Preventing Functional Urinary Incontinence in Hip-Fractured Older Adults Through Patient Education: A Randomized Controlled Trial

Abstract

The purpose of this study was to evaluate whether an educational intervention would reduce the incidence of functional urinary incontinence (UI) in older adults with a fall-related hip fracture. The project was conducted as a multicenter randomized controlled trial (RCT). A total of 109 patients that had been admitted to six hospitals in Castilla-La Mancha (Spain) for acute treatment of hip fracture, previously continent and without cognitive impairment, were enrolled and randomly assigned to the experimental group (EG) or the control group (CG). Intervention (on EG): urinary habit training (Nursing Interventions Classifications taxonomy) was performed during hospital stay (second to fourth postoperative day), with a telephonic reinforcement 10 days after discharge. The CG received routine care. Primary outcome measure: incidence of UI. Follow-up: telephone assessment 3 and 6 months after discharge (blinded evaluation). The incidence of UI at 6 months was 49% (CG) versus 25.5% (EG) (relative risk = 0.52, 95% confidence interval [0.3, 0.9]; number necessary to treat = 4). The mean of UI episodes was 0.54 (EG) versus 1.8 (CG), p = .007. The educational intervention prevents the development of UI and decreases the number of episodes in case of appearance, in a statistically significant way.

Keywords

falls aged clinical trial hip fractures nursing evaluation research urinary incontinence patient education

Highlights

Hip fractures are related to the appearance or worsening of urinary incontinence (UI).

A nursing-focused educational intervention of teaching urinary habit training has reduced the incidence of functional UI in hip-fractured older adults.

Only one educational session during inpatient stay and a telephonic reminder were performed, so this intervention is feasible in daily practice.

Introduction

Hip fractures in older adults are a major health problem due to their high incidence and serious consequences (mortality, disability, and high costs associated with direct and indirect treatment). In Spain, their overall incidence in subjects over 65 years old varies between 301 and 897/100,000 inhabitants, that is more than 60,000 cases of hip fracture every year (Fernández-García et al., 2015), similar to the figure recently calculated for the United Kingdom, of 64,000 cases annually. This number is forecast to rise due to greater life expectancy and the resulting aging of the population (Fernández-García et al, 2015; Griffin et al., 2015). Hip fractures are related to gender (three quarters of them occur in women (Seitz et al., 2014; González-Zabaleta et al., 2015; Mariconda, et al., 2015) and old age. Increased mortality stands out among the consequences of hip fracture, it being between 15% and 36% 12 months after fracture (Alarcón et al., 2011; Córcoles-Jiménez et al., 2015;Mariconda et al., 2015; Seitz et al., 2014).

Functional recovery has become the goal of treatment of these fractures (Alarcón et al., 2011) because many patients do not recover their previous level of independence (Córcoles-Jiménez, et al., 2015; González-Zabaleta et al., 2015; Griffin et al., 2015; Molero Bastante et al., 2013; Vergara et al., 2014). One year after fracture, the percentage of recovery of prior level range between 48% and 70% (Córcoles-Jiménez, et al., 2015), with only between 33% and 50% of those that previously were independent making a total recovery (Bertram et al., 2011; Candel-Parra et al., 2008), and this means the need for care from family and cohabitants, so the patient is often institutionalized. Another capacity that is affected after hip fracture is urinary continence.

The prevalence of urinary incontinence (UI) in Spain is estimated to be between 14% (men) and 30% (women) in people older than 65 who live at home (Zunzunegui Pastor et al., 2003). Among its consequences, the most noteworthy are the deterioration in quality of life, appearance of episodes of depression, greater mortality (although the results are not consistent between studies), and risk of pressure-induced lesions (Hernández-Fabà et al., 2007). In addition, it leads to considerable costs corresponding to treatment, the use of absorbent devices and the need for informal care (Prado Villanueva et al., 2011). In the United States, the total economic burden of UI was estimated to be $76.2 billion by 2015 (Testa, 2015). In Spain, the annual cost of absorbent devices for older adults in 2003 was 1,000 euro/person, an amount which does not include the cost of other skin-care products (Zunzunegui Pastor et al., 2003).

