Strategies to Inform Innovations in Continence Care for People Living with Dementia in the Acute Hospital Setting: A Mixed Methods Narrative Synthesis Review

Background: People living with dementia are at signicant risk of developing urinary and/or faecal incontinence but are also at risk of functional incontinence or being labelled as being incontinent. Despite the growing population of PLWD and importance of continence care little is known about the appropriate management, organisation, and interactional, strategies for PLWD admitted to acute hospitals. This mixed methods narrative systematic review sought to identify successful strategies across all care settings that could then be used to inform innovations in continence care for PLWD in the acute hospital setting. Methods: In phase 1 a scoping search of two electronic databases (MEDLINE and PSYCinfo) and a consultation with stakeholders was undertaken. Findings from were presented to the project steering and two priority areas for phase 2 were identied which were communication and individualised care plans. In phase 2 eight databases and relevant UK government and other organisational websites were searched for English language citations from inception to August 2020. Critical appraisal was conducted using the Mixed Methods Appraisal Tool (MMA Version 11). Thematic synthesis was employed and the strength of synthesised ndings for the intervention studies was assessed using the GRADE approach and the and condence in synthesised qualitative and survey ndings was assessed using the CERQual tool. Results: In phase 1, 1348 citations were found and 75 included. In phase 2, 6247 citations were found 14 research studies and 14 policy and guidance documents were included. The quality of studies varied. Material was synthesized in order to identify the facilitators and barriers around developing communication strategies and individualised management plans in response to the continence needs of PLWD. Conclusions: Recognising that PLWD are not always able to communicate their continence needs verbally is important. Incorporating interpersonal and communication skills into the context of continence care within training for those working with this patient group is crucial for continence to be maintained during an acute admission. Continence care in the acute setting should be tailored to the individual and be developed in partnership with staff and caregivers.

2. Acute, long-term and community healthcare and home settings 3. Urinary or faecal continence/incontinence, or toileting issues 4. Conservative management or care practices (de ned as "any therapy that does not involve pharmacological or surgical intervention" [47, p. 1020

] including catheterisation
Of the 1348 citations retrieved, 75 were included (see additional le S1 for PRISMA ow diagram). The ndings were summarised into a number of broad, descriptive, maps [48] to identify the ways in which continence is assessed and managed across settings. The ndings from the scoping exercise in keeping with the EPPI-Centre approach were presented to stakeholders with interest in the eld in order to ascertain views on the priority areas for the second phase of searching.
The key stakeholder groups included PLWD, family carers, and practitioners drawn from different occupational groups (n = 32) and are shown in Table 1). All stakeholders as part of this process were asked to complete a priority setting exercise which was facilitated by answering the question. "What do you think are ve of the most important ways that continence could be managed for PLWD when they are in hospital?" The responses from the individual and group consultations were collated, coded and grouped together and a list of the ways of managing continence in the hospital setting was generated.

NHS Continence Service
An outpatient based service. The role of the team is to accept and take referrals from primary care general practitioners (GP's), district nurses and others to see patients with incontinence and to assess and put in place a suitable management plan for them Group discussion followed by individual priority setting exercise with CNSs Individual Interview with nurse consultant followed by setting exercise Occupational therapist (n = 1)

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Currently works on an elderly ward with both functional patients and PLWD. Previous employment was on a speci c dementia ward in a community hospital Individual interview followed by priority setting exercise PLWD (n = 2) Family carers (n = 11) DCA (n = 10) One activities coordinator of local care home (n = 1) Volunteer from the Alzheimer's society (n = 1)

