Feature: Not a normal part of aging

Activities staff and therapists should be flexible with programs.
Activities staff and therapists should be flexible with programs.

High prevalence of loss of bladder or bowel control takes a heavy toll on resident confidence and contributes to social isolation, anxiety and depression. 

At least one-in-three long-term care residents experience some degree of incontinence, according to national nursing home survey statistics from the U.S. Department of Health and Human Services.

If not managed properly, it can cause even bigger problems, such as skin breakdown, subsequent infection or increased fall risk. 

These risks ensure that incontinence management remains a top challenge for long-term care operators. Aside from staff shortages and residents' tendency to try to hide their condition from family, friends and caregivers, lack of understanding about incontinence care also contributes greatly to the problem. 

Caregivers might view incontinence as a normal part of the aging process and assume that once a person becomes incontinent, it cannot be reversed. 

It's an unfortunate misunderstanding that experts say leaves staff focusing solely on managing moisture exposure, rather than working to treat and proactively manage the cause of incontinence. 

“Changing the negative stigma requires a holistic approach to reducing episodes of incontinence. This can be achieved by increasing residents' and care providers' awareness of the topic of continence management,” says Amin Setoodeh, RN, BSN, BS, vice president of clinical services at Medline Industries Inc. 

Delving deeper

Effective incontinence management requires a facility-wide and evidence-based approach. 

Investigating the cause of incontinence for each resident and diagnosing the type is necessary to determine if the incontinence is treatable and reversible, experts note. This approach helps because many incontinent individuals may be uncomfortable bringing up the topic with clinical staff, says Alex Sargeant, Hartmann USA. 

To catch incontinence episodes early, he recommends caregivers take the lead by inquiring daily whether the resident has noticed any wetness on their clothes or sheets. If so, asking whether this has affected their activities and daily routines, such as engaging in social events or meals, will help staff determine the best treatment or management approach. 

“By continuing to engage individuals about how they are doing in this regard, both caregiver and resident become more comfortable talking about it,” Sargeant says. “This gives caregivers the information they need to address the condition appropriately, whether that means choosing particular absorbent products, checking for voids on a regular basis, changing products more or less frequently, and so on."

All departments should be involved in incontinence management, including housekeeping, maintenance, dietary, activities, therapy, social services and nursing. Each has a valuable role, stresses Betsy Meyers, vice president of Midwest sales for Gentell. This includes activities staff, who can schedule programming that accommodates toileting schedules; social services, who can  address resident self-esteem and family support; and therapy staff who can supply assistive devices and strength training or transfer skills for residents. 

Another important department is dietary, who can provide adequate fluids and nutritional support for healthy skin integrity or repair, and bladder and bowel health. The maintenance staff can advise on lighting and mattresses, and housekeeping/laundry employees should be encouraged to identify residents who become incontinent. Finally, certified nursing assistants are often on the front lines of toileting and skin maintenance, and can assist nurses with skin treatments.

“We must promote continence rather than encourage dependency,” says Setoodeh. “Each care provider, resident and family member should learn more about different types of incontinence, the cause and the available treatment options. If the goal is optimal health, everyone needs to work together to implement an individualized care plan.”

By doing routine bowel and bladder assessments — upon admission and then on an ongoing basis — incontinence can be managed proactively. The same is true of diligent documentation. Keeping individual resident logs allows staff to consistently and systematically track toileting trends, monitor continence-related progress or setbacks, and determine the best strategy for keeping incontinent residents healthy and active.

Focus on flexibility

Every resident has different continence needs and preferences, so operators must adopt a flexible approach, experts emphasize. For Levindale Hebrew Geriatric Center and Hospital in Baltimore, this means ongoing communication among staff and residents, daily monitoring and logging of resident toileting practices, and hourly rounding to cue residents and prevent avoidable accidents. Those who void more often get even more frequent caregiver visits. 

“This is helpful because we may have just rounded, but then a resident may go minutes later,” explains Gloria Blackmon, BSN, RN-BC, director of nursing for long-term care at Levindale. “When we have these individualized plans, we can flex staff to keep up with frequent rounding and prevent someone from having to wait until the next hourly round.”

Having a good grasp on residents' activity and bedtime schedules also contributes to a successful continence program at Levindale. This allows staff to tailor hydration, toileting cues and even diuretic administration around each resident's needs. 

If a resident attends a particular activity each day or week, caregivers can work with dietary staff to ensure fluids are offered earlier in the day, or after they return from their function. Staff may cue them to use the restroom before their activity. 

Night owls may benefit from taking diuretics later in the day because they'll be awake in their room anyway, which can make toileting easier and not impede their participation in other activities offered throughout the day, points out Blackmon. Nursing assistants are the best research detectives. 

