Incontinence-associated dermatitis (IAD) is a common type of moisture-associated skin damage related to prolonged exposure to urine and faecal incontinence (Gray et al, 2011). Historically, a variety of terms were used to describe this condition, including moisture lesions, irritant dermatitis, perineal dermatitis and nappy rash (Gray et al, 2007; Beeckman et al, 2015; Ferreira et al, 2020) but IAD is the accepted terminology now used across the literature, defined as ‘a type of irritant contact dermatitis (inflammation of skin) found in people with urinary and or faecal incontinence’ (Beeckman et al, 2015) and as such can occur in any age group.
IAD is a top-down injury presenting as redness of the skin including oedema of the surface of the skin, and may be accompanied by blisters, serous exudate, epidermal erosion, and secondary cutaneous infection (Gray et al, 2012; Beeckman et al, 2016). The affected skin area may have varying depths of damage to the epidermis, be patchy or continuous with poorly defined edges, while affected intact skin may be firmer and warmer than adjacent unaffected areas (Beeckman et al, 2015). Histopathological analysis of IAD reveals inflammation of the upper dermis, resulting in erythema (Houwing et al, 2007; Mugita et al, 2015). Erosion is followed by dermal and epidermal proliferation as well as vascular occlusion, resulting in necrobiosis and partial tissue loss. In contrast, pressure injuries are largely caused by bottom-up damage when pressure or shear destroys deeper tissues such as muscle (Gray et al, 2012). Histopathological analysis of pressure injury indicates ischaemia as the major culprit (Houwing et al, 2007), and ultrasonic imaging reveals subdermal pockets of oedema near underlying bone (Quintavalle et al, 2006).
Ageing and IAD
Older adults are particularly vulnerable to IAD as age-related changes to the skin increase its fragility, which is stressed further by a moist environment created by urine, faecal or combined incontinence (Beeckman, 2017; Ferreira et al, 2020). Normal ageing makes skin more fragile and prone to injury owing to epidermal thinning, collagen and elastin loss, and general moisture loss (LeBlanc et al, 2018). Ultraviolet (UV) radiation damage, inherited diseases including ichthyosis (dry skin), drugs, clothing irritants, incontinence maceration, and repetitive skin cleansing may all cause skin fragility (Wounds UK, 2018). The prevalence rates of urinary incontinence vary across a person's age profiles, with countless causes, which can be multifactorial. Urinary incontinence has been defined as involuntary leakage of urine in an inappropriate place, combined with social and hygienic consequences (Abrams et al, 2010). The prevalence rates of incontinence increase as the population ages; however, it is not an inevitable or acceptable part of ageing, as it can be treated or managed effectively in most circumstances (Buckley and Lapitan, 2010; Jung et al, 2015). Studies have identified prevalence rates of incontinence as 44–57% for women aged 40–60 years, in contrast to men in the older age profile, with reported statistical figures of 11–34% (Buckley and Lapitan, 2010; Flanagan et al, 2012; Qaseem et al, 2014). Prevalence may also be influenced by the situation and setting where the person lives: the British Geriatrics Society (2018) identified that the prevalence rates of urinary incontinence are one in three individuals in residential care, and two in three individuals in a nursing home. Urinary incontinence is one of the most common reasons why an individual may be admitted into a care setting (Royal College of Physicians, 2015; Wagg, 2015). These statistics are similar to a finding by Jeong et al (2012), who recorded that 50% of individuals living in residential homes experience urinary incontinence.
Faecal incontinence, the involuntary loss of faeces, which can be either solid or liquid, can also affect individuals of any age (D'Ancona et al, 2019). Although the prevalence of faecal incontinence is higher in the older population and women, like urinary incontinence it is not an inevitable part of the ageing process (Campbell et al, 2016; Russell et al, 2017). The prevalence of faecal incontinence within acute care settings in the last decade ranges from 6.5% to 20%, with a higher prevalence occurring with increasing age (Stokes et al, 2016). In older adult residential settings, the prevalence of faecal incontinence is even higher, varying from 25.4% to 66%, with a systematic review reporting a medium prevalence of 42.4% across 17 studies (Rohwer et al, 2013; Musa et al, 2019; Ferreira et al, 2020). All types of incontinence, but in particular faecal and combined incontinence, are risk factors for developing IAD (Kottner et al, 2014; Johansen et al, 2018; Kayser et al, 2019; Chen et al, 2023).
