Why Dementia? its just a name

During the past 20 years we have moved a long way since the days of labelling, or have we?

In psychiatry we rarely use the term schizophrenia, previously known as Precox Dementia, instead we describe the individual has having a personality disorder coupled with delusional ideas and some form of hallucinations. What happened to the Manic Depressive? Oh yes it was renamed Bi-Polar disorder. I understand that the labelling theory introduced us to putting people into little boxes and indicated that the illness was at the forefront of psychiatric care and not the person and that the needs of the institution, the Psychiatrist, the Nurse and the care plan came first. Obviously now everything is person-centered and the needs of the individual are prioritised. We have learned that everyone’s illness is unique to them because of their background, culture, faith and overall Social Psychology. We even dropped Senile from Senile Dementia, which left us with plain old dementia.

 

We have come a long way since the work houses and the lunatic asylums, where the residents of such institutions were either Demented, Possessed with demons, or just plain old lunatics. It did not get much better as we entered the 20^th century, for years we referred to those suffering from mental illness as mental defectives. For years we believed that drilling a hole in the frontal lobe or temporal lobe was the cure for lunacy, ECT for many years, right up to the end of the 20^th century became the preferred method of treatment.

 

Dementia, what does it mean? What does it say, what is it?

I was once asked;

 “Paul, what is the difference between dementia and Alzheimer’s disease?”

 without being flippant I said

“It’s the same as the difference between a BMW and a car!”

I felt awful to be honest but it was the first thing that came to mind to describe the answer.

Let me explain. Dementia is a latin word which means poor mental health, so going back to Senile dementia, we dropped the wrong word if we needed to indicate that it was to be referred to the elderly, Senile meaning old in latin. So breaking the word down (De meaning against or poor/bad and Mentia meaning the mind, the brain) simply means mental illness or of poor mental health.

Why do we use the term dementia for most of the time when dealing with old age psychiatry.

The truth is, dementia covers; anxiety, depression, stress, personality disorders, bi-polar, vascular (dementia)mental illness, usually caused by a stroke, Alzheimer’s Disease (shrinking of the brain in the first instance), Lewy Body, Korsakoff’s Syndrome, CJD, Frontal/Temporal lobe (dementia) mental illness, caused by trauma to the head, in fact any illness of the mind is a dementia or as we commonly know it by, Mental illness.

 

To summarise then; we should either continue to use the archaic term of dementia to describe all forms of mind related illnesses or we just drop the archaic term, which isn’t even belonging to a live language anymore, and use the more user-friendly term mental illness.

Musical Entertainment and the elderly in care homes. The Truth.
I have been entertaining in care homes for over five years. I have utilised my musical knowledge and skills, coupled with my therapy background, my in depth knowledge of dementia and the care home industry at senior management level.
I have noticed that care home residents get little or no therapeutic benefit from a Singer/entertainer, no matter how skilled they are, if they turn up sing a few songs, accompanied by keyboard or guitar. It is neither memorable nor beneficial to the well being of the care home resident, especially dementia residents.
I have found that you don't need to be the greatest instrumentalist or singer. All it needs is a little bit of thought and insider knowledge to be a channel for therapeutic well-being. The reason I am chosen to return time after time is:
1. The set list: Does each song mean something to the resident?
2. Being Personable and engaging.
3. My knowledge and ability to put into practice validation, reminiscence and music therapy.
Performing in care homes is not the most lucrative way of making money, not that you are doing it for profit. Many care homes rely on donations to their comfort funds or activities funds, usually petty cash only. Therefore you should not expect high fees usually between £30 and £80.

PR Healthcare Training

Paul Reynoldson Healthcare Training Services.

The above company used to be called Re-Educate Training, however since the company was formed a lot has changed including the way the company is run.
I can still provide all the mandatory training courses such as; Basic First Aid, COSHH, Health and Safety, Infection Control, Medication Safety, Mental Capacity Act, Safeguarding, Record Keeping and Report Writing, Basic Food Hygiene, Role of the Care Worker, Duty of Care, Confidentiality, Equality and Diversity et al. I also am able to train on the statutory training requirements such as Manual Handling. As well as the courses already mentioned I can deliver courses on Dementia Care, Mental Health, End of Life Care, Care Planning, Ageing Skin, Pressure Area Care, Catheter Care and Continence Care plus I can also deliver a bespoke session for you on Fire Safety.
I can also provide a train the trainer course (for in house trainers only) on manual handling
Fees are as follows:

£25 per head, per session....minimum 6 candidates, maximum 12 candidates.
all attendees will receive a workbook with knowledge quiz to complete at the end of the session and a certificate at the end of their training to satisfy the requirements of CQC

Train the Trainer Manual Handling £100 for three day course minimum 6 candidates, maximum 12 candidates (ideal for a care group)

Saving money versus Resident Care

OK what is the greater need.
In care homes it is fashionable to cut costs on incontinence products, especially on pads. Usually giving dementia residents 2 pads in the day and 1 pad at night.
Dilemma: leave a resident with a pad on for the full night despite it being full of urine and faeces because there is no other pad to change to. Creating an epidemic of urinary tract infections and skin integrity problems costing more to treat than the saving made on pads.
Take the pad away and leave the resident to wet or soil the bedding with urine soaking everything leaving the resident not only wet through but cold also and all of the associated skin problems as a result, again costing more to rectify than the saving made on pads.
More importantly isn't the result of withholding pads for "monetary gain" a form of physical and emotional abuse.
If you work in a care home and this happens at your place of work you need to stop a think. Do you want to be labelled as an abuser because your company want to save approximately 2% of its annual budget.
Pure false economy. Get it stopped now complain, raise issues, if necessary go to the CQC.

