Masalah-Masalah Kesehatan Pada Lansia Dan Penanganannya: I Gede Putu Darma Suyasa, SKP, MNG, PHD

Masalah-masalah kesehatan
pada lansia dan penanganannya

I Gede Putu Darma Suyasa, SKp, MNg, PhD
S1I Keperawatan
Stikes Bali
Dosen Stikes Bali Adjunct Academic Status

Ketua Lembaga Penelitian dan (Lecturer Level B)
Pengabdian Kepada Masyarakat, School of Nursing and Midwifery,
Stikes Bali Flinders University
1
Batasan topik
• Inkontinensia fekal
• Inkontinensia urin
2
Faecal incontinence
3
Definition of faecal incontinence
• No accepted international consensus
• Faecal Incontinence:
“Involuntary loss of liquid or solid stool that is a
social or hygienic problem”
• Anal Incontinence:
“Involuntary loss of liquid or solid stool or flatus
that is a social or hygienic problem”
(Norton et al. 2009)
4
School of Nursing & Midwifery
Faecal incontinence in older people
Survey of Geriatricians on the effect of faecal incontinence on nursing

home referral (Grover et al. 2010)
“…this survey shows that faecal

incontinence has a significant effect on the
decision to refer an elderly patient to a
nursing home”
5
Faecal incontinence in institutionalised older people
Chiang et al. 2000 (USA)

• Retrospective chart review
• Sample: 413 nursing home residents
• Prevalence:
• urinary incontinence only: 12.8%
• faecal incontinence only: 2.1%
• dually incontinent: 57.4%
6
Faecal incontinence in institutionalised older people
Aslan et al. 2009 (Turkey)

• Interview
• Inclusion:
• Agree to participate
• Not having disabilities related to hearing, seeing and
speaking and other mental health problem
• Sample: 619 nursing home residents
• Prevalence: 10.5%
7
Faecal incontinence in community-dwelling older people
Edwards and Jones 2001 (The UK)

• Interview
• Sampling: random
• Sample: 2,818 aged 65 years +
• FI: “Do you have any difficulties in controlling
your bowel?”
• Prevalence: 3%
8
Goode et al. 2005 (The USA)

• Interview
• Sampling: ??
• Sample: 1,000 aged 65 years +
• FI: “Affirmative response to the question: ‘‘In the
past year, have you had any loss of control of
your bowels, even a small amount that stained
the underwear?’’
• Prevalence: 12%
9
Suyasa et al. 20011 (Bali, Indonesia)

• Interview
• Sampling: simple random
• Sample: 303 aged 60 years +
10
Suyasa et al. 2011
11
Risk factors of faecal incontinence
• Increasing age
• Admission to acute care hospital:
• 33% reported by Bliss (2000)
• Gender??
• Young women are vulnerable associated
with childbirth
• Obesity
• Poor general health
• Physical limitations
• Urinary incontinence
12
• Gastrointestinal symptoms:
• Diarrhoea
• Constipation (overflow)
• Haemorrhoids
• Obstetric injuries:
• Parity
• Forceps delivery
13
• Neurological disease
• Cognitive impairment
• Spinal cord injury
• Stroke
• Traumatic brain injury
• Diabetes mellitus
14
• In older people:
• Overflow incontinence secondary to
constipation and stool impaction
• Functional incontinence due to impairments
in mobility, dexterity, vision, intelect/
awareness
• Dementia-related incontinence
• Cormobidity-related incontinence: stroke,
DM, sacral cord dysfunction, loose stool
Further reading:
Norton, C, Whitehead, W, Bliss, DZ, Harari, D & Lang, J 2009, 'Conservative and pharmacological
management of faecal incontinence in adults', in P Abrams, L Cardozo, S Khoury & A Wein
(eds), Incontinence, 2009 edn, Health Publication Ltd, Paris.
15
16
17
Management and treatments
Lifestyle interventions
Conservative managements
Containment options
Medical/surgical
18
Weight reduction
Obesity is a risk factor for FI (Whitehead et al. 2009)
Prevalence of faecal incontinence decreased after bariatric
surgery: from 19.4% to 9.1% at 6 month and 8.6% at 12
months (Burgio et al. 2007)
Older people who were overweight were more likely to
experience a greater amount of faecal incontinence (Bliss et
al. 2004).
19
Smoking cessation
Nicotine can speed recto-sigmoid transit and may increase
faecal urgency
But no studies found in relation to faecal incontinence
20
Physical exercise (Schnelle et al. 2002)

RCT in nursing homes
A structured daily exercise program combined with increased
fluid intake and regular prompted toileting
After 32 weeks, frequency of faecal incontinence decreased
from 7% to 3%
21
Conservative treatments
“…expert consensus …and the world literature is

unanimous in recommending conservative
interventions, singly or in combination, for the
majority of patients with FI as first-line
management.”
(Norton et al. 2009, p. 1323)
22
Diet and fluid management

Bowel management
Pelvic floor muscle training
Biofeedback
23
Diet and fluid management