Dementia Consultation Event
A whole day event in which where issues around toileting and continence were explored through narrative and creative presentations (through pictures, poems and artistic expression, arts and discussion.
Group discussion followed by individual priority setting exercise Key: CNS: clinical nurse specialists DCA: dementia care advisors; PLWD: people living with dementia Descriptive maps of the ndings from phase 1 and a summary of the consultation with the stakeholders were presented to the project steering group which included a family carer, the research and development director of nursing for a local health board and six researchers. Informed by the principles of nominal group technique [49,50], those present were invited to record on a "post it" note written responses to the question 'What do you think are the most important ways that websites (for example Alzheimer's Society and Dementia UK) were searched. Keywords and index terms identi ed as relevant and re ecting the projects agreed priorities in phase 1 were used and individual search strategies developed for each database. This review also drew on the individual search strategies developed for the Cochrane Incontinence Review Group [51]. An example search strategy for Medline is provided in additional le S2.
To identify published resources that have not yet been catalogued in the electronic databases, recent editions of the Screening, quality appraisal and data extraction Screening and selection of all citations was conducted using standardised systematic review methods involving all members of the project team [52]. Multiple articles by the same authors reporting ndings from the same study were linked together to help inform decisions on which studies to include. The methodological quality of all included research publications was independently assessed by two reviewers using Mixed Methods Appraisal Tool (MMAT-Version 2011).
This tool was developed for the appraisal of methodological quality of qualitative, quantitative and mixed methods studies [53,54]. Any disagreement on quality was resolved through discussion with a third reviewer. Each study was assigned a score based on the number of criteria met (25%-one criterion met; 100%-all criteria met). Studies were excluded from the review if they scored less than 50% for quality, meaning that they ful lled a maximum of only two of four criteria [53]. Nonresearch evidence (e.g. policies, reports) were not subjected to quality appraisal. Study ndings for the primary research studies for the purposes of this review were considered to be all text that was labelled as results or ndings. All nonresearch material were available as electronic documents and were searched using keywords relevant to the priority areas (for example communication, tailored, individual). This data were then considered to be ndings and extracted and entered verbatim into Microsoft WORD (see additional le S3).

Synthesis
Thematic synthesis was employed to bring together data from both qualitative and quantitative primary research studies and non-research material [55]. The quantitative data was 'qualitised' whereby the extracted quantitative data was converted into textual descriptions to allow integration with the qualitative data. For all data descriptive codes and themes were generated through line by line coding of text of the ndings and were developed inductively based on close reading of the content of all items included. The next step was to go beyond the content of the original studies to create analytical themes to see how the themes answered/addressed the study objectives [44]. To answer the third objective and to provide an overarching synthesis, the reviewers inferred what the barriers and facilitators were from the descriptive themes within the synthesized ndings from the rst two objectives.
The strength of the overarching synthesised ndings for the intervention studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach [56]. This rates the quality of a body of evidence as high (further research is very unlikely to change our con dence in the estimate of effect), moderate (further research is likely to have an important impact on our con dence in the estimate of effect and may change the estimate), low (further research is very likely to have an important impact on our con dence in the estimate of effect and is likely to change the estimate) or very low (any estimate of effect is very uncertain). Con dence in over arching synthesised qualitative and survey ndings was assessed using the Con dence in the Evidence from Reviews of Qualitative research (CERQual) tool [57]. The original CERQual approach was designed for qualitative ndings but has previously been used by members of this research team in additionally adopting CERQual for the assessment of the con dence of synthesised ndings from surveys and other non-intervention quantitative studies [58,59]. The con dence of synthesised review ndings is based on the assessment of four components: the methodological limitations of the qualitative studies contributing to a synthesised review nding, the relevance to the review question of the studies contributing to a synthesised review nding, the coherence of a synthesised review nding, and the adequacy of data supporting a synthesised review nding. Four levels are then used to describe the overall assessment of con dence as high, moderate, low or very low. When a synthesised review nding is assessed as being 'high con dence', this indicates that this synthesised review nding should be seen as a reasonable representation of the phenomenon of interest. If there are concerns with regard to any of the above four components, then this indication is weakened and a lower level of con dence attained [57].

Description of included material
The database searches yielded a total of 6,247 citations after duplicates were removed (see Fig. 1). Fifteen research publications (consisting of 14 unique research studies) were included in the nal review along with a total of 14 policy and guidance documents. Details of full text publications excluded from the review are provided in additional le S4.