Mental Capacity Act and Deprivation of Liberties Safeguards

The introduction of the Mental Capacity Act firmed up the past and current situation for ‘decision making’ and ‘mental capacity’

The Mental Capacity Act (2005) is a law of statute and was implemented in 2 stages

What New Things Did the Act Introduce?

New Lasting Powers of Attorney and deputies (October 2007

A new Court of Protection (October 2007

A new Office of the Public Guardian

A new criminal offence (April 2007)

A new Independent Mental Capacity Advocate service (April 2007)

A code of Practice (April 2007)

Other New Rules

The Act also brought in rules regarding:

Acts in connection with care and treatment

Advance decisions to refuse treatment

Research projects involving people who lack capacity

Care and Treatment

If there is no Lasting Power of Attorney or an appointed Deputy:

The care giver or treatment provider must follow a ‘best interests checklist’ before making a decision on what is in a person’s best interests

Advance Decisions

What is an Advance Decision?

A decision made by someone who HAS mental capacity

It is a legal document about treatments a person want or doesn’t want should they lose mental capacity. It should clearly state when treatments should either stop or not be administered. These decisions must be respected by a doctor

Someone other than the person wanting to make an Advance Decision can sign the document, Provided that the person wanting to make the decision agrees and is a witness to the signature. A person signing an Advance Decision must understand what it means

Research

People lacking mental capacity cannot make the same judgemental decisions as those with mental capacity

The act brought in new rules about involving people lacking mental capacity in research projects. Research Ethics Committees will make decisions as to whether research involving people lacking mental capacity follow the new rules.

Summary

The Mental Capacity Act legislates for decision making in care and health

In the absence of a Lasting Power of Attorney or court appointed Deputy care providers must follow a strict checklist before making any decisions concerning care – this has implications for ordinary day to day decisions

The Act introduced Advance Decisions allowing the medical profession to know what treatments a person wants should they ‘lack capacity’ at some time in the future

Research of any kind must have the consent of the person and must stop as soon as the person does not want to continue

Deprivation of Liberty Safeguards

Introduction

The Deprivation of Liberty Safeguards were introduced to prevent random decisions depriving vulnerable people of their liberty and for their protection. The safeguards ensure that service users who need to be deprived of their liberty have representatives and rights of appeal with regular review and monitoring. The safeguards cover people in hospital and care homes registered under the Care Standards Act 2000 – whether placed publicly or privately.

The legislation is part of the Mental Capacity Act 2005  and amends the Act to meet the ‘Bournewood Gap’  http://www.equalityhumanrights.com/about-us/our-work/human-rights/human-rights-inquiries/our-human-rights-inquiry/case-studies/the-bournewood-case

The safeguards were introduced into Mental Capacity Act 2005 (MCA) through the Mental Health Act 2007

Mental Capacity Act 2005

Amended by the Mental Health Act 2007

Also amending the Mental Health Act 1983

DoLS Regulations came into force April 1st 2009

The safeguards arise from the “Bournewood” case – a ECtHR case – Article 5

HL had been deprived of his liberty unlawfully because of a lack of a legal procedure which offered sufficient safeguards against arbitrary detention (5(1)) and speedy access to court (5 (4))

Bournewood Trust were found to have exercised complete and effective control

The Safeguards

A legal procedure to enable lawful detention of a person who is Over 18, and Lacking capacity to consent to the arrangements for their care, and Receiving care where levels of restriction & restraint are so high that they are being deprived of their liberty, and Within a hospital or care home, and Where detention is not already authorised under the Mental Health Act

The Relationship of DoLS to MCA

Any action taken under the deprivation of liberty safeguards must be in line with the principles of the Act:

Assume capacity unless it is established that a person lacks capacity

A person is not be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success

A person is not to be treated as unable to make a decision merely because he makes an unwise decision

Any action taken under the deprivation of liberty safeguards must be in line with the principles of the Act:

An act done (or decision made) under the Act (or on behalf of a person who lacks capacity) must be done (or made) in his best interests

Before the act is done (or the decision is made) regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action

What Does This Mean?

Any care or treatment (given to a person without mental capacity to give consent) that restricts liberty to the point of deprivation is a breach of human rights, Unless a DoLS authorisation has been made

Assessments

The Assessment Process

Once it has been determined that a referral for authorisation of Dols is needed there is a formal process to follow

Where the need is immediate an urgent authorisation can be made

Urgent authorisations should normally only be used in response to sudden unforeseen needs

The assessments have to ensure that all requirements are met

The regulations stipulate who does these assessments

Six assessments:

Age

Mental health

Mental capacity

No refusals

Eligibility

Best interests

Key Terminology

Relevant Person (RP) The person being deprived of their liberty

Managing Authority (MA) Hospital or Care Home – the care provider Responsible for requesting an assessment of deprivation of liberty

Supervisory Body (SB)The Primary Care Trust (PCT) or  Local Authority (LA) responsible for assessing the need for and authorising deprivation of liberty

