Mandy Fader

Incontinence-Associated Dermatitis: A Comprehensive Review and Update

In 2009, a multinational group of clinicians was charged with reviewing and evaluating the research base pertaining to incontinence-associated dermatitis (IAD) and synthesizing this knowledge into best practice recommendations based on existing evidence. This is the first of 2 articles focusing on IAD; it updates current research and identifies persistent gaps in our knowledge. Our literature review revealed a small but growing body of evidence that provides additional insight into the epidemiology, etiology, and pathophysiology of IAD when compared to the review generated by the first IAD consensus group convened 5 years earlier. We identified research supporting the use of a defined skin care regimen based on principles of gentle perineal cleansing, moisturization, and application of a skin protectant. Clinical experience also supports application of an antifungal powder, ointment, or cream in patients with evidence of cutaneous candidiasis, aggressive containment of urinary or fecal incontinence, and highly selective use of a mild topical anti-inflammatory product in selected cases. The panel concluded that research remains limited and additional studies are urgently needed to enhance our understanding of IAD and to establish evidence-based protocols for its prevention and treatment.

Incontinence-associated Dermatitis: Consensus Statements, Evidence-based Guidelines for Prevention and Treatment, and Current Challenges

In 2010, an international consensus conference was held to review current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previous issue of this Journal. This article summarizes key consensus statements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a discussion of the major challenges currently faced by clinicians caring for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertriginous dermatitis, and that a consistently applied, structured, or defined skin care program is effective for prevention and management of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermatitis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.

Current evidence on intermittent catheterization: sterile single-use catheters or clean reused catheters and the incidence of UTI.

PURPOSE Intermittent catheterization is a commonly prescribed procedure for people with incomplete bladder emptying not managed by other methods. The most frequent complication of intermittent catheterization is urinary tract infection (UTI). It is unclear what strategies, including sterile vs clean catheters or coated vs uncoated PVC catheters, affect the incidence of UTIs. This systematic review summarizes current evidence on the relationship between sterile single-use catheters or clean reused catheters and the incidence of UTIs. SEARCH STRATEGY The Cochrane Incontinence Group trials register, Medline, EMBASE, CINAHL, and ERIC were searched, plus the reference lists of relevant articles and conference proceedings. Randomized controlled trials comparing at least two different products or methods for intermittent catheterization were included. DATA COLLECTION AND ANALYSIS Three reviewers assessed the methodological quality of trials and abstracted data. MAIN RESULTS Of the 13 trials that met the inclusion criteria on intermittent catheterization protocols, there was considerable variation in length of follow-up, definitions of UTI, and numbers of subjects. Attrition was a problem for several studies, and all were underpowered. Several studies were more than 10 years old, and outcome measures were imprecise, making it difficult to draw conclusions on the benefit of one catheterization method over another. CONCLUSIONS There are no definitive studies illustrating that incidence of UTIs is affected by sterile single-use or coated catheters compared to clean reused catheters. However the current research base is weak and design issues are significant. Based on the current data, it is not possible to state that one catheter method is better than another and further research on the topic is strongly recommended.

Managing incontinence using technology, devices, and products: directions for research.

Background: Millions of Americans with incontinence use some type of device or product to manage or collect urine or feces. However, research on their clinical uses, problems requiring nursing care, and patient satisfaction is lacking. Objectives: To review the various products and devices used for incontinence, identify directions for research and development on technology, and outline the ways nurses can influence and participate in those investigations. Methods: Existing literature on incontinence technology, devices, and products was analyzed to generate a plan for future research. Results: Gaps in knowledge exist about the uses, best practices, quality of life factors, and problems associated with catheters, absorbent products, other internal and external devices, and skin care products. Conclusions: Collaboration among public and private sectors would result in greater likelihood of high quality clinical research that has sufficient power and integrity, more efficient use of resources special to each setting, and expedited application of technologies for patient use.

Coated catheters for intermittent catheterization: smooth or sticky?

Objective To evaluate the current range of hydrophilic‐coated catheters for intermittent self‐catheterization, focusing on the adherence of the catheter to the urethral mucosa at the end of catheterization.

Laxative use in care homes

AIM This paper is a report of an investigation into the factors associated with laxative-taking by older people in care homes. BACKGROUND Constipation is a common source of discomfort, pain and morbidity for care home residents, and laxative-taking is prevalent. Differences in the extent to which older people suffer from constipation may result from care routines rather than demographic or clinical factors. DATA SOURCES Primary data were gathered from care records as part of a larger study in seven care homes (without on-site nursing) in London, England in 2003-2004. METHODS Backward stepwise logistic regression modelling was used to investigate factors (age, sex, level of dependency [Barthel]), number of comorbidities, number of medications, constipating medications, length of stay in care home, diagnosis of dementia/Alzheimer disease) associated with regular laxative-taking. RESULTS Of 168 residents, 99 (58.9%) were routinely given laxatives. Taking more medicines (moving up one category: 0, 1-2, 3-4, 5-6, > or = 7) increased the likelihood of taking laxatives more than threefold, after controlling for all other factors. Women were 2.9 times more likely to take laxatives than men. Having dementia/Alzheimer disease increased the likelihood of taking laxatives by 2.6 times. Laxative-taking was statistically significantly lower in two of the care homes. CONCLUSION Laxative use amongst older people in care homes varies and may not be based on rational criteria. Nurses working in care homes and with care staff can help to implement appropriate bowel care for older people.