Given the prevalence of incontinence in the older adult population and coupled with increasing skin fragility, impaired sensory perception, declining mobility and cognitive function and increasing functional dependence, the risk of developing IAD also increases with advancing age (Johansen et al, 2018; Ferreira et al, 2020; Koudounas et al, 2020). IAD can impact negatively on older adults' physical and psychosocial wellbeing. It increases patient burden leading to poorer quality of life, loss of independence, disruption in daily activities including sleep, causes pain and considerable discomfort and increases the risk of pressure ulcer development (Beeckman et al, 2014; 2015; Wang et al, 2018; Gray and Giuliano, 2018; Ferreira et al, 2020). Furthermore, IAD also poses significant challenges in healthcare delivery as it can be difficult, time-consuming and expensive to manage and may also reflect the quality of care provided (NHS England, 2018).
Establishing prevalence
An important starting point for evaluating the burden of IAD is the empirical assessment of older adults for IAD and developing clear evidence of its prevalence rate. However, the literature over the past decade highlights a wide variation in the prevalence of IAD across different regions, healthcare settings and age profiles and to date no prevalence studies have been conducted in an Irish setting. Even in the broader field of incontinence prevalence, there have been very few studies conducted in Ireland, although in 2019, an acute hospital in the West of Ireland conducted a study on the point prevalence of urinary and faecal incontinence (Condon et al, 2019).
How IAD prevalence is reported can differ across studies. Kayser et al (2019) suggested two ways to determine IAD prevalence. First, the fraction of both continent and incontinent patients, combined, is used to determine IAD prevalence. The second option is to determine only how many incontinent patients have IAD – IAD exclusively affects incontinent people, thus addressing this would be more accurate.
In research using cross-sectional surveys, the prevalence of IAD among continent and incontinent participants in acute care settings varied between 4.3% (Clark et al, 2017) and 7.6% (Johansen et al, 2018), while a prevalence estimate in a similar group based on secondary data analysis reported a higher IAD occurrence at 21.3% (Gray and Giuliano, 2018). Concurrently, IAD prevalence among continent and incontinent older adults in long-term care ranges from 5.2% (Boronat-Garrido et al, 2016) to 35% (Hahnel et al, 2017). A higher prevalence of IAD (50%) among incontinent older adults has also been reported in long-term wards within acute care settings (Ferreira et al, 2020). In a Belgian long-term care facility, a two-arm interventional study revealed that the control group exhibited a baseline prevalence of IAD at 22.8%, while the experimental group exhibited a similar figure at 22.3%. Chronic incontinence (urinary, faecal, or dual) was a prerequisite for all subjects to qualify for inclusion in the research (Beeckman et al, 2011a)
Variation in IAD prevalence may be due to multiple factors including differences in clinical criteria used to diagnose IAD and the lack of international validated and standardised IAD data collection tools. Several IAD assessment/categorising tools are available, including the IAD severity tool (Borchert et al, 2010), the Skin Assessment Tool (Beeckman et al, 2011b), the Ghent Global IAD tool (Beeckman et al, 2018) and the Scottish Skin Excoriation Tool (National Association of Tissue Viability Nurse Specialists Scotland, 2020). Variation may also be due to the use of different assessment methods to identify the presence of IAD. These includes direct clinical observation and visual inspection, as recommended by the Global IAD Expert Consensus Panel (Beeckman et al, 2015) or diagnosis based on secondary data analysis or from electronic data sets; thus, compounding the challenges in comparing estimates of IAD prevalence across regions.
There are concerns about the possible under reporting and misdiagnosis of IAD due to difficulties healthcare staff have in differentiating it from pressure injuries (Schofield, 2020). The prevalence of IAD may indeed be higher than that reported in the literature. A reduction in IAD occurrences is seen as a key indicator of the effective implementation of continence care pathways and services and it highlights the need for ongoing IAD prevalence studies (NHS England, 2018).
