Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 493

Given that people with faecal incontinence often will not volunteer that information, active case finding is essential in at‐risk groups, including those with frailty, neurological disease, or urinary incontinence and those taking potentially causative drugs such as opioids or metformin.

The goals of evaluating faecal incontinence in older adults should be to establish the frequency and severity of incontinence and the impact on the individual’s quality of life. Appropriate goal‐setting with the patient and their caregiver is essential, as well as exploring the extent to which treatment options are acceptable.

The mainstay of the assessment of faecal incontinence is the clinical history. This should include the duration of symptoms, frequency and consistence of normal, controlled bowel movements, frequency and consistency of faecal incontinence, and consistency to flatus. Objective assessment of stool consistency with the Bristol stool scale⁴⁹ allows accurate and consistent description of stool types. An assessment of potentially contributing medical conditions as above, as well as a comprehensive drug history, including over‐the‐counter and dietary supplements, should also be taken. A functional history should be taken, covering the patient’s ability to identify and get to facilities and undress, get dressed, and wash their hands, as well as a description of the facilities available in the patient’s home, including access, grab rails, and the necessity to climb stairs. As with the assessment of urinary incontinence, asking the patient to go to the bathroom in the clinic and observing the process can be illuminating. A dietary history covering the intake of soluble and insoluble fibre, fruits, and vegetables is also important, and involving a dietician can be helpful.

The physical examination can help identify the underlying cause of faecal incontinence and should include as a minimum an abdominal examination, brief neurological examination, and digital rectal exam to assess anal tone, sensation, squeeze pressure, and faecal loading. The perineum should be inspected for dermatitis, haemorrhoids, surgical scars, fistulae, and rectal prolapse or ballooning of the perineum on straining, indicating weakness of the pelvic floor. In women, a vaginal exam to assess for posterior compartment prolapse should also be included. In those with a history or symptoms of cognitive impairment, a cognitive screening tool such as the Montreal Cognitive Assessment⁵⁰ should be performed. The assessment of faecal incontinence is summarized in Table 19.2.