among the elderly. As this health condition leads to significant financial burden to nations’ health care systems, identifying how this can be remedied or prevented is of utmost importance. Thus, in this proposal, the prevalence of the different types of urinary incontinence among the elderly confined in elderly homes will be investigated. In addition, the prevalent causes or risk factors related to the development of this health condition will be identified.
Significance of the Study
This proposed study will be conducted mainly for the purpose of increasing the people’s awareness on the growing problem on urinary incontinence among the elderly. This study will benefit adults by informing them of the different types of urinary incontinence and their respective causes. The knowledge of the causes of urinary incontinence will then stress the importance of knowing how this condition can be prevented.
The medical institution and healthcare providers will also benefit from this study as this research will emphasize on the importance of primary health care in response to the increasing prevalence of urinary incontinence. The knowledge of the different types of urinary incontinence and their causes can help in identifying health care priorities and designing preventive plans for the elderly. The families and care givers of patients with this kind of health condition will benefit from this research as well through the provision of the current status of urinary incontinence and other new information related to it. Overall, this study will be significant in updating current knowledge about the condition as well as its prevalence. More importantly, the study will be of benefit in promoting the importance of healthy living.
Limitations of the Study
The proposal will focus on the prevalence of urinary incontinence in Hong Kong old age homes particularly those residing in Community Geriatric Assessment Team (CGAT) in the HK West Cluster. The participants in the study will be limited to those over 65 years of age afflicted with any of the four types of incontinence who are able to give an informed consent to be included in the study. The study will also exclude from its sample those who are already afflicted with the disease before they are admitted to the old age homes.
The research design of the research proposal, cross-sectional study, also places a restriction in the data that can analyzed for the study. Cross-sectional study gathers information about a particular group, the sample group, to present an analysis of a situation only for a particular point in time. The study will be of particular use and relevance for immediate projects regarding urinary incontinence in old age homes and projects in the near future. The analysis that will be generated from the study will apply only to the current condition of urinary continence in old age homes.
LITERATURE REVIEW
Urinary incontinence is the involuntary loss of urine that is treatable condition and can be prevented. (2000) It has considerable distressing consequences and has such physical, psychological, social and financial impact both for the patient and the caregiver. (2000) Urinary incontinence can also result to skin breakdown and to recurrent urinary tract infections. ( 2000) The American Foundation for urologic disease has given some of the possible causes of urinary incontinence: (a) urinary tract or vaginal infections; (b) effects of medicine; (c) constipation; (d) weakness of certain muscles; (e) blocked urethra due to an enlarged muscle; (f) diseases and disorders involving nerves and/or muscles; (g) some types of surgery.
“Incontinence is not a result of old age nor is it a disease.” (1998) In a study conducted by, the elderly people considered incontinence as part of the old age. (1998) They are not aware that there is a treatment for incontinence and they worry too much on the cost and the embarrassment that the condition entails. ( 1998) Incontinence is accompanied by “dependence, shame, guilt and fear.” (1998) A person with this kind of condition, especially the older people feels isolated and depressed, have low self-esteem, and become dependent to the caregivers. (2000) Depression is associated with incontinence mainly because it causes the incontinent people to withdraw from their social life because of embarrassment. (2000) The financial aspect of incontinence stems out from the supplies, laundry and cleaning costs and the hired caregivers or payments to the institutions where the incontinent people are left to be cured or to be taken care of.
There are four types of incontinence, stress, urge, overflow and functional. “Stress Urinary Incontinence involves the leakage of small amounts of urine when pressure inside the abdomen increases.” ( 2000) It is related to “congenital or acquired incompetence of the urinary sphincter”. (2000) Abdominal pressure that may protract stress incontinence includes laughing, coughing, and sneezing. ( 2000) In some cases, stress incontinence constitutes continuous leakage even while at rest. (2000) “Urge Urinary Incontinence is the inability to inhibit bladder contractions until a toilet is reached” which may include “involuntary detrusor contractions, detrusor hyperactivity with impaired bladder contractility and an involuntary sphincter. (2000) Detrusor hyperactivity with impaired bladder contractility is the involuntary detrusor contraction that occurs with “the need to strain in order to empty the bladder.” (2000) There is a condition in incontinence which is a combination of stress and urge incontinence. It is commonly called as mixed incontinence which is more common to older women.