Traditionally, UI was classified into four types (urge, stress, mixed, and overflow) (Hernández-Fabà et al., 2007; Testa, 2015), but in the last few years, consideration has been given to other forms (e.g., transient incontinence) which are related to reduced mobility or cognitive impairment (De Gagne et al., 2013; Prado Villanueva et al., 2011; Testa, 2015). Both the North American Nursing Diagnosis Association (NANDA) and the Society of Urologic Nurses and Associates, among their diagnoses, include “Functional urinary incontinence” (approved 1986; revised 1998, 2017) (Herdman & Kamitsuru, 2018), which is defined as the inability of a usually continent person to reach the appropriate place in time to avoid the unintentional loss of urine. Neuromuscular impairment and alteration in environmental factors appear as related factors (Herdman & Kamitsuru, 2018), both of which are present in patients with hip fracture.

The relation between UI and hip fracture has been known for many years. Palmer et al. (1997) found an increase of between 20% and 43% after fracture, there being a higher risk in men and persons with cognitive impairment, although the sample was small. In 2002, a new study found that 21% of women admitted to hospital due to hip fracture developed incontinence during their hospital stay (Palmer et al., 2002). More recently, other studies carried out in the United Kingdom and Canada (Zusman et al., 2017) found a 41% to 44% prevalence of UI among hip-fractured patients, far higher than that estimated for the adult population, although the prior state of continence was not assessed. In the institutionalized population over 65 (autonomous region of Madrid), the prevalence of UI among those who had suffered a hip fracture was 71.7%, compared with 48.8% for those who had not (Prado Villanueva et al., 2011). In patients admitted to hospital for rehabilitation after hip fracture, 30.6% suffered from incontinence compared with only 3.2% prior to fracture (Molero Bastante et al., 2013). Recent studies have found that the percentage of continent patients dropped to 47.3% 3 months after fracture compared with 67% prior to it (González-Zabaleta et al., 2015); and after 1 year, the figure fell from 79% to 59% (Córcoles-Jiménez et al., 2015). The probability of recovering continence was calculated to be 79.2% 6 months after fracture, increasing very slightly after 1 year (81.9%) (Alarcón et al., 2011). All these data highlight the moderate to high prevalence of UI in older adults after hip fracture.

For the treatment of UI, there is evidence that points to the efficacy of both pharmacological treatment and behavioral interventions, such as prompted voiding. Compared with usual care, prompted voiding (whether alone or combined with exercise) reduces episodes of daytime UI in nursing home residents, although its effects have only been shown in the short term (Fink et al., 2008). The Registered Nurses’ Association of Ontario (RNAO), via its Best Practice Clinical Guidelines, promotes the use of prompted voiding for treating UI in acute and chronic care centers, as well as at home (RNAO, 2011). An intervention based on behavioral and lifestyle instructions and performed by trained nurses reduced the number of episodes and the use of absorbent devices in the general population with incontinence (Borrie et al., 2002). Behavioral therapy interventions aim to improve symptoms through promotion of voiding habits, and this is appropriate for every category of UI (Testa, 2015). Voiding on a routine schedule, usually every 2 to 3 hours, makes it possible to avoid bladder distension and resulting UI (Testa, 2015). However, these techniques are not commonly used: only 27.3% of institutionalized older adult patients with UI follow some system of scheduled urination (Prado Villanueva et al., 2011); furthermore, there are few published studies or guidelines on UI care in the post–hip fracture setting, and the activities to promote continence are not consciously undertaken in these settings (Hälleberg Nyman et al., 2017). Nevertheless, UI should be prevented because of the increased risk of new falls and fractures, social isolation, and the potential institutionalization that can ensue if continence is not managed (Zusman et al., 2017); it was necessary to test a feasible intervention, avoiding the complexity that those aforementioned activities could entail.

The aim of this study was to examine the efficacy of a nursing-focused educational intervention involving urinary habit training to prevent UI in hospitalized older adults admitted for surgical treatment of hip fracture, and who were previously continent and cognitively intact. The main hypothesis was that carrying out an educational intervention involving urinary habit training prior to discharge would reduce both the incidence of functional UI and also the number of episodes of incontinence in this type of patients.

Methods

Design

Multicenter randomized controlled trial (RCT), with blinding in results assessment. The CONSORT checklist of information to include when reporting a randomized trial assessing nonpharmacologic treatments (NPTs) (Boutron et al., 2017) was used in this study.

