Parts science, humanity

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Parts science, humanity
Parts science, humanity

Scientists, medical research and lots of equity, both sweat and money, have led to remarkable advances toward cures for things such as cancer and Alzheimer's disease. This leaves many wondering why a seemingly benign issue such as incontinence — which affects far more seniors than any single deadly disease — hasn't been “cured” yet.

“Nobody dies from incontinence or having to go 10 times a night,” says Britton Garrett, senior strategic market development manager for Medtronic Senior Living, which is developing a program for treating overactive bladders in the elderly. “But when you think of an 85-year-old man in the middle of the night trying to get up from his bed to go to the restroom, there are risk profiles associated with that action that unfortunately can put his life at risk.”

By far, the biggest risk is stumbling and falling in haste en route to the restroom or, as indelicate as it sounds, slipping from a leak.

According to the Wound Ostomy and Continence Nurses Society, roughly 80% of individuals affected by urinary incontinence can be cured or improved. Yet in their zeal to manage incontinence, many providers unwittingly trade one potential problem for another by relying on medications that pose cognitive risk or poorly made briefs that could contribute to bedsores.

But much progress is being made to reduce or even eliminate at least some forms of incontinence that not only could positively impact a facility's bottom line through greater staff efficiencies and reduced liability but also by restoring residents' dignity and independence.

Through relatively simple measures such as thorough initial assessments and other documentation, old-fashioned vigilance, and even alternative therapies, incontinence and its attendant risks can be mitigated. Also at the top of that list: Adopting a person-centered approach to toileting that places the resident's needs above staff convenience.

Vigilance, checks pay off

Ensuring quality sleep and providing proven alternative therapies can go far in managing incontinence. But to administrators like Gary Minassian, administrator/owner of Crestwood Nursing & Rehabilitation Center in Warren, RI, there's no substitute for an effective bond between caregiver and resident.

Two years ago, Crestwood adopted a new approach to incontinence care that began with thorough assessments upon admission.

Knowing that cognitively impaired yet highly independent and mobile residents with incontinence are among the highest risk for falls, Minassian understood the importance of constant vigilance and observation. That led to the establishment of a program that included certified nursing assistants documenting in a diary their observations of resident behaviors, including eating habits, body language during exercises, changes in gait and mood, and the times when toileting occurs.

Conducted for a specified period after admission or change in health status, the documentation allowed caregivers to better predict interventions that would prevent accidents, whether it involved an incontinent episode or falls.

A good activities program in a positive group environment is another tool to Crestwood's success in mitigating incontinence.

“This makes it easier to observe residents with sensitive body language,” Minassian adds. “For example, being more fidgety may be more indicative of the need to go the bathroom.” Exercise time also allows for more direct supervision, “which gives you more control that helps you prevent incontinence accidents.”

Crestwood's nursing staff also reviews each resident's diagnosis to uncover any contributing factors for incontinence, such as benign prostatic hyperplasis, bladder prolapse and constipation. All CNAs also are required to develop detailed care plans based on what they documented in their diaries and are permanently assigned to specific residents to improve long-term success.

“This helps because they get to see the patterns,” he explains. “This way they would know when to toilet the resident.”

Virtues of sleep

For most providers, quality adult briefs have been a godsend for incontinence care. For at least one major briefs manufacturer, the time-worn practice of nighttime bed check and changing rounds every two hours is beginning to be viewed as more detrimental than helpful.

A National Institute on Aging study of more than 9,000 individuals aged 65 or older showed that chronic issues with obtaining quality sleep are more widespread than originally thought, according to Domtar, the global parent company of Attends and other products. More than 50% of study respondents reported having at least one chronic sleep complaint. Moreover, poor quality sleep has been linked to cognitive decline, fatigue and daytime sleepiness, moodiness, depression, falls and reduced quality of life.

In January 2016, Domtar conducted a pilot study at Superior Care Home Nursing and Rehabilitation Center in Paducah, KY, to explore the impact of doing away with nighttime bed checks. The “clinical study of holistic continence care” was conducted over a 12-week period. The results affirmed what many caregivers had been telling the company: Quality sleep was viewed as more beneficial than nighttime toileting.

Among the study findings, stopping automatic nighttime bed checks led to:

  • 71% maintenance or improvement of activities of daily living scores
  • 90.5% stable or improved Brief Interview of Mental Status Scores, a key metric of cognitive health
  • An improvement of mood severity scores in 57% of residents
  • “Dramatic” improvement in gait and balance
  • Significant reductions in linen costs; labor hours were reduced on the third-shift laundry and re-directed to other care duties.

“We assessed how wearing a product with absorbent core technologies that allows for multiple voids and still remain dry overall improves performance scores like these,” says Chris Lee, brand manager for Domtar Personal Care. He notes that allowing residents to get five to six hours of quality uninterrupted sleep results in “greater alertness and calm in the mornings.”

Lee adds that the 12-week study resulted in a “significant reduction in falls” during daytime hours, presumably related to improved gait and cognition.

Alternative therapy

The need for frequent toileting and/or urgency to void in the elderly increases the risk of falls by 26% and bone fractures by 34%, according to WOCN. The group also notes that 53% of homebound older persons have overactive bladder/urge incontinence. A significant percentage occurs in senior living communities.

For nearly a decade, peripheral tibial neuromodulation (PTNM), a technique that involves insertion of an acupuncture needle near the ankle, close to the nerve root serving the bladder, has been used with a great deal of success to curb and, in some cases, cure overactive bladder in cognitively healthy and ambulatory seniors.

Unfortunately, many seniors cannot access the therapy because it needs to be conducted in a physician's office.

In OAB sufferers, the pathway between the tibial nerve and the brain is distorted or broken, giving them a false sense of urgency to void. The PTNM technique essentially restores the link.

Medtronic embarked on a broad new initiative to raise awareness of PTNM among skilled nursing homes (called “Restore Senior Living”) and is developing a device (called “NURO”) that can allow it to be administered inside the facility, obviating the need for an office visit and, it is hoped, radically increasing resident adherence and success mitigating urge incontinence, or OAB, Garrett says.

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