Incontinence and associated skin care

There are four types of urinary incontinence (stress, urge, overflow, functional) and multiple types of skin problems that may alter the quality of life of older adults. This article will focus on prevention and management of functional incontinence and the skin problems, dermatitis and pressure ulcers related to it.

DEFINING INCONTINENCE

“Incontinence is a common, bothersome, and potentially disabling condition in the geriatric population. It is defined as the involuntary loss of urine or stool in sufficient amount or frequency to constitute a social and/or health problem.”1 Although aging alone does not cause incontinence, prevalence of urinary incontinence (UI) is highest in long-term care facilities and often is the reason for institutionalization.2

Stress incontinence results in urine loss with increase in intra-abdominal pressure (cough, laugh). Urge incontinence produces inability to delay voiding after sensation of fullness. Overflow incontinence occurs from the effects of urinary retention on bladder and sphincter function. Functional incontinence is related to impaired physical or cognitive function, unwillingness, or environmental barriers. Ascertaining type is crucial to planning specific treatment.

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PREVENTION, MANAGEMENT

Several general interventions assist in prevention of UI: preventing urinary tract infections and fecal impaction, controlling diabetes mellitus and heart failure, correcting hypercalemia, reducing diuretic fluids, avoiding physical or chemical restraints and managing medications that can cause UI (ACE inhibitors, calcium channel blockers, beta- and alpha-adrenergic agonists, alpha-adrenergic blockers, diuretics, cholinesterase inhibitors, psychotropics, narcotic analgesics and anticholinergics).

Determining whether the impaired function is physical or cognitive is imperative to formulating interventions to prevent or manage functional UI, including motivational and environmental approaches. Factors contributing to physical impairment include pain, edema, joint stiffness, fatigue, weakness, instability, altered mobility-anything that causes an inability to move quickly enough to get to the bathroom after feeling the urge and/or the inability to manage clothing. The most common factors contributing to cognitive impairment are delirium, dementia (usually Alzheimer’s disease [AD]) or delirium superimposed on dementia.

When possible, pain should be treated with non-pharmacologic methods or with medications that do not cause drowsiness or confusion. Fatigue, weakness and instability have multiple contributing factors and may require extended time for improvement. Increasing mobility may help to improve the contributing factors and prevent incontinence. Strategies to promote continence while the contributing factors are resolving include providing a commode close to the person’s bed or chair, placing the chair near the bathroom after the person has had fluid intake and/or a diuretic, placing assistive equipment for ambulation within reach and having handrails in the bathroom.

Usually the person will not need reminders to void, but might need a staff person to respond quickly to the call light or a verbal request for assistance. Physical assistance to the bathroom may be needed, but usually toileting can be managed by the person. Clothing with elastic or Velcro is easier to manage than clothing with buttons, snaps and/or zippers.

To prevent nighttime incontinence, limit fluids in the evening, give diuretics before late afternoon and answer call lights immediately during the night offering to provide assistance to the bathroom. Incontinent briefs are not appropriate for persons with functional incontinence related to physical, but not cognitive, limitations and may foster dependency and limit restorative efforts.1 Avoid indwelling catheters to avoid risk for urinary tract infections.1-3

Persons with delirium may have incontinence during the late evening and night when they are confused, yet be clear and continent during the day and early evening. If they have no underlying dementia and are taken to the bathroom or bedside commode each time they awaken, incontinence probably won’t occur.

INCONTINENCE AND DEMENTIA

Because persons with AD regress backward through their own life as the illness progresses and lose knowledge and skills in reverse order of attainment, interventions to prevent or manage incontinence differ by stage.4 Independent toileting is not impaired during stage 4 and perhaps stage 5. Reminding or prompting the person to void regularly, soon after a diuretic, and before going out and perhaps guiding him/her to the bathroom may be necessary during stage 5. If a male with AD has visual-spatial misperception, an elevated, contrasting color toilet seat might help prevent misses. During stage 6, the person may need assistance with mobility, clothing and/or the position and steps of elimination, including cleaning mucous membranes and skin after. If the person with AD can find the bathroom and manage clothing, continence may be maintained into stage 7. During stages 6 and 7, our words probably won’t be understood and written words may be read but not comprehended. Because of disinhibition or not remembering socially acceptable behavior, the person with AD might find interesting places for elimination. Having a trusting relationship that promotes collaboration with the person, using nonverbal communication and structuring the environment to provide an uncluttered path to a visible bathroom with nothing in sight that looks like a chamber pot are simple but effective interventions.