Sample

Patients above 65 from community/own home with hip fracture caused by fall, and admitted to the University General Hospital of Albacete, the General Hospitals of Almansa, Villarrobledo, Hellín (all in the Province of Albacete), Virgen de La Luz (Cuenca), and University General Hospital of Ciudad Real. All these hospitals form part of the public health system of the autonomous region of Castilla-La Mancha (Spain). Inclusion criteria: patients continent before fall, operated on to repair fracture, and with a stable caregiver (defined as any person, such as a family member, who is giving regular, ongoing assistance, and who lives with the patient). Exclusion criteria: a degree of cognitive impairment (due to trauma or any other cause) that does not allow the patient to understand the educational intervention (Pfeiffer’s Short Portable Mental State Questionnaire >4); refusal to take part in the study.

Sample Size

Assuming an incidence of functional UI in this type of patients of approximately 35% and that the incidence in the experimental group (EG) decreases to 10% (confidence level 95%, power 80%), 100 patients are necessary (Epi Info v.6). The sample size was increased by 10% to allow for possible losses during follow up. The subjects were included by consecutive sampling of the patients who fulfilled the criteria at the different hospitals, and randomly assigned to either the EG or the control group (CG). The randomization sequence was generated by the lead researcher using a random number generator, and remained concealed from the researchers who carried out patient enrolment, and who were required to make a telephone call to learn to which group each patient was to be assigned once they had been included in the study, in order to reduce any risk of selection bias.

Intervention

The educational intervention used in this study was designed on the basis of the Nursing Interventions Classification (NIC) (Butcher et al., 2018). NIC, which is internationally recognized, is a care classification system that describes the interventions that any nurse can perform and execute as a part of the nursing care plan. Each intervention within NIC has a definition in general terms and a list of a variable number of specific activities.

For this study, we selected the “Urinary habit training” (0600) intervention. Its aim is to establish a predictable pattern of bladder emptying to prevent incontinence and can be applied in any type of UI. And from the whole list of activities corresponding to this intervention, those chosen to be taught to the patient and main caregiver (on the basis of the recommendations of Testa, 2015 and RNAO, 2011), in order for them to be performed at home, were as follows:

Establishing an initial time interval for going to the toilet, in accordance with voiding pattern and usual routine.

Establishing successive intervals of no less than 2 hours for going to the toilet.

Helping patient to go to the toilet and prompting voiding at the prescribed intervals (if they had limited or restricted mobility, the activity was modified by providing the patient with a bedside commode or urinal).

Using the power of suggestion (letting a tap run or flushing the toilet) to help the patient to void.

Reducing the interval for going to the toilet by half an hour if more than two episodes of incontinence occur in 24 hours; increasing the interval by half an hour if the patient has no episodes of incontinence in 48 hours, until an optimum interval of 4 hours is achieved (Butcher et al., 2018).

Maintaining the toilet visits, just as they have been scheduled, to help establish and maintain the voiding habit.

Acknowledging or giving positive reinforcement to the patient when they void at the scheduled time, and not making any comment when the patient suffers incontinence.

Primary Outcome Variables

Development of “Functional urinary incontinence” (Herdman & Kamitsuru, 2018). This has been operationalized by means of the Nursing Outcomes Classification (NOC) criteria for “Urinary continence” (0502) (Moorhead et al., 2018). This is defined as the “control of elimination of urine from the bladder,” and we chose the indicator “voids in appropriate receptacle” (050204). It is measured on the Likert-type scale, from 1 to 5 (from “never” to “always”). For the purposes of statistical analysis, we took “continent” to refer to those patients who replied “always,” and “incontinent” to those who were anywhere else on the scale. The number of episodes of incontinence in the day (24 hours) prior to the interview was recorded, distinguishing between daytime and night time episodes, as well as the type of absorbent devices used (by means of a diary to document voiding habits that the patient/carer had to complete each day). Secondary outcome variable: independence in terms of basic activities of daily living (ADLs).

Other Variables

Demographic (age and gender, as stated in the medical record); those related to the fracture and its surgical repair (type of fracture, type of intervention performed, length of hospital stay, and complications); ability to walk after surgery, time before patient starts to walk; mental status; and mortality.