Overflow Urinary Incontinence is a condition where only small amounts of urine are lost even when the bladder is excessively full because “the outflow of urine is disrupted by mechanical or neurologic causes”. (2000) “The pressure in an over distended bladder builds up until it is sufficient to overcome the outflow resistance and allow the passage of the urine.” (2000) The symptoms for functional incontinence usually include the symptoms of stress and urge incontinence. ( 2000) It is caused “by factors outside the genitourinary system” like “environmental restraints, mobility restrictions, cognitive difficulties and psychiatric disorders”. (2000)
Caregivers for people who have urinary incontinence should be more patient and understanding as the task is very demanding. People with this condition require twenty-four (24)-hour assistance for their toileting needs. Aside from the persona needs of the patient, a caregiver also has to deal with soiled sheets and laundry and cleaning up the mess. There are also times when one caregiver is not enough for one patient. According to some caregivers, the second leading reason why the elderly people are being left in nursing homes by their loved ones is because the person has urinary incontinence. (Ebersole and Hess, 1998, 288)
In the book of (2002), they adopted the definition of Hawes of residential care. They referred to residential care as “a closed community-based living arrangement that houses two or more unrelated adults and provides assistance with instrumental activities of daily living.” ( 2002) Residential care is also known as: “board and care homes, residential living centers, assisted living homes, congregate living facilities, personal care homes, homes for the aged, shelter care homes, adult care homes, or family care homes”. (2002) The SOC Theory of individual development involves “acquisition and maturation” until “decomposition and attrition of life processes”. ( 2002) One of the tenets of SOC is that increase in age entails increase in the need for culture to compensate for the losses brought about by old age. (2002) “Culture creates opportunities to facilitate function in the presence of eventual biological decline through degenerative processes associated with aging”. (2002) Therefore, residential care is a cultural effort to compensate for the losses associated with old age. (2002) The object of residential care is to extend the life and create a caring environment, “maintain active life expectancy for as long as possible”, despite the difficulties and hardships brought about by aging. ( 2002) There are three relevant factors in the SOC Theory: (a) selection- “reducing the number of options available so as to focus one’s skills and abilities on obtainable outcomes”; (b) optimization- “unctional response to loss by focusing on abilities that are still intact”; (c) compensation- “developing new strategies to compensate for loss”. (2002)
RESEARCH PROBLEM
The research will study the rate of incidence of urinary incontinence among the elderly Hong Kong living in old age homes. In line with this, the research will study the probability of being cured among those afflicted with urinary incontinence.
(Question form: 1. What is the rate of incidence of urinary incontinence among the elderly In old age homes in Hong Kong?
: 2. What is the probability of urinary incontinence being cured?)
RESEARCH AIMS/OBJECTIVES
The research aims to:
1. To determine the prevalence of the four (4) types of urinary incontinence in retirement homes, namely, Stress Incontinence, Urge Incontinence, Overflow Incontinence and Functional Incontinence.
2. To identify the risk factors of urinary incontinence.
3. To investigate the development of urinary incontinence in retirement homes.
4. To identify the reasons for abandonment of the elderly in retirement homes.
HYPOTHESIS
1. There is a significant rate of incidence of urinary incontinence among the elderly in old age homes.
2. There are greater numbers of urinary incontinence cases that can be cured.
RESEARCH PLAN
The research will utilize the cross-sectional study in gathering data for the study. It is a “snapshot of a population at a particular point in time” to provide the researchers of either “a retrospective or a prospective inquiry”. (2000) The sample will include different subjects and not comparable, and thus, not appropriate for causal research. The study will include all the residents of Community Geriatric Assessment Team in the Hong Kong West Cluster aged sixty-five (65) and above. There are twelve (12) government nursing homes and twenty-four (24) privately owned residential care. For the purpose of this study, a total of twelve (12) Geriatric Health Nurses participated for data collection. The participants should suffer any of the four types of urinary incontinence. The study will not include in the data collection those who are: (a) unconscious, unable to hear or see, and/or verbally communicate; (b) totally dependent e.g. bedridden patients, paraplegia, quadriplegia; (c) severe cognitive impairment; (d) incontinent or have a Foley’s catheter prior to admission; (e) has been using Foley’s catheter for a long-term with medical diagnosis; (f) unable to give informed consent.
