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You Ain’t Cool Unless You Pee Your Pants

Written by Sarah Brown, BS, RN, LNHA
Executive Director, Empira

“You ain’t cool unless you pee your pants!” – Billy Madison

Some of you may remember this classic line from the 1995 comedy movie, Billy Madison. Adam Sandler plays the role of an adult, Billy Madison, who has to complete all of grade school over starting with Kindergarten. While on a school field trip in 3rd grade, Billy notices his classmate had an “accident”. Sensing his classmate’s embarrassment, Billy pretends to pee his pants too to save the boy from embarrassment. Because the rest of the class looks up to Billy as an older cool kid they accept his claims and the boy is saved from embarrassment. Part of this scene includes a cut to an elderly woman who says, “If peeing your pants is cool… consider me Miles Davis.” Fun Fact (Miles Davis was influential Jazz musician with a record titled Birth of the Cool in 1957.)

Although incontinence is common, it is not a normal part of aging.

With stereotypes like the one in the movie and daily exposure to the widespread prevalence of incontinence observed in care centers, it is very easy to normalize and expect incontinence with aging. In the United States, incontinence is common for older adults and according to the National Association for Contienence (NAFC), incontinence is second, only to falls, as the reason for nursing home placement.

Incontinence affects on average 70% of residents in the Empira consortium. We have learned through the Empira Falls Prevention & Reduction program that incontinence is a common contributing cause of falls and toileting schedules also have a major influence on several other nursing home care plan areas including sleep, nutrition, hydration, skin integrity and mobility.

One thing the movie portrayed accurately is the social impact of incontinence. Through conversations with residents Empira became increasing aware of the impact it has on quality of life in our care centers. We have learned that resident don’t feel like Miles Davis, the king of cool. Residents have shared the following statements about what it is like. As you read the comments you will see they feel more like the embarrassed school mate:

  • “Because I have so many accidents I prefer not to go to my social engagements.”
  • “I buy two of every outfit because I got tired of explaining to my friends why I changed clothes.”
  • “I am limited in my ability to venture too far from bathrooms for fear of accident and embarrassment.”
  • “Going to the bathroom becomes all consuming and takes over my whole day’s schedule.”
  • “I was surprised how quickly incontinence products were suggested and it was presented as my only option.”
  • “I was living at home until I began to have incontinence issues. It was the reason I had to move to a nursing home”
  • “I don’t attend family events outside of the nursing home because my bathroom needs are more trouble than it is worth.”
  • “Bathroom routines are embarrassing and distract from living life.”

I am not saying we should all start peeing our pants.

We as aging service providers need to acknowledge that we are not helping older adults feel cool or understood as Billy Madison did with his empathetic gesture. I am not saying we should all start peeing our pants but I am saying we should all start with empathy and understanding of the impact incontinence issues has on those we care for. Our current status quo of continence care in nursing homes has normalized incontinence to the point where we don’t even see it as a problem that deserves investigating. The resident comments above convey that our actions say, this is normal, there is nothing more we can do other than offer incontinence products and a 2 hour toileting schedule.

We need more thorough understanding and more options for treatment and management besides the house special standard incontinence product. I want to encourage us as aging service providers to keep learning and to create new standards that give incontinence the time it deserves. This will allow for discovering root causes, preventative measures and alternative options for residents.

Starting January 2020, the Empira collaborative has created and deployed a new approach to incontinence titled STREAM (Strategies Targeting Resident Elimination and Assessment Management). This program will be in 25 skilled nursing homes in metro and rural Minnesota.
STREAM was made possible by PIPP funding through the MN Department of Human Services.

STREAM was developed after listening to residents share the negative impact toileting and incontinence has on their everyday life. This program will challenge current assessment practices that do not accurately reflect the resident’s condition and replace it with technology-based assessments to improve accuracy and efficiency. STREAM funding provides each community with a Clinical Informatics Specialist (CIS) who will utilize the technology based assessments and data to strengthen resident care plans for a holistic approach to individualized care.
We believe improved understanding of the root cause will lead to better options for prevention, treatment, and management and ultimately resulting in higher quality of care.

Stay tuned to follow the STREAM journey. If you are interested in learning more about continence and emerging best practices visit

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