Instrumentation

Mental status

Pfeiffer’s Short Portable Mental Status Questionnaire (SPMSQ) (Spanish version) (Martínez de la Iglesia et al., 2001) was administered by the health care professionals, with 10 questions about temporal-spatial orientation, recent memory, and earlier events. A point is awarded for each error, allowing one more error in people with only basic education. A score between 0 and 2 is considered to correspond to an intact mental status, between 3 and 4 to mild intellectual impairment, between 5 and 7 to moderate impairment, and between 8 and 10 to severe impairment.

Independence in terms of the ADLs: the Barthel Index (BI) (Mahoney & Barthel, 1965), which is widely used for the geriatric population, can be obtained by an interview with the patient or main caregiver. It has 10 items that refer to fecal and urinary continence, and autonomy in feeding, washing-bathing, dressing, grooming, toilet use, chair–bed transfers, walking, and climbing or descending stairs. Each item receives a score of between 0 and 15, with intervals of 5 points. The maximum score (100) indicates independence for the ADLs and the minimum score (0), total dependence; if it is greater than, or equal to, 60, the dependence is considered mild, 40 to 55 moderate, 20 to 35 severe, and less than 20 is considered total dependence.

Procedures

In the first 24 hours after admission, the researchers visited the possible candidates to determine whether they met the criteria, also administering SPMSQ and identifying urinary continence by means of the NOC “Urinary continence” (0502) as described above. Once the patients had given their informed consent, the initial variables for both groups were obtained by interview and by consulting the medical records. All the participants (both EG and CG) received the usual medical care for their particular needs, which means the provision of specialized medical care collaboratively by orthopedic surgeons, geriatricians, and aged care services (offered by social workers). This usual medical care included the administration of antibiotics for the prevention of postoperative infection, analytical control for the early detection of anemia, surveillance of bleeding of the surgical wound and prevention of pulmonary thromboembolism by the administration of low molecular weight heparin and early mobilization. Patients were routinely catheterized prior to surgery to monitor urine output with the use of indwelling urinary catheters, which were removed 48 hours postoperatively. The standardized analgesia during hospitalization included nonsteroidal analgesics and opiates, with individualization of the doses on demand for each patient. After discharge, rehabilitation exercises were indicated to be performed in bed or seated (flexo-extension of ankle and hip, hip abduction, and body alignment), as well as the start of walking with mechanical help from 2 to 3 days after the surgical intervention.

Participants in the EG also received the said educational intervention (“Urinary habit training” NIC, 0600), which was performed during their stay in hospital (second to fourth postoperative day) by a trained researcher at each one of the hospitals. This moment was chosen to ensure that patients had already overcome the early postoperative period, and to guarantee that they received the intervention before discharge. The trained researchers were six nurses, one for each hospital, and always the same one at each hospital; their training was carried out at the initial moment of the study, prior to starting the clinical trial, by a meeting with the main researcher and using roleplay. A single meeting was enough to train them because the intervention is easy to learn.

These trained researchers taught the activities to the patient and carer together, and the average duration of the intervention was half an hour. On finishing, some time was given so that questions could be asked and doubts voiced, and the patient and carer were asked to repeat what had been taught to check they had understood; in addition, they were given a leaflet (drafted by the research team; its content reproduced the activities chosen from the NIC “Urinary habit training” to be taught to the patient and carer) with drawings to reinforce their memory of the intervention, as well as a diary to document voiding habits (the patients in CG were provided with these diaries when they had consented to participate in the study). Only one education session was performed on each patient/carer because of the short length of the hospital stay and because the idea was to test an intervention that was feasible in daily practice, of short duration and without repetitions. The patients and caregivers were asked to put into practice what they had learnt as soon as possible. Between the 7th and 10th day after hospital discharge, the same researcher telephoned them to remind them about the recommended activities, repeating the list of activities.

Subsequently, another researcher (always the same one) that did not know which group (EG or CG) the patient belonged to telephoned 3 and 6 months after discharge to obtain, either directly from the patient or from their carer, the BI, the date of starting to walk, the urinary continence (this was obtained by a self-report based on the diary to document voiding habits that the patients were provided with during their hospital stay), and what they attributed the incontinence to, if the latter existed. The participants in the EG were not specifically questioned about their adherence to treatment, since the interviewer did not know to which group each patient was assigned (blind evaluation of outcomes). The probability of recovering continence hardly varies between 6 and 12 months (Alarcón et al., 2011), so it was decided to end the follow-up at 6 months.