Assessor - Carry out assessments as per the regulations

Representative (RPR) Provides independent support to the RP

Independent Mental Capacity Advocate (IMCA) Represents RP being referred for authorisation. Represents RP where a best interests assessor is assessing possible unlawful deprivation of liberty. May stand in (no ‘representative’). May support the RP and/or their representative when instructed by the SB or at the request of RP or their representative

Court of Protection

Where deprivation of liberty safeguards and procedures will be challenged and where arguments about public protection and best interests can be resolved

Action to be Taken by the Managing Authority (MA) The hospital or care home manager identifies the person at risk of deprivation of liberty . They then request authorisation from the supervisory body  (SB)

An assessment is commissioned by the supervisory body. An IMCA is instructed for anyone without a representative

The Six Stage Assessment

Age assessment (is the person 18+)

Mental health assessment

Mental capacity assessment

Best interests assessment

Eligibility assessment

No Refusals assessment

The Assessment

If any of the assessments undertaken do not meet the criteria for authorisation the request for authorisation is refused, all assessments support authorisation:

Best interests assessor recommends period for which deprivation of liberty should be authorised and person to be appointed as representative. Authorisation is granted and persons representative appointed (RPR or IMCA

Authorisation implemented by managing authority (MA)

The Best Interest Assessor is an independent public body in their own right and responsibility. Their assessment can only be overruled by the Court Of Protection who Can also give a Standard Authorisation with conditions attached

Authorisation Expiry - Authorisation expires and Managing authority (MA) requests further authorisation

Same process starts again

Emergencies

The Managing Authority (MA) can issue an urgent authorisation for seven days while simultaneously obtaining authorisation (where it believes the need is immediate)

This procedure should normally only be used in response to sudden unforeseen needs but also may be used in care planning (e.g. to avoid delays in transfer for rehabilitation where delay would reduce the likely benefit of rehabilitation)

The period of time must not exceed 7 days (only the Supervisory Body can extend to 14 in exceptional circumstances)

Reviews and Appeals

The RP or the RPR/IMCA can request a review at any time

The MA can request a review if circumstances change

The person or their representative can also appeal to Court of Protection (which has powers to terminate authorisation or vary conditions)

Assessments in More Detail

Assessments – Mental Capacity

To establish whether the RP lacks capacity to consent to the arrangements proposed for their care or treatment. This is assessed by a person eligible to act as a Mental Health Assessor or Best Interests Assessor

Assessments – No Refusal

To establish whether an authorisation for DoL would conflict with any other existing authority for decision making for the RP

This is undertaken by Best Interest Assessor

Assessments – Eligibility

To establish whether the RP is subject to the Mental Health Act 1983 or whether they should be covered by the Mental Health Act 1983 instead of a DoL authorisation. This is undertaken by a Best Interests Assessor who is also an Approved Mental Health Practitioner or a Section 12 Approved Mental Health Assessor

Assessments – Mental Health

To establish if the RP is suffering from a mental disorder within the meaning of the Mental Health Act 1983 (but excluding additional criteria for learning difficulty)

This is undertaken by a Doctor who is Section 12 Approved ( Mental Health Act 1983 ) or a registered medical practitioner with 3 years special experience in the diagnosis and treatment of mental disorders (and have completed approved training)

Assessments – Best Interests

To firstly establish whether DoL is occurring (or is going to occur) and if so whether it is In the RP’s best interests Necessary to prevent harm to themselves and that the DoL is proportionate to the likelihood and seriousness of the harm

To evaluate the care plan

To consider less restrictive alternatives against likelihood of harm

To seek the views of anyone involved or interested in the persons welfare

To involve the RP and support them to take part in the decision

To consider views of the mental health assessor

To decide if it is in the RP’s best interests to deprive them of their liberty

To make a recommendation for care where the requirement is not met

To determine how long the authorisation should last

To stipulate any necessary conditions associated with DoLs

To recommend someone to be appointed as the RP’s representative

To produce a report detailing conclusions and why (submitted to the SB)

To conduct review assessments

And Finally . . . . .Monitoring

The Care Quality Commission (CQC) will be monitoring safeguards and practices the CQC will intervene where it believes standards are failing and (where necessary) take appropriate action

Mental Health Act 2007 Deprivation of Liberty Safeguards (MCA / DoLS)

What is Depriving a Person’s Liberty?

Safeguards – Who They Apply To

The safeguards apply to anyone aged 18 and over who: Suffers from a mental disorder or disability of the mind (e.g. dementia or a profound learning disability) Lacks the capacity to give informed consent to the arrangements made for their care and / or treatment For whom deprivation of liberty (within the meaning of Article 5 of the European Commission for Human Rights) is considered to be necessary in their best interests to protect them from harm (after an independent assessment)

The safeguards cover:

Patients in hospitals

People in care homes registered under the Care Standards Act 2000 (whether placed under public or private arrangements)

Background

The White Paper Our Health, Our Care, Our Say (Department of Health)

“people with ongoing care needs, whether their needs arise in older age, or through illness or disability, should be cared for in ways that promote their independence, well-being and choice”

Human Rights Act 1998

The Convention guarantees the following rights and freedoms:

Article 2: The right to life

Article 3: The Right to Freedom from Torture and Inhuman or Degrading Treatment or Punishment

Article 4: The Right to Freedom from Slavery, Servitude and Forced or Compulsory Labour

Article 5: The Right to Liberty and Security of Person.