Diet change is commonly used for managing faecal
incontinence (Bliss, Fischer & Savik 2005; Suyasa et al.
2011)
Review on two RCT’s: (Norton et al. 2009)
Soluble dietary fibre is recommended for the management
of faecal incontinence associated with loose stool
No evidence of increased fluid
Caffeine restriction may be beneficial to reduce the desire to
defecate, but no evidence on faecal incontinence
24
Draf
25
Draf
26
Bowel management
Attempt to establish a bowel routine
Urgency resistance training
For neurological patients:
Digital rectal stimulation: a gentle and slow rotation or circular
movement of finger
Manual evacuation
Rectal irrigation
27
Practical advice: toileting position
28
Practical advice: toileting programs
• Remind/assist the individual to toilet
• For individual who is unable to communicate the need to

void or defecate use a fixed scheduled, example:
• once in 2 to 4 hours
• after meal
• before going out
• before bed
• For individual who has a moderate cognitive impairment,

best to record the need for toilet first and make a
schedule for toilet based on the record
29
Pelvic floor muscle training

a low cost treatment
involves no morbidity,
could be applied as an early intervention in the treatment of
faecal incontinence (Norton et al. 2009)
30
Pelvic Floor Muscle Exercise
Draf
Continence Foundation of Australia, 2011
31
Biofeedback
A training technique to help patient learn exercise the pelvic
floor muscles effectively while relaxing the abdominal
work
Involves placing a small electric probe into anus
The sensor relays detailed information about the movement
and pressure of the muscles in the rectum to an attached
computer
32
Containment options
Incontinence pad
33
Containment options
Anal plugs
A systematic literature review from the Cochrane Library
Anal plugs could be helpful in preventing faecal incontinence
but were difficult to tolerate by participants (Deutekom &
Dobben 2010)
34
Practical management: skin care
Clean the bottom area with water or wipe with wet tissue, or
cotton wool
Wipe the bottom area very gently
Use soap and moisturizer which sometimes helps
Don’t forget to dry
35
Practical management: managing the odour
Fresh flowers in rooms

Hand wash
Clean the toilet
Check the pants for small accidents
Odour control sprays or air refreshers
Carry a small spray in the bag and spray if the problem occurs when
away from home
36
Practical management: strategies for social
occasions
• Try to go to toilet before going out

• Wear elastic clothing and opens easily
• Wear a disposable diaper
• Take also a bag with a supply of spare clothes and most
importantly include a plastic bag to seal soiled clothes and
soiled diapers
• Don’t forget to locate a toilet, so that it can be found
quickly when needed
• Avoid food and drink that contribute to poor bladder/bowel
control
37
Practical management: improvement of toilet
facilities
• Easy-to-open doors
• Easily cleaned floor
• Good ventilation
• Hand-washing facilities
• For older people:
Toilet with grab rails Commode
38
Practical management: emotional support
Listen to their feelings of embarrassment or fear
Give positive feedback when they are able to reach self-

management goals
Do not negatively judge when they fail
Don’t forget to use some strategies for social occasions
39
Case study (Paul’s story)
• Paul, 80 year old man, lives with wife and 50 year old son
• History of faecal incontinence for many years, currently
experiencing up to 5 episodes of incontinence a day
• History included prostate hypertrophy, poorly controlled
diabetes, obesity, breathing problems, arthritis
• Number of recent falls
• Stated confined to house due to poor balance and pain on
movement, also fearful of leaving the house due to
unpredictability of his bowel motions
40
Case study
• Food diary:
• no fruit
• high fat diet - cakes, lollies, ice cream, sausages,
white bread with lots of butter and jam
• no water only tea and soft drink
• only vegetable was potato
41
Case study
Referral to the doctor:

review medications and diabetes management
Continence management plan:

dietary changes including smaller meals, regular meals times,
increasing fruit and vegetables, cereals, wholemeal breads
increase water consumption
reduce fat intake
exercises for pelvic floor strength
toilet timing and positioning, especially after meals
skin care to reduce inflammation
42
Case study
• Introduced small outings of 30 minutes initially and

increased with confidence
• Wife took spare clothes, deodoriser and disposable pull

ups pads
43
Case study
After 12 months:
• Less pain on movement, socially had even been on a
holiday to the coast and stayed with family, blood glucose
levels stable, faecal incontinence once a month
• Wife overjoyed less washing, now non existent faecal
odour in the house, easier to cook for Paul with more
variety in his diet
44
Thank you
45

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Copyright:

Available Formats

Masalah-masalah kesehatan

pada lansia dan penanganannya

Dosen Stikes Bali Adjunct Academic Status

• No accepted international consensus

Survey of Geriatricians on the effect of faecal incontinence on nursing

“…this survey shows that faecal

Chiang et al. 2000 (USA)

Aslan et al. 2009 (Turkey)

Edwards and Jones 2001 (The UK)

Goode et al. 2005 (The USA)

Suyasa et al. 20011 (Bali, Indonesia)

Suyasa et al. 2011

Physical exercise (Schnelle et al. 2002)

“…expert consensus …and the world literature is

Diet and fluid management

Diet and fluid management

• Remind/assist the individual to toilet

• For individual who is unable to communicate the need to

• For individual who has a moderate cognitive impairment,

Pelvic floor muscle training

Continence Foundation of Australia, 2011

Wipe the bottom area very gently

Use soap and moisturizer which sometimes helps

Don’t forget to dry

Fresh flowers in rooms

• Try to go to toilet before going out

Toilet with grab rails Commode

Listen to their feelings of embarrassment or fear

Give positive feedback when they are able to reach self-

Do not negatively judge when they fail

Don’t forget to use some strategies for social occasions

Referral to the doctor:

Continence management plan:

• Introduced small outings of 30 minutes initially and

• Wife took spare clothes, deodoriser and disposable pull

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