McKnight's Long-Term Care News, March 2019, page 34, Feature 2

BSkilled nursing educators worth their mettle today will strongly warn bedside caregivers to throw out any preconceived notions they may have about incontinence.

A big one is the widely disproved notion that incontinence is an “old person’s disease.” Another one is that “incontinence cannot be cured.”

In a recent study, in fact, significant numbers of professional nurses and a vast majority of nurse assistants told Indiana University researchers they believed bladder disorders are a normal part of aging.

Time and again, researchers have refuted incontinence mythology. Along the way, their efforts all too often show how frail elderly individuals can quickly tumble down a path of declining health, endless indignities and painful bed sores. That is, if open minds and a thorough assessment had not prevailed before a resident’s head hit the pillow for the first time.

Taking the long view

The risks for improper, inadequate or missing assessments can be dire.

“The failure to fully understand the underlying reasons that are influencing incontinence can and does lead to depression and possibly life-threatening conditions such as urosepsis from a urinary tract infection,” says Martie Moore, RN, chief nursing officer of Medline.

The body’s most vulnerable organ is skin. That fact places huge importance on choosing the right products and methods.

“Resident dignity, comfort and quality of life — not to mention, skin health — can be quickly compromised if their incontinence is not managed appropriately,” says Michelle Christiansen, vice president of clinical sales and marketing at Medline. “If a resident is placed into a product that is not absorbent enough to manage their output or if the product does not fit right, the resident’s skin can become compromised.”

Medline’s Continence Management Program educates healthcare workers on moisture management, proper product selection and application, as well as dignity and management strategies for various types of incontinence.

Tony Forsberg, RN, national clinical director of Essity Health and Hygiene, is fond of quoting Albert Einstein, who famously said if he had one hour to solve a problem on which his life depended, he’d take 55 minutes to study the problem and five minutes to devise a solution.

“Fully understanding the problem is critical in determining the very best path forward,” Forsberg says. “If the assessment is not thorough, our solutions may not be the best possible option for this individual. Incontinence may worsen, self-esteem may be negatively impacted, participation in activities may be reduced, mobility may decrease and the risk of falls may increase. And, we may have missed an opportunity to have a positive impact on the individual.”

Improper or missing assessments also can set into motion a cascade of unforeseen problems, and damaged skin is only one of them.

To Megan Ramirez, director of marketing and public relations for the Wound, Ostomy and Continence Nurses Society™ [WOCN®], the psychosocial implications are far reaching. 

Among the most problematic of them are: isolation, pressure injuries [with other factors], kidney disease, autonomic dysreflexia, financial burden, lawsuits, impactions, dilated colon, caregiver burnout, inability for placement in certain care facilities, distrust of care provider and lost revenue.

One slip, many ramifications

Missing that initial assessment opportunity can have severe consequences. This has always been true but takes on even more meaning Oct. 1 with the onset of the Patient-Driven Payment Model, which demands an excellent initial appraisal.

“Short-term, if a resident is not assessed properly, it can impact their immediate plan of care. Long-term, it can affect how they are managed and or treated for specific conditions,” observes Michele Mongillo, senior clinical director for First Quality Healthcare. 

In both scenarios, residents may miss an opportunity for a behavioral toileting program, be placed in a product that does not manage their specific type of incontinence, or miss a related skin condition such as associated dermatitis, she explained.

Missing the clues

One of caregivers’ greatest sins is conducting an assessment that overlooks a host of hints both subtle and overt.

All too often, those performing assessments fail to connect the dots and miss a critical clue that’s either a symptom or cause.

“Assessments related to continence status vary as widely as the non-specialist clinician,” says Ramirez. “There are influencing factors to episodes of incontinence. For example, a patient who has a slow or unsteady gait, vision issues or trouble getting up out of the chair may spend so much time getting to the toilet that they just do not get there before their bladder empties.”

Frequently, those performing initial assessments may know of a residents’ comorbidities but fail to associate how they relate to the loss of control over their bowel and bladder. Falls and UTIs are popular examples.

“Incontinence is a symptom of changes within the body systems,” says Moore. “It is not a disease within itself but really an outcome of whatever is influencing the performance of the bladder.” Diseases such as Parkinson’s, Alzheimer’s, diabetes and hypertension are just a few that will have urinary incontinence consequences as the disease progresses, Moore says.

It’s also easy to misjudge the severity, nature and timing of the resident’s incontinence when performing an initial assessment. Any one of them should generate a flurry of questions.

“Is it a few drops, a gush or a full bladder emptying that is quite saturating?” Ramirez says. Timing is a critical factor when assessing possible causes of bowel incontinence. “Is it related to eating? If so, which meal or time of day? Is any urge felt at all? Was their attempt at retention to be in a more private place? In this type of incontinence, anal sphincter function and integrity are very important.”

Best practices, products

The ravages incontinence incurs on skin underscore the weight that assessments have in choosing the right products that both repair and prevent damage.

In a study reported in the Journal of Aging Life Care, researchers called incontinence-associated skin disease (IASD) “a prevalent but under-recognized form of skin damage in the older person with urinary or fecal incontinence.” They recommended a structured skin care regimen as a form of prevention and treatment. That includes perineal cleansing with a cleanser that mimics the skin’s pH, and application of a moisturizing agent and skin protectant.

The industry has responded with a variety of high-quality incontinence briefs and cleaning and protection products.

Nursing home providers say product selection and formulary compliance are essential. Empowering staff to choose the best evidence-based products is another. At a late 2018 industry roundtable discussion sponsored by Essity, participants agreed that real promise could be found in products that can promote the strong natural barriers of skin itself.

Christiansen believes that assessments should be conducted soon after the resident is admitted to a facility, at any time there is a change in cognition, or if caregivers “find themselves really struggling to manage moisture and skin health.”

A great deal of current research is focusing on best practices around sourcing the right product for the right condition, as well as how best to gauge the effects on quality of life when determining treatment options.

In October 2017, WOCN hosted a consensus conference on absorbent products. 

“Given the significant lack of available evidence on the proper use of these products, the society convened a group of continence care experts to assess gaps in the evidence base and obtain consensus in needed areas,” Ramirez says. 

The goal of the conference was to develop evidence- and consensus-based statements. Those conclusions were published in the May/June 2018 issue of the Journal of Wound, Ostomy and Continence Nursing, and form the basis of “The Body Worn Absorbent Product Guide,” an evidence- and consensus-based clinical decision tool, she adds. The free online clinical tool is expected to debut this summer.

Product considerations vary by a number of factors, including a resident’s gender, the type of incontinence, timing and the levels of urine and feces expelled in each episode, Ramirez says.

Mongillo stresses the need for facilities to have options when it comes to undergarments.

“A resident’s quality of life and dignity may be affected if they are wearing a product that they don’t necessarily need,” she says. “Products should be selected based on the resident’s individual needs, including their level of incontinence and functional mobility. Staff may have only one or two types of products, which don’t often promote a resident-centered approach to incontinence.”

Moore and Christiansen both suggest recording voiding habits in a patient journal. 

“Utilizing a bladder diary can identify patterns of incontinence with appropriate intervention taken from timed voiding, bladder training and other interventions,” Moore says.

“A thorough, detailed voiding diary will provide the very best information needed to choose a product,” Christiansen says. “It is important to consider what the resident can manage. We want to look at issues such as mobility, cognition and medication. Sizing is also a crucial element to overall comfort. If a product is too big, it may sag and leak. If a product is too small, it can irritate the skin.”

Incontinence is irritating enough as it is, everyone agreed. There’s no sense in giving it another way to aggravate an already touchy issue