A specific form was designed for data collection, and a written protocol was established to ensure consistency in the obtaining of data by the researchers at the different hospitals. A trial run was carried out to fine tune the design of the form and the study procedures.

Analyses

Performed using the intention-to-treat approach. Descriptive: absolute and relative frequencies (categorical variables), central tendency, and dispersion measures (continuous variables). Bivariate analysis: Testing homogeneity of the groups and contrasting possible associations between development of UI, intervention performed, and other theoretically related variables, using chi-square, Student’s t and analysis of variance (ANOVA), correlations, and other nonparametric tests, depending on which was appropriate after testing normality conditions (Kolmogorov–Smirnov). We calculated 95% confidence intervals (CIs), relative risk (RR), and number necessary to treat (NNT).

Ethical aspects: The written informed consent of all the patients was obtained prior to participation. The intervention performed did not involve any risk at all. Anonymity, privacy, and confidentiality of the data obtained were guaranteed. The project received the approval of the Ethics Committee of the health authority for Albacete (Act 04/08).

Results

A total of 109 patients were included in the study, of which 77 (70.6%) were women. In the EG, there were 53 patients (48.6%), and 56 (51.4%) in the CG. During their stay in hospital, the most common complication was anemia requiring transfusion (9 patients in preoperative period and 26 in postoperative period). In the follow-up period, seven patients were lost: five died and two could not be located (Figure 1). None of the patients presented urinary retention or other urinary complications.

Figure 1.

CONSORT flow diagram of participants.

The patients’ initial data, as well as the homogeneity data for both EG and CG, are shown in Tables 1 (categorical) and 2 (continuous variables). No statistically significant differences were found between the groups when considering age, gender, independence in ADLs, mental status, hospital stay, type of fracture, type of surgical intervention, or the complications that arose during hospital stay. All the patients were continent before randomization (percentage of continence 100%, always urinate in appropriate receptacle 100%, both EG and CG), since prior urinary continence was an inclusion criterion.

Table 1.

Group Homogeneity on Admission to Hospital (Categorical Variables).

Variables	Total sample% (n)	Experimental group% (n)	Control group% (n)	Chi-square	p
Gender
Male	29.4 (32)	56.3 (18)	43.8 (14)	1.055	.304
Female	70.6 (77)	45.5 (35)	54.5 (42)	1.055	.304
Fracture type
Subcapital	27.5 (30)	28.3 (15)	26.8 (15)	0.278	.87
Subtrochanteric	22.9 (25)	20.8 (11)	25 (14)
Pertrochanteric	49.5 (54)	50.9 (27)	48.2 (27)
Type of surgical intervention
Total prosthesis	12.8 (14)	13.2 (7)	13.2 (7)	2.471	.461
Partial prosthesis	22 (24)	17 (9)	26.8 (15)
Nail-plate	59.6 (65)	66 (35)	53.6 (30)
Intramedullary nail	5.5 (6)	3.8 (2)	7.1 (4)
Preoperative complications
Anemia with transfusion	8.3 (9)	5.7 (3)	10.7 (6)	0.918	.338
Without complications	91.7 (100)	94.3 (50)	89.3 (50)	0.918	.338
Postoperative complications
Anemia with transfusion	23.9 (26)	24.5 (13)	23.2 (13)	7.27	.508
Pneumonia	2.8 (3)	1.9 (1)	3.6 (2)
Seroma	1.8 (2)	0	3.6 (2)
Others	4.5 (5)	3.8 (2)	5.3 (3)
Without complications	67 (73)	69.8 (37)	64.3 (36)

Table 2.

Group Homogeneity on Admission to Hospital (Continuous Variables).

Variables	Total sample (n = 109)M (SD)	Experimental group (n = 53)M (SD)	Control group (n = 56)M (SD)	CI 95% difference	Mann–Whitney U	p
Age	80.56 (6.65)	80.62 (6.81)	80.5 (6.55)	[–2.41, 2.66]	0.1*	.92
Hospital stay	7.71 (3.52)	7.54 (3.82)	7.87 (3.23)	[–1.66, 1.01]	1,356.5	.437
Independence in ADLs (BI) prior to fracture	95.5 (7.75)	96.22 (6.42)	94.82 (8.84)	[–1.54, 4.35]	1,349	.346
Mental status (Pfeiffer)	1.78 (1.4)	1.56 (1.37)	2 (1.41)	[–0.96, 0.09]	1,226	.110

Note. ADL = activities of daily living; BI = Barthel Index; M = mean; SD = standard deviation.

