Urinary incontinence is a hidden epidemic. UI is among the 10 most common chronic conditions in the United States and is even more common than hypertension, depression or diabetes.

A majority of residents in skilled nursing facilities have some degree of incontinence. UI is quite costly in terms of quality of life of residents and the financial impact on facilities. As such, our Bladder Training Program seeks to address any incontinence issues among our residents.

Benefits of the program include:

• Improves residents’ quality of life
• Improves quality measures
• Decreases the risk of pressure ulcers
• Decreases the cost of UI care (the direct cost of UI care is greater than the cost of breast, cervical, uterine and ovarian cancers combined, to the tune of an estimated $12.4 billion annually)

Pelvic Floor Muscles

1. Pelvic Diaphragm: Levator ani muscle (Puborectalis, Pubococcygeus, Iliococcygeus) and Coccygeus muscles
2. Urogenital Diaphragm: Deep transfer perineal, Sphincter urethrae
3. Sphincters and erectile muscles of urogenital and intestinal tract: External anal sphincter, Bulbospongious, Ischiocavernosus, superficial transverse perineal

Methods

Step 1: Patient identification — Review Quality Indicator report. Look for residents with “Urinary Incontinence.” There is correlation between UI and fall, so consider those who have fallen. Look at female patients with history of hysterectomy (there is a strong correlation between the procedure and UI).

Step 2: Nursing assessment — Identify type of incontinence, i.e., stress, urge, mixed, functional or overflow, by using incontinence assessment form and simple three-day voiding diary:

• Stress type: Leakage of small amount of urine during physical movement, usually from pelvic floor muscle weakness.
• Urge type: Involuntary loss of urine associated with a strong desire to void. Leakage of large amounts of urine at unexpected times, including sleep. Sensory loss is a strong influence.
• Mixed type: Occurrence of stress and urge together. This is the most common type in the elderly.
• Functional type: Incontinence resulting from inability to access toilet due to physical disability, weakness, external obstacles, inability to manage clothing and/or cognitive impairment.
• Overflow type: Unexpected leakage of small amounts of urine (without movement) because bladder is excessively full due to damaged bladder, obstructed urethra or nerve damage.

Step 3: Therapy evaluation — Stress, urge and mixed are the most common types to address by therapy intervention. Develop four-week pelvic muscle exercise (PME) training program.

Step 4: Four-week treatment — PMEs to improve the strength and tone of pelvic floor and related muscles to maintain continence. PMEs include Kegel exercises, hip adductor exercises, obturator internus/abductor exercises, transverse abdominal exercises and gluteal sets.

Step 5: Re-evaluation — With improvement in urinary incontinence after four weeks of trial of PMEs, patient d/c from program. If no significant improvement in UI after four weeks of PMEs, electric stimulation and/or biofeedback is indicated, followed by reassessment.

 

By Kumar Pradeep, DPT, DOR, Legend Oaks Healthcare and Rehabilitation, South San Antonio, TX

After noticing a recent increase in falls and fall-related injuries at our building, we wanted to better understand the mechanisms of the falls and implement a comprehensive, interdisciplinary fall prevention program.

Consider the following data:

• March 2016: 29 falls, 21 residents, eight repeat offenders*
• April 2016: 40 falls, 29 residents, 13 repeat offenders*

*Repeat offenders refers to residents who sustained more than one fall in a one-month span

What is the Falling Leaf Program?

This program was developed by Carolyn Spradlin as an adaptation to the Falling Star Program. The identified problem with the Falling Star Program is that it identifies patients at any risk of falls and results in a large number of patients in the program, thus decreasing the effectiveness.

In contrast, the Falling Leaf Program identifies the residents who are at the highest risk of falls. The program works to monitor these specific residents and determine the underlying reasons for these falls. A visual symbol of a leaf is placed outside the patient’s door and is used as a way for team members to intervene more quickly and better meet their needs.

How is it implemented:

• Spacing out Falling Leaf residents among CNAs

• Reassessment of residents on effectiveness of interventions
• Nursing staff identified causes of falls: toileting needs, ADL routines, timing of medications, environmental hazards, etc.