Added to this, the population of older people in Ireland is growing, along with the demand for residential care for those who can no longer live independently due to illness or disability – approximately 6% of older people in Ireland are in residential care.
Aim
The aim of this study was to undertake the first IAD point prevalence study across three older adult care settings in Ireland, quantify the size of the problem and benchmark IAD prevalence against similar healthcare settings in other countries, as reported in the literature.
Methods
Design
This was a descriptive, cross-sectional, multi-site study. A point prevalence methodology was used to collect data in three extended care settings for older persons in Ireland, with each site audited on a specific date in July 2019.
Study setting
The study took place in three public-funded community residential care facilities for older persons in Ireland. Overall, 191 residents participated in the study. All residents aged 65 years or older, who were receiving care from the participating institutions on the day of data collection, were considered eligible for participation. People receiving day-care services in any of the three settings were excluded.
All three sites are residential care facilities funded by the Health Service Executive (HSE), Ireland. Site A, B, and C had 100, 54 and 38 residents, respectively.
Inclusion/exclusion criteria
The inclusion criteria were: persons residing in any of the three extended care settings for older persons, at the specific time of data collection, over 65 years of age. The exclusion criteria were: persons attending day care services, persons younger than 65 years, and those unable to provide informed consent
Ethical considerations
Ethical approval was not required as the study was deemed an audit by the relevant research ethics committee. Participant informed written consent was sought and every effort made to maximise the participant's ability to engage in the decision-making process as per national consent and safeguarding policies (HSE, 2014; 2017).
Data collection
Two clinical nurse specialists applied the Scottish Excoriation and Moisture Related Skin Damage Tool when undertaking this study to identify the existence of IAD through clinical observation and visual skin inspection. This tool was used due to the lack of validated and standard tools for IAD. The clinical nurse specialists have extensive competency in wound management, tissues viability and continence promotion, which they applied when using the Scottish Excoriation and Moisture Related Skin Damage Tool to identify IAD severity. In addition, the clinical nurse specialists created a collaborative working relationship with the entire staff of the three extended care settings to ensure a cohesive, combined and integrated approach to this study. The two nurse specialist worked together throughout this comprehensive study, with the clinical constancy and use of the Scottish Excoriation and Moisture Related Skin Damage Tool to support them in this research.
Instruments
A demographic form recorded participant's age, gender, continence status and scores from the Barthel Index, the Mini-Mental State Exam (MMSE) and the Braden and Waterlow pressure injury risk assessment tools. Incontinence was defined as any involuntary loss of urine, faeces or both. Participants with a urinary catheter in place were deemed continent if they had no faecal incontinence.
The Barthel Index, a 10-item scale, evaluates performance-based activities of daily living and overall level of independence versus dependence (Mahoney and Barthel, 1965). It has good inter-rater reliability and demonstrated validity for use with older adults (Bouwstra et al, 2019). The total score available is 20 with lower scores indicating severity of dependence. The MMSE, a widely used test of cognitive function with older adults, has recognised test-retest reliability (0.80-0.95) (Baek et al, 2016). A score of 25 or under indicated possible cognitive impairment.
The Braden Scale, a validated tool (Kring, 2007; Huang et al, 2021), consists of six subscales (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear) with each subscale scored. A low cumulative score indicates a higher risk of developing a pressure injury. The Waterlow Scale assesses known risk factors for developing pressure injuries (Walsh and Dempsey, 2011). The combined total score helps to determine whether the patient is ‘at risk’, ‘high risk’ or ‘very high risk” of developing a pressure ulcer. The higher the score the higher the risk. Both the Braden and Waterlow pressure ulcer risk assessment tools are extensively used in diverse care settings. However, it is important to note that both instruments have some limitations. Clinical nursing judgement is essential for interpreting the findings of the test and implementing appropriate preventive and treatment actions (Braden, 2012; Charalambous et al, 2018). The skin inspection form recorded the presence and severity of IAD, with the presence of IAD assessed using the Scottish Excoriation and Moisture Related Skin Damage Tool (National Association of Tissue Viability Nurse Specialists Scotland, 2020). This tool determined IAD case definition and diagnosis and aided differentiation between IAD and a pressure injury.
