Diagnosis and treatment of incontinence in the institutionalized elderly

A selective, stepped strategy will diagnose the cause of incontinence in most institutionalized elderly patients. It consists of rectifying the transient causes of incontinence, searching for serious and treatable underlying conditions, and then formulating a differential diagnosis. If the benefit of empiric therapy exceeds the risk it can be initiated, recalling that incontinence in these patients is multifaceted, and that small improvements in many areas unrelated to the urinary tract will often be sufficient to restore continence. If the risk of empiric therapy exceeds the benefit, further urodynamic testing is warranted since it is safe, feasible, and reproducible. Such an approach will minimize the use of invasive testing, indwelling catheters, and toxic medications. Coupled with optimism, creativity, and persistence, it can lead to substantial improvements in the lives of many incontinent institutionalized patients. Ultimately, the optimal care of incontinence in the nursing home will require an increased number of motivated and well-paid nursing assistants, less invasive diagnostic testing, and improved, better targeted therapy. Still, even in 1989, much can be done to "cure sometimes, relieve often, and comfort always."