Sheaths for urinary incontinence: a randomized crossover trial.

Objective To evaluate the full range of self‐adhesive continence sheaths for men available in the UK and thus provide clinicians and consumers with a basis for product selection.

Conservative interventions for incontinence in people with dementia or cognitive impairment, living at home: a systematic review

BackgroundDementia is a distressing and disabling illness with worldwide estimates of increased numbers of people with the condition. Two thirds of people with dementia live at home and policies in many countries seek to support more people for longer in this setting. Incontinence both contributes to carer burden and is also a significant factor in the decision to move into care homes. A review was conducted for evidence of effectiveness for conservative interventions, which are non-pharmacological and non-surgical interventions, for the prevention or management of incontinence in community dwelling people with dementia.MethodFourteen electronic databases were searched, including MEDLINE, EMBASE and CINAHL (from inception to 2012). Assessments of risk of bias were made. Meta-analysis was inappropriate due to the heterogeneity of the interventions and outcome measurements. A narrative analysis was undertaken.ResultsFrom 427 identified abstracts, 56 studies were examined but only three met the inclusion criteria, all more than a decade old. All three focused on urinary incontinence. Two studies were exploratory or pilot studies. All had a control arm. The interventions were of advice for the carer to implement. Two included toileting education of prompted voiding or an individualised toileting schedule. There was insufficient evidence to support or rule out effectiveness of any of these interventions. Some interventions were unacceptable for some carers. None specifically reported the perspective of the person with dementia.ConclusionsThere was insufficient evidence from any studies to recommend any strategies. There remains an urgent need for both research and also clinical guidance for health professionals tailored to community settings where the majority of people with dementia live.

Continence products: Research priorities to improve the lives of people with urinary and/or fecal leakage

Although many successful treatments for incontinence exist they are not effective or suitable for all people. Inconspicuous and dependable management with continence products and devices plays a crucial part in maintaining quality of life. We aim to briefly review what is known and not known in the field of continence products and devices and set out suggested priorities for research and development. The field of continence product research encompasses techniques and designs from basic laboratory science, through to clinical trials of products and to evaluations of service delivery models. Priorities for research include determining prevalence and costs of product use, development of patient reported outcomes, and development of methods for measuring skin health and for quantifying urine/faecal leakage. Product development priorities include better washable pads for women, absorbent products for fecal incontinence and flatus filters. Clinical trials of different product categories (e.g., devices for men) are needed, as are qualitative studies of patient experiences of product use. Neurourol. Urodynam. 29:640–644, 2010.

Novel Insights into the Proteus mirabilis Crystalline Biofilm Using Real-Time Imaging

The long-term use of indwelling catheters results in a high risk from urinary tract infections (UTI) and blockage. Blockages often occur from crystalline deposits, formed as the pH rises due to the action of urease-producing bacteria; the most commonly found species being Proteus mirabilis. These crystalline biofilms have been found to develop on all catheter materials with P. mirabilis attaching to all surfaces and forming encrustations. Previous studies have mainly relied on electron microscopy to describe this process but there remains a lack of understanding into the stages of biofilm formation. Using an advanced light microscopy technique, episcopic differential interference contrast (EDIC) microscopy combined with epifluorescence (EF), we describe a non-destructive, non-contact, real-time imaging method used to track all stages of biofilm development from initial single cell attachment to complex crystalline biofilm formation. Using a simple six-well plate system, attachment of P. mirabilis (in artificial urine) to sections of silicone and hydrogel latex catheters was tracked over time (up to 24 days). Using EDIC and EF we show how initial attachment occurred in less than 1 h following exposure to P. mirabilis. This was rapidly followed by an accumulation of an additional material (indicated to be carbohydrate based using lectin staining) and the presence of highly elongated, motile cells. After 24 h exposure, a layer developed above this conditioning film and within 4 days the entire surface (of both catheter materials) was covered with diffuse crystalline deposits with defined crystals embedded. Using three-dimensional image reconstruction software, cells of P. mirabilis were seen covering the crystal surfaces. EDIC microscopy could resolve these four components of the complex crystalline biofilm and the close relationship between P. mirabilis and the crystals. This real-time imaging technique permits study of this complex biofilm development with no risk of artefacts due to sample manipulation. A full understanding of the stages and components involved in crystalline encrustation formation will aid in the development of new protocols to manage and ultimately prevent catheter blockage.