Faecal incontinence is a complex issue for many older people. This article provides an overview of the condition, its causes, policy and guidance providing advice on the subject, general management, complications and support available for carers, with a focus on faecal incontinence in those with dementia.
Faecal incontinence involves the involuntary loss of stool or flatus—a distressing condition that has a significantly negative effect on the affected individual's quality of life (Ahmad et al, 2010). It is estimated to affect 15% of the population and is, thus, an important issue in many areas of healthcare, due to its effects and complications, which affect the physical and mental wellbeing of the patient. Cost is also an issue, as the absorbent pads required are very expensive, yet in high demand, under NHS funding. Estimates of prevalence may be inaccurate and lower than the reality, as Ahmad et al (2010) noted that faecal incontinence is a heterogeneous problem, ranging from minor faecal soiling to incapacitating urge or passive faecal incontinence.
Ahmad et al (2010) noted that faecal incontinence often results in admission to residential care when, in fact, the condition could be managed more cost-effectively in the community, provided the patients and their carers have the right support from specialists and district nurses to maintain a good standard of care and prevent complications.
Among the challenges of this condition are that it is socially debilitating and isolating; it can result in skin damage and other consequences; and it cannot be ‘cured’, although it can be managed well. The aetiology is multifactorial, and treatment must be tailored to the individual, as so many different causes can be found for this condition, from gut motility issues and dysfunctional bowel problems to mental health issues.
Managing faecal incontinence
The National Institute for Health and Care Excellence (NICE) (2007) clearly set out guidance for all health professionals who are managing a patient with faecal incontinence. The guidance states that these health professionals must have the relevant skills, training and experience, and work in an integrated continence service. Particular attention should be paid to sensitive assessment and treatment of the issue in patients from high-risk groups, such as people with:
- Frailty linked with older age
- Loose stools or diarrhoea from any cause
- Recent childbirth, especially where there has been a third or fourth obstetric injury
- Neurological or spinal disease or injury
- Severe cognitive impairment
- Urinary incontinence
- Pelvic organ prolapse or rectal prolapse
- Previous colonic resection or anal surgery
- Previous pelvic radiotherapy
- Perianal soreness, itching or pain
- Learning disabilities (NICE, 2007).
Support for patients and carers
All staff working with someone experiencing faecal incontinence should be aware of the physical impact as well as the emotional toll the condition takes on not only the patient but their carer (NICE, 2007). Both the patient and carer should be kept fully informed on the condition and be given access to the appropriate sources of information, in a language and format appropriate for their needs. They should be given the chance to discuss the assessment, management options and the relevant physical, emotional, psychological and social issues. It is also important that the health professional be aware that the condition is usually a symptom of a different condition, with multiple contributory factors.
Diet is important and, with the right advice, this can help both the patient and carer, so that faecal incontinence can be managed more effectively. NICE (2007) stated the importance of recommending a diet that promotes an ideal stool consistency and predictable bowel emptying. Where unsure, a specialist or dietitian should be consulted. The health professional should consider existing therapeutic diets, ensure the overall nutrient intake is balanced and consider a food and fluid diary so as to establish a baseline. The carer could be advised (where the patient lacks capacity) to modify one food at a time when attempting to identify what contributes to the symptoms. It is recommended that a person with clinical dehydration should have 1.5 litres of fluid a day and that urinary output should be measured where intake is uncertain (for example, in someone with dementia who may not remember to drink, spill a drink or throw one away). It is important to screen the patient for malnutrition, as nutrients can be lost if someone is dehydrated by constant loose stool incontinence or diarrhoea (NICE, 2007).
Toilet access
Sometimes, faecal incontinence becomes an issue due to the person not being able to reach or access the toilet in time. This may be because of other physical or bowel conditions, where they may feel an urge to pass a stool but cannot mobilise quickly enough to the toilet. Someone who is confused may also find it very hard to remember where the toilet is, and it may be that adjustments to housing are needed to account for disabilities and ensure timely toilet access is made optimal in the patient's residential environment.
