Volume 41 Number 1

Introduction

A considerable number of patients have lived and coped with their stoma for many years before their cognitive ability deteriorates leading to potential stoma management issues. Other individuals may require stoma forming surgery and have a pre-existing cognitive impairment diagnosis. This paper examines stoma-related issues many ostomates with cognitive impairment experience and will demonstrate how stoma care nurses (SCN) are in the best position to offer practical solutions/strategies to improve their quality of life.

Background

Cognitive impairment is the sixth most common comorbidity in ostomates over the age of 70 years¹. Cognitive impairment is defined as difficulty:

• Remembering.
• Learning new things.
• Concentrating.
• Making decisions that affect everyday life.

Dementia is typically diagnosed when acquired cognitive impairment has become severe enough to compromise social and/or occupational functioning².

It is important for health professionals to know and understand the person with dementia and also the dynamics within the family and/or with carers to be able to effectively manage the decision-making process and the practical elements of stoma care³.

Clinical Assessment Process

Carers and family members often report the issue of pouch detachment with subsequent peristomal skin problems as their main concern. SCNs are often asked to come up with solutions to these ongoing issues. Ensuring a holistic and collaborative assessment is crucial and assists in guiding the family/carer towards the most appropriate pouching system which is fundamental in maintaining comfort and improving quality of life for their loved one.

Living with a cognitive impairment results in limited ability for the patient to communicate their issue and therefore the prescribing SCN must use all their professional judgement to select the most appropriate product. Perkins and Repper stress that when engaging with a patient, the specialist must be prepared to listen, thereby conveying intent and respect and helping to establish a rapport with the patient and his/her family⁴. de Rooij et al. found that an elderly person with dementia in long-term care is never an isolated entity, but has to be seen in the light of the surrounding social system. The studies’ preliminary results demonstrate that building partnerships between residents, families and staff is possibly related to satisfaction with care, showing that including the family perspective can be of value in assessing the social surroundings of elderly people with dementia⁵.

The University of California, Los Angeles, Alzheimer’s and Dementia Care Program states that agitation and anxiety are often triggered by feeling a loss of control, misperceiving situations or actions as threats, inability to communicate clearly, and frustration with tasks or interactions with family and caregivers. How a caregiver approaches and communicates with a person suffering from dementia can make a difference.

In the author’s experience, many patients with cognitive impairment become agitated due to an underlying peristomal skin issue which they are unable to communicate effectively. Hayashi and Masayo describe the care of an 82-year-old woman with dementia⁶. Although the symptoms did not affect her daily life, after surgery that resulted in a stoma, the patient began to show challenging behaviours in caring for her stoma by washing her appliance out in the kitchen and removing her appliance at inappropriate times. On investigation, it was found that she had sore peristomal skin and it was felt that her behaviour disorder was associated with the sore skin.

Multiple factors can contribute to peristomal skin problems, therefore obtaining a full history from the patient/carer is crucial in ensuring appropriate assessment and treatment. Some factors to consider are that:

