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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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Top Ten Sleep Disturbances – #7 Pain

Written by Heather Johnson, RN
Resource Nurse, Empira

A Serious Intruder on Restorative Sleep

Donna distesa a letto con dolore alla schiena

A recent poll of the American public, found that 21% of Americans experience chronic pain and 36% had had acute pain in the past week. Combine those totals, and it equates to 57%, leaving only 43% of Americans who report being pain free. Pain ranks as number seven in the Top Ten Sleep Disturbances.

People with pain often report feeling less control over their sleep. They report being worried about lack of sleep and its effects on their health. Worry leads to stress. Stress and poor health, often go hand-in-hand and can often be linked to fragmented sleep. Fragmented sleep translates to interrupted sleep which prevents a person from receiving 7-9 hours. Seven to nine hours of uninterrupted sleep is necessary for restorative sleep. Restorative sleep is needed for physical and emotional healing. Sleep loss is known to contribute to feelings of depression and fatigue, which in turn can increase a person’s pain perception. Research indicates that if a person experiences poor sleep due to pain one night, they are more likely to experience pain the next night, and the next night, and so on. We know that pain can be a serious intruder on restorative sleep.

Pain, depression, and fatigue are interrelated. Further, pain often is linked to insomnia, and, when both of these problems coexist, the perfect recipe for additional problems has been created. Additionally, evidence suggests that sleep loss increases reports of pain, when you don’t sleep well you have a heightened sensitivity to pain. This vicious cycle of poor sleep due to pain affects multiple areas of a person’s day to day life.

What can a person do?

  • Determine the source of the pain. Is it physical pain? Is it emotional pain? Get to the root of the problem, identify the root cause. Once you’ve identified the source, address the source with the right solution or intervention.
  • Seek direction from your medical provider.
  • Exercising or stretching of sore muscles by stimulating blood flow and easing pain
  • Evaluate your positioning in bed; your pillow, mattress, and environment.
  • Retrain you brain to think of something positive as you head to bed for the night.
  • Research non-pharmacological interventions such as, relaxation techniques (focus on your breathing), guided imagery, aroma therapy, heat/cold, and massage.
    If it’s physical pain, consider a longer acting pain reliever, one that will last throughout the night.

Don’t let pain rob you from a good night of sleep!

Cosio, D., Lin, E; PPM: Practical Pain Management. Disturbed Sleep: Causes and Treatments. 2018. Accessed November 20, 2018.
National Sleep Foundation. Recommended Sleep. 2015. Accessed November 20, 2018.
Onen, SH., Alloui, A., Gross, A., Eschallier, A., Dubray, C. 2001. The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects. J Sleep Res. 10, 35-42. doi:10.1046/j.1365-2869.2001.00240.x

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Falling From Grace

Author:  Heather Johnson, RN Clinical Educator & Program Specialist

Without a doubt, I can say almost 100% of our population has fallen at some point in their lifetime.  When I pose this as a question to participants in educational sessions I often find a handful of individuals that honestly report they have never fallen.  Unless you are some type of super-human and are as agile as a mountain goat or monkey, you have fallen at some point in your lifetime and the odds are you will fall again.

My older sister was nicknamed “Grace” in our childhood years as she mastered the uncanny ability to fall even while going UP the stairs in our home.  We often referred to this ability as her “talent” and would laugh if we were present to witness her mishap.  As we grew older and more experienced I came to understand how the consequences of her missteps could carry horrific injuries.

While a fall for any age can have serious results, the impact of a fall for an older adult can be grave.

Are you aware one in four Americans aged 65 and older falls each year?  Every 11 seconds, an older adult is seen and treated in a hospital emergency room due to injuries sustained from a fall?  Hip fractures, broken bones, hematomas and traumatic brain injuries are often the result of a fall for those over the age of 80.  One in five hip-fracture patients will die within one year of their injury.  Yes, they will die.  The trajectory is not in their favor.

I spent this past week at the 4th Annual National Falls Prevention Conference in Philadelphia and took part in a learning experience that left me feeling both extremely positive and proud about the work we are doing in falls prevention.   Simultaneously I was overcome with a desire to continue to push harder and work for better outcomes for our seniors.  While in Philadelphia, I had the opportunity to see the very steps Sylvester Stallone made internationally recognizable in the movie Rocky, the ever-famous steps of the Institute of Art Museum. In the movie, Rocky not only climbs these steps in different weather elements, but he runs.  He runs, he trains, makes himself stronger, and he becomes more agile each day.  Rocky was relentless in his training with his desire to ultimately become the Heavy Weight Boxing Champion. While you may not be training to become the next world famous boxer, we certainly can be left inspired by his grit and undying desire to improve himself.  At the age of 71, Sylvester Stallone makes it well known that he takes his physical health and exercise seriously.

What can we do?  Evidence-based best practices support assisting individuals with maintaining (or even improving) mobility, balance and core muscle strengthening through regular exercise.  These are proven ways to greatly reduce the chances of falling at all ages.  This alone is the number one way to prevent falls!  The National Council on Aging offers a wide range of exercise and for all abilities.   

By encouraging and promoting activity, you are not only reducing the risk of falling for an older adult, you are also encouraging their opportunities for socialization which, in turn, has been proven to decrease episodes of both depression and anxiety.

 Falling is not a normal part of aging and there are numerous ways that are proven to reduce the chances of having a fall.

I encourage you as a care provider, a son or daughter of aging parents, as a grandchild or as a friend to a senior, to not only consider the physical environment, footwear, and eye glasses when striving for preventing a fall, but to also consider what you can do to help promote movement, core strengthening and social opportunities for the aging.   By doing so, maybe we can all extend each other a bit more “Grace.”

Written by:  Heather Johnson RN, Clinical Educator and Program Specialist