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Incontinence and associated skin care

September 14, 2011
by By Martha Sparks, PhD, GCNS-BC, NGNA Fellow
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Martha sparks, phd, gcns-bc, ngna fellow
Martha Sparks, PhD, GCNS-BC, NGNA Fellow


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.

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