An occupational therapist can be referred to in order to provide equipment, to ensure toilets are more easily accessible. It is important that the patient and carer know that clothing makes a difference—if it is loose and easy to remove, this increases the chance of accessing the toilet in time, along with help from the carer being readily available. The person may also need physiotherapy to help them with mobility. An assessment by a multidisciplinary team can be provided via the GP or case manager in the community, for a multifactorial range of needs. This can help to determine what referrals are required to which services, to improve the patient's overall physical and mental health and, as a result, to potentially treat the faecal incontinence.
Long-term care
The person with faecal incontinence may have a long-term care package in place and, if their needs are identified to be increasing and no longer within the carer's remit, a reassessment may be required. There should be a single point of contact for the patient, such as a continence or district nurse with the appropriate training. They can liaise with social services to help reassess the patient's needs for their social care package.
In general, the advice health professionals need to provide relates to preserving the patient's dignity and independence. It may also include providing psychological and emotional support involving referral to therapists or counsellors if it seems the person or their carer's ability to cope with the faecal incontinence could improve with this type of intervention.
The person's symptoms should be reviewed by their continence nurse or point of contact every 6 months, and management options should be considered, including specialist referral. Contact details should be provided for relevant support groups; for advice on continence product choice availability and use and whether these are NHS or privately funded; and for advice on skin care (NICE, 2007).
Dementia care
Dementia is increasingly prevalent in the ageing population. With the onset of worsening confusion, memory loss, agitation and other emotionally troubling states, personal care ends up a difficulty for both patients and their carers. The carer faces challenges, as a patient who has dementia may perceive the provision of personal care as unwanted, as though it were an attack, and they may not be able to comprehend that it is required. To leave the person who refuses such care alone could cause indignity and harm and even count as neglect in the eyes of the law. It should always be ensured that a patient is fully assessed according to deprivation of liberty standards. Given the extensive skin damage that could result from lack of personal care, it may be deemed necessary to deprive them their liberty in the most dignified way possible, in order to maintain their best interests. An advance care plan is also useful in the very early stages of dementia or even before any such diagnosis, which can stipulate such care to be consented to before capacity is lost.
Another difficulty is that a person with dementia is often older and may have other pre-existing functional issues, commonly associated with mobility. This would make it difficult to prompt the person to get to the toilet in time if they happen to be able to communicate it, due to the extra communication, persuading and reminding they may need, as well as physical support, which they may then immediately reject, depending on their mental state. Goodman et al (2015) noted that dermatitis, delirium, general discomfort and unplanned hospital admissions are stressful and confusing for a patient and more likely to complicate the problem of faecal incontinence further. The more frequent the incontinence, the more that person's quality of life decreases, while affecting any opportunity for social interaction and stimulation, both compounding the sense of isolation already felt by a person living with dementia. Goodman et al (2015) also noted that having to deal with faecal incontinence already can affect care home staff turnover and staff morale in such environments. Carers often receive less clinical support in the patient's own home or in a care home, which can further lower morale if most patients have faecal incontinence.
Goodman et al (2015) noted that barriers to effective faecal incontinence care tend to be ageism, lack of training, pad restrictions resulting from financial controls and poorly integrated services. The authors also noted a lack of local dementia-specific information and guidance relating to managing faecal incontinence optimally in these patients. The impact of the leadership, culture of care and care home routines on residents' health and wellbeing has been recognised, and it has been found that impaired mobility, stroke and diabetes all contribute to faecal incontinence (Goodman et al, 2015).
Care planning
A programme of care should consider the person's restrictions that affect their ability to go to the toilet. Adjustments should be made, equipment should be provided and nutrition should be optimised. The patient should be assessed appropriately for the number of pads they need while also ensuring that the carer is clear on and has the time to check the patient's pad every few hours, as advised by the continence nurse or tissue viability nurse, if skin complications coexist. The patient should also be prompted, if appropriate, to use the toilet. Routine is important.
NHS continence service goals
NHS (2018) guidance states that continence nurses and all those working in delivering continence services should ensure patients and their carers are treated with empathy in a respectful manner, that they are listened to, and that they are actively involved in care decisions. The guidance also emphasises the importance of the approach being person-centred.