Characteristics of the included material
Information on the characteristics of included research studies, including assessments of quality, are given in Tables 2 to 4 and details of the non-research material is available in additional le S4.  The aim of this study was to develop and test a continence assessment tool and supporting resources for people with dementia, to be used by primary care professionals, primarily community nurses (pg 95) Stage 1: Face to face consultations were facilitated to describe a broad range of principles and issues that would underpin an assessment tool designed to address the needs of people with dementia Stage 2: A prototype dementiafocused continence assessment tool was developed using the data generated in stage 1, asking for agreement or disagreement to items plus suggestions for further items. This was used to consult, in writing, both the expert group in stage 1 and also a further group of carers and specialist continence professionals. The prototype was further adapted.
Stage 3: A different, wider group of experts (carers and professionals) was consulted in writing. They were sent the draft dementia-focused assessment tool together with a questionnaire to test its face and content validity.

Outcome measures
Recipients were asked (1) whether or not the tool would improve recognition of the problems (face validity) and (b) to rate each item for importance and identify missing or unnecessary items (content validity) MMAT score: 75% Key: AD: Alzheimer 's disease; CI: con dence intervals; MMAT: Mixed methods appraisal tool; MSE: mental state examination PLWD: people living with dementia; SD: standard deviation The intervention group was taught an IST procedure that compensated for cognitive impairment by providing memory-impaired patients toileting reminders Initially, assignment was to one of two intervention groups: one group of participants was visited every 2 months, and the other group after a 6-month interval. There was also a control group At the 6-month follow-up the two intervention groups did not differ with respect to UI. The original two intervention groups were combined, leaving a single intervention group and a control group. Data collection Interviews to ascertain: The speci c problems areas that were addressed in the intervention The speci c strategies that the caregiver indicated a willingness to try (attempted) The strategies the caregiver actually used for being incontinent could be said to be a form of verbal abuse. Although some ward staff promote continence, this does not appear to happen consistently within acute settings [74]. Relatives expressed concern that PLWD would be happy to go to the toilet if assistance was provided, but that staff encouraged them to "do it in the nappy" [74 p. 8]. Other times, it was found that in some cases, routine toileting was avoided, and cues ignored when staff members were busy, or appeared uncomfortable with or disinterested in providing support [74,87]. Ostaszkiewicz

Presence of PLWD during outpatient consultations
There is a lack of consensus as to whether PLWD should be present with their caregivers during outpatient consultations [70][71][72]. Health care providers believed that care recipients should be present when discussing continence problems during consultations [72], however, caregivers expressed mixed opinions [70,71]. Caregivers who favour this approach, view the HCP as an authority in this subject, with the result that they believe the PLWD would be more likely to cooperate with management strategies because they had been involved in the discussion [70]. Whereas those who opposed this reported that they did not want to upset or make their care recipient anxious by discussing a problem that the PLWD might not fully understand or be able to control [70]. Those caregivers who were daughters, felt the need to be sensitive to their parent's privacy and feelings, preferring to discuss incontinence in greater depth with their HCPs this nding was not found for spouses. However, time constraints or inability to meet alone with the HCPs prevented in-depth discussions from taking place [71]. Some caregivers suggested that HCPs could explain the problem and management options in simple terms when the care recipient was present in outpatients and then speak separately to the caregiver, providing more details [70].