The most recent scores from the instrument tools, as recorded in participants' clinical notes, were reported including scores from the Barthel Index bladder sub-section and the Braden mobility/moisture and Waterlow mobility subsections. There were differences across sites in the use of assessment tools. Of the three research sites, site B (n=54) did not use the Barthel Index and site A (n=100) did not use the Waterlow Scale. It was noted that a proportion of participants only had the Waterlow subscales scores recorded. Participants' care plans were also audited to ascertain if they were incontinent of urine or faeces or both. Two clinical nurse specialists (tissue viability and continence management) with the aid of the Scottish tool visually inspected, observed and assessed incontinent participants' skin for signs of IAD.
Data analysis
Data were analysed using SPSS version 25. IAD prevalence was calculated for the total population and the population with incontinence using percentages and confidence intervals (CI). Descriptive statistics were used to describe the demographic and assessment tools data with bivariate associations between categorical data explored using chi square (χ2) tests. Logistic regression was used to determine which variables were associated with IAD (participants who were continent were excluded from the analysis as they had no risk of developing IAD). Variables in the final regression model, entered in a single step, had a univariate significance of ≤0.25 with no collinearity.
Results
Overall, 191 (99%) residents consented to participate in the study. Participants' age ranged from 69 years to 101 years with males accounting for 42% (n=81/191) of the population. Table 1 shows the information gathered from patients' clinical notes on level of independence, cognitive impairment, pressure injury risk assessment, mobility and skin moisture, using the tools previously described.
Table 1. Characteristics of participants
| Total population (N=191*) | Population with incontinence (N=165*) | Population with IAD (N=22*) | |
|---|---|---|---|
| Age (years) – mean (SD) | 85.3 (7.7) | 85.44 (7.6) | 86.45 (8.1) |
| Gender: Females – n, % | 110, 57.6% | 102, 61.8% | 16, 72.7% |
| Barthel score† | n=138§ | n=122§ | n=18§ |
| Mean (SD) | 6.75 (5.6) | 5.69 (4.9) | 5.56 (4.9) |
| Range | 0–20 | 0–17 | 0–17 |
| MMSE score¶ | n=169§ | n=144§ | n=18§ |
| Mean (SD) | 13.94 (9.75) | 12.6 (9.62) | 15.6 (7.2) |
| Range | 0–30 | 0-30 | 0-25 |
| Braden score ** | n=100§ | n=89§ | n=14§ |
| Mean (SD) | 17.68 (3.8) | 17.24 (3.8) | 16.57 (3.9) |
| Range | 7–24 | 7–23 | 12–23 |
| Waterlow score †† | n=67§ | n=59§ | n=6§ |
| Mean (SD) | 16.73 (5.4) | 17.6 (5.2) | 19.5 (4.2) |
| Range | 3–29 | 3–29 | 15–26 |
| Braden mobility scale – n, % | n=100§ | n=89§ | n=14§ |
| Very poor | 14, 14% | 14, 15.7% | 5, 35.7% |
| Probably inadequate | 27, 27% | 26, 27.2% | 4, 28.6% |
| Adequate | 35, 35% | 33, 37.1% | 4, 28.6% |
| No limitations | 24, 24% | 16, 18% | 1, 7.1% |
| Waterlow mobility scale – n, % | n=87§ | n=74§ | n=8§ |
| Fully | 19, 21.8% | 12, 16.2% | 1, 12.5% |
| Restless/fidgety | 15, 17.2% | 11, 14.9% | - |
| Apathetic | 4, 4.6% | 4, 5.4% | - |
| Restricted | 16, 18.4% | 14, 18.9% | 2, 25% |
| Bedbound | 4, 4.6% | 4, 5.4% | - |
| Chairbound | 29, 33.3% | 29, 39.2% | 5, 62.5% |
| Braden moisture scale – n, % | n=100§ | n=89§ | n=14§ |
| Constantly moist | 3, 3% | 3, 3.3% | 1, 7.1% |
| Very moist | 12, 12% | 12, 13.5% | 2, 14.3% |
| Occasionally moist | 37, 37% | 37, 41.6% | 7, 50% |
| Rarely moist | 48, 48% | 37, 41.6% | 4, 28.6% |
Number is based on two units that used this assessment tool;
§Analysis based on this number;
¶MMSE=Mini Mental State Examination, number is based on those with complete data, had the cognitive ability to answer all questions;
**Only one unit used this tool;
††Two units used this tool (n=91) but only 67 residents had total scores recorded, a higher number of residents had mobility subscale score recorded (n=87)
Prevalence of incontinence and incontinence-associated dermatitis
The prevalence of incontinence was 86.4% (Table 2) with a significantly higher proportion occurring in females (χ2 =8.866, df=1, P=0.003). The largest proportion of participants with incontinence were over 80 years of age (79%, 130/165).