“They know the residents and their routines well and it's important to rely on their knowledge,” she says.

Activities staff and therapists also should be flexible with their programming, allowing for restroom breaks to accommodate all residents — not just those known to be incontinent.

“They should also remind [residents] of the nearest restroom,” stresses Blackmon. “We also make sure residents who are known to have [incontinence issues] are provided with the right absorbent products to make them more confident and less likely to avoid participation in favorite activities for fear of accidents.”

The right products

There's a plethora of advanced incontinence products on the market today that can simplify the care process, boost resident confidence, improve skin health, and help remove the negative stigma surrounding incontinence. 

“It's important to establish a guideline for selection of the most appropriate absorbent disposable continence management product that promotes containment and dignity for each resident, based on [the resident's] assessment,” says Setoodeh. 

Skin-friendly products and those designed for residents whose skin is sensitive or requires more airflow are readily available. However, it's important that caregivers pick the right products for each resident's unique needs. Without the right products, staff might attempt to create their own solution, such as double-padding a resident to increase absorbency — a move that can increase pressure, friction and skin temperature.

Odor control is essential, but traditional products not designed for incontinence won't be sufficient, it is generally agreed. 

“People dealing with incontinence issues can wear undergarments to hide the physical aspects of incontinence, but everyday or over-the-counter products are not formulated to deal with these odors,” says David Anderson, national sales manager for Apollo Corp. “Special products formulated for incontinence clean-up can help staff clean and condition residents' skin, and also remove stubborn odors.”

Cleansing with a pH-balanced   cleanser is also vital. Unfortunately, many caregivers skip this step in favor of plain soap and water. Because most soaps are alkaline, their use for incontinence cleansing may impair the skin's protective acid mantle and inadvertently promote skin irritation or breakdown in incontinent residents, says Elaine McGowan, BSN, RN, CWCN, DAPWCA, vice president of Clinical Affairs for DermaRite Industries. 

Caregivers also may mistakenly believe that simply changing the incontinence brief is sufficient if the episode of urinary continence is considered minor. 

“This leaves potentially irritating urine residue on the skin,” McGowan stresses. 

Another mistake, she says, is applying a thick, single application of barrier product and assuming it will offer many hours of protection. Further, many barriers are formulated to be rubbed in, with no unabsorbed product visible on the skin, and this is often overlooked.

For best results, a skin protectant/barrier containing dimethicone or petrolatum should be applied after every incontinence episode, explains Beth Young, BSN, RN, CIC, clinical consultant for GOJO Industries Inc. 

For moderate incontinence-associated dermatitis, a zinc oxide-based product should be considered, she says. “Only a thin layer of skin protectant is needed. If used consistently, these routine practices help prevent odors and protect the resident from itching, discomfort and pain that can be associated with incontinence.”

Language, optimism vital

Simple dialogue changes and product selection practices can further reduce the stigma and anxiety surrounding incontinence. Training all staff to refer to “adult briefs” rather than “diapers” is important, as is using only pads when they are adequate, as opposed to automatically defaulting to briefs, which are more obvious under clothing, according to Meyers. 

Levindale offers a wide range of products — from full briefs to absorbent, elasticized pull-ups, pads, and more. The community also has transitioned from nighttime briefs to pads.

“This is better for skin,” advises Blackmon. Because residents and family members are accustomed to the use of briefs, care teams communicate this change so everyone understands the benefits and lend their support.

Sensor-based solutions connected to a real-time location system also can improve incontinence care, allowing for precise, event-based follow-up. 

A sensor placed in a brief instantly alerts caregivers that an incontinence event occurred, allowing the staff member in charge of that resident to offer prompt assistance, according to Ahuva Goldschmidt, marketing communications coordinator for PointRF Systems. The company's sensor-brief technology, currently in pilot stage, can be particularly beneficial for residents at risk for skin ulcers and other forms of breakdown. PointRF technology also lets staff track resident location and bathroom visits, which facilitates trending and predictive analysis. 

Last year, Medline Industries also began promoting SIM® (Smart Incontinence Management). SIM, which is distributed and marketed through Medline via a partnership with Australian company Simavita, captures information through a technologically advanced sensor inserted in a specially designed continence liner. 

Even with the best products and practices employed, one of the most effective ways to minimize the negative stigma associated with incontinence and keep residents mobile and active is to adopt a comprehensive, yet carefree approach to incontinence care.

“If a resident has an incontinence episode, we downplay it to reduce embarrassment and make them feel more comfortable,” says Blackmon. 

“We also encourage residents to be part of the care, allowing them to do as much of it as they are able,” she says. “We understand it's a very personal issue and we work hard to make them as comfortable as possible, and to meet their individual needs, so they keep doing the things they enjoy without worry.”