Initiating conversations during outpatient consultations
There was a lack of consensus with regard to whom caregivers' thought should be responsible for initiating conversations about incontinence during dementia related consultations within outpatient settings [70][71][72]. Caregivers believed that it is the responsibility of HCPs to initiate conversations about incontinence during both initial consultations and follow up appointments [70]. However, there were differences depending on whether the care recipient was a parent or a spouse.
Caregivers who were daughters or daughters in law would only discuss incontinence with HCPs when it became problematic to manage at home, whereas husbands tended to communicate their wives' problems much sooner [71]. In contrast HCPs thought that conversation about incontinence should be initiated by the caregiver [70]. However, when HCPs did initiate conversations about incontinence, they reported that this was appreciated by the caregiver who was receptive and engaging in discussion around the topic [72]. However, within secondary care, not all HCPs saw addressing incontinence as a priority and thought that the topic should be dealt with by the patient's primary care providers rather during a specialist secondary care referral [72]. Extended family and friends who were caregivers reported that HCPs don't always ask about incontinence during consultations [71]. A lack of awareness of available resources or concerns about frightening patients/caregivers about potential problems before they occurred, was suggested as possible explanations as to why HCPs do not routinely discuss incontinence and fail to initiate conversations about incontinence [72]. Time was found to be the most common barrier reported by HCPs to discussing incontinence, because they believed that a lot of information needed to be covered during the appointments and discussing incontinence issues can take more time than was typically allocated [72]. Possible solutions suggested by HCPs were for the patient/caregiver to have a follow up appointment to discuss incontinence or to offer referrals to a nurse in continence care [72].
The language of incontinence during outpatient consultations Caregivers desired "straight talk" from HCPs about incontinence and its management in relation to PLWD [70]. Hispanic caregivers stressed that it was essential for providers to discuss incontinence using language that those with English as a second language can understand. They strongly supported having written materials about incontinence in PLWD and treatment plans available in Spanish [71]. During outpatient consultations caregivers rarely used the term incontinence, instead use terms such as having accidents, leaking, losing control, wetting or messing their pants, having a urine/bowel problem, urgency, diarrhoea, loose bowels, being unable to hold it, and not getting there in time, di culty in getting to the bathroom, leaking, soiling themselves [70,72]. Health care providers also tend to adopt these terms when discussing incontinence with family caregivers or patients [72]. Caregivers when questioned said that they did not know the right terms and didn't want to be disrespectful to their care recipients. However, once they were made aware of the term incontinence, they were happy to use it [70]. assuming a different posture [37] someone looking around [87] dgeting [10,77,86,87] getting up and walking around or pacing [76,77,86,87] or restlessness [10,68] holding their crotch or their stomach [10,77,87] different facial expressions such as worry [10] or sorrow [68] going to the corner of the room [77] pulling at their clothes [10,86] Hutchinson et al., [87] also reported a number of affective cues which included anger, profanity and acting frustrated and irritable. One study investigated common behaviours when PLWD experience either bowel movement or urination needs, found that anxiety, restlessness, and taking off/putting on clothes inappropriately occurred in more than 30% of patients Finding the appropriate words and symbols to describe the toilet Wilkinson et al.,[67] sought to evaluate the comparative suitability of a range of words or symbols to label a toilet for PLWD. As part of an institutional survey (n = 24) the words that were used to label the toilet were "toilet "(67%), "Male/Female" (11%) and there in some institutions there was no labelling (22%). Only four institutions used symbols, and these included the international symbol (n = 1), toilet symbol (n = 1), yellow wrapping over door (n = 1) and ceramic plaque upon which was written the word "Toilet". A further survey was conducted with participants living with dementia and was reported within the same publication and the preferred word and symbol for toilet varied signi cantly (p < 0.05) according to their level of dementia (which had been assessed using the Folstein mental state examination and classi ed as normal, mild, moderate and advanced). "Ladies" or "Gents" was preferred by those with normal cognition and "toilet" by those with moderate dementia. The international symbol (male and female symbols) was preferred by people with normal cognition or mild dementia whilst the toilet symbol was preferred by those with more advanced dementia [67].

The importance of individualised continence care
Targeted and individualised/person centred continence care [10,33,73,75,79,82] that is established after a thorough clinical assessment has taken place [10,33,84,86] is seen as being important. This would include the use of a bladder diary [10]. Individualised care continence care is described as about what is best for the PLWD [10,79], avoiding harm [10] and about promoting autonomy and independent living [10].