Table 2. Prevalence of incontinence and incontinence-associated dermatitis
| Total population (N=191*) | Population with incontinence (N=165*) | Population with IAD (N=22*) | |
|---|---|---|---|
| Prevalence of incontinence – n, % | 165, 86.4% | n/a | n/a |
| Incontinence type – n, % | |||
| Urine | 51, 26.7% | 51, 30.9% | 6, 27.3% |
| Faeces | 9, 4.7% | 9, 5.5% | 3, 13.6% |
| Urine and faeces (combined) | 105, 55% | 105, 63.6% | 13, 59.1% |
| IAD prevalence – n, % | 22, 11.5% | 22, 13.3% | n/a |
| IAD severity – n, % | |||
| Mild | 15, 7.9% | 15, 9.1% | 15, 68.2% |
| Moderate | 5, 2.6% | 5, 3% | 5, 22.7% |
| Severe | 2, 1% | 2, 1.2% | 2, 9.1% |
| IAD location – n, % | n/a | n/a | |
| Anal cleft | 16, 72.7% | ||
| Sacral cleft | 6, 27.3% | ||
| IAD shape n, % | n/a | n/a | |
| Diffuse | 10, 45.5% | ||
| Multiple lesions | 2, 9% | ||
| Linear | 10, 45.5% | ||
| Kissing lesions | 0 | ||
| IAD edges – n, % | n/a | n/a | |
| Diffuse | 3, 14% | ||
| Irregular | 17, 77.3% | ||
| Necrosis – n, % | n/a | n/a | |
| Yes | 0 | ||
| No | 22, 100% | ||
| IAD depth – n, % | n/a | n/a | |
| Superficial | 22, 100% | ||
| Other | 0, 0% | ||
| IAD colour – n, % | |||
| Pink | 0 | ||
| Red | 16, 72.7% | ||
| Red and macerated | 5, 22.7% | ||
| Macerated | 1, 4.5% |
The point prevalence of IAD in the total population was 11.5% (95% CI, 7.4-19.9%) and 13.3% (95% CI, 8.5-19.5%) in the incontinent population with no statistical difference between males and females in either population (χ2= 2.332, df=1, P=0.127 and χ2=1.280, df=1, P=0.258, respectively). All episodes of IAD in the incontinent population occurred in those older than 70 years of age with the highest number occurring in the 80-89 age category (n=11, 6.7%). Given the low number of IAD events it was not feasible to explore the correlation between type of incontinence and the presence of IAD in the incontinent population.
For those with IAD (n=22), 86% of cases occurred in those over the age of 80 years. All of the IAD cases had cognitive impairment, 77% (17/22) had an MMSE score below 25 and 18% (4/22) were unable to complete the assessment due to the level of their cognitive impairment. Only two of the 22 participants with IAD were fully mobile or had no limitations to their mobility.
Further details on the characteristics of the IAD cases are presented in Table 2.
Univariate and logistic regression analyses
The χ2 analyses of the total population showed that being incontinent was related to: being female, being more dependent (Barthel), having possible cognitive impairment, poorer mobility (Braden and Waterlow) and a high risk of pressure ulcer development (Waterlow) (see Table 3).
