Management of Fecal Incontinence in Frail Older Adults Living in the Community

  • Kathleen F. HunterEmail author
  • Melissa Northwood
  • Veronica Haggar
  • Frankie Bates


Most older adults live in the community either alone or in a family arrangement. Community-living older adults are diverse, and the health status of some is characterized by complexity related to having multiple morbidities and possibly frailty. Assessment and management of fecal incontinence in frail community-dwelling older adults with health-related complexity may be enhanced using a complexity framework that accounts for social, environmental, and political contextual factors as well as health/medical concerns. This chapter will explain common problems that contribute to fecal incontinence in these older adults such as impaction with overflow, constipation, diarrhea, and mild to moderate cognitive impairment. It will address special considerations that the advanced practice nurse must take into account including hearing and vision impairment, physical limitations, the physical environment and toilet access in the home, diet and hydration, and the role of the caregiver. The chapter will then discuss appropriate management interventions. Interventions highlight the importance of a holistic approach, client and caregiver engagement and education, and referral to other healthcare professionals and community services.


Fecal incontinence Frailty Older adult Community-living Health complexity 


  1. 1.
    World Health Organization. World report on ageing and health. Geneva: WHO; 2015.Google Scholar
  2. 2.
    De Vries N, Staal J, Van Ravensberg C, Hobbelen J, Rikkert MO, Nijhuis-Van der Sanden M. Outcome instruments to measure frailty: a systematic review. Ageing Res Rev. 2011;10(1):104–14.CrossRefPubMedGoogle Scholar
  3. 3.
    British Geriatric Society. Fit for frailty: consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. London. London: British Geriatric Society; 2014. Google Scholar
  4. 4.
    Santos-Eggimann B, Cuénoud P, Spagnoli J, Junod J. Prevalence of frailty in middle-aged and older community-dwelling Europeans living in 10 countries. J Gerontol A Biol Sci Med Sci. 2009;64(6):675–81.CrossRefPubMedGoogle Scholar
  5. 5.
    Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. J Am Geriatr Soc. 2010;58(4):681–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Ser A Biol Med Sci. 2001;56(3):M146–M57.CrossRefGoogle Scholar
  7. 7.
    Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol Ser A Biol Med Sci. 2007;62(7):722–7.CrossRefGoogle Scholar
  8. 8.
    Schober M. Introduction to advanced nursing practice: an international focus. Cham: Springer; 2016.CrossRefGoogle Scholar
  9. 9.
    Wagg A, Chen LK, Johnson IIT, Kirschner-Hermanns R, Kuchel G, Markland A, et al. Incontinence in frail older persons. In: Abrams P, Cardozo L, Wagg A, Wein A, editors. Incontinence. 6th ed. Bristol: International Continence Society; 2017. p. 1309–441.Google Scholar
  10. 10.
    Schaink AK, Kuluski K, Lyons RF, Fortin M, Jadad AR, Upshur R, et al. A scoping review and thematic classification of patient complexity: offering a unifying framework. J Comorb. 2012;2:1):1–9.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Zullig LL, Whitson HE, Hastings SN, Beadles C, Kravchenko J, Akushevich I, et al. A systematic review of conceptual frameworks of medical complexity and new model development. J Gen Intern Med. 2015;31(3):329–37.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kuluski K, Gill A, Naganathan G, Upshur R, Jaakkimainen RL, Wodchis WP. A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers. BMC Fam Pract. 2013;14(1):133.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    De Giorgio R, Ruggeri E, Stanghellini V, Eusebi LH, Bazzoli F, Chiarioni G. Chronic constipation in the elderly: a primer for the gastroenterologist. BMC Gastroenterol. 2015;15(1):130.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kwan D, Farell B. Polypharmacy: optimizing medication use in elderly patients. Can Geriatr Soc J Continuing Med Educ. 2014;4(1):21–7.Google Scholar