The Hong Kong Hospital Authority has a database named the CMS from which the nurses have the access to get the data about the residents, their medical record, treatment and other relevant facts. The Hong Kong Hospital Authority has provided the researchers a Consent Form and Guidelines by which to comply in order to have access to the data needed for the study.
Time Schedule
Task
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Introduction
Literature Review
Data Collection
Data Analysis
Conclusion
Review/Redraft
Submission
ANALYSIS
The research shall utilize the function independence measure in assessing the residents of the old age homes included in the Community Geriatric Assessment Team in Hong Kong West Cluster. The functional independence measure (FIM) is a functional assessment “used in long-term care facilities and home health programs”. () “The FIM was developed to address the lack of a uniform measurement of disability…to describe a person’s functional abilities and limitations in activities required for daily living…intended as a measure of disability…from the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation”. () There are two methods administered by certified rater for FIM: (a) clinician observation; (b) structured interview. (Corrigan)
The FIM scoring system ranges from one (1), which is classified as “total assistance, to seven (7), classified as “complete independence” from all eighteen (18) items. () The total score may range from eighteen (18) with 126 as the highest score. “Scores falling below six (6) require another person for supervision and assistance”. () Two (2) underlying constructs for FIM are the: (a) FIM Motor (physical function)- “a linear combination of thirteen (13) items representing self-care, sphincter control, mobility and locomotion; (b) FIM Cognitive (cognitive function)- “a linear combination of the five (5) items comprising the communication and social cognition domains”. (Corrigan)
The following are the Motor Items for the functional independence measure: (a) Self-care- eating, grooming, bathing, dressing (upper body), dressing (lower body), toilet; (b) sphincter control- bladder management and bowel management; (c) transfers- bed/chair/wheelchair, toilet, tub/shower; (d) locomotion- walk/wheelchair, stairs. The following are the Cognitive Items in the FIM: (a) communication- comprehension, expression; (b) social cognition- social interaction, problem solving, memory. ()
The following are the item ratings of FIM and their description: (a) 7- complete independence (no helper, no devices, reasonable time and safety); (b) 6- modified independence (no helper, uses device, more time or safety is a concern); (c) 5- supervision or set-up (helper for set-up, cueing or supervision only); (d) 4- minimal assistance (helper contributes less than 25% of effort required); (e) 3- moderate assistance (helper contributes less than 50% but more than 25%); (f) 2- maximal assistance (helper contributes less than 75% but more than 50%); (g) 1- total assistance (helper contributes more than 75% of the effort required). ()
The functional independence measure can be used in analyzing the level of dependency of old people in old age homes with urinary incontinence. The level of dependency of the elderly people left in old age homes can provide insights on the reasons why they are being left in old age homes. Also, the measurement can provide awareness on how the elderly people with urinary incontinence can be helped and taken care of.
The Mini-Mental State Examination (MMSE) is a short, quantitative measure of the cognitive status of the adults, especially the older people and those hospitalized. It is compose of (11) questions, with thirty (30) as the highest score, to test the five (5) areas of cognitive function: (a) orientation; (b) registration; (c) attention and calculation; (d) recall; (e) language. () A score of 23 or lower indicates cognitive impairment. It is advisable to be used “routinely, systematically and thoroughly”. (1999)
The question is as follows:
Patient_____________________ Examiner _____________Date____________
Maximum Score
Orientation
5 ( ) What is the (year) (season) (date) (day) (month)?
5 ( ) Where are we (state) (country) (town) (hospital) (floor)?
Registration
3 ( ) Name 3 objects: 1 second to say each. Then ask the patient
all 3 after you have said them. Give 1 point for each correct
answer. Then repeat them until he/she learns all 3. Count trials
and record.
Trials ___________
Attention and Calculation
5 ( ) Serial 7’s. 1 point for each correct answer. Stop after 5
answers.
Alternatively spell “world” backward.
Recall
3 ( ) Ask for the 3 objects repeated above. Give 1 point for each
correct answer.
Language
2 ( ) Name a pencil and watch.
1 ( ) Repeat the following “No ifs, ands, or buts”
3 ( ) Follow a 3-stage command:
“Take a paper in your hand, fold it in half, and put it on the
floor.”
1 ( ) Read and obey the following: CLOSE YOUR EYES
1 ( ) Write a sentence.
1 ( ) Copy the design shown.