Student’s t test.

Tables 3 and 4 show the outcome variables for both groups. As can be seen, the EG patients maintain continence at a percentage greater than that of those in the CG, both at 3 and 6 months after discharge (74.5% vs. 51%, p = .014; NNT = 4). The effects of the intervention (“always” urinate in appropriate receptacle) were sustained in 36 patients (94.7%) in EG at 3 and 6 months. In those cases in which incontinence appears, in the EG there are fewer episodes (a mean of 0.54 in the daytime, 0.35 at night) than in the CG (1.8 and 0.9, respectively), a difference which is statistically significant. This means a smaller percentage of patients that use adult pads (EG 55.6%, CG 70%; p = .44) as opposed to sanitary towels 6 months after discharge.

Table 3.

Outcomes for Groups. Categorical Variables.

Variables	Total sample% (n)	Experimental group% (n)	Control group% (n)	RR	NNT	CI 95%	Chi-square	p
Always urinates in appropriate receptacle (3 months)
No	36.5 (38)	25.5 (13)	47.2 (25)	0.54	5	[0.31; 0.94]	5.268	.022*
Yes	63.5 (66)	74.5 (38)	52.8 (28)	0.54	5	[0.31; 0.94]	5.268	.022*
Always urinates in appropriate receptacle (6 months)
No	37.3 (38)	25.5 (13)	49 (25)	0.52	4	[0.3; 0,9]	6.03	.014*
Yes	62.7 (64)	74.5 (38)	51 (26)	0.52	4	[0.3; 0,9]	6.03	.014*
Type of pads used (3 months)
Adult pads	77.4 (24)	66.7 (6)	81.8 (18)	0.81		[0.49; 1.35]	0.839	.36
Sanitary towel	22.6 (7)	33.3 (3)	18.2 (4)	0.81		[0.49; 1.35]	0.839	.36
Type of pads used (6 months)
Adult pads	65.5 (19)	55.6 (5)	70 (14)	0.79		[0.41; 1.52]	0.573	.449
Sanitary towel	34.5 (10)	44.4 (4)	30 (6)	0.79		[0.41; 1.52]	0.573	.449

Note. RR = relative risk; NNT = number necessary to treat; CI = confidence interval.

Statistically significant differences.

Table 4.

Outcomes for Groups (Continuous Variables).

Variables	Total sampleMean (SD)	Experimental groupMean (SD)	Control groupMean (SD)	CI 95% difference	Mann–Whitney U	p
Day time episodes of incontinence (3 months)	0.94 (1.8)(n = 104)	0.31 (0,76)(n = 51)	1.54 (2.26)(n = 53)	[−1.89, −0.57]	970	.002*
Night time episodes of incontinence (3 months)	0.5 (1.02)(n = 104)	0.21 (0.5)(n = 51)	0.79 (1.29)(n = 53)	[−0.95, −0.19]	1,047	.012*
Day time episodes of incontinence (6 months)	1.17 (2.14)(n = 102)	0.54 (1.46)(n = 51)	1.8 (2.51)(n = 51)	[−2.06, −0.44]	964.5	.007*
Night time episodes of incontinence (6 months)	0.62 (1.23)(n = 102)	0.35 (0.86)(n = 51)	0.9 (1.47)(n = 51)	[−1.02, −0.07]	1,015	.016*

Note. CI = confidence interval; SD = standard deviation.

Statistically significant differences.

Table 5 shows the other variables in the study. There are no significant differences in the time at which the patients started walking, but there are in the independence in ADLs (which include continence) after 6 months.

Table 5.

Other Variables Involved.