Elders who exhibit challenging elimination behaviors need to be observed and assessed for patterns so interventions can be individualized. Staff behaviors need to change in order to achieve behavioral change in persons with AD. Gentleness, humor, singing, reminiscence and positive reinforcement are more effective than humiliation or punishment. When a person with AD regresses to the point that he or she does not recognize what the urge to void means, incontinent briefs are appropriate. Products that wick moisture away from the skin are imperative to prevent skin problems and perhaps behavior related to discomfort. Changing the brief and cleansing skin on an individualized schedule increases comfort and decreases skin problems. One more caveat: If assisting a female with AD to toilet, allow her to remove her underpants herself. She probably was taught early and adamantly to allow no one to remove them.

INCONTINENCE AND SKIN CARE

Dermatitis and pressure ulcers are skin problems frequently associated with incontinence. In the March 2010 issue of Long-Term Living, the article, “Incontinence-associated dermatitis,” is summarized here. “Perineal dermatitis, recently relabeled incontinence-associated dermatitis, is an inflammation of the skin that occurs when urine and/or stool comes into contact with the skin. IAD is painful and can range in severity from erythema with or without loss of skin integrity and infection.”3 Care, cleansing products and protective barriers must maintain normal pH and prevent friction. Care products include gentle cleansers, protective moisture barriers, underpads or absorbent briefs and external collection devices.

“A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence, as a result of unrelieved pressure.”5 Prevention is a realistic goal unless the tissue is fragile and/or blood flow is compromised.1 “Pressure reduction to preserve microcirculation is a mainstay of preventive therapy.”5 The level of pressure reduction needed is influenced not only by microcirculation but also by the ability to effectively address other contributing factors. Controllable factors, as assessed by the Braden Scale, include moisture, activity, mobility, nutrition and friction and shear.6 All these factors can be modified with quality care. Incontinence increases the likelihood of moisture, limited activity/mobility and friction and shear. Preventing incontinence, encouraging mobility and activity, improving nutrition and teaching staff and persons with physical limitations how to move in ways that prevent friction and shear are helpful in preventing pressure ulcers.

Prevention of UI and its related skin complications can enhance quality of life for older adults. Consistent, competent, compassionate staff-adequate in number and with support and role models-is required to achieve this goal.

Martha Sparks, PhD, GCNS-BC, NGNA Fellow, teaches gerontology courses at the University of Southern Indiana and practices independently as a Gerontological Clinical Nurse Specialist. To contact Dr. Sparks, email

msparks@usi.edu.

References

1. Kane RL, Ouslander JG, Abrass IB, Resnick B. Essentials of Clinical Geriatrics, 6th ed. Chicago:McGraw-Hill, 2009.
2. Dowling-Castronova A, Specht JK. Assessment of transient urinary incontinence in older adults. American Journal of Nursing 2009; 109 (2): 62-71.
3. Nix D, Haugen V. Incontinence-associated dermatitis. Long-Term Living 2010; 59 (3): 32-3.
4. Reisberg B. Functional assessment staging (FAST). Psychopharmacology Bulletin 1988; 24:653-9.
5. Bluestien D, Javaheri A. Pressure ulcers: Prevention, evaluation, and management. American Family Physician 2008; 78 (11): 1186-94.
6. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nursing Research 1987; 36 (4): 205-10.www.bradenscale.com.

ABOUT NGNA

The National Gerontological Nursing Association (NGNA) was founded in 1984, and is dedicated to the clinical care of older adults across diverse care settings. Members include clinicians, educators and researchers with vastly different educational preparation, clinical roles and interest in practice issues. For more information, contact the NGNA National Office at 1-800-723-0560 or info@ngna.org.

Long-Term Living 2011 September;60(9):22-25

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