Objective two
The second objective was to identify and explore the communication strategies and individualised management plans that Prompting [10,78,80,81] Get to know the PLWD [78] and how they communicate [79] Health care providers introducing themselves and seeking PLWD approval before performing tasks [73] Ask the PLWD how you can help them manage their continence [77] Communicate with the family to determine usual behaviour patterns [87] Get to know the PLWD such as previous routines, habits and lifestyle [77,79] Don't make assumptions and see the person as an individual [79] Caregivers reported that they sought additional information about incontinence from the internet but were concerned about the accuracy of the information retrieved, whether they could understand it, and had concerns about their searching skills [71]. They wanted support and reassurance that they were providing the care that was required and they wanted information before any problems such as incontinence occurred so that they could feel prepared [70].
One further study described how nursing staff communicated with residents' families about methods to manage incontinence when taking the PLWD "on an outing" [73 p. 2432] The advice included information about how to check and change pads, how to assist the resident to the toilet, and how long pads could potentially last without needing to be changed [73].

Communication strategies for outpatient appointments
There were a number of recommendations presented by both caregivers and HCPs in terms of resources that could be provided for the caregivers attending outpatient consultations [70][71][72] for example: A guide for caregivers was developed that covered talking to a health care provider about these problems; with de nitions of common clinical terms [70] A pre-visit check list or written materials of some type so that patients/caregivers could indicate whether incontinence was present, this could then prompt the HCP to start a discussion during the consultation [72] Readily available handouts that would offer more detailed explanations of what had been covered during the appointment [72] Short, focused handouts that could stand alone and address a single concern [72] Using technology to present instructions Two pilot studies [60, 61] conducted by the same authors explored the effectiveness of verbal instructions, presented automatically through simple technology, in helping persons with mild-to-moderate AD regain basic daily activities. The technology consisted of a modi ed Walkman with recordings of verbal instructions that directed the PLWD to undertake bathroom related activities in a certain order. Sensors detected when a PLWD entered the bathroom prompting the rst instruction telling them to sit on the toilet. After a long pre-determined interval this instruction was then followed by another instruction for them to wash their hands with the soap. The Walkman was activated by a battery-powered, radiofrequency photocell, light-re ecting paper, and a microprocessor-based electronic control unit. Data from both studies showed that the use of verbal instructions and basic technology to control their presentation has the potential to be effective in helping people with mild or moderate AD recapture relevant daily activities, including toileting [60, 61].

Components of individualised care plans
A number of different components that may be considered as part of individualised care plans have been identi ed which include; being theory based [33], being concerned with the practical issues [75], and involved multi-components exploring both day time and night care of incontinence [33]. There was a general consensus that the needs of both PLWD and their caregivers need to be considered [10,33,[82][83][84]. The advice given by the Alzheimer's Society was that a continence care plan should be tailored to the individual. This should aim "to cure toilet problems or incontinence wherever possible" [75 webpage]. Other components to consider include changing medication [75], changes to lifestyle [75], exercise [75], skin care [33,84], manipulating the type, quantity and timing of food and drink [75], describe support available from HCPs [75] and follow up advice [75].
Ostaszkiewicz et al., [84] comments that nurses and care workers need support in order to develop individualised strategies to "optimize the care-dependent person's rest/sleep in the context of the person's concurrent need for continence and skin care" [84 p524/5]. Three studies described individualised care plans as part of wider interventions [63, 65, 66]. One was conducted within nursing homes and one member of staff from each home was selected to take part in a training program who then became responsible for educating other staff members. The intervention in this instance was multi-faceted covering individualised and comprehensive care that focused on providing adequate uids and meals, encouraging patients to use toilets and reducing the size of their incontinence pads. This approach differed signi cantly from the usual UI care in which incontinence pads would be changed only at scheduled times. Improvements across the different methods of urination were observed (incontinence pads, commode, urinary chamber pot) with only 11% of residents showing improvements during the day which were non-signi cant, whereas 19% of residents showed signi cant improvement during the night, changing from using incontinence pads to using the toilet. Overall a large number of residents' toileting remained unchanged following the intervention [63].
Two studies [65, 66] evaluated an environmental skill-building program which was a home environment individualised intervention delivered by occupational therapists, which included toileting and incontinence. The intervention was designed to enhance the caregiver's ability to problem solve about their environment and to develop effective solutions to situations they considered problematic. The study by Gitlin and Corcoran [66] was a pilot study and the 59% of caregivers reported incontinence as problematic in their daily management routine. Problems included night-time and/or daytime incontinence of the bladder and/or bowel, resistance to toileting, or confusion as to how to perform an aspect of the toileting task.
Seventeen effective caregiver initiated environmental solutions for incontinence were observed and of these, nine solutions (53%) were accepted by the caregivers and integrated into their management routine by visit ve of the intervention. For the later study by Corcoran and Gitlin [65] 29% of caregivers identi ed continence as a problem area that needed addressing. Twenty-six attempted strategies that involved assistive devices and of these, 21 (81%) were used. Fifty-one attempted strategies to manipulate the type, quantity and timing of food and drink and 46 (90%) were used. The authors did not provide any further detail on the nature of the assistive devices.
One further study implemented a person-centred approach that focused on incontinence for residents with cognitive decline in residential treatment facilities [64]. The health workers were provided with training, however only 20 out of 100 participated although the process outcomes were measured among all residents who agreed to participate in the study.
There were no statistically signi cant mean differences in quality of life scores before and after the intervention or between control and intervention participants. However, the quality of care improved for the intervention participants in that, fewer aids were needed to manage incontinence and an increased number of UI assessments were conducted.