_____ Total Score
ASSESS level of consciousness along a continuum ____________
Alert Drowsy Stupor Coma
(“MINI-MENTAL STATE.” A PRACTICAL METHOD FOR GRADING THE COGNITIVE STATE OF PATIENTS FOR THE CLINICIAN.: 189-198, 1975. )
The MMSE has been widely used in the field of dementia. But the practicality of using this test, which takes about 5-10 minutes, has been found useful in determining cognitive impairment. It has also been used to detect progress and determining the rate of areas of functional impairment. The socres obtained using MMSE can also be used in determining Alzheimer’s disease, which is also common to old age people. The range of scores includes: (a) 30-25 for normals; (b) 24-21 for mild impairment; (c) 20-14 for moderate; (d) 13 and less for severe cases. It should be noted, however, that MMSE is not a diagnostic nor a neurological examination.
ETHICS
The data for the research will be gathered from the database developed by the Hong Kong Hospital Authority called the CMS. The process of data collection is under Privacy Concern 2 of the Standing Committee on Ethics in Research involving Humans where the information from the third party is without the consent of the individual like those gathered from the databases. The problem associated with this kind of data collection is the that the third party that may have provided the information may receive complaints from the individuals whose information was given without their consent that may induce the third party to help further in the research. In order to avoid these problems, the researchers can provide the individuals and/or the organizations with the necessary information regarding the research, or it can be the organization the researchers the address and contact numbers of the potential candidates for the research and the researchers can contact the individuals themselves or the individuals can contact the researchers themselves.
The researcher should also ensure the confidentiality of the information given to them by the organization or by the individuals themselves. The confidentiality statement should include how the data regarding the research will be stored and who can have access to the research. One technique to protect the privacy of the information is to use pseudonyms for the participants in the research. Since the information will not be collected anonymously, the individuals should have access to the information on the research. The researchers should also have contingency plans in case fortuitous events such as disclosure of confidential information and other adverse events in the course of the study. A letter of permission from the organization or individuals providing the information should also be included. The researcher should also prepare a separate approval form for the organization from the Human Research Ethics Committee (HREC) if they should need one. The researchers should also include in their form the individuals and organizations to whom the information will be disclosed, or if the information will not be disclosed, they can simply state “Not Applicable”. They should also give reasons for the disclosure, or non-disclosure, of information. The reasons for the purpose of public interest, as provided in the significance of the study, should outweigh the reasons for breaking the confidentiality and privacy of the participants on the research.
The researchers have to fill the Application for Ethical Approval of a Research Project Involving Humans and the Guidelines Sheet provided by the Monash University. Additional documents include the Form P, (Privacy Form), Explanatory Statement, Consent Form (from the participants agreeing to participate in the research), and the Permission Letter (from organizations/ schools/ company allowing the recruitment of participants to the research). The documents should include three (3) hard copies and two (2) photocopies which should not be stapled. Only the Application Form 1 can be submitted electronically for considering the research proposal with the file name, date- last name of the Chief Investigator. It should be noted that only the hardcopies of the documents are considered for submission, and not eh electronic submission of documents. The documents should have the signature of the: (a) Chief Investigator/ Supervisor; (b) all named co-investigators/student researchers; (c) Head of Department / School / Acting Head of Department / School/Director of Centre/Associate Dean of Research (ADR). The original copies of the documents should have the original signatures of the persons involved in the research.
DISSEMINATION
The Community Geriatrics Assessment Team in Hong Kong West Cluster can be given a copy of the result of the analysis of the research. The result of the research can be particularly helpful in participating old age homes with residents afflicted with urinary incontinence. It can help them address the needs and issues of the elderly people with this condition. Also, a summary of the research results can also be published in a local health magazine for additional information for other old age homes that are not part of the study. The research results can be of help not only for participating old age homes, but also for those other old age homes with residents who have urinary incontinence.
PROJECT FUNDING
The Tung Wah Group of Hospitals- Fung Yiu King Hospital specializes in geriatrics and orthopedic. Part of its hospital services include the Community Geriatric Assessment Team (CGAT) which provides assessment services for elderly people seeking residential care services. The CGAT provides “advises on the overall care programme and appropriate residential placement for geriatric patients based on their care needs”, rehabilitation programmes and training of staff for institutions. () It is of greater advantage for the researchers to be funded by the same institution that will be providing them with the information necessary for the research. In return, the researchers can provide the CGAT the exclusive rights to the full research results.
Credit:ivythesis.typepad.com
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