UI is common in dementia, particularly as the disease progresses. PLWD are twice as likely to have UI than people without the diagnosis. In a longitudinal study of 12,432 women aged 70-75 with a 3 year follow-up, there was a strong association of UI with a dementia diagnosis (OR 2.34). Older PLWD are 65% more likely to be admitted to hospital than people without dementia. In some series, up to 25% of inpatient beds are occupied by PLWD. The assessment and management of UI for PLWD is poorly described but reports suggest that this is characterized by containment and processes of care which threatens dignity and adds to the dehumanizing of people with double stigma. There are few systematically derived data which inform the care of UI in older PLWD in hospitals. This scoping review aimed to synthesize what is known and identify research and knowledge gaps in order to inform future research in this area.

This review was guided by the Joanna Briggs Institute (JBI) method for scoping reviews,
and presented according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR) checklist (Figure 1).
 Retrieval of Studies 
A medical librarian searched for peer-reviewed literature from Medline, Embase, Scopus, CINAHL plus, PsycINFO, Cochrane Collaboration and Google Scholar. An initial search in Ovid MEDLINE was done in September 2021, a detailed search of all included databases and a search of reference lists of included studies was updated in March 2023. A grey literature search was performed in February 2023 and included reviewing references of relevant studies, online searches and contacting experts in the field. Keywords were chosen to retrieve literature related to the management of UI in PLWD in the hospital setting.
Screening & Data Extraction
After duplicates were removed, two reviewers practiced screening a random sample of studies and showed adequate inter-reviewer agreement. They then screened all titles and abstracts independently using Covidence software. Articles that passed abstract screening were read in full by reviewers independently and consensus was reached on which articles to include. Studies were excluded if they did not specify participants’ dementia status, took place in a non-hospital setting or focused on prevalence and impact rather than care practices. The purpose of this scoping review was to provide a narrative of existing research. Therefore, quality appraisal of included studies was not performed as part of this review.
The data extraction form included the authors, publication year, country, study design, study setting, participant characteristics, and findings, and was informed by a customizable Covidence structure. Decisions about what to include on the data extraction form were made on the basis of current literature guidelines and at the discretion of the reviewers.

The online database search yielded 1052 articles after duplicates were removed (Figure 1). Overall, 1068 articles were excluded, with the following common reasons for exclusion: setting not in hospital, UI or dementia not a criterion, or the study did not focus on treatment. 17 articles passed abstract screening and moved to full text review, of which 2 articles fit the inclusion criteria. 18 articles were retrieved from the grey literature search, of which 0 were included. One mixed methods review was identified that outlined useful information on the current care practices for UI in PLWD across all settings, but as it did not focus on the hospital setting it was excluded.
Both of the included articles were ethnographic studies that used field notes and interviews to identify various issues with current UI care strategies for PLWD in hospitals (Table 1). Boddington & Featherstone [2] carried out an ethnography over 154 days across five hospitals in England and Wales, and conducted interviews with staff, carers and patients. Featherstone et al. [3] undertook over 180 days of observational fieldwork across six wards in three different hospitals throughout England and Wales, and also interviewed staff. A journal publication from the second study was also identified, but was excluded as a separate study as the reported findings were presented in the initial longer report.

The two included studies identified four key issues with UI care for PLWD in hospitals. These comprised lack of privacy, loss of autonomy, communication challenges and staff dependency on absorbent pads as the management strategy of choice.

Once in the hospital ward, a patient’s life abruptly transitioned from private to public. PLWD may be exposed to staff, patients and visitors while being wheeled around in a
 
commode, leading to embarrassment. Pads and other continence care products were visible to the public. Constant staff monitoring of continence schedules also infringed on patient privacy. Hospital wards that had nurses stationed centrally, surrounded by patient rooms, resulted in constant surveillance and a lack of privacy while patients used toilets. A lack of privacy led to embarrassment and discomfort for PLWD.

Preservation of autonomy was sacrificed in hospitals, with care providers adopting task focused processes of care. The continuous recording of patient continence schedules by staff made patients question their own bodily needs, leading to a feeling of losing control. Competing priorities of the medical team deprioritized continence care, provision being at the behest of staff rather than patient need. An overbearing safety culture prohibited PLWD from leaving their bed to toilet without assistance, promoting incontinence and unsuccessful toileting.

Staff were unable to recognize a patient’s need to use the toilet based on non-verbal cues. “Pad culture” referred to the use of continence pads for PLWD as a precaution for accidents regardless of their UI status. Placing PLWD in pads came with the  expectation that they used the pad. As such, the need to maintain continence, mobility and independence was deprioritized. When PLWD requested assistance with using the toilet, staff often refused and encouraged patients to use their pad instead.

Despite the high proportion of PLWD admitted to hospital, there is little research on UI care for PLWD in this setting. The two ethnographies identified provide insight into the poor care of UI in PLWD in the UK. Concern about overuse of absorbent pads and catheters in hospitals has been previously identified in the research literature, but the studies here provide additional insight into the situation faced by PLWD and the staff trying to provide care. Studies from other countries would aid in understanding care for this population from an international perspective. Barriers and facilitators to implementation of continence care that maintains the function and dignity of PLWD while in hospital need to be identified at the staff as well as system level. This would be helpful in designing novel approaches and intervention trials to identify effective strategies and improve quality of care.

Continence 7S1 (2023) 101008
DOI: 10.1016/j.cont.2023.101008