Variables	Total sampleMean (SD)	Experimental groupMean (SD)	Control groupMean (SD)	CI 95% difference	Mann–Whitney U	p
Days until walking at home	20.77 (41.02)(n = 97)	20.77 (26.05)(n = 49)	20.77 (22.34)(n = 48)	[−9.77; 9.78]	1,121	.691
Days until walking in the street	52.78 (41.02)(n = 80)	55.25 (43.64)(n = 44)	49.77 (37.96)(n = 36)	[−12.95; 23.9]	739	.608
Independence in ADLs (BI) after 3 months	75.81 (22.27)(n = 104)	80.88 (18.04)(n = 51)	70.94 (24.9)(n = 53)	[1.49; 18.38]	1,052	.051
Independence in ADLs (BI) after 6 months	77.2 (25.73)(n = 102)	83.03 (23.41)(n = 51)	71.37 (26.83)(n = 51)	[1.77; 21.55]	882	.005*

Note. CI = confidence interval; ADL = activities of daily living; BI = Barthel Index; SD = standard deviation.

Statistically significant differences.

The percentage of independent individuals for each of the different items that make up the BI, distinguishing between those in the EG and the CG, can be seen in Figure 2 (situation prior to fracture, without statistically significant differences), Figure 3 (at 3 months after hospital discharge) and Figure 4 (6 months after discharge, highlighting the significant differences in the urinary continence percentage).

Figure 2.

Independence in basic activities of daily living (ADLs) before fracture.

Figure 3.

Independence in the ADLs 3 months after fracture.

Figure 4.

Independence in the ADLs 6 months after fracture.

Where the patients or carers identified some cause for the appearance of incontinence (only 19 cases), the most frequent were functional causes, such as walking slowly and not reaching the toilet in time (8 subjects, 42.1% of those that gave a cause), wearing a pad for convenience to avoid the effort of going to the toilet, or not having sufficient help (5 subjects).

Discussion

As in other studies carried out on hip-fractured older adults, the average age of the patients included in this work is high and there is a predominance of women (Alarcón et al., 2011; González-Zabaleta et al., 2015; Vergara et al., 2014). Among the activities that determine independence in ADLs, those that were most affected after fracture were those involving mobility, such as walking, climbing, and descending stairs and transfers, while the least affected was the ability to feed oneself (González-Zabaleta et al., 2015). The incidence of UI after fracture in these previously continent patients was 37%, which is similar to that in other studies (Edwards, et al., 2011; Molero Bastante et al., 2013). All of this leads to a considerable degree of dependence and deterioration in the patients’ quality of life, in addition to an increased risk of developing other pathologies, such as injuries caused by pressure/moisture. Direct and indirect costs increase, together with the burden for the carers.

This work addresses an important clinical topic, and quality of care issue, in nursing practice and research that is central to improving prevention and treatment of UI after a hip fracture in older adults, an aspect not consciously undertaken in many settings of orthopedic care. The chances of recovering urinary continence are higher in the first 6 months after fracture (Córcoles-Jiménez et al., 2015), as the likelihood of recovery is less than 10% in the following 18 months (Alarcón et al., 2011), which emphasizes the need for an early intervention. Although from a clinical perspective, the hospital environment may seem inappropriate for carrying out educational interventions aimed at patients and carers (due to short hospital stays, acute diseases that can affect cognitive status or attention, etc.), there is an increasing number of experiences that have shown their efficacy in improving knowledge and behavior, even in the context of postoperative periods following major surgery (Ibarrola Izura et al., 2014). The knowledge acquired by patients/carers during in-hospital educational interventions could be used after discharge to promote better health outcomes.

This study was developed under the NANDA-NIC-NOC model, as a theoretical framework for nursing care. In a severe pathology such as hip fracture, the educational intervention performed managed to prevent the appearance of UI, with a considerable reduction in RR and an excellent result in terms of NNT. The number of episodes when UI appeared also decreased. This suggests the possibility of setting up prevention programs for functional UI as part of the care provided, in a manner consistent with the results presented by Zusman et al. (2017).

The educational intervention used on patients/carers in this work proposes a training of the urinary habit that the patient and his or her caregiver must perform or promote, similar to the prompted voiding recommended by the RNAO in its Best Practice Clinical Guideline to promote continence (RNAO, 2011). As in our case, in prompted voiding, the carer intervenes before undesired voiding occurs, encouraging the patient to go to the toilet at regular intervals adapted to the patient’s routine and praising them when they achieve sphincter control. To the existing evidence concerning the efficacy of this type of interventions for the management of UI in institutionalized older adults in the short term (Roe et al., 2015), in our case, we can add the continued efficacy after 3 and 6 months. BI includes urinary continence; therefore, an improvement in urinary continence should improve the global score, as seen in this study. Maintaining continence could lead to an improvement in others items, such as dressing (without pads or sanitary towels) or bathing.