Table 3. Chi square analysis
| Pearson χ2 | df | P | |
|---|---|---|---|
| Age categories | 2.295 | 4 | 0.682 |
| Gender | 8.866 | 1 | 0.005** |
| Barthel total score | 23.016 | 1 | 0.000*** |
| MMSE | 9.337 | 1 | 0.006** |
| Braden total score | 3.692 | 1 | 0.064 |
| Braden mobility score | 5.202 | 1 | 0.025* |
| Braden moisture score | 2.181 | 1 | 0.209 |
| Waterlow total score | 18.582 | 1 | 0.000*** |
| Waterlow mobility score | 10.412 | 1 | 0.002** |
P<001;
***P<0001
As expected, analyses of the total population also revealed a positive relationship between the presence of IAD and being incontinent (χ2=3.918, df=1, P=0.048); but all other variables (age, gender, activities of daily living, incontinent state, cognitive impairment, risk of pressure ulcers, mobility and moisture) were non-significant. Using similar variables, a logistic regression analysis involving the incontinent population found no predictor variables for IAD among the variables that met the cut-off point for this analysis (age categories, incontinent state, MMSE total score and Braden mobility).
Discussion
This study, to the authors' knowledge the first of its kind in Ireland, found in the total resident population of three extended care settings an IAD point prevalence of 12%, with a 13% occurrence in residents who experienced incontinence. Two ways to determine IAD prevalence have been proposed – either considering it as a fraction of all patients, or only the proportion of incontinent patients with IAD – so this study provides both statistics to compare with earlier research. These findings compare favourably with similar research undertaken in older adult residential care settings where the prevalence of IAD (35%) in a total population of residents in a German nursing home (Hahnel et al, 2017) was 24% higher than that observed in the present study. In relation to residents who are incontinent, Van den Bussche et al (2018) noted a prevalence of 22% across three Belgium nursing homes; 9% higher than this study. A similar high prevalence of IAD among incontinent nursing home residents (22%) was noted in an earlier study in Belgium (Beeckman et al, 2011a), illustrating the challenges involved in preventing IAD occurrence. A high prevalence of IAD was also found in long-term hospitalised older adults, with Ferreira et al (2020) reporting a prevalence of 50% in a study in Brazil. Similar to the methods presented here, these studies used visual inspection, physical examination of the skin and IAD assessment tools when determining IAD presence.
It is interesting to note that research using secondary data analysis or analysis of data sets reports lower and contrasting occurrence of IAD in older incontinent adults across a variety of care settings. A retrospective analysis of International Pressure Ulcer Prevalence survey data reported an IAD prevalence of 18% and 14% in incontinent older adults across long-term acute care and rehabilitation settings (Kayser et al, 2019). In contrast, research that examined secondary data found a lower rate of IAD among nursing home patients who are incontinent. Bliss et al (2017) reported a prevalence rate of 5.5%, whereas Boronat-Garrido et al (2016) reported a comparable rate of 5.2%.
Of the 22 residents with IAD, 17 had cognitive impairment with only 9% of the total study population having no cognitive impairment. Although our study found no relationship between IAD and cognitive impairment other studies have identified diminished cognition awareness as a risk factor for IAD (Beeckman, 2017). Further exploration of diminished cognition as a risk factor for IAD in older person settings may be warranted.
Of note, the prevalence of incontinence in residents in this study was 86%. This is somewhat higher than the previously reported range of 63-69% from studies in older adult care settings (Kayser et al, 2019; Suzuki et al, 2020). Studies also differ on the prevalence of incontinence in females, with a significant higher proportion of those incontinent in the present study being female. Ferreira et al (2020) noted a similar occurrence to the authors' study, with a higher proportion of females experiencing incontinence.
