The population is ageing—this is not surprising information. Around 18.2% of the UK population were aged 65 years or older in 2017, a figure that is projected to grow to 20.7% by 2027 (Office for National Statistics, 2018). Although we are aware of the physical and psychological signs and symptoms around ageing, are we applying those to stoma care and looking at how we can best support our patients as they age with their stoma?
As people age, they can develop heart disease, cancer, diabetes, suffer a stroke or any number of other debilitating long-term conditions. Medication lists get longer with polypharmacy becoming a huge problem in the over-65s (Maher et al, 2014). Other physical issues such as failing eyesight, loss of appetite, mobility, dexterity and memory all contribute to problems with maintaining independence with stoma care and it can take time and experience to determine what exactly is causing the issue.
Diet and appetite
Loss of appetite can be caused by a cocktail of medication, mouth ulcers caused by ill-fitting false teeth, a change in circumstances such as bereavement or a move to a nursing home or depression. If the ostomate is not eating regularly or does not have a varied diet, the stoma output will naturally alter. The patient may report constipation, excess flatus or watery stool and the stoma nurse will usually check what medication the person is currently taking, followed by asking for a breakdown of a daily food intake. Checking that teeth are fitting correctly is a simple but effective step to ensuring the ostomate can chew and swallow food properly.
In June, a review published by the Care Quality Commission (CQC) (2019) found that nursing homes were (still) not providing care that met the guidelines, with low awareness of the recommendations on oral health care issued by the. National Institute for Health and Care Excellence (2016). I suspect there are many more older people relying on care agencies in their own homes that are also not getting oral care as necessary. Oral thrush will alter the taste of food as will chemotherapy treatment and certain antibiotics such as metronidazole. People with dementia may suddenly develop a sweet tooth, when it was not their usual preference, or suddenly find sweet things inedible. Try to find whichever foods can tempt someone to eat after eliminating any potential causes of poor appetite or inability to eat. People who live on their own also report they ‘can't be bothered’ to cook for one person and survive on snack meals.
Staff in a nursing home may not have had experience of caring for a person with a stoma and therefore do not fully understand the importance of diet and how the resident may need to discuss meal options with the kitchen staff.
I recently had experience of this when I was asked to review an elderly gentleman with an ileostomy who staff assumed had diarrhoea and other concerns. I carried out some basic stoma training and it became apparent that the staff had not realised that the output of an ileostomy is usually loose. They also did not understand that the food he was eating was having an effect on the output, and they were then happy to become more involved in his menu choices and advise the kitchen staff accordingly. They then asked me why the gentleman's output was so different from that of another resident. On further questioning, it emerged that this female resident had a colostomy so I was able to explain the difference in stoma and expected output. During this discussion, which included more dietary advice, it became apparent that the lady enjoyed eating liquorice regularly. I was able to explain that this would account for the erratic output they had spoken about as liquorice is a natural laxative.
The discussion and training session was extremely beneficial for the staff and residents and we only needed to make a couple of minor alterations to the residents' diet for everyone to be happy and problem free.
Medication side effects
As the population is ageing, the list of medications each person is taking seems to be getting longer by the day. The side effects of many medications usually includes either constipation or diarrhoea, therefore it is always worth checking what medication a patient is taking, as this may be the reason for an altered pattern or output. We may not be able to alter the medication, but we can liaise with the GP and possibly try alternatives or add a laxative or regular antidiarrhoeal (eg Imodium) depending on the symptoms caused by side effects. The RCNi Learning CPD portal has several informative modules around dementia and medication that provide important information but which are quick and easy to complete (https://rcnilearning.com).
Eyesight
Failing eyesight is a common ailment associated with old age. How many patients do we see who have not had an eye test for over 2 years? This may be because they have moved areas, forgotten to book an appointment or just resigned themselves to the fact that their eyes are getting worse and nothing can be done. Encourage patients to have a regular eye check or remind the nursing home carers that an optician may be required and that something as simple as a new pair of suitable spectacles could make a huge difference.
Poor eyesight will affect a person's ability to see the stoma well enough to clean the area/skin properly or to change the pouch accurately. It is also important that the individual can see clearly how to drain and fasten the pouch safely and to spot any possible skin reactions or problems
Mobility and dexterity
Loss of muscle tone as we age can result in someone not being able to stand for as long as they did before. The knock-on effect of this may be the person having to sit to change their stoma pouch, or to prepare a meal.