Article 6: The right to a fair and public trial within a reasonable time.

Article 7: The Right to Freedom from Retrospective Criminal Law and no Punishment without Law

Article 8: The right to respect for private and family life, home and correspondence

Article 9: The Right to Freedom of thought, conscience and religion

Article 10: The Right to Freedom of Expression            

Article 11: The Right to Freedom of assembly and association

Article 12: The Right to marry and found a family

Article 14: The prohibition of discrimination in the enjoyment of convention rights

What Are The Safeguards?

A legal procedure to enable lawful detention of a person who is:

Over 18, and Lacking capacity to consent to the arrangements for their care, and Receiving care where levels of restriction and restraint are so high that they are being deprived of their liberty, and They are receiving care/treatment in a hospital or care home, and Where detention is not already authorised under the Mental health Act.

Policies and Training

Staff should receive training on the Mental Capacity Act and Dols

Managers should ensure that policies and practice are in line with the Act and Dols

You need to understand:

Capacity assessment

How to support decision making

How to determine ‘best interests’ decisions

The definition of restraint and least restrictive option

Dols – Implications for Institutions

Approximately 21,000 vulnerable adults in care homes and hospitals may be in danger of having their liberty deprived in a range of ways (Department of Health)

Care homes need to review care practice for specific service users in order to provide it in a less restrictive way

MCA Code of Practice (Supplement 2.5)

The ECtHR (European court of human rights) and UK courts have determined a number of cases about deprivation of liberty

Their judgments indicate that certain factors can be relevant to identifying whether steps taken:

Involve more than restraint, and Amount to a deprivation of liberty

Factors determined (so far):

Restraint is used (including sedation) to admit a person to an institution where that person is resisting admission

Staff exercise complete and effective control over the care and  movement of a person for a significant period

Staff exercise control over assessments, treatment, contacts and residence

An institutional decision that the person will not be released into the care of others (or permitted to live elsewhere) unless the staff in the institution consider it appropriate

A request by carers for a person to be discharged to their care is refused.

INCONTINENCE

Bladder problems affect more than 9.6 million women and 1.14 million men in the UK
At least another 650,000 adults have difficulties with bowel control
In general terms incontinence means difficulties with the retention of urine and/or faeces

In 2005 the first national audit of incontinence care for older people in the UK revealed widespread failure to diagnose and manage continence problems

Before we look at ‘incontinence’ we need to look at ‘continence’

What is ‘continence’?

Continence – A Definition

‘The ability to store urine in the bladder or faeces in the bowel and to excrete voluntarily where and when it is socially appropriate’
Key words – excrete voluntarily and socially appropriate

If ‘continence’ is seen as a voluntary action in socially acceptable circumstances then ‘incontinence’ is any variation from this. Many people do not consider themselves incontinent but do experience leakages from the bladder or bowel

Incontinence – Some Definitions

Urinary incontinence:

A condition in which the involuntary loss of urine is a social and hygienic problem

Faecal incontinence:

The involuntary or inappropriate passage of faeces

Enuresis

Enuresis is nocturnal incontinence (bedwetting)
Enuresis occurs most often in children but can continue into adulthood
Primary enuresis – where bladder control has never been achieved


Urinary incontinence affects, on average, 40% of men and women living in nursing homes
70% of incontinence sufferers can be cured

30% can benefit from proper management

Faecal Incontinence

Faecal incontinence can be:
Mild or severe
It can sometimes be referred to as staining
It affects
Children aged 5 to 16 - 1%
People under 65 (living at home) – 0.4%
People over 85 (living at home) – 15%

People living in nursing homes – 30%

The Need For Continence Awareness

 examined the quality of care for older people with urinary and faecal incontinence in England, Wales and Northern Ireland

It focused on:

Primary care

Secondary care

Care homes

The audit was undertaken by the Royal College of Physician’s Clinical Effectiveness and Evaluation Unit

It was commissioned by the Healthcare Commission known as the CQC since 2009
The audit was based on the following standards:

The National Service Framework for Older People [2001]

The Department of Health guidance “Good practice in continence services”[2000]

159 Trusts covering:

195 Hospitals

141 Primary Care Trusts

29 Care Homes

9,000 patients and 700 care home residents

Urinary incontinence affects some 24% of older people and 30 - 60% of people in institutional care

Faecal incontinence occurs in approximately 1-4% of adults and up to 25% of people in institutional care. The Care Value Base forms the basis of all ethical decisions and judgments made in health and social care. One of the components of the Care Value Base is that everyone has a right to dignity

Both urinary and faecal incontinence cause much distress and loss of dignity for the older person. Effective management of continence depends on a thorough assessment of the service user leading to a diagnosis

A service user may already have continence problems, or they may develop problems whilst in your care

Every care professional should be alert to the ongoing needs of the service user. An assessment should be carried out routinely for all service users as part of the care planning process, and Immediately a problem is identified reviews should be on an ongoing basis

Anyone in the care team could be the first person to identify a need

As assessment should be carried out routinely for all service users as part of the care planning process, and immediately a problem is identified reviews should be on an ongoing basis

The audit found that even specialist NHS staff with good continence knowledge did not examine patients thoroughly or give routine assessments

They also found that where a thorough examination and assessment had been made only the symptoms were managed when in some cases there could be a cure

The aim should always be to cure wherever possible rather than just manage the problem

The audit also identified:

A lack of written policies
Missing documentation
Limited provision of staff training
High use of indwelling catheters in hospital settings
Widespread rationing of continence pads

The National Service Framework for Older People set the requirement that service providers should establish integrated continence services by April 2004

The audit found only limited action toward this and that service provision remains extremely variable

Only 59% of primary and 32% of secondary care sites had a written policy which covers continence care for older people

Each care setting should have a written policy covering continence care

Nearly all settings asked a screening question relating to bladder and bowel care, but only 64% of primary and 44% of secondary sites had a basic assessment protocol. Each care setting should have a written protocol of basic assessment in addition to a screening question. Integrated continence services were only present in 53/138 of primary care, 50/195 secondary care sites and 10/27 care homes taking part in the audit.