Health care professionals and caregivers working in partnership
The importance of HCPs and caregivers working together to deliver individualised/person centred continence care was a feature of three intervention studies [62, 65, 66] and was encouraged within four pieces of non-research material [75,79,82,83]. Within one intervention study nurse practitioners worked with the carer to plan the schedule for the PLWD and this was followed up with monthly phone calls and bi-monthly visits [62]. Occupational therapists worked with the caregivers in a further two intervention studies [65, 66] to deliver solutions to toileting and incontinence problems, which consisted of ve visits over two [65] or three months [66]. Other HCPs that work with PLWD and their caregivers include continence advisors [75] or other HCPs specialising in continence care [79]. Working in partnership with caregivers and PLWD is important [75,79,83] and enables HCPs to gather their personal story [82] to work out the best solutions and to ensure that specialist help can be accessed when needed and so that what is recommended is achievable [75].
Establishing a toileting routine within the home environment The importance of developing a regular toileting schedule was discussed brie y within one study [66] and one piece of non-research material [10] and was the focus of one intervention study [62]. The intervention group in the study by Jirovec and Templin [62] were taught an individualised scheduled toileting procedure, which compensated for cognitive impairment by providing memory impaired patients with toileting reminders such as verbal prompts. Initially, assignment was to one of two intervention groups: one group of participants was visited every two months, and the other group after a six-month interval. There was also a control group. At the six-month follow-up, the two intervention groups did not differ with respect to UI, therefore the original two intervention groups were combined, leaving a single intervention group and a control group. The authors conducted a completer's only analysis and reported that incontinence decreased in the experimental group (28 of the 44 participants still in the study at six months) with almost no change in the control group.
Further analysis of this data using the non-parametric sign test was conducted, demonstrating a signi cant decrease in the experimental group (Z = − 1.83, p < .05). The participants were coded according to any decrease in percentage of incontinent episodes versus staying the same or not showing improvement in incontinence. However, two previous reviews conducted a re-analysis of the data which found that although the results favoured the experimental groups, they were not statistically signi cant [41,88].
Objective three and overarching synthesis The third objective was to identify the facilitators and barriers around developing communication strategies and individualised management plans in response to the continence needs of PLWD. In addressing this objective, a matrix that consisted of three overarching nal synthesised ndings (communication that is digni ed, person centred and respectful, Page 26/39 communication during outpatients appointments and delivering individualised continence care) was juxtaposed with barriers and facilitators alongside the results of interventions was produced (see Table 5). The extent to which the review ndings are reasonable representations of each theme using the GRADE and CERQual approach is presented alongside each component of the overarching syntheses. Where there were no research studies that presented information on barriers or facilitators, we drew on the information within the non-research material. settings was improved, which in turn increased positive interactions [91].
The second overarching synthesis nding comprised low quality evidence that explored different aspects of communication occurring between PLWD, caregivers, and HCPs during outpatient appointments. The caregivers' role has been characterised as is one of both an informant and an advocate during an outpatient appointment [92]. The synthesis showed that HCPs feel it is important that PLWD were present at outpatient appointments, however, caregivers expressed divided opinions as to whether PLWD should attend outpatient appointments with them. Previous research on doctorpatient communication has focused on disclosing a diagnosis of dementia [4] and caregivers report discomfort in the presence of the PLWD when divulging sensitive information [93]. An educational intervention that sought to improve patient centred care for PLWD and their carers during medical encounters with old age psychiatrists suggested a number of changes to the consultation structure [94]. One of which was to offer the PLWD and carer a choice of whether they attended the consultation separately as well as together in order than patient centred care during their consultations could be developed. We did not nd any evidence of any strategies for use in outpatient settings to better support PLWD, their families, or staff, about incontinence and promote continence. The ongoing care of PLWD in both an outpatient and primary care setting when managing continence issues is an area that requires further research.
The nal overarching synthesis was concerned with the delivery of individualised continence care. It is well documented in a number of guidelines and across the material produced by the various charities, that individualised care plans should consider the needs of both PLWD and their caregivers, and involve multi-components exploring both day-time and night care of incontinence if they are to be helpful in facilitating continence. What this synthesis revealed is that there is a lack of interventions related to the delivery of individualised continence care for PLWD and only three intervention studies [62, 65, 66] providing low quality evidence were identi ed that incorporated some aspect of individualised care. Hagglund in her systematic review of incontinence care for PLWD also reported a lack of evidence-based interventions and pointed out the need for the "effective continence-promoting interventions and improved individualized nursing" (Hagglund 2000, p. 311). There is evidence also of a "policy/practice-research gap", given there is a signi cant and well-meaning focus on person-centred care in policy and practice yet there is little research to support staff in how to achieve this in practice. It is also recognised as important that HCPs and caregivers work together to deliver individualized/person centred continence care for PLWD. Each PLWD is unique and HCPs need to be enabled to recognise the speci c individual needs of each person as opposed to assuming a "one size ts all" approach when it comes to continence care. Continence care needs to be personalised and responsive to the PLWD preferences and needs.