The timing of voiding, which is usually recommended every 2 to 3 hours, can be individualized to best match an individual’s habit and schedule (Testa, 2015). In this study, the optimal interval for voiding was fixed at 4 hours, in accordance with the NIC’s “Urinary habit training.” In any case, 4 hours is an ideal goal, which may be feasible or not depending on the possibilities of each patient.

Adjustments in lifestyle can have a great impact on the incidence of UI (Testa, 2015), but in our study, this kind of general measures were not included as part of the educational intervention, since prior to the fracture, the patients did not present UI, so it did not seem necessary to modify their previous lifestyle.

Among the strengths of our study, we can point to the possibility of intervening autonomously on functional UI, via a nursing diagnosis, with an independent intervention that is simple, internationally recognized and well received by patients and carers. There were hardly any dropouts in the follow up. The fact that the study was carried out at several different hospitals means that it would be easily reproducible in other environments. The way in which the results were classified to identify continence is very strict, as only those patients who always managed to urinate in the appropriate receptacle were considered “continent”; any other situation (“frequently,” “sometimes,” etc.) was considered as “incontinence.” Patients who showed continence at 3 months continued to show it at 6 months. Although no longer-term outcomes were measured, continence would probably have continued.

With regards to limitations, the data about the continence and independence of the patient in the ADLs were sometimes collected from the carers, which could introduce a bias. However, this is a practice that is used in many studies of older adults (González-Zabaleta et al., 2015) and research has been published that endorses the consistency between the carer’s answer and that of the patient regarding incontinence and the ADLs (Shaw et al., 2000). As an educational intervention, its blinding to the participants and researchers was not possible, but a blinded assessment of the outcomes was carried out. Patient comorbidity, chronic disease burden, or postoperative pain was not included among the variables in this study. Prior to hip fracture, all the patients were continent, and the randomization performed on the selected sample allowed both groups to be homogeneous in terms of their characteristics. Pad count or pad weight were not included among the study outcomes; only the type of pad, assuming that the use of sanitary towels correlates with lower incontinence volumes than the use of adult pads.

This study only examined the effect of the intervention on patients who were cognitively intact, continent, and who had undergone surgical repair; many older adults who were admitted to hospital due to hip fracture already suffered from disturbed continence or cognitive impairment, and in this kind of patients, the trial findings would not be able to be generalized. It is possible that the time spent by researchers teaching the intervention to patients may have motivated them to pay attention to maintaining their continence, although the amount of time was very short.

Conclusion

An educational intervention consisting in urinary habit training has reduced the incidence of functional UI in older adults who were continent prior to hip fracture surgery subsequent to a fall, both at 3 and 6 months after discharge, in a statistically significant way.

Footnotes

Acknowledgements

The authors would like to thank the patients and carers for their collaboration. They would also like to thank their workmates Enrique Ortega-Domínguez, María-Jesús Ibáñez-Andrés, Eva-María Mora-Mesa, and Mónica Serrano-Latorre, who helped with the collection of data at the different hospitals. Without their assistance and effort, this study would not have been possible.

Authors’ Note

The funding sources had no involvement in study design, or in the collection, analysis or interpretation of data; or in the writing of this report or in the decision to submit this article for publication.

Author Contributions

M.P.C.J., A.V.M., M.A.E.F., M.M.M., M.D.J.S., and E.C.P. developed the initial protocol for the study. M.P.C.J., A.V.M., M.A.E.F., M.M.M., A.J.P.M., and R.J.A.G. collaborated in the data collection process and performed the intervention. M.P.C.J. carried out the statistical analysis. All the authors have participated in the interpretation of the results. M.P.C.J., A.V.M., E.C.P., and M.A.E.F. have written the final version of this article, which has been approved by all the authors.

IRB Protocol/Human Subjects Approval Numbers

This project received the approval of the Ethics Committee of the health authority for Albacete (Act 04/08).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Fondo de Investigación Sanitaria (grant no. PI080676) and the Fundación para la Investigación Sanitaria en Castilla-La Mancha (FISCAM) (grant no. PI200726).

ORCID iD

María-Pilar Córcoles-Jiménez

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