Functional Incontinence and Impaired Cognition - Term Paper Example

Running Head: FUNCTIONAL INCONTINENCE AND IMPAIRED COGNITION Functional Incontinence and Impaired Cognition [The Writer’s Name] [The Name of the Institution] Functional Incontinence and Impaired Cognition Introduction Functional incontinence means a specific suffering situation in which the lower urinary tract is intact but the patient is restricted by musculoskeletal disability or, in other words, may suffer from severe cognitive impairment. For most people intellectual function does not significantly diminish with age; small loss of brain cell efficiency is compensated for by experience. It is reasonable to assume that someone in a residential home may have stiff joints, diminished eyesight and poor hearing but not that there will be any impairment in intellect. There is, however, a group of people who do suffer serious mental impairment in old age as a result of disease or damage to the brain, who can be described as suffering brain failure, otherwise known as dementia. People with dementia suffer progressive loss of brain function. Such is the nature of their disability that they are more likely than the general population to require residential care. The two common conditions of incontinence and sleep disorders are frequently neglected. Urinary incontinence is common, costly, and occurs frequently in older people and is a neglected problem. It leads to social isolation, depression, and a lack of self-esteem. It appears in 15 to 30 percent of all older people living in the community and can be as high as 50 percent in residents of old age homes (Diokno et al., 2004). Incontinence is not an inevitable result of the aging process. Several interventions can be used to improve the condition substantially, if not cure it altogether. Urinary incontinence is not a feature of normal aging and must be identified as a treatable, chronic disability in elderly people. Frequently medications prescribed for hypertension, such as diuretics, can magnify the problem of incontinence. Impaired mobility may also result in incontinence if the patient is unable to get to the toilet in time and if the patient lacks the manual dexterity necessary to remove clothing in order to use the toilet. The accidental leakage of urine or faeces results in physical as well as psychosocial problems for the patient. The physical problems are those of perineal skin irritation, sores, and urinary tract infections. The elderly person who experiences incontinence is embarrassed by leakage. When the condition persists it may lead to the withdrawal from social interaction and the person may limit participation in physical activities such as walking and exercise classes, becoming progressively more isolated. Health care professionals should be aware of the available treatment for incontinence and acknowledge their role in educating the patient and the community about this problem (Tata, 2005). Residential Aged Care Facility and Quality of Life People can become disorientated in time of life as well as time of day. They may have one-sided conversations with someone long dead, such as their mother. When confronted with the truth they may confabulate (deny they were doing it) or say they were talking to someone in the next room. The disorientations in time and space can cause frustration and anger. Someone with dementia may become more dependants on others for personal care: 40%-50% of people with established dementia are incontinent two or three times a week and a further 20% are occasionally incontinent. The onset of incontinence varies with the individual and can be influenced both by physical loss of function and regime. The ability to dress and clean oneself can disappear. The most successful therapies for dementia sufferers are based on reinforcement of the familiar. Some people react very badly to relocation, and in any case few people are used to living with large numbers of others. Many of the successful homes for dementia sufferers are based on small self-contained family groups, ideally of eight people, but up to 13 have been adopted. The groups have discrete living and sleeping areas and live as a self-contained unit, with staff dedicated to their care. This is not the cheapest option: staff costs take up between 60% and 70% of the annual budget of a residential institution, and a building form which demands one additional staff member will have an impact on the fee for each resident. It is common practice to segregate groups according to the severity of their condition. It can be distressing for someone with dementia to be with people in a more advanced stage of the disease, and in an all-purpose home the confused residents may trouble the others. Consideration may be given to the provision of a segregated area for a small group of residents. At least some separate sitting areas are desirable so that one or two disturbed and disturbing people can be parted from the rest. These should be located where they can be supervised without the need for additional staff or they will not be used. People with dementia behave in a way which involves risk to themselves and to others. Many of those in residential care are there because their families can no longer cope with the dangers of living with the demented. Buildings for confused people need to be safe, but they should also respect the freedom of the individual. Regimes which give residents the most freedom and autonomy do so in the knowledge that they have to accept a higher degree of risk