On further inspection many of the services said to be integrated were missing vital elements
Only 49% of secondary care trusts offer structured training on the management of continence
Each care setting should provide structured training on the management of continence
Only 49% of secondary care trusts offer structured training on the management of continence
Each care setting should provide structured training on the management of continence
80% of services had a written policy that pads should be available on the basis of clinical need

However 81% of primary care and 76% of care home services limited the maximum number of daily pads for patients. 60% of primary and 70% of secondary care patients received pads as a way of managing their condition rather than treating the underlying problem

There are ethical and financial implications for correctly assessing all service users

A proper assessment would eliminate this ethical dilemma ensuring that pads were available to those who need them

Inadequate assessment of incontinence with an emphasis on containment rather than cure is expensive, from both a financial and health perspective

Dealing with continence care correctly will:

Reduce the numbers of incontinent service users in your care
Provide a higher standard of care
All settings should have a written policy
All settings should have a screening question and basic assessment protocol
All staff should receive training

All staff should be clear on the fact that they are part of the ongoing process of assessment and review.

Stress Incontinence

Stress incontinence is the involuntary leakage of urine

It can occur when a person:

Laughs

Exercises

Coughs

Sneezes

Why Does Stress Incontinence Occur?

If the muscles controlling the bladder become weakened urine can leak

It is more common just after childbirth and during the ageing process

The Urinary System

Some of you will have knowledge of the urinary system
It will be useful to look at how the urinary system works to better understand incontinence
Urine is produced in the kidneys, It passes down to the bladder (a muscular organ) via the ureter
The valve controlling the bladder is called the urethral sphincter

This valve opens to allow urine to flow out of the bladder, It closes to hold urine in.

The pelvic floor muscles help support the bladder
They assist in the retention of urine in the bladder

Stress incontinence can occur if either the sphincter muscle or the pelvic floor muscles become weakened, When these muscles become weakened they cannot contract (tighten). Once weakened they are unable to cope with any extra pressure (e.g. a cough, sneeze etc)

Men and urinary incontinence

The elderly experience the same bladder problems as other adults

Where the elderly differ, though is in their ability to respond and to compensate for problems which a younger adult may find trivial

Evidence suggests that the presence of urinary incontinence alone increases the chance of an elderly person becoming institutionalised earlier than a continent elderly person. With people living longer the expanding proportion of the elderly will place an increasing burden on services delivering continence care. However, incontinence should never be viewed as a normal consequence of ageing

Age Related Effects

Studies have shown that:
Detrusor contractile function
Bladder capacity
Urinary flow rates

All decline in association with greater age. As well as incomplete emptying of the bladder. In men, the progressive enlargement of the prostate with age tends to dominate the behaviour of the urinary outflow tract

As enlargement increases, the bladder requires a greater contractile effort to overcome the effects of the obstruction

The overactive bladder is the commonest cause of urinary incontinence in the elderly, regardless of sex

In many cases the cause of an overactive bladder is not known, However it is commonly associated with progressive enlargement of the prostate 

Detruser Instability (Overactive Bladder)

It is also associated with neurological injury or disease
E.g.
Spinal cord injury
MS
Cerebrovascular disease

Parkinson’s or Alzheimer’s disease

Individual symptoms are extremely important in making a diagnosis of detrusor overactivity

Not everyone will experience all symptoms and many go to great lengths to avoid experiencing incontinence  E.g. restricting fluid intake or increasing urinary frequency

Diagnosing Detruser Instability- Getting the True Picture

In addition to taking a relevant history it is useful to get the service user to complete a diary

If the service user is unable to do this alone help can be given by the care professional/member of the family

Continence Care

The diary would record:
Urinary frequency
Volumes passed
The number of incontinence episodes
Fluid intake

Urinalysis

Urinary tract infection and calculi may cause urinary urgency and urge incontinence and should be excluded at an early stage

The simplest method to exclude infection is to use a rapid urinalysis dipstick

Absence of Infection

In the case of reoccurring infections or haematuria (in the absence of infection) further investigation is needed. Referral to the GP is required

Drug Treatments

Antimuscarinic drugs are still the most widely used treatment in the UK though the side effects have limited their tolerability:

Dry mouth
Constipation
Blurred vision

Oesophageal reflux

Oxybutynin

The most commonly prescribed treatment for the overactive bladder in the UK is Oxybutynin
Oxybutynin is both antimuscarinic, a direct muscle relaxant and a local anaesthetic agent
Studies have shown that high dose oxybutynin (5mg tds) increases the incidence of side effects

The withdrawal rate has varied between 22-40% with up to 80% suffering significant adverse reactions

More recent studies, using lower doses of the drug has shown a reduction in adverse effects and an enhanced level of tolerability

Bladder Retraining

Most drug therapy has conventionally been used in combination with bladder retraining

This technique involves the simple maxim “hold on” (simple to say but requiring much motivation and will power). Even in the most motivated patient, bladder retraining can take months to achieve a lasting change in habit. There is a high relapse rate.