  15. 15.
    Westra BL, Savik K, Oancea C, Choromanski L, Holmes JH, Bliss DZ. Predicting improvement in urinary and bowel incontinence for home health patients using electronic health record data. J Wound Ostomy Cont Nurs. 2011;38(1):77–87.CrossRefGoogle Scholar
  16. 16.
    De Lillo AR, Rose S. Functional bowel disorders in the geriatric patient: constipation, fecal impaction, and fecal incontinence. Am J Gastroenterol. 2000;95(4):901–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Shah BJ, Chokhavatia S, Rose S. Fecal incontinence in the elderly: FAQ. Am J Gastroenterol. 2012;107(11):1635–46.CrossRefPubMedGoogle Scholar
  18. 18.
    Petersen RC, Caracciolo B, Brayne C, Gauthier S, Jelic V, Fratiglioni L. Mild cognitive impairment: a concept in evolution. J Intern Med. 2014;275(3):214–28.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Wimo A, Jönsson L, Bond J, Prince M, Winblad B, International Alzheimer’s Disease. The worldwide economic impact of dementia. Alzheimers Dement. 2010;9(1):1–11.e3.CrossRefGoogle Scholar
  20. 20.
    Guthrie DM, Declercq A, Finne-Soveri H, Fries BE, Hirdes JP. The health and well-being of older adults with dual sensory impairment (DSI) in four countries. PLoS One. 2016;11(5):e0155073.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Bickley LS. Bates’ guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins; 2017.Google Scholar
  22. 22.
    Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol. 1989;42(8):703–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983;31(12):721–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist. 1969;9:179–86.CrossRefPubMedGoogle Scholar
  25. 25.
    Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Finne-Soveri H, Sorbye LW, Jonsson PV, Carpenter GI, Bernabei R. Increased work-load associated with faecal incontinence among home care patients in 11 European countries. Eur J Pub Health. 2008;18(3):323–8.CrossRefGoogle Scholar
  27. 27.
    Gove D, Scerri A, Georges J, van Houten P, Huige N, Hayder-Beichel D, et al. Continence care for people with dementia living at home in Europe: a review of literature with a focus on problems and challenges. J Clin Nurs. 2016;26(3-4):356–65.CrossRefPubMedGoogle Scholar
  28. 28.
    Mullins J, Bliss DZ, Rolnick S, Henre CA, Jackson J. Barriers to communication with a healthcare provider and health literacy about incontinence among informal caregivers of individuals with dementia. J Wound Ostomy Cont Nurs. 2016;43(5):539–44.CrossRefGoogle Scholar
  29. 29.
    Drennan VM, Cole L, Iliffe S. A taboo within a stigma? A qualitative study of managing incontinence with people with dementia living at home. BMC Geriatr. 2011;11:75.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Santini S, Andersson G, Lamura G. Impact of incontinence on the quality of life of caregivers of older persons with incontinence: a qualitative study in four European countries. Arch Gerontol Geriatr. 2016;63:92–101.CrossRefPubMedGoogle Scholar
  31. 31.
    Bliss DZ, Mimura T, Berghmans B, Bharucha A, Chiarioni G, Emmanuel A, et al. Assessment and conservative management of faecal incontinence and quality of life in adults. In: Abrams P, Cardozo L, Wagg A, Wein A, editors. Incontinence. 6th ed. Bristol: International Continence Society; 2017. p. 1993–2085.Google Scholar
  32. 32.
    Registered Nurses Association of Ontario (RNAO). Strategies to support self-management in chronic conditions: collaboration with clients. Toronto: Registered Nurses Association of Ontario; 2010.
  33. 33.