than those where the residents are highly supervised and monitored. Older people with dementia do not spend their time running riot but from time to time staff will need to cope with disturbed behaviour. In order to do so they need good contact with each other and good access to the resident. It is not uncommon for three people to be needed to manage a problem; one to distract, one to support and one to carry out whatever task needs doing. If the resident is in a wheelchair or seated in a special support chair a lot of space is needed. Spaces which are restricted by walls and furniture like toilets and bathrooms, corridors or dining rooms need careful consideration. There will be times when the residents will need to be attended by staff on each side. Cleaning people up after incontinence happens regularly. Staff will need to get someone who may be in a wheelchair out of a room into a bathroom or shower to wash and clean them. Clothing needs to be sluiced. It can be a daily frustration for staff if the doors are too narrow and swing the wrong way or if there is not enough room for a helper on each side of the toilet. Clarity of form and layout and good visibility are important. This is not particularly easy to achieve in a large residential building; there are many nursing and residential homes where the staff get disorientated from time to time, let alone the residents, particularly in bedroom corridors which can all appear identical with closed doors all round and not even a window to give a clue as to where you are. It is reasonable to assume that any residential building for more than 10 people will be confusing, not just to its dementia residents, and design techniques to counteract this are needed. Wandering Behaviour “Wandering” is a common problem and it is frequently seen in older people with cognitive impairment, especially in dementia patients (Hodgkinson et al., 2007). Newspapers and broadcast media report stories of cognitively impaired leaving from homes and long-term care facilities and becoming lost. Some wanderers are found and alive but some are injured or dead or never found. The behaviour is one of the most troubling behavioural and psychological symptoms of dementia to cause stress to the caregiver (Neville et al., 2006; Hodgkinson et al., 2007). However, aetiology of wandering behaviour has not discovered fully. During the illness, many wander putting themselves at risk and challenging to cares and institutional staff (Miskelly, 2005). Therefore, understanding and use some strategies (environmental modifications, technology and safety, physical/psychosocial interventions and care giving support and education) to manage the behaviour are essential for caregivers and institutional staff. When the condition becomes established the problem is more likely to be acknowledged and diagnosed. Memory and learning become disconnected. People find themselves in rooms with no idea of why they went there. Kettles get put on and forgotten, the gas turned on and not ignited, meals put out and not eaten. Knowledge of and interest in the outside world diminishes, and also the personal world of family and friends. There can be 'holes' in the memory: people or things may not be recognized. The dementia sufferer lives in the present moment. Around a third of the mildly impaired suffer serious depression as a result of their condition. Some show signs of anxiety and aggression, others manifest an emotional indifference. The depression, anxiety and aggression diminish as the disease progresses and the sufferer becomes more disconnected from life. As the disease progresses memory failures become very marked. There is an inability to recognize objects, for example that a sleeve is something you put your arm into. Changes in floor finish can be confused with a step. People are not able to recognize themselves in a mirror. There is disengagement from events in the world, then friends and family. The ability to dress, eat or keep clean, indeed the whole concept of self is lost. Many of the confused are restless, especially who have led an active life. They wander about, or perform self-imposed tasks over and over again. Many are active and physically fit, capable of covering considerable distances in their travels. There may be logic to be discerned from the activities being performed; people will get up and go to a previous work place, but they may get lost on the way. A former tradesman may go to 'work' on the plumbing installation (many of the activities can be destructive to the building fabric). Individuals have their own timetables which are at odds with the rest of the world; they will get up and dress in the middle of the night and want meals at times which may not suit institutions. Falling Behaviour Falls in older people can lead to hospitalization, disability, and premature death (Arfken et al., 2004). Fifty-two percent of deaths owing to domiciliary accidents in people over the age of 65 result from falls. One in three people over the age of 65 years and approximately one out of every two people over the age of 80 years fall at least once a year. Falling may also result in psychological trauma with resultant fear of falling (Tinetti and Speechley, 2003). This fear may lead to social isolation, through avoidance of activities that put them at risk of falling. Because they restrict their activities, debilitation will occur. Arfken et al. (2004) observed an association of fear of falling with decreased mobility and quality of life. This would suggest the need for effective