Prevention of Incontinence-Associated Dermatitis in Nursing Home Residents
Lambert D. Prevention of incontinence-associated dermatitis in nursing home residents. Annals of Long-Term Care: Clinical Care and Aging. 2012;20(5):25-29.
Incontinence-associated dermatitis (IAD) is an inflammatory skin condition that occurs when the skin is exposed to urine or stool.1 IAD is also known as perineal dermatitis or diaper rash, but incontinence-associated dermatitis is the preferred term because it more precisely identifies the cause of the dermatitis, acknowledges that the condition may affect more than the perineum, and because diaper rash is considered to be a demeaning term when used for adults.2,3 More recently, the term moisture–maceration injury has been used. This broader new term is the most useful, as it acknowledges that skin injury can occur not only from the skin’s exposure to urine or stool, but also from perspiration, wound exudates, or other body fluids.4
Although incontinence has been considered a normal part of aging, it can be attributed to factors beyond aging, including changes in medications or hormone levels, infections, or dementia; thus, IAD should not be dismissed as merely a consequence of a condition associated with aging. It is imperative to identify the etiology of IAD, especially when new-onset incontinence occurs, because incontinence can be transient, manageable, or reversible.5 Prevention of IAD is crucial, as it is a major risk factor for pressure ulcers, which can easily become infected and lead to loss of life. Furthermore, caring for a patient with skin breakdown or pressure ulcers is time-consuming and increases the cost of providing care.3
As the population of elders in the United States increases, IAD is becoming a growing concern, especially because it is also a Centers for Medicare & Medicaid Services’ (CMS) quality-of-care indicator. This review aims to identify the evidence-based practices that might be used to prevent IAD in nursing home residents.
This literature review included searches of the University of Cincinnati Search Summons, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PubMed/MEDLINE databases using the following key words: incontinence-associated dermatitis, perineal dermatitis, and moisture–maceration injury. The search yielded more than 1100 results. Inclusion criteria were journal articles with full text online and those related to the prevention of IAD in nursing home residents. Excluded studies were those conducted in facilities other than nursing homes and those evaluating the consequences of IAD rather than prevention strategies. Articles were analyzed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for rating the quality of evidence.6 According to this approach, articles were graded from A to D, with A being of the highest quality and D being of the lowest quality.
Twenty-four articles met the inclusion criteria. Almost half were expert opinions or systematic reviews. Many of the articles discussing trials or program interventions had conflict-of-interest limitations. Table 1 depicts the number of articles and their GRADE ratings.6
Rates and Risk Factors
The literature review showed that, although urine or fecal incontinence may be common in nursing home residents, the documented rate of IAD varies considerably. Junkin and
Selekof7 found bowel and bladder incontinence rates as high as 78% in nursing home residents, with about 43% having some form of IAD. In contrast, a study by Bliss and colleagues8 that reviewed the records of 10,215 residents found IAD in only 5.7%, with 48% of those having both urine and fecal incontinence.
Risk factors for IAD were consistent throughout the literature and included advanced age, chemical irritation, infection, length of exposure to moisture, and mechanical stresses. As people age, their skin becomes more susceptible to IAD because of a thinning epidermis and dermis, reduced blood supply, and increased moisture loss.9,10 In addition, cell turnover slows, which means healing takes longer once IAD develops. Gray9 identified chemical irritation (from urine or stool), pathogen overgrowth or infection (such as yeast or Staphylococcus), and mechanical damage (such as friction and shear) as contributing factors to IAD development. The normal protective acid mantle on the skin is lost when exposed to the alkalinity of feces or urine.11 Ammonia in urine is caustic, making the skin susceptible to breakdown, and fecal contact with broken skin can cause infection and deeper skin damage. In one study, Gray and associates4 found that the duration of urine and fecal exposure to the skin was the major contributing factor to IAD. In another study, Gray12 identified poor nutrition and decreased mobility as risk factors. Langemo and colleagues13 found that being a woman or cognitively impaired also conferred risk.
Once IAD occurs, there is a high risk for pressure ulcer development. Junkin and Selekof7 reported a 37.5% greater risk of developing pressure ulcers as well as an increased risk of infection and morbidity among patients with incontinence. Nix and colleagues14 also identified IAD as a major risk factor for developing pressure ulcers. The Braden Scale for Predicting Pressure Ulcer Risk, a validated assessment tool, includes moisture from urine and fecal incontinence as risk factors for pressure ulcers.2