Clean Intermittent Catheterisation

In combination with antimuscarinic drugs, many elderly men who would not be candidates for surgical treatment can be successfully managed by this technique

Surgery

Surgery is most applicable for those with detrusor overactivity associated with other conditions such as outflow tract obstruction

There are several techniques that can be used

Post Prostatectomy Incontinence

The incidence of incontinence following prostatectomy varies between 1-15% depending upon the procedure used . In late life, pre-existing bladder problems may co-exist

Nocturnal Frequency

Nocturnal frequency is deemed to be excessive if greater than twice nightly

There are several physiological changes, which lead to an increasing likelihood of developing nocturnal frequency. Normally, adults produce two thirds of their twenty-four hour urine output by day and the other third by night . In older individuals this changes and there is a redistribution of fluid at night. In addition, some older adults have a delayed diuresis (increased formation of urine by the kidneys). Together these factors mean that the kidneys are working harder overnight to produce greater quantities of more dilute urine. The amount of which may be in excess of functional bladder capacity. For highly dependent men in a care setting nocturnal incontinence requires a major effort to manage effectively. The use of pads and barrier creams can minimise the disruption of sleep patterns

Cognitive Impairment

For those patients who are cognitively impaired (where there is little chance of active participation in behavioural methods of treatment) drug treatment may help. However there is little evidence that drugs can be effective

Strategies:

Scheduled voiding (toileting at regular intervals)
Individualised toileting programmes  (toileting is planned around known voiding habits)
Prompted voiding programmes (prompting to visit the toilet at regular intervals)

Prompted voiding programmes requires the care professional to know whether the patient is wet or not and depends upon the ability of the patient to request toileting

All 3 strategies been found to be effective in reducing incontinence episodes in nursing home patients

All methods are very labour intensive but there is evidence that (for regular toileting regimens) a four hourly interval is as effective as a two hourly one

Containment

For some elderly males the only option available for the treatment of their urinary incontinence is containment 

The main aims of containment devices:

Protection of skin and clothing
Prevention of malodour

Devices include condoms, clamps, absorbent underwear, single use and reusable pads

 

 

Pinciples of Safe Manual Handling and Lifting in the Care Home

Manual Handling Principles and Practice

To provide learners with the underpinning knowledge and skills required, to undertake the manual handling of objects and people, safely within the workplace.Legislation demands that anyone who is required to handle loads of any kind during their working day are appropriately trained in the theory and techniques of Manual Handling.It is important therefore, that you understand the legal requirements relevant to this.

Legislation is an Act of Parliament

Act of Parliament

Health and Safety at Work Act 1974(Great Britain)

Health and Safety at Work Act 1978(Northern Ireland)

Human Rights Act 1998(2000)

Disability Discrimination Act 1995(2005)

Mental Capacity Act 2005(2007)

Corporate Manslaughter and Homicide Act 2007(2008)

Regulations

Management of Health &Safety at Work Regulations 1992 (1999)

Manual Handling Operations Regulations 1992  (2002)

Provision and Use of Work Equipment   Regulations 1998   (P.U.W.E.R)

Lifting Operations and Lifting Equipment Regulations 1998 (L.O.L.E.R)

The reporting of injuries, diseases and dangerous occurrences regulations 1995 (R.I.D.D.O.R)

Employees Duties

Places a duty on the employee to co-operate with the employer with regard to the use of equipment and devices and report without delay any work situation which might present  a serious and imminent danger

You are personally accountable for your own actions /omissions regardless of advice or instruction from another individual

You are responsible for clear concise documentation

REMEMBER IF YOU DOCUMENT YOU WILL BE SUPPORTED IF YOU DON’T YOU WON’T

What is the COST of carelessness

Health and Safety Executive

Improvement Notices

Prohibition Notices

Commissioning Bodies

Social Services

Fire Service

Company Insurers

Where an employer is found negligent the line manager or equivalent may also be liable and punished accordingly

If a person is accused of negligence for failure to comply with Health and Safety legislation she / he must prove that it was not reasonably practicable to do so

Risk Assessment

Under the Manual handling operations regulations RISK ASSESSMENTS MUST be completed.

There are 2 types

INFORMAL

FORMAL

The purpose of Risk Assessment is to identify hazardous situations that may cause strains and injury

Hazard

Something that has the potential to cause harm

Risk

The likelihood of harm occurring

What are you looking for?

Hazardous situations may involve

Holding awkward postures for a long time

Repetitive awkward or heavy activities

Working at speed beyond capability

Insufficient rest periods between tasks

Working in poor lighting, draughty, cold or hot environment

Pushing pulling or lifting heavy loads

What has to be assessed?