interventions to prevent falls and limit the consequences of falls in elderly people. In this regard there is a major role for health professionals in both education for prevention and treatment. Several factors may contribute to a fall: transient ischemic attacks characterized by altered consciousness, light-headedness or vertigo, seizures, or cardiovascular conditions, and environmental hazards. The latter seem to be responsible for more than half of the falls in older people (Schunk, 2006) Falls frequently lead to fractures of the hip and the femoral neck which are among the major causes of mortality, morbidity, and loss of function. Falling is widely recognized as a major health problem with life-threatening consequences. Tinetti and Powell (2004) estimated that over one third of all individuals over the age of 65 suffer falls each year, resulting in hospitalizations, nursing home admissions, and even death. Injuries resulting from falls in the geriatric population are predictable and preventable. Physical and psychosocial factors associated with falls in the elderly can be addressed through prevention and intervention programs. These programs usually address the risk factors associated with falls, and how those risks can be minimized. Physical restraints are items used to restrict, restrain or prevent movement of a person. It is the forcible confinement of a confused, disorientated, psychotic or irrational person (Schunk, 2006) Physical restraints are never used for the convenience of the staff or as a substitute for conscientious nursing care. Restraints include mitts to prevent removal of drainage tubes, or leg and arm restraints to limit mobility and prevent the patient from climbing out of bed or harming someone at the bedside. Waist and body restraints, such as a straitjacket, also prevent the patient from hurting himself (Bower, McCollough & Timmons, 2005). Restraints can help minimize behaviour problems and help make medical treatment easier if a resident is temporarily uncooperative or highly agitated (Bloom, 2003) Some residents actually feel safer and more secure, and need not worry about falling, if they have proper physical restraints. (Cooper, 2000). Conclusion Working in the field of aged care, a nurse expects to come across residents with various physical and mental disabilities. These people are in care because of their inability to perform essential activities of daily living. Therefore it becomes the nurse's responsibility to understand and care for the residents and their respective disabilities. Such complications likely to be encountered working in aged care could include Communication, a high percentage of residents in care have dementia and cannot comprehend the message being sent, in some cases are unable to construct a coherent reply. This communication struggle is frustrating, and could be one of the causes of behavioural issues. Disruptive and abnormal behaviour is common and may be a result of dementia, causing the resident to do obscene things without comprehension. Attention seeking activities and violence may be the result of emotions such as fear, anxiety, boredom and resentment. Mobility is affected; old age through to an accident or disease in their lifetime, if not through dementia, the mobility of an elderly person is generally somewhat reduced. Many residents are wheelchair bound and others use walking frames. Along with age and deterioration of the body come hearing and vision deficits. These greatly affect the care, and level of care required also adding to a residents frustration levels. References Arfken, CL, Lach, HW, Birge, S), et al. (2004) The prevalence and correlates of fear of falling in elderly persons living in the community. American Journal of Public Health 84(4): 565-570. Bloom, SN (2003) The frail and Institutionalised elderly. In: Guccione, AA (ed) Geriatric Physical Therapy, pp. 378-390. St Louis: Mosby. Bower, F.L, McCollough, C.S., & Timmons, M.E. (2005). A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings. The Journal of Knowledge Synthesis for Nursing, 7, (2). Cooper, C.J. (2000). Reducing the use of physical restraints in nursing homes: regulatory harassment or good medicine? Postgraduate Medicine, 107(2). Diokno, AC, Brock, BM, Brown, MB, et al. (2004) Prevalence of urinary incontinence and other urological symptoms in the non-institutionalized elderly Journal of Urology 131: 474-479. Hodgkinson, B., Koch, S., Nay, R & Lewis, M (2007). Managing the wandering behaviour of people living in a residential aged care facility. International Journal of Evidence-based Healthcare, 5(4), 406-436. Miskelly, F (2005). Electronic tracking of patients with dementia and wandering using mobile phone technology. Age & Ageing, 34(5), 497-499. Neville, C.C., McMinn, B. & Cave, P (2006). Implementing the wandering evidence for older people with dementia: key issues for nurses and carers. International Journal of Older People Nursing, 1(4), 235-238. Schunk, C (2006) Cognitive impairment In: Guccione, AA (ed) Geriatric Physical Therapy, pp. 140-148. St Louis: Mosby (Year Book). Tata, GE (1995) Incontinence. In: Pickles, B, Compton,A, Cott, C, et al. (eds) Physiotherapy with Older People. London: WB Saunders. Tinetti, ME, Speechley, M (2003) Prevention of falls among the elderly. New England Journal of Medicine 320: 1055-1059. Tinetti, M, Powell, L (2004) A multifactorial intervention to reduce the risk of falling among elderly people living in the community. The New England Journal of Medicine. 331: 821-827. Read More