Complications
Physical complications often include irritation to the skin due to the frequent exposure to faeces, along with the wiping required and products used on the skin. Another factor that leads to complications is poor nutrition, resulting usually from more severe faecal incontinence, and supplements may, therefore, be required. For someone with dementia, it could be worthwhile to use distraction techniques while carrying out personal care. Dehydration can result from more severe faecal incontinence, and nutritional support may be required in line with regular prompting to drink enough water and keeping an eye on the patient's blood pressure. Jelly drops are an appetising ‘treat’ that mainly comprise water and act as a prompt to rehydrate throughout the day, if they do not like the idea of drinking water, which often can be the case in a person with dementia who simply may forget or dislike sipping water.
General complications of faecal incontinence also include emotional and social distress, avoidance of work and social situations as a result, and depression.
Skin care
The Bladder and Bowel Organisation (2017) published a document relating to skin care, giving advice with regards to the issue of incontinence. The document explained that the combination of moisture, friction and bacteria results in a cycle that often causes skin breakdown. Frequently washing of the skin with soap and water causes it to dry and reduces skin integrity. A normal bar of soap has a pH of approximately 9.5, which is much higher than the skin's natural acidity, but, in more recent years, manufacturers have developed'soapless' products that are much less irritating (Bladder and Bowel Organisation, 2017). Likewise, pH balanced cleansers are preferable to soap and water, as well as cleansers that use emollients and barrier products, for optimal skin health. Rubbing or using a rough towel can cause damage to delicate skin, and, therefore, soft disposable cloths may be better. The skin should be dried through gentle patting, so as not to damage the skin through rubbing it (Bladder and Bowel Organisation, 2017). Skin creases should also be dried thoroughly, especially the lower skin folds of the stomach and genital area, to avoid skin irritation and infections. Contrary to what the author witnessed 16 years ago as a healthcare assistant on the wards, talcum powder is not recommended for use, as this obstructs the pores and prevents the skin from functioning at its optimal level. If the patient tends to itch and has dry skin, an emollient is recommended, to be used twice daily. There are various specialised barrier products to maintain optimal skin function while reducing the potential complications skin could experience from faecal incontinence. Cleansing the skin and using the right barrier product should be seen as part of a series of interventions, with the goal of keeping the skin barrier intact.
Conclusion
Overall, faecal incontinence is a common issue among many people in an ageing population. Functional issues, whether they are cognitive or mobility-related or a complexity of both, can further complicate the matter for the patient, increasing care demands of a carer who, without support and advice, may not provide optimal care in someone who has a complex range of needs and regular faecal incontinence. Incontinence care can be improved by providing the carer with a single point of contact in the continence service and access to support and advice. They should be supported in creating a tailored continence care plan that links to multiple other areas of daily living, such as activities, nutrition, hydration, meal times, routine and mobility. Improved incontinence care can recover the self-esteem often lost by people with incontinence and their carers. Complications are multifactorial, and skin care is essential—namely through appropriate cleaning and drying, using pH balanced products and appropriate emollients and barrier creams. Thoughtful consideration should be given to the emotional wellbeing of people with incontinence and advanced dementia, who may be experiencing delirium or severe agitation. Ensuring that they receive optimal continence care will help minimise this distress.
KEY POINTS
- Faecal incontinence has multifactorial causes, with physical or cognitive disabilities further increasing the risk of this problem
- Routine is important in any incontinence patient, with optimal hydration and nutrition giving regularity in toileting, as well as prompting those who may be confused to use the toilet to avoid unnecessary incontinence and to promote independence
- Provision of the appropriate equipment from the occupational therapist, assistance from care staff and other support for disabilities can reduce the risk of incontinence, as toileting becomes more accessible with these adjustments.
CPD REFLECTIVE QUESTIONS
- What interventions can be made medically, socially, and functionally to improve outcomes with regard to faecal continence?
- How can you provide ease and comfort and overcome difficulties while providing continence care for a person with dementia?
- How can a care plan be formulated and tailored to the needs of a patient with dementia and facecal incontinence?