The implementation of innovativewireless telemonitoring systems hasthe potential to significantly change

urinary continence (UC) management forindividuals living with dementia inresidential accommodation. Effective UCplans lead to better quality of life forolder people and care staff andimprovements in the economic costs ofdelivering effective care. The aim of this article is to demonstratehow the use of sensor technology canpromote effective urinary continence carefor individuals living with dementia inresidential accommodation. We know that individuals living withdementia in residential aged carefacilities (RACFs) are at risk ofexperiencing continence problems andvery often require support to maintaintheir UC. Care staff working inresidential accommodation spend muchof their time on UC care (O’Connell,Ostaszkiewicz & Hawkins 2011). It follows that organisations providingaged care are continually seeking moreefficient and effective ways to undertakeUC assessments which save time, aremore accurate, increase dignity for thepeople involved, and which informperson-centred UC care plans. A small group of studies havedemonstrated the benefits of usingtechnology to undertake UC care(Ostaszkiewicz, Chestney & Roe 2010;Lancioni et al 2011; Koutsojannis, Lithari& Hatzilygeroudis 2012; Yu et al 2012a, b)and as the technology continues todevelop we can assume its use willincrease over time. This article provides a contemporaryreview of effective UC care forindividuals living in residentialaccommodation using innovative sensortechnology which will soon becomecommonplace in aged care organisations.The factsThe financial costs of urinaryincontinence (UI) for aged care services isconsiderable (Deloitte Access Economics2011). It is estimated that UI careaccounts for 60 per cent of all residentialaccommodation nursing care time(Bremner 2004) and the cost of caring for

individuals who experience UI inresidential accommodation in Australiais about $1.3 billion per annum(Australian Institute of Health andWelfare (AIHW) 2006). Over two-thirdsof older people living in residentialaccommodation need assistance to usethe toilet and half of them experience UI(Pearson 2003).Continence problems become morecommon in later life because the co-morbidities that some older peopleexperience increase their risk ofexperiencing continence problems.Nervous system disorders, such asdementia or Parkinson’s disease, affectthe muscles which control urine flow andincreases the risk of an individualexperiencing urge incontinence(Thompson 2006). The presence of dementia andcontinence problems are predictors ofolder people re-locating into residentialaccommodation and are the first andsecond most common reasons identifiedwhy individuals leave a communityhome (Pearson 2003; AIHW 2006). Areview of 169,900 client records fromAged Care Assessment Teams (ACATs)and RACFs in Australia found that 87 percent of registered nurses recorded UI as a‘significant’ or ‘very significant’ reasonfor relocation into a RACF.We also know that continenceproblems cause a range of associatedphysical health problems, for example,physical pain, propensity to fall,agitation, skin breakdowns andinfections. Ineffective continence care hasa negative impact on the quality of life ofresidents (Wagner et al 1996;International Consultation on

Incontinence Questionnaire Project 2012)and can lead to poor emotional andmental health. UI can lead to a loss ofindependence, isolation andembarrassment, resulting in low self-esteem, loneliness and feelings ofdepression. Effective management of UI istherefore important to promote thehealth and well-being of individuals andreduce the costs associated withcontinence care by aged care services.Current practices in assessment and managementIn Australia, one of the aged carestatutory standards includes therequirement that all older people whorelocate into residential accommodationare provided with a 72-hour UCassessment to inform their UC care plan(Aged Care Accreditation Standards1997). Similar to all population groups, arange of problems can cause UI forindividuals living with dementia and oneof the most common causes is known asfunctional UI. Functional UI is caused bythe inability of an individual to movesufficiently quickly to void into a toilet,adequately remove clothing to preventan episode of UI, recognise a toilet orremember the location of a toilet(O’Connell, Ostaszkiewicz & Hawkins2011). Currently, the majority of UIassessments in residentialaccommodation are completed manuallyby care staff. The care staff record specificinformation (times of episodes of UI,toileting times, successful orunsuccessful voids into a toilet,

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Vol 2 No 1 February/March 2013 Australian Journal of Dementia Care 35

Sensor technology: a smartway to manage continence

Urinary incontinence is one of the most emotionally

challenging issues facing people with dementia,

and supporting continence is a major concern of

both professional and family carers. Paul Fish and

Victoria Traynor show how technology is able to

assist with continence management

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36 Australian Journal of Dementia Care February/March 2013 Vol 2 No 1

