Definition and causes
Faecal incontinence involves the involuntary and frequent loss of stool, making it a distressing condition that has a significantly negative effect on the quality of life of the person affected (Ahmad et al, 2010). About 15% of the population suffers from it, and it is a common issue in many areas of healthcare, often being considered a comorbidity. Faecal incontinence also has financial strains on the individual, as the absorbent pads required are very expensive, yet in high demand under the NHS funding. Estimates of prevalence may even be inaccurate and lower than the reality. As Ahmad (2010) has noted, faecal incontinence is a heterogeneous problem ranging from minor faecal soiling to incapacitating urge or passive faecal incontinence and embarrassment, which may prevent patients from seeking help.
The conern with this condition is that it is socially debilitating and isolating and can result in skin damage and other such consequences, which cannot always be resolved. It can, however, be managed well.
The aetiology of faecal incontinence is multifactorial and treatment would need to be tailored to the individual, as there are various causes for this condition, ranging from gut motility issues, dysfunctional bowel problems, to mental health issues.
Managing faecal incontinence
National Institute for Health and Care Excellence (NICE) (2007) has set out guidance for all healthcare professionals who are managing a patient with faecal incontinence. The guidance states that patients should be managed by healthcare professionals who work in an integrated continence service, who have the relevant skills, training and experience.
High risk groups require attention as they are at a greater risk of ill health if not treated or are unable to seek help for their incontinence due to their vulnerable condition. These high risk groups include: frail older people; people with loose stools or diarrhoea from any cause; women following childbirth (especially where there has been a third or fourth obstetric injury); those with neurological or spinal disease or injury, people with severe cognitive impairment, those with urinary incontinence; people with pelvic organ prolapse or rectal prolapse; someone who has had a colonic resection or anal surgery; people who have had pelvic radiotherapy; those with perianal soreness; itching or pain; and people with learning disabilities (NICE, 2007).
Support for the patient and their carer
The NICE (2007) guidance also states that all staff working with someone experiencing faecal incontinence should be aware of the physical impact as well as the emotional toll the condition can have on both the patient and their carer. Both parties should be fully informed on their condition and have access to the appropriate sources of information, in a language and format appropriate for their needs. The patient and their carer 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 healthcare professional has a good understanding of the condition's multifactorial causes.
Support for the patient and care in management of faecal incontinence
Diet is important and with the right advice, both the patient and carer can manage faecal incontinence more effectively. NICE (2007) states the importance of recommending a diet that promotes an ideal stool consistency and predictable bowel emptying. Where unsure, the specialist or dietitian should be liaised with.
The healthcare professional should consider existing therapeutic diets, ensure the overall nutrient intake is balanced and consider keeping 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 someone 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, someone with dementia who may not remember to drink, may spill a drink or may potentially throw it away). It is very important to screen the patient for malnutrition as a lot of nutrients can be lost if someone is dehydrated by constant loose stool incontinence or diarrhoea (NICE, 2007).
Toilet access
Faecal incontinence becomes an issue for people who cannot access or reach the toilet on time. They may have other physical conditions or bowel conditions, where they may feel an urge to pass stool but cannot mobilise quickly enough to reach the toilet. Someone who is confused may find it hard to remember where the toilet is. In such cases, it may be helpful to bring adjustments to someone's housing situation to account for such disabilities and to ensure optimal and timely toilet access. An occupational therapist can be referred to in order to provide equipment and to ensure toilets are more easily accessible.
Clothing can also make 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, should the patient need to use the toilet. The person may also need physiotherapy—this may help them with their mobility, to ensure they avoid faecal incontinence. An assessment by a multidisciplinary team (MDT) member can be provided through the general practitioner (GP) or case manager in the community, for a multifactorial range of needs and to determine what referrals are required to which services. This can improve the patient's overall physical and mental health and as a result, potentially treat the faecal incontinence.
Long-term care
There may be a long-term care package in place and if the needs of the patient are increasing and no longer within the carer's management, a reassessment may be required. There should be a single point of contact for the patient, such as the continence or district nurse (DN) with the appropriate training. They can liaise with social services to help determine a reassessment of the patient's needs for their social care package.
In general, the advice healthcare professionals need to provide would be on preserving the patient's dignity and independence. It can also be related to the provision of 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, with management options being considered, including specialist referral, providing contact details for relevant support groups, advice on continence products’ choice availability and use, and whether these are NHS or privately funded, and advice on skin care (NICE, 2007). A ‘just can't wait’ card is a useful thing to have so that the patient can potentially move to the front of a queue for toilets if out and about—this aids independence.
Dementia care
Dementia is increasingly prevalent among our ageing population. With the onset of worsening confusion, memory loss, agitation and other emotionally troubling states that the person may experience, personal care ends becoming a difficult task for them and their carer. The carer would try to help the patient, but of course, this is challenging. From the author's own experience of working closely with a patient with dementia, providing care can be difficult, as the patient may perceive it as unwanted, as though it were an attack, since they are not able to comprehend that personal care is required. To leave the person who refuses such care is undignified for them and would essentially be unlawful. It should always be ensured that a patient is fully assessed according to deprivation of liberty standards. In such instances where the patient cannot fully comprehend the situation, and considering the extensive damage that could be done to their skin, and their overall physical and mental health should they be left untreated, it may be deemed necessary to deprive them their liberty in the most dignified way possible, in order to maintain their best interests should they have had insight to make such a decision for themselves. An advanced care plan is also useful in the very early stages of dementia or even before any such diagnosis, that can stipulate such care to be consented to before capacity is lost.