Limitations
The search was for English-language only materials. The studies included in this review varied in methodological quality, which impacts on the overall results and conclusions that can be drawn. A strength of this review has been the inclusion of the views and interests of stakeholders, including PLWD which led us to focus on communication and individualised care.
Another strength of this review was the use of the CERQual approach which allowed us to determine a level of con dence in the synthesized review ndings.

Conclusions
The ndings from the syntheses derived from this review of the international literature can help with informing innovations in continence care for PLWD in the acute hospital setting. Recognising that PLWD are not always able to verbally communicate their continence needs or that they require assistance is important. Incorporating interpersonal and communication skills in the context of continence care for those working with PLWD is crucial for continence to be supported and maintained in the acute setting. Training of those who work with PLWD and their carers should include continence care and also incorporate interpersonal and communication skills.
Developing and implementing interventions that seek to improve the delivery of individualised continence care within the acute setting that can be tried and tested, and could be "rolled out" to suit the majority of PLWD and their caregivers would be di cult. Taking into the account the varying and many needs of individual people, their circumstances, and symptoms, would make such interventions challenging. The complexity of living with continence problems alongside any other longterm health conditions such as dementia has been acknowledged, however, addressing this requires a holistic approach (Age UK 2018). What we do know is that continence care in the acute setting, which is tailored to the individual and that is developed in partnership with HCPs and caregivers is more likely to be successful.  DE is the guarantor and a rms that the manuscript is an honest accurate and transparent account of the study being reported that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained

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