continence aid changes and checks forvoiding into a continence aid, fluidintake and presentation of the individualduring the day) that requires the carestaff member to manually check forvoiding into the continence aid. Themore frequently the care staff check, themore accurate the information collectedwill be. The information generated from theassessment identifies the care needs ofindividuals and the assessmentinformation is used to develop a person-centred UC care plan. The current practice of manual UIassessments is intrusive, unreliable,labour-intensive and generallyunpleasant for the individuals and thecare staff. Failure to detect accuratevoiding patterns results in an impersonaland undignified practice ofsimultaneously taking groups of olderpeople to the toilet at the same pre-determined times each day (Yu et al2012c; Martin et al 2006).The way forward: technological innovationInnovative technology is a way forwardto generate valid data to accuratelyassess the natural bladder voidingpattern of individuals, inform care plansand deliver individualised UC care. TheUC care plans developed from digitalassessments might include a toiletingassistance program that optimises carestaff workflow and achieves effectivetoileting and appropriate continence aidselection for individuals. A small range of studies have shownthe benefits of technology in providingmore effective UC assessment andmanagement (Ostaszkiewicz, Chestney& Roe 2010; Lancioni et al 2011;Koutsojannis, Lithari & Hatzilygeroudis2012; Yu et al 2012a, b). Nikoletti, Youngand King (2004) evaluated voidingpatterns in 41 older people living inresidential accommodation using anelectronic monitoring device. Themonitoring device consisted of a small,moisture sensitive plate (sensor) placedinside an absorbent disposable pad. Thesensor communicated to a portablemonitoring device carried by the carestaff that sent alerts advising them whenthe older person is incontinent.Monitoring the time of voiding over aperiod of days allowed care staff toidentify individual voiding patterns withprecision. Care staff were taught to use theknowledge generated from UCassessments to identify the optimumtimes to optimum times to help the older

person to use the toilet. During a three-month intervention, the participantsexperienced improved UC care. Thefrequency of episodes of UI wassignificantly decreased for 86 per cent ofparticipants and one-third of theparticipants’ urinary voids in the padswere reduced by more than 25 per cent. There were two broad categories ofpatients identified who would benefitfrom the study: older people who cannotcommunicate their toileting needs or aresubstantially dependent on assistance;and older people with impairedcognitive function who are reasonablycompliant with toileting. The toileting schedules generated fromthe systems assisted care staff ineffectively managing the residents’incontinence and providing a betterquality of life.Wireless systemIn Singapore, Wai et al (2008) developed asmart wireless continence managementsystem for residential accommodationand hospitals. The aim of the study wasto alert care staff to perform pad changeswithin a timely automated manner toreduce pad dermatitis/rash that can leadto potential skin issues.The system used ‘smart’ continenceaids to discreetly monitor and alert carestaff that an episode of UI had occurredby transmitting information via wirelesstechnology to an intelligent central

management system. This informationassisted care staff to know when tochange the pad or assist a person to thetoilet irrespective of their ability tocommunicate the need.Ang et al (2008) trialled a wirelessintelligent UC management system forthe University Malaya Medical Centre(UMMC). It used ‘smart’ continence aidsto discreetly monitor and estimate thenumber of voiding events, detect otherrelevant clinical conditions and alert carestaff that an episode of UI had occurredby transmitting information via wirelesstechnology to an intelligent centralmanagement system. The Wireless Intelligent IncontinenceManagement System consists of threecomponents: an incontinence detectionsystem and smart diaper, mesh wirelesssensor network and intelligent centralmanagement software. The aim of this system was to provideaccurate bladder diaries to improve habittraining as a toileting assistance program.Habit training matches the toileting timeswith the person’s voiding pattern. Thisimproves successful toileting byproviding care staff with an accuratetoileting schedule to assist them to knowwhen to help people with dementia touse the toilet. Yu et al (2012a, b) evaluated a newwireless telemonitoring system calledSIM (Smart Incontinence Management)to inform care planning for UC for older

A telemonitoring system for urinary continence assessment and individualised care planning

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people living in residentialaccommodation. The telemonitoringsystem comprised an electronic sensor,which is inserted into a speciallydesigned disposable continence aid wornby the resident, and a computer softwarepackage which manages information andsignals alerts (see diagram opposite). Thetelemonitoring system provides care staffwith an alert when an older personwearing the device passes urine andtransmits and electronically recordsurinary output.Individualised care planThe Yu et al study looked at 32 olderpeople living with dementia in aresidential facility in Melbourne. Baselinedata of the current continence practicewas recorded using the electronictelemonitoring system: voiding patternsover 72 hours and urinary output of theparticipants. This data was then used todevelop an individualised UC care plan.Re-assessment was undertaken after twoweeks and five weeks and new UC careplans implemented at these times.Evaluation data consisted of urinaryoutput, content of care plans andadherence to care plans.The results showed significantincreases in the number of times theparticipants were provided withassistance to use the toilet by care staff (p < 0.001), successful toilet use (p = 0.016) and the volume of urinevoided into continence pads was reduced (p = 0.013). This study suggests that theimplementation of a wireless

telemonitoring system for UCmanagement for individuals living withdementia in residential accommodationis associated with more successfulassistance in toileting and fewer episodesof incontinence. The SIM system has received positiveanecdotal feedback. One family carernoted: “We’re happier, because Daddoesn’t feel like he needs to arrive soearly each morning to [the nursing hometo] make sure Mum is helped to go to thetoilet. He trusts the electronic system.”Another anecdotal benefit has been thatcare staff in the participating RACFsdemonstrated an increased awarenessabout the UC needs of the elderlyresidents together with increases inappropriate contact time. References

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Paul Fish is the head of Marketing andClinical Research of Simavita, acompany established to deliverinnovative continence managementsolutions. He can be contacted at:pfish@simavita.com; Associate ProfessorVictoria Traynor is Associate Director ofthe NSW/ACT Dementia TrainingStudy Centre. She can be contacted at:vtraynor@uow.edu.au

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