Fader, Mandy; (2001) The management of night-time incontinence: An investigation into the effects of different pad changing routines on skin and sleep. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Absorbent pads are the main method of managing urinary incontinence in residential settings for elderly people. Improvements in technology have resulted in highly absorbent products which may be worn all night, but the effects of prolonged pad wearing on aged skin are unknown. Wet skin is known to be more susceptible to dermatitis, friction and abrasion. Nighttime pad changing (and resident turning) have been found to be associated with sleep fragmentation. However it has not been demonstrated that changes in nighttime continence management result in less sleep fragmentation. The following question was posed: What is the effect of different pad changing regimes on the skin health and sleep of elderly women living in residential settings. In addition, earlier findings were explored, which indicated that a substantial proportion of residents, who were turned by staff, also turned themselves METHODS: A cross-over design was used. Following a two week baseline period subjects from residential settings were randomly allocated to one of two pad changing regimes: a frequent pad changing regime (whereby residents were changed at 22.00, 02.00 and 06.00) or a less frequent pad changing regime (with residents changed at 22.00 and 06.00 only). Each regime lasted four weeks and was followed by the alternative regime. Skin measurements were taken twice during each regime from selected skin sites using the following tools (i) the Diastron erythema meter (ii) visual grading scale (iii) the Servomed evaporimeter (to measure trans-epidermal water loss) (iv) a pH meter. The primary outcome variable was measurement of erythema using the Diastron erythema meter. Sleep measurements were made twice during each regime using the Stowood Scientific Instruments Visi-lab which comprises an infra-red camera and video with movement and audio detection. RESULTS: Eighty one subjects from 18 nursing/residential homes for elderly people completed the skin component of the study and twenty-two subjects from 5 homes completed the sleep component. Statistical analysis for erythema meter, trans-epidermal water loss, pH and sleep fragmentation data (mean number of movements per hour) was carried out by fitting general linear models and visual grading data were analysed using the Mainland-Gart method. Video data (of self- turning) were analysed descriptively using a coding sheet. No significant differences were found in the severity of erythema, or skin pH, between regimes. However, measurements of trans-epidermal water loss were significantly higher in the less frequent pad changing regime indicating that skin was 'wetter' (P = 0.01; difference of means 12.14, 95% confidence interval 2.89 - 21.39). Five subjects developed grade 2 pressure ulcers (abrasions) during the less frequent pad changing regime, but none in the frequent pad changing regime; this result was not significant (P = 0.1; 95% confidence interval 0 - 1.09). No significant differences were found in the sleep measurements (mean number of movements per hour) between regimes. During both pad changing regimes staff seldom turned residents. Subjects who turned themselves were more likely to be turned by staff at the time of pad change, but overall redundant turning was not evident. CONCLUSIONS: No evidence was found that a less frequent pad changing regime has an effect on skin erythema, pH or on sleep fragmentation. However, there is evidence that the skin is wetter, which may make it more vulnerable to friction and abrasion. The non-significant finding of greater incidence of grade 2 pressure ulcers is a cause for concern and merits further investigation. MAIN RECOMMENDATIONS FOR PRACTICE: Residents may use one standard good quality night pad (without changing) throughout the night. Residents who have had (or develop) grade 2 pressure ulcers (including 'wet skin abrasions') should have their pads changed during the night to reduce skin wetness.

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