    Markle-Reid M, Browne G, Gafni A. Nurse-led health promotion interventions improve quality of life in frail older home care clients: lessons learned from three randomized trials in Ontario, Canada. J Eval Clin Pract. 2013;19(1):118–31.CrossRefPubMedGoogle Scholar
  34. 34.
    Alzheimer’s Association. 2014 Alzheimer’s disease facts and figures. Alzheimers Dement. 2014;10(2):e47–92.CrossRefGoogle Scholar
  35. 35.
    OECD. Pensions at a glance 2015. Paris: OECD Publishing; 2015.Google Scholar
  36. 36.
    Finne-Soveri H, Sørbye L, Jonsson P, Carpenter G, Bernabei R. Increased work-load associated with faecal incontinence among home care patients in 11 European countries. Eur J Pub Health. 2007;18(3):323–8.CrossRefGoogle Scholar
  37. 37.
    Varanese S, Birnbaum Z, Rossi R, Di Rocco A. Treatment of advanced Parkinson’s disease. Parkinsons Dis. 2010;480260.
  38. 38.
    Smith SM, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ. 2012;345:e5205.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc. 2008;56(10):1946–52.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Bliss DZ, Norton C. Conservative management of fecal incontinence. Am J Nurs. 2010;110(9):30–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478–98.CrossRefPubMedGoogle Scholar
  42. 42.
    Ostaszkiewicz J, Hornby L, Millar L, Ockerby C. The effects of conservative treatment for constipation on symptom severity and quality of life in community-dwelling adults. J Wound Ostomy Cont Nurs. 2010;37(2):193–8.CrossRefGoogle Scholar
  43. 43.
    Robbs L, editor. Fecal incontinence: assessment and treatment. Hamilton, ON: McMaster University Press; 2014.Google Scholar
  44. 44.
    Registered Nurses Association of Ontario (RNAO). Prevention of constipation in the older adult population. Toronto: Registered Nurses Association of Ontario; 2011. Google Scholar
  45. 45.
    Franklin LE, Spain MP, Edlund BJ. Pharmacological management of chronic constipation in older adults. J Gerontol Nurs. 2012;38(4):9–15.CrossRefPubMedGoogle Scholar
  46. 46.
    Liu LWC. Chronic constipation: current treatment options. Can J Gastroenterol. 2011;25(Suppl B):22B–8B.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Nugent KP. Rectocele pathophysiology and presentation. In Cohen R, Windsor A, editors. Anus: Surgical treatment and pathophysiology. London: Springer; 2013. p.91–6.Google Scholar
  48. 48.
    Hanson L-AM, Schulz JA, Flood CG, Cooley B, Tam F. Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success. Int Urogynecol J. 2006;17(2):155–9.CrossRefGoogle Scholar
  49. 49.
    McClurg D, Hagen S, Hawkins S, Lowe-Strong A. Abdominal massage for the alleviation of constipation symptoms in people with multiple sclerosis: a randomized controlled feasibility study. Mult Scler J. 2011;17(2):223–33.CrossRefGoogle Scholar
  50. 50.
    Doughty D, Jensen LL, editors. Assessment and management of the patient with fecal incontinence and related bowel dysfunction. St. Louis, MO: Mosby Elsevier; 2006.Google Scholar
  51. 51.
    Norton C, editor. Bowel control and managing a misbehaving bowel. Wilmette, IL: The Simon Foundation; 2011.Google Scholar
  52. 52.
    Bliss DZ, Savik K, Jung HJG, Whitebird R, Lowry A, Sheng X. Dietary fiber supplementation for fecal incontinence: a randomized clinical trial. Res Nurs Health. 2014;37(5):367–78.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Kathleen F. Hunter
    • 1
    • 2
    Email author
  • Melissa Northwood
    • 3
    • 4
  • Veronica Haggar
    • 5
  • Frankie Bates
    • 6
  1. 1.Faculty of NursingUniversity of AlbertaEdmontonCanada
  2. 2.Glenrose Hospital Continence ClinicEdmontonCanada
  3. 3.Saint Elizabeth Health CareHamiltonCanada
  4. 4.Aging, Community and Health Research Unit, School of NursingMcMaster UniversityHamiltonCanada
  5. 5.Homerton University Hospital NHS Foundation TrustLondonUK
  6. 6.Urology Wellness ClinicSt. Joseph’s HospitalSaint JohnCanada

Personalised recommendations