Promoting continence and healthy skin in dementia care
As most caregivers will tell you, skin care and continence management can be a real challenge for a resident with dementia. In a retrospective caregiver survey1 conducted in England, it was determined that at least 72 percent of residents afflicted with end-stage dementia had urinary incontinence. Multiple factors create a complex situation that must be addressed, piece by piece, for each resident. Incontinence and proper skin care go hand in hand. Goals for residents with mild to severe forms of dementia include maintaining successful continence, providing dignified means of incontinence assistance, promoting healthy skin and providing appropriate perineum care as needed.
Chronic urinary incontinence has many causes: loss of bladder muscle tone, lack of nerve perception, abnormal prostate in men or physical diseases that make it difficult to get to the bathroom in time. Reversible urinary incontinence can be caused by a urinary tract infection, vaginal infection or irritation, certain medications or polypharmacy.
Management of incontinence for a resident with Alzheimer’s disease or other types of dementia must be highly individualized. Each resident needs to be assessed appropriately. It is important to determine the type of incontinence the resident has, then it is possible to determine the best method of treatment. Residents should be seen by their doctor and diagnostic tests such as a urinalysis, blood tests or bladder scans may be ordered. Once the doctor discovers the cause of the incontinence, he or she will be able to offer advice on how best to proceed with management of the condition.
For a cognitively impaired resident, a routine toileting schedule is usually successful. Schedules must be individualized and they work best in smaller environments, where staff support is more readily available. To encourage the resident to participate in the act of toileting and self-care, the caregiver should deliver clear and simple one-step directions. Speak with resident and his or her loved ones about past routines and toileting patterns and continue to provide a similar pattern in the care community. This shared information should be written in detail in a care plan and it should be easy for staff to access. Train caregivers to recognize nonverbal signs that a resident needs to use the restroom, such as pacing, agitation or a grimaced look on the resident’s face.
Disposable undergarments are beneficial for residents with cognitive impairment who may not have the physical or cognitive ability to use the restroom themselves in a timely manner. The disposable undergarments wick away moisture from the skin, almost eliminating one of the largest risk factors in loss of skin integrity.
INCONTINENCE AND SKIN BREAKDOWN
Unmanaged urinary incontinence leads to skin breakdown. Other risk factors for poor skin integrity include inadequate oral nutrition, dehydration, lack of sensory perception, decreased mobility or medical conditions that affect the resident’s circulation. As a resident ages, his or her skin loses elasticity and becomes drier, which also increases the risk for loss of skin integrity. It is imperative that the caregiving team is aware of these risk factors and what they can do to minimize them.
Residents should have a dietary consultation with their doctor or community dietary director at least annually and as the resident’s needs change. Direct caregivers should offer snacks between meals; residents with cognitive impairment often have more success with smaller portions offered more frequently, as opposed to three meals daily. Fluids should be available and accessible at all times and encouraged often. When providing assistance to a resident during bathing or dressing tasks, the caregiver should be observant of any areas of skin breakdown, including bruising, skin tears and dermal ulcers, and report these conditions promptly if discovered.
Residents with impaired mobility should be assisted at least every two hours in repositioning themselves. Again, a routine restroom schedule and providing assistance with perineum care after toileting will help the resident maintain good skin health.
THE “SUMMER HOUSE” SOLUTION
Healthy skin cannot be achieved without good personal hygiene, and bathing a resident with dementia is sometimes difficult. It is common for residents with dementia to be fearful during bath times, so it’s important to create a soothing and unintimidating environment.
Claremont Manor Retirement Community is a Front Porch community in Claremont, Calif. Front Porch is one of Southern California’s largest not-for-profit providers of retirement living communities, with 11 full-service retirement communities in California and two adult living communities: one in Louisiana and one in Florida.
Claremont Manor recently launched a new memory support home called Summer House, a six-suite home designed for residents with memory impairment. The restrooms and shower rooms are designed in warm colors and textures to aid in a calm bathing and showering experience. Also, the Summer House caregiving team spends time with residents and their families before they move in so that the team can obtain in-depth information about each resident’s personal hygiene preferences and routines, and continue those regimens as closely as possible. Summer House is very much a family home, and the 2:6 staff-to-resident ratio allows us to provide personalized care for each individual.
Caring for a resident who has a diagnosis of Alzheimer’s or other type of dementia can be challenging, particularly in the areas of continence management and skin care, but with the correct preventative measures in place, you can successfully provide for your residents’ needs.
Holly S. Hart, LVN, is the director of Residential Health Services at Claremont Manor, a CCRC in Claremont, Calif. She has worked in the field of geriatrics for more than 12 years, and has experience in skilled nursing, assisted living, home care, and dementia care. Hart recently completed her training in RCFE (rerecently discussed Front Porch and its various services in a recent interview with Long-Term Living.
1.McCarthy M, Addington-Hall J, Altman D. The experience of dying with dementia: A retrospective study. International Journal of Geriatric Psychiatry 1997;12:404-9.
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