Remember T.I.L.E

T - Task

I  - Individual

L - Load

E – Environment

Tasks

You need to consider

Where the load is

The distance moving the load

Whether the load is above head height or on the ground

If it involves twisting or stooping

Is it repetitive

Individual

Need to consider

strength, height, weight

State of health and fitness

Age

Clothing

Gender

Dexterity

Experience

Motivation and attitude

Knowledge and skill

Load

Need to consider

Size and weight

Shape

If the handler’s vision is blocked

Whether it’s easy to grasp

If it’s alive

Whether it is harmful e.g. hot or sharp

Will it move or shift during handling

Environment

Need to consider

How much space is available

Uneven, slippery floor

Variations in levels e.g. stairs

Unsuitable lighting

Untidy or cluttered area

Unsuitable temperature or weather

Suitability of equipment available

Five steps to Risk Assessment

Decide if there is a problem

Who might be harmed and how

Are existing precautions adequate

Record your findings

Review and revise your assessment

Who should carry out the Risk Assessment?

Trained manual handling risk assessor

Manager

Line Manager

Responsible person at that time

Good risk assessment will result in

Less work related injury

Increased efficiency

increased staff morale

REMEMBER

All manual handling activities must be risk assessed and controls put in place to reduce the risk of injury so far as reasonably practicable

Ergonomics

Ergonomics is the science of fitting the job to the worker.The greater the mismatch between the physical capacity of the worker and the requirements of the job the greater the risk of injury

Physical / Psychological Aspects

Body shape and size

Posture

Mental Abilities

Personality

Knowledge and Experience

Ergonomic Evaluation consists of

Assessment

Planning

Implementation

Good ergonomics makes good sense and leads to a more effective, less stressful work which is beneficial to everyone!

Aspects to consider

The job being done and the demands on the worker

The equipment to be used is it appropriate to the task and the environment,assessing people, their jobs, equipment, working environment and the interaction between them which gives us the ability to design safe, effective and productive work systems

Statistics

Many Manual Handling injuries are cumulative rather than being truly attributable to any single handling incident.The injured do not always make a full recovery the result can be physical impairment or even permanent disability

When are you most susceptible to injury?

At the beginning or early into a shift

Lunch time

At the end of the day

Annual cost to industry from disability due to low back pain problems is estimated at around 6 billion. Back pain is the second most common reason for absenteeism,30% of all workplace injury claims are back related

Spine

The human spine is made up of 33 small bones, called vertebrae. These bones are stacked on top of each other to form a column. Between each vertebra is a cushion known as an intervertebral disc.

The vertebrae are held together by ligaments, and muscles are attached to the vertebrae by bands of tissue called tendons. Openings in each vertebrae line up to form a hollow canal.

The spinal cord runs through this canal from the base of the brain however it does not continue all the way down this canal it stops at L2 (lumbar vertebrae) where it branches out  Nerves from the spinal cord branch out and leave the spine through spaces in the vertebrae. The spine is strong and flexible with a natural “ S” shaped curve.

The spine has 4 defined curves which are

Cervical Vertebrae-support the head and neck

Thoracic Vertebrae-anchor the ribs

Lumbar Vertebrae-support the major part of the body’s weight and provide a stable centre of gravity during movement

Sacrococcygeal- supports part of the body’s weight and provides a stable centre of gravity during movement

Spine has 3 main functions

To protect the spinal cord

To allow movement

To support the upper body

Intervertebral  Disc

An intervertebral disc is described as a lattice network of fibres, onion like in appearance with a jelly like substance within. The disc receives it’s nutrition from the vertebral end plates which can be found above and below each disc. The disc receives it’s nutrition by a process known as diffusion

The main function of the disc is shock absorption

Repeated stresses can cause minute tears and bulging of the disc which in turn invades the spinal space . This is known as a prolapsed or herniated disc or commonly known as a “slipped disc”

Muscles

The human body consists of 650 individual muscles, which are attached to the skeleton by strong fibrous tissue known as tendons. Messages from the brain cause muscles to contract and relax.

Muscles provide power and control so that we can move this is achieved primarily by muscle groups and not by individual muscles.

To perform safe moving and handling we use 4 sets of muscles

Hip Flexor Muscles

Begin at the front of the spine, travel through the pelvis, attach to the front of the leg joining the back to the legs

Function

Used for running and walking

Side and Hip Muscles

Join the hips to the ribs, travel from the back to the front of the body

Function

Provide strength, support and movement

Back Muscles

Travel down both sides of the spinal column the largest being the Latissimus Dorsi

Function

Used for movement and weight bearing

Stomach Muscles

Travel from the ribcage to the pelvis

Function

Used for strength and support for the abdominal cavity and provide protection for the lower back. Good condition of the abdominal muscles is vital to back care

Soft Tissue Injuries

Strain

Strain is an injury to a muscle or tendon caused by twisting or pulling while improperly moving or lifting heavy objects causing overstressing of the muscles

Soft tissue injuries

Sprain

Sprain is an injury to one or more ligaments which can be as a result of a fall, sudden twist or blow to the body that forces a joint out of its normal position resulting in overstretching or tearing of the ligament

Principles of safe Handling

F = Feet

L = Load

U = Unlock (loosen up)

E = Even elbows (90 deg.)

N = Natural Spine ‘S’ shape

C = Communication/ Command

Y = Your back, Your responsibility

Good Handling Techniques

Assess the load

Position the feet

Head up

Lift with legs

Keep load close to waist

Put down then adjust

Team Lifting

Planning the lift and having a good hold are particularly important in team lifting.

Apply the principles for  two-handed symmetrical lifting.

Where the nature of the load precludes the use of this technique then the guidance
appropriate to the nature of  the load should be applied.