• Visual symbol means all staff members check in on resident when passing the room to make sure all needs have been met

Initial Findings

• Over 50 percent of falls during PM/NOC shifts
• Majority of falls related to toileting needs and unsupervised transfers
• Many falls occur within first week of admission
• 28/99 residents were identified as “high risk” and placed on the Falling Leaf Program in beginning of May

Results After One Month of Program

• May 2016: 22 falls, 16 residents, five repeat offenders. After one month of implementation, there was a decrease in the number of falls, number of residents falling and number of repeat offenders.
• Of the 22 falls in May, 14 were sustained by Falling Leaf Program participants, indicating a need for further interventions in this population.
• Only three Falling Leaf Program participants had more than one fall in May, demonstrating some effectiveness of our program in decreasing the number of falls of these “high risk” individuals.

Conclusion

The implementation of this program at our facility is still in its early stages as we continue to work out any issues that arise. Some of our initial future plans include weekly reviews to assess for residents who can be removed from the program as well as any additional identified high-fall-risk residents who need to be added to the program. Additionally, we have recently started involving our pharmacy representative in fall meetings to assist with medication reviews to further decrease potential falls.

By Nicole Veniegas, DOR, MS, OTR/L; Kathryn Case, MOT, OTR/L, Magnolia Post Acute Care, El Cajon, CA

View full poster here: Falling Leaf – Magnolia

As healthcare professionals, we often discuss dementia in the context of various stages, that is, how far a person’s dementia has progressed. Sometimes, we’ll define a person’s stage simply as early-stage, middle-stage or late-stage; however, to be more exact, we use the Global Deterioration Scale (GDS), which assigns seven different dementia stages based on the degree of cognitive decline.

Below, we’ve provided an overview of these stages, along with appropriate activities for the resident. You’ll see that the stages progress from pre-dementia through the final stages when a patient requires much greater assistance.

Stage 1

• No other symptoms other than stress-related memory problems

Stage 2

• Increased short-term memory loss
• Individual is good at using compensatory strategies to mask short-term memory loss

Stage 3

• Compensatory strategies are no longer working for the person
• People are starting to notice that strategies are unsuccessful

Stage 4

• Individual now recognizes strategies aren’t working for them
• Family members are starting to notice individual is not safe at home

Appropriate activities: games, cooking axs, puzzles, crafts, bingo

Stage 5

• Individual no longer realizes memory loss is occurring
• Damage to the brain has progressed
• If you work in a long-term facility, you might notice that in this stage the patient states “I’m just visiting here; I don’t live here”
• Individuals should be independent with self-care activities and benefit from familiar signage and audio tapes from family for calming
• Posture and gait will appear normal and the individual will still make eye contact when conversing
• Validation therapy is important and entering the world of the individual with dementia

Appropriate activities: crafts, gross motor games, puzzles, sorting tools, stuffing envelopes, bingo, coloring, painting, baking and cooking, sorting and matching, sing songs, counting exercises, sorting and folding clothes, setting the table

Stage 6

• In this stage, if the individual does not feel comfortable, the clothing item is usually removed
• Vision changes occur and peripheral vision becomes limited or non-existent; depth perception is also limited
• Falls increase due to decreased depth perception and shorter stride length (they begin to shuffle their feet)
• Leather-soled shoes recommended
• Eye gaze slowly progresses downward and at the end of this stage, it is about 1 to 2 feet in front of them. Signage should be placed 20 to 30 inches from the floor at this stage due to decreased ability to visually track upward.
• Most will stop feeding themselves. Caregiver education is important to make sure the resident eats and stays hydrated.
• It’s important to remember that in this stage, new learning does not occur even with constant repetition

Appropriate activities: same as stage 5 but with greater amount of cueing, scrapbooks, photo albums, busy boxes, reminiscing. May push objects such as mops or brooms, parachute, may hit or kick a target, dusting, washing tables, stirring juice or batter

Stage 7

• This is the last stage of the GDS
• Most of individuals with dementia will stop speaking during this period
• This stage appears to be a time where senses dominate everything
• Most people in end-stage dementia will die of aspiration pneumonia (this is where you will collaborate with other disciplines to enable the individual with a better chance for safely swallowing food items)
• Research has shown that the last taste receptors we have are sweet and bitter. It’s better to provide food in separate bowls with sugar or sugar substitute all over the food.

Appropriate activities: tactile stimulation, music, drumming, reminiscing, roll golf ball, sitting and head control during axs, kneed bread dough, take out raisins, husk corn and remove silk, pudding painting

The GDS provides a precise means of identifying a patient’s degree of cognitive decline. By defining a patient’s disease stage, we can determine the best treatment approaches and facilitate good communication between patients and caregivers.

By Amber Howard, DOR, Legend Oaks Healthcare and Rehabilitation, North Austin, TX