Someone with dementia is often elderly, with pre-existing functional issues, commonly with mobility. This would make it difficult to prompt that person to get to the toilet on time if they happen to be able to communicate it, due to the extra amount of 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) stated that dermatitis, delirium, general discomfort and unplanned hospital admissions being stressful and confusing for a dementia patient are more likely to complicate the problem of faecal incontinence further. Goodman et al (2015) suggested that 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.
Barriers to effective incontinence care
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 this type of patient. Literature however does exist regarding the impact of the leadership, culture of care and care home routines on residents’ health and well-being, which has found that impaired mobility, stroke and diabetes can contribute to faecal incontinence.
Goodman et al (2015) also noted that having to deal with faecal incontinence can affect care home staff turnover and staff morale. 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.
Care planning
A programme of care should be made that considers the
person's restrictions affecting their toileting. Adjustments should be made and equipment provided, nutrition optimised, and the patient should be assessed appropriately for the amount of pads they need, while also ensuring the carer has the time for checking the patient's pad every few hours as advised by the continence nurse or tissue viability nurse, should any skin complications coexist. The patient should also be prompted, if appropriate, to use the toilet. Routine is important. With specific reference to care homes, although the results are generalisable to any care setting, Goodman et al (2015) stated that literature discusses nutrition and hydration, meal time patterns, medication use, as well as activities of daily living, as all being essential for informing the implementation of care plans in relation to faecal incontinence.
NHS continence service goals
NHS (2018) guidance suggests that continence nurses and all those working in delivering continence services should ensure a patient and their carer are treated with empathy in a respectful manner, that they are listened to, and that they are actively involved in making decisions about their care. The guidance also stipulates the importance of the approach being person-centred, where there is a single point of contact and proactively planned care with ongoing support given to the patient and their carer, noting that consideration is needed for planning around the complex needs of an individual who may have disabilities or long-term conditions, for example, dementia.
Complications
General complications include emotional and social distress, avoidance of work and social situations, which can result in depression as well as physical issues. 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, as well as poor nutrition, resulting usually from more severe faecal incontinence where the body does not get enough nutrition from food and therefore, supplements may be required. Blood tests should be able to determine if supplements would be required, regular skin assessments, and ensuring the patient has enough social connection to raise their mood. It can be worthwhile to use distraction techniques with dementia patients, as comfort often can be brought from something as simple as a toy. Dehydration can result from more severe faecal incontinence and nutritional support may be required in line with regular prompting to drink enough water and by keeping an eye on the patient's blood pressure. Jelly drops are an appetising ‘treat’ that are mainly comprised of water, so they act as a great way to prompt someone to rehydrate throughout the day. This is particularly useful with patients who have dementia, who simply may forget to drink water, or may dislike sipping water, but may regularly be prompted by the sight of a treat.
Skin care
Bladder and Bowel Organisation (2017) published a document relating to skin care, giving advice with regards to the issue of incontinence. The document explains that the combination of moisture, friction and bacteria results in a cycle that results often in skin breakdown. Frequently washing the skin with soap and water causes it to dry and reduce its 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 which are much less irritating, the document notes. pH balanced cleansers are preferable to soap and water, especially 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 by 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, so as 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, and functional issues, whether they are cognitive, mobility-related or a complexity of both, can further complicate the matter for the patient. This can increase care demands of a carer who, without support and advice, may not provide optimal care for someone who has a complex range of needs and regular faecal incontinence. It must be ensured that the carer has a single point of contact in the continence service, access to support and advice and help creat a tailored continence care plan that links to multiple other areas of daily living. These include activities, nutrition, hydration, meal times, routine and mobility, and can facilitate better care and self-esteem, which is often lost by not only the person who has incontinence, but also their carer. Complications are multifactorial and skin care is extremely important—using appropriate cleaning and drying, pH balanced products and appropriate emollients and barrier creams. Emotional wellbeing should be thoughtfully considered and it must be ensured that someone with dementia receives optimal care for continence, while also minimising the distress such care may cause in someone with advanced dementia who might experience delirium or severe agitation.
Key points
- Faecal incontinence has multifactorial causes, with physical or cognitive disabilities further increasing risk of this problem
- It can be difficult for carers to provide the best continence care without specialist single point of contact advice and support and appropriate products
- Many patients with more severe dementia will have a Deprivation of Liberty Safeguards procedure in place as importance of continence care overrides their refusal to receive it, to avoid complications that further reduce quality of life
- Complications can be mental or emotional due to the distress it can cause, and skin complications are common, mitigated by appropriate washing, drying, and use of emollient and barrier products
- Routine is important in any incontinence patient, with optimal hydration and nutrition giving regularity in toileting, and 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 risk of incontinence as toileting becomes more accessible with these adjustments