Strategies through life - An integrated approach to incontinence care

Failing to understand the causes and true impact of incontinence means missing a huge clinical and political opportunity. The 4th GFI - “Strategies through life: An Integrated Approach to Incontinence Care” - deconstructed the issue of incontinence to examine the moments when intervention, prevention and value might be maximised, and outcomes optimised for individual and society alike.

A worsening macroeconomic situation coupled with an aging population, points to significant long-term implications for funding healthcare. Policy makers will inevitably be required to bring spending under control, and society will face some significant choices. 

Against this reality, Panos Kanavos of the London School of Economics presented the opportunities for new sustainable and economically viable models of healthcare required to reduce the inevitable future funding gap.

Healthcare systems have been particularly affected by the rise in the number of elderly people in proportion to those of a working age. In 1960 there were six people of working age in relation to one retired person. In 2012, that had halved to three.

Given this decline, it is important to keep people with incontinence and their carers economically productive, especially as healthcare spending is growing faster than average Gross Domestic Product (GDP), largely due to high cost medicines introduced in the last 5 years.

The real cost of incontinence 

Tackling incontinence is an opportunity to reduce healthcare spending and the potential cost saving is substantial, yet the extent of the problem is currently rarely measured by its real cost. Incontinence has many associated clinical and social consequence, each with a layer of cost attached: skin hygiene problems; falls; depression; social isolation; and the ultimate personal and social cost of institutionalising the individual.

Dr Adrian Wagg Professor of Healthy Ageing from the University of Alberta explained to the conference how society stands to gain by understanding the true causes and costs of incontinence, and building integrated systems of care accordingly.

The World Health Organisation has already recognised incontinence as a public health care problem and defined it as a disease. Co-Chair of the GFI Professor Ian Milsom from the Sahlgrenska Academy of the University of Gothenburg, presented the theory that we should not look at incontinence as an unavoidable, and in some instances, acceptable consequence of aging and other causes. But instead, look at incontinence as an issue with the potential to improve the health of society.

It is with this in mind that the 4th GFI heard where the real opportunities exist, and the new ways of organising resources to save money and improve the lives of millions of people world-wide.

Early Life

GFI’s co-chair, Dr Daniela Marschall-Kehrel, an urologist from the Urological Office, Frankfurt, told the conference, “If there is any cure for incontinence, then we must start in childhood and educate children better on how they should empty their bladder and bowel.” 

There was increasing evidence that toilet-training children too early may lead to the development of ‘holding’ mechanisms. This can cause emptying disorders and incontinence later in life. Although this is worrying, it indicates that there may be opportunities to identify problems early on and help the individual. 

Diane Newman, Co-director of the Penn Centre for Continence and Pelvic Health, University of Pennsylvania Medical Centre, supported the fact that bladder health needed to be talked about early on, through primary care systems, in schools, and by parents to lift the taboo. By exposing people to the condition and knowledge that bladder health can be treated if medical treatment is sought early, and given the knowledge about the right toilet habits early on, fewer people will suffer from bladder problems later in life. 

Medical intervention

Studies have shown that the incidence of urinary incontinence post partum is almost double in women delivering vaginally compared to delivering by Caesarean section. Caesarean section appears to decrease the risk but this protective effect diminishes over time and disappears after multiple deliveries. The mode of delivery also has a substantial effect on the development of pelvic organ prolapse (POP). Instrument delivery increases the risk of POP more than five-fold compared to Caesarean section, and for this reason forceps should be excluded from the delivery room. However, there is no evidence to justify elective Caesarean section simply to avoid pelvic floor symptoms.

According to Heinz Kobl, Professor of Obstetrics and Gynaecology, Johannes-Gutenberg University, Mainz, Germany, “More research is needed to identify groups of patients that benefit from a particular mode of delivery or surgical intervention.”

“More basic research is needed to understand the changes that occur to the pelvic floor during pregnancy and delivery and how these changes are linked to urinary incontinence. To minimise these changes and reduce the likelihood of urinary incontinence and pelvic floor disorders, obstetricians caring for women during pregnancy must increase their knowledge and offer the right type of delivery to the right patient.”

Communication and acceptability

The conference also heard how some sectors of society are notoriously difficult to reach. 
Dr Ian Banks, President of the European Men’s Health Forum, said men delay seeking advice until their symptoms become severe and difficult to manage. 

This fact was supported by Tim Harvey, a patient advocate who gave his moving personal testimony to the conference.
“I always thought that it should not happen to men and could not talk about it. So I suffered in silence.”

Preventing falls, tackling obesity

Dr Jeanette Brown, Co-director of the Penn Centre for Continence and Pelvic Health set out the clear link of increased risk of falls and fractures associated with incontinence issues for both men and women.

This is a real opportunity for primary care, to identify patients at risk, treat them holistically and prevent falls. This may also enable patients to retain their independence in their own homes for longer.

The link between obesity and incontinence was clearly noted at the conference. Losing weight can be hard, and dieters may need extra motivation. Dr Jeanette Brown, suggested that this correlation between weight and incontinence may be used as a motivator to stay a healthy weight, as well as a motivator for losing weight. 

Loosing weight as a motivator to improve urinary incontinence will also have a huge benefit for patient health in general, from reduced risk of diabetes and other health conditions, as well as reducing healthcare spending around the world.

Meet the needs of the carer

Incontinence has a huge impact on the millions of people world-wide who are required to provide care to a family member at an inestimable cost. Without family carers the State is left to manage the situation Therefore it is important that family carers are fully supported by the formal care system to enable them to carry on providing care for as long as possible. 

Dr Giovanni Lamura, a social gerontologist at the National Institute of Health and Science on Ageing in Ancona, Italy, presented research showing how caring for a person with incontinence can lead to an accelerated and sometimes dramatic reduction in the carer’s quality of life. The consequence of which is the emotionally and financially costly exercise of the person being prematurely institutionalised. 

Simple and low cost interventions, however, can make a big difference to carers. Better support, access to information, choice of treatment/pads, and interaction with healthcare professionals. 

Dr Mike Nolan, Professor of Gerontological Nursing at the University of Sheffield, illustrated how good quality information given to carers at the right time is very important. As is the relationship between formal and family carers, with a greater understanding of the family carer’s needs and desires.

Integrated care

Professor Ian Milsom, from the Sahlgrenska Academy of the University of Gothenburg, concluded that we have to act to persuade politicians and the media to take the issue of incontinence seriously. Governments around the world need to define clear pathways for incontinence care to make sure that patients, carers and healthcare professionals can turn a condition with the potential to increase costs in society, into a condition that, when treated and manged properly, has a comparatively low impact.

The 4th GFI-seminar was held under the patronage of the Danish Presidency
of the Council of the European Union - The Danish Ministry of Health.