• The ageing process may lead to peristomal skin thinning and therefore skin becomes more fragile and susceptible to breakdown. Altered bowel habit secondary to medication or dietary changes may contribute to increased pouch changes which potentially leads to peristomal skin breakdown. Simply changing from a 1-piece to a 2-piece system should be considered, allowing increased wear time and fewer invasive changes which will minimise the potential for peristomal cell stripping and promote increased comfort for the ostomate.
• The patient may have developed a parastomal hernia which is the most common late-stage complication among permanent ostomates, representing a considerable challenge to patients and health professionals⁷. The incidence of parastomal hernias increases with age and in many cases leads to skin thinning and potential enlargement of the stoma. As the hernia increases in size the existing pouch aperture may become too small, potentially leading to undermining of faecal matter with subsequent faecal dermatitis. Re-measurement of stoma aperture and appropriate sizing will create an effective seal between the stoma and the adhesive, preventing contact dermatitis and helping to protect the skin; also, introducing a flexible pouch system with increased wear time. Consider a hernia support garment to minimise discomfort which may also reduce the patients’ attempts to tamper with their pouch.
• A recent history of weight loss or weight gain may result in body profile changes within the peristomal area contributing to potential leakages and peristomal skin breakdown. Where possible, observe the patient in the sitting, standing and lying position to ascertain skin folds or creases and potential weak spots for effluent leakage. Introducing a stoma ring or convex pouch may be necessary to ensure adequate seal and prevention of leakages. Convex barriers help to correct the less-than-perfect stoma and/or peristomal planes, preventing stool or urine from seeping under the barrier⁸. It may also be necessary to consider the use of an ostomy belt in conjunction with convexity if there are abdominal contour changes or stoma retraction. It is widely recommended that a SCN should provide a full assessment prior to commencing a convex product.
• Memory problems make stoma care very difficult, if not impossible, for patients with dementia. Many dementia patients forget that they have a stoma and have a need to empty or change their pouch⁹, often inappropriately removing or discarding their bag¹⁰. The impact on family and professional carers of people with dementia can be both challenging and extremely stressful. The constant unnecessary removal of the pouch can lead to peristomal irritation and breakdown. Family and caregivers may need to take a more active role in ostomy management and may require additional training if the patient has been managing independently for many years. Family and caregivers may need to set reminders for emptying or changing the ostomy appliance. Guiding the patient and carer towards the most secure pouching system can help to minimise the opportunity to tamper and ultimately remove their pouch, thus reducing ongoing anxiety within the home environment. Advising the carer to dress their loved one in clothing that has no openings in the front might also help to reduce tampering with their pouch. Another tip is to consider concealing the pouch with a belly wrap or ostomy wrap to prevent tampering with pouch.

Case Study: Australia

In a recent case from Australia, a gentleman living in an assisted care facility became uncomfortable with his pouch and regularly pulled at it. This resulted in frequent leaks; the gentleman became very agitated and more challenging to care for. His SCN was contacted to assess the situation. She recommended trialling the eakin dot^® 2-piece system. This product has a skin friendly hydrocolloid designed for longer life wear and an easy to use connection mechanism with a reassuring click sound when attached. The pouch is released by pulling the coupling down from the top and remains securely in place when the body of the pouch is tugged, therefore eradicating the risk of the pouch being pulled off accidentally. The result has been transformational. The leaks stopped, the pouch was easily checked and simple to change if necessary. The gentleman’s anxiety about his stoma ceased, and he became much more settled, greatly improving his quality of life.

Discussion

Dementia is a growing challenge. As the population ages and people live longer, it has become one of the most important health and care issues facing the world³. It is an area that requires further consideration and closer collaboration between manufacturers and nurses to develop effective solutions.

To summarise, there are four key areas to consider when prescribing the most appropriate pouch for those with dementia or cognitive impairment:

• Increased pouch wear time.
• Skin friendliness.
• Easy but controlled pouch changes.
• Security.

Conclusion

Ostomates with cognitive impairment or severe dementia can be amongst the most challenging patients we encounter. Lack of understanding and insight into their condition and particularly their stoma often leads to agitation, with subsequent tampering of pouch and catastrophic accidents. A large percentage of patients with dementia will be elderly and therefore are at increased risk of factors contributing to peristomal skin issues. It requires considerable skill and judgement by the SCN to provide a holistic assessment and ensure the most appropriate product selection for this group of vulnerable patients, ultimately ensuring a positive impact on both the ostomate and the people who care for them.

Ethics

No clinical investigation was carried out, no ethics approval was required. Full consent has been obtained for the case study included.

Conflict of Interest

The author is an employee of TG Eakin Ltd.

Author(s)

Marie McGrogan
RGN ENB 216
Clinical Advisor, TG Eakin Limited, Co. Down, Northern Ireland
Email marie.mcgrogan@eakin.co.uk

References

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