The most common type of incontinence in this study was combined urinary and faecal incontinence, which is similar to that reported by others (Boronat-Garrido et al, 2016; Van den Bussche et al, 2018; Kayser et al, 2019; Ferreira et al, 2020). Although urinary and faecal incontinence are not an inevitable part of ageing it cannot be ignored that combined incontinence is prevalent among older adults in residential settings, leading to complex skin damage, and is a risk factor for developing IAD (Kottner et al, 2014; Johansen et al, 2018; Kayser et al, 2019). This requires the implementation of effective continence management care pathways and strategies following continence assessment (Buckley and Lapitan, 2010; Jung et al, 2015; Musa et al, 2019).
Prior studies reported an association between incontinence and limited mobility and cognitive impairment (Jachan et al, 2019; Suzuki et al, 2020; Hernandez-Martinez-Esparza et al, 2021). These findings are consistent with findings here, which also identified an association between incontinence and being more dependent (Barthel), having a higher risk of pressure ulcer development (Waterlow) and being female. In relation to IAD, a variety of independent predictor factors were identified in the literature, which include, for example, limitations to activities of daily living, poor mobility, all types of incontinence, in particular faecal incontinence, more friction and shear, increased pressure ulcer risk, moisture, not receiving preventive interventions for IAD, increased body mass index and falls risk score (Kottner et al, 2014; Boronat-Garrido et al, 2016; Bliss et al, 2017; Kayser et al, 2019). The study presented here found within the total resident population a relationship between being incontinent and IAD; however, in contrast to other studies and using logistic regression analysis, the authors did not identify any independent predictor factors for the development of IAD. This may be due to the low prevalence of IAD among the group of patients who were incontinent.
A recommendation for future research would be that, to allow for more consistency in reported prevalence rates, prevalence rates for the incontinent population only should be reported.
Strengths and limitations
This study reported on both the total and incontinent population sets in three extended care settings for the older person. This provided evidence-based data within the context of the population at risk of IAD. Reporting data from both groups allows for comparability of study findings within the context of the wider international literature. IAD diagnosis were based on clinical observation, visual inspection and use of assessment tools by two clinical nurse specialists thereby increasing accuracy in differentiating IAD and pressure ulcers. Data relating to IAD risk could only be collated according to the tools used, which has implications for exploring predictive analysis of mobility and overall level of independence as a risk factor for IAD. Further exploration of risk factors is warranted.
Conclusion
Nationally and internationally all health professionals face the ever-increasing longevity of life for older individuals. As such, IAD can be challenging for the older person and nursing staff within older adult extended care settings. This study provides (to the authors' knowledge) the first point prevalence empirical data on the occurrence of IAD in Ireland and although its prevalence in the incontinent older adult population is only 13%, significant resources are needed to manage and treat this condition. The data can act as an incentive for the healthcare service to review and amend existing continence quality improvement initiatives, inform decision-making in relation to future planning and budgeting of new quality improvement projects and act as a benchmark for ongoing auditing of IAD.
With more than one in eight residents in extended care facilities having IAD it is clear that the assessment of IAD needs to be integrated into the routine care of the residents. A standardised validated tool needs to be developed and adapted at a national level. This tool needs to be easy to use and accessible to all health professionals to allow for comparison of prevalence rates.
KEY POINTS
- Incontinence-associated dermatitis (IAD) is a skin inflammation caused by contact with urine or faeces or both
- IAD is a top-down injury, presenting as redness of the skin including oedema of the surface of the skin, and may be accompanied by blisters, serous exudate, epidermal erosion, and secondary cutaneous infection
- IAD can impact negatively on older adults' physical and psychosocial wellbeing, it increases patient burden leading to poorer quality of life, loss of independence, disruption of daily activities including sleep, causes pain and considerable discomfort and increases the risk of pressure ulcer development
- This article provides empirical data on the first point prevalence study on the occurrence of IAD in Ireland. The point prevalence of IAD across the total population and incontinent population was 11.5%, and the prevalence of incontinence was 86.4% – a significantly higher proportion were female
CPD reflective questions
- How does incontinence-associated dermatitis (IAD) impact on the individual and caregivers?
- Drawing on your clinical experience and education, what processes and practices should you, the nurse, carry out if you observe IAD on a patient's skin?
- Reflect on the relationship between IAD and pressure injuries. Does IAD contribute to pressure ulcer development? How would you distinguish between them?