What Works to Improve and Manage Fecal Incontinence in Care Home Residents Living With Dementia? A Realist Synthesis of the Evidence

Buswell M1, Goodman C2, Roe B3, Russell B2, Norton C4, Harwood R5, Fader M6, Harari D7, Drennan VM8, Malone JR9, Madden M3, Bunn F2. J Am Med Dir Assoc. 2017 Sep 1;18(9):752-760.e1. doi: 10.1016/j.jamda.2017.05.025.
Author information

1 Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, United Kingdom. Electronic address: m.buswell@herts.ac.uk. 2 Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, United Kingdom. 3 Faculty of Health & Social Care, Edge Hill University, Ormskirk, United Kingdom. 4 Florence Nightingale Faculty of Nursing and Midwifery, King's College London, London, United Kingdom. 5 Health Care of Older People, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom. 6 Health Sciences, University of Southampton, Southampton, United Kingdom. 7 Guys and St Thomas' NHS Foundation Trust & King's College London, London, United Kingdom. 8 St Georges, University of London and Kingston University, London, United Kingdom. 9 Bangor University School of Health Care Sciences, Bangor, United Kingdom.


The prevalence of fecal incontinence (FI) in care homes is estimated to range from 30% to 50%. There is limited evidence of what is effective in the reduction and management of FI in care homes. Using realist synthesis, 6 potential program theories of what should work were identified. These addressed clinician-led support, assessment, and review; the contribution of teaching and support for care home staff on how to reduce and manage FI; addressing the causes and prevention of constipation; how cognitive and physical capacity of the resident affects outcomes; how the potential for recovery, reduction, and management of FI is understood by those involved; and how the care of people living with dementia and FI is integral to the work patterns of the care home and its staff. Dementia was a known risk factor for fecal incontinence (FI), but how it affected uptake of different interventions or the dementia specific continence and toileting skills staff require, were not addressed in the literature. There was a lack of dementia-specific evidence on continence aids. Most care home residents with FI will be doubly incontinent; there is, therefore, limited value in focusing solely on FI or single causes, such as constipation. Medical and nursing support for continence care is an important resource, but it is unhelpful to create a distinction between what is continence care and what is personal or intimate care. Prompted toileting is an approach that may be particularly beneficial for some residents. Valuing the intimate and personal care work unqualified and junior staff provide to people living with dementia and reinforcement of good practice in ways that are meaningful to this workforce are important clinician-led activities. Providing dementia-sensitive continence care within the daily work routines of care homes is key to helping to reduce and manage FI for this population.

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