Poor dexterity will affect how a person applies their stoma appliance and may lead to ongoing problems. Arthritis may be the cause; however, many of our patients are now suffering with peripheral neuropathy due to diabetes or the side-effects of chemotherapy (Cancer Research UK, 2017).
Dementia
Dementia is not an inevitable part of ageing, but more likely to be seen in older people. The Alzheimer's Society (2019) estimates there will be over 1 million people in the UK with dementia by 2025, and that 70% of people in care homes have dementia or severe memory problems. Awareness around dementia is fortunately in the forefront of everyone's minds with dementia-friendly initiatives starting not just in health care but also shops, bus stations and many other public areas.
Dementia can be problematic in stoma care for many reasons. The ostomate may simply forget what to do, how to change or empty the pouch. They may also forget the stoma is there and not realise the pouch needs emptying or changing. I'm sure I am not the only stoma nurse to visit a patient who has forgotten to remove the adhesive backing from the flange and is wondering why it will not stick. I also had a gentleman who began applying the pouch onto his abdomen upside down, which then meant he could not drain the pouch but could not understand why.
Nursing home staff and family members of people with dementia often report that the patient has begun to pull off the stoma bag frequently and throw it on the floor, which is out of character and distressing for the people in the close environment. Stoma nurses are often asked to find a solution, something that is not easy. My first lines of enquiry are to ensure the pouch is fitting correctly and that the skin is not sore. Many times the patient is removing the pouch because it feels sore or itchy underneath or may be leaking and there is usually a simple solution to remedy this. Use of flange extenders, stoma belts or close-fitting underwear may have a place; however, I would always advise the stoma nurse to observe the patient and obtain a full history before making any adaptations. The patient may be disorientated or bored and a simple distraction may be all that is required to change the focus away from the stoma and onto something else such as listening to music, doing a jigsaw or going for a walk. ‘Fiddle mitts’/‘twiddle mitts’ or ‘fidget blankets’ have been a welcome additions to some hospital wards and residential homes to encourage other ways of keeping hands busy.
I have recently been fortunate enough to hear Wendy Mitchell speak about how she has had to adapt her life since being diagnosed with early-onset dementia. I can heartily recommend her bestselling book Somebody I Used to Know or you can follow her on her blog (www.whichmeamitoday.wordpress.com) or on Twitter (@WendyPMitchell) where you will find many pearls of wisdom around simple everyday problems that she and others encounter.
Other lifestyle issues
Of course, not every older person is frail, housebound or taking several medications every day. There are many older people enjoying good health and leading an active social life. In this case, our advice may be more suited to hobbies/exercise, holiday and travel information. Many retired individuals are playing golf or bowls several times a week or attending their local gym. Exercise and hernia prevention advice is for all ages and not just for those returning to work or college.
Alcohol intake is on the increase with people aged 55-64 most likely to be drinking at a higher or increasing risk level (NHS website, 2011). Although we do not want to stop anyone's fun, we do need to explain to our patients that alcohol can increase the stoma output and flatus or loosen the stool. It is also worth mentioning that overindulging may result in a person sleeping through the night and not checking if the pouch needs emptying.
The older population are taking more holidays and travelling to more and more exotic destinations (Age UK, 2012). Our usual holiday advice is relevant, including about packing extra supplies, airport regulations, disposal of products, staying hydrated and dietary considerations. Discussions around holiday clothes and swimwear are not just for the younger ostomate anymore!
Lastly, we need to consider other lifestyle issues, such as sexual activity, in our older ostomate. Traditionally older widows and widowers did not remarry or join the dating scene; however, there has been a change over recent years and now older people are having a second bite of the relationship cherry.
Most stoma nurses will discuss sexuality with their patients but admit to not actively broaching the subject with older people. The 2018 Association of Stoma Care Nurses UK conference delivered many exciting topics around sexuality and discussing sexual activity with patients, alongside caring for patients with dementia, so it is hoped that this will lead to a more comprehensive approach in the future for all ages.
Having a stoma at any age brings many challenges, we simply need to use our experience and knowledge to adapt to each individual situation accordingly, irrespective of the person's age. Lastly, we should keep an open mind and not be afraid to ask for help—we may need to try something that we have never done before. Ultimately the patient's satisfaction is the most important goal.