Indicators of Abuse

Caused by moving and handling

Bruising to wrist and arms

Scratches/Cuts

Friction Burns

Fractures

Soft Tissue injuries

Fear/Aggression/non-compliance

The following illustrations are common sights that can regularly be seen in the workplace, highlighting bad and unacceptable practice deemed as controversial with no benefit to the Service User or the handler

Action may be taken under disciplinary policies where there is evidence that employees are carrying out any of the following controversial manoeuvres without due cause (emergency situations needing immediate action to avoid serious harm to the service user’s health)

Australian Lift

According to the Royal College of Nursing, cited by Back Care(1999) this lift is responsible for more injuries to nurses than any other the handlers posture is compromised and they are lifting the most of the Service Users weight. Additionally, the Service User has no therapeutic or rehabilitative benefit.

Pivot Lift

An extremely dangerous form of moving and handling with the possibility of disc damage extremely high . There is a very high risk of injury to both the handler and the Service User

Cradle Lift

Involves excessive stooping

Requires the lifter to flex and bend sideways

Excessive pressure placed on the intervertebral discs of the lifter

Drag Lift Underarm Hook

Dangers to Handlers

Posture Stooped & Twisted

Top Heavy

Insecurity of Hold

Dangers to Client

Injury to shoulder joint

Friction to skin, feet & ankles

Compromises chest expansion

Proven to be dangerous to both the Service User and the handler. The handler is stooped and twisted they are top heavy and have an insecure hold. The Service User is caused unnecessary pain, friction to the skin on their feet and ankles, injury to shoulder joints and expansion of their chest is compromised

Lever Principle

For every 10 kilos of weight, 10 times as much pressure is placed on the lower back if incorrectly lifted.

Manual Handling Equipment

The following clearly states the procedures that must be adhered to prior to using any piece of equipment

Hoists

This mechanical aid must be used by 2 members of staff who must be present at all times. Assisted bath hoists must be used by 2 members of staff who must be present at all times

Scales that attach to the spreader bar must be removed.  A service user must not be transferred with scales attached

When in use the brakes must be off to allow the hoist to find its centre of gravity, however if using the hoist on a slope or to raise the Service User from the floor the brakes must be on for the first couple of inches of the manoeuvre.

It is not permitted to transport the Service User through a doorway or along a corridor on this equipment

Stand Aid

This mechanical aid must be used by 2 members of staff who must be present at all times. When in use the general rule is that the brakes should be applied however some appliances may differ

Refer to the manufacturers handbook

You are not permitted to transport the Service User through a doorway using this equipment

Hoist / Stand Aid Checklist

The following checks must be carried out by 2 members of care staff prior to each use

Ensure the equipment is clean and fit for purpose

Familiarise yourself with the equipment

Explain the procedure to the Service User

Check the safe working load ensuring that it is adequate to take the weight of the Service User

Check the LOLER sticker to ensure that the equipment is within its required service date if not seek advice from the Nurse in Charge / Manual Handling Facilitator

Check the battery has been charged

Check the emergency stop button (not all mechanical aids have this facility)

Check handset is functioning and not damaged

Check the legs on the equipment open and close freely

Remember

Do not use this equipment if you have not been trained to do so by a Manual Handling Facilitator

Slings

The following checks must be carried out by 2 members of staff prior to each use

Correct sling for purpose

Correct size for the Service User

Identification label is intact and the Safe Working Load is clearly visible

Evidence that the sling has been serviced as per LOLER regulations

All stitching is intact if Not Do Not Use The Sling

All straps are intact not frayed or damaged

Velcro fastening is free from threads and deemed fit for purpose

There are no flaws such as small holes in the body of the sling

Sling is clean and free from body odours

Both members of staff must be present at all times

Both members of staff must ensure that the straps have been secured to the hoist by tugging on each individual strap prior to raising the hoist

Damaged or flawed equipment must be taken out of use immediately and reported to the Nurse in Charge/Manual Handling Facilitator

Slide Sheets

Recommended slide sheets for use are

Quintal Variglide

Locomotor

Quintal User Specific (infection control)

Bariatric(specific to that Service User)

Ensure slide sheet is clean

Ensure that there are no small tears, flaws  or discolouration if so do not use

Ensure slide sheet is fit for purpose

Never discard the slide sheet on the floor

Wheelchair Safety

Remember you are the line manager for the task and responsible for the safety of the Service User

A full risk assessment has been completed

The footplates are in situ (unless the risk assessment states otherwise)

If lap straps are attached they should not be removed

The brakes are in working order

The tyres are inflated

Bariatric

Definition

 “the branch of medicine or surgery that deals with the causes, prevention and treatment of obesity

On average someone over the weight of 25 stone

This would also depend on their Body Mass Index (is a measure of body fat based on height and weight)

Statistics

30,000 deaths are caused by obesity

NHS spends £300 million a year

Three quarters of Brits are overweight

Majority of obese people are under 45

The management of extremely heavy Service Users in the past 10years has become a core topic at many conferences relating to manual handling

All obese Service Users should be accorded their Human Rights and organisations should have systems in place that do not impinge on these rights.

In Conclusion

Musculoskeletal Disorders are the most common occupational illness in Britain and injury can occur while doing any activity that involves some movement of the body from heavy lifting to typing

Always remember the Safe Principles of Manual Handling.