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Letters to the Editor
Diaper with cushion buttock
Dear Editor, Diapers are widely used for fecal and urinary incontinence in self-care-dependent older adults; in particular, treatment of fecal incontinence is difficult for both patients and caregivers. Diapers should be changed as soon as possible after excretion of stools, but it is sometimes difficult for self-care-dependent older patients to let caregivers know when they have excreted.1 A shortage of caregivers is another limitation to the ideal treatment of fecal incontinence. Stools and/or urine around the perineum for a longer period of time might have many consequences of not only discomfort of patients, but also skin reactions, which exacerbate decubitus and urinary infection.2 Furthermore, lean buttocks in these partients would accelerate decubitus in the perineum and caudal area. In the present report, we have developed a new type of diaper with a big hole around the perineum. The new diaper is supported by a cushion buttock in order to separate direct contamination of excretion, and to compensate for lean buttocks. A cushion buttock might reduce pressure ulcers around the perineum and caudal area. Figure 1a, shows a round cushion buttock with an outer frame of 32 cm in length × 34 cm in width 6 cm in thickness, and an inner hole of 26 cm in length × 13 cm in width, which is made of a combination of three different sponges for enabling the patients to attach it comfortably to their buttocks for a long time. Both the front and rear of the round buttock are relatively thin (3 cm in thickness) in order to remove pressure for the caudal area. The cushion buttock is compressed to approximately 2 cm in thickness to allow for 50 kg in bodyweight sitting on it. The cushion buttock is covered by a thin waterproof bag, and can be detached with a fastener for laundering (Fig. 1b). The cover of the cushion buttock extends laterally with front arms. Figure 1c show an ordinary paper diaper, except for a hole covered by a bag. The hole is made by cutting longitudinally by 28 cm in the center of the diaper, which is covered by a bag of approximately 500 mL in capacity, which has absorbable paper inside and is waterproof outside. The diaper is adhered to the covered cushion buttock (Fig. 1d). The diaper with the cushion buttock is fixed so the hole of the diaper, which is 24 cm in length × 11 cm in width and 5 cm in depth in the final shape, does not dislodge from the anus (Fig. 1e). The diaper with the cushion buttock is inserted beneath the hips of patients lying down in the supine position, and is rotated laterally and adjusted to © 2014 Japan Geriatrics Society
the position of the perineum by pulling the diaper from the opposite side of the patient. Dislodgment of the diaper from the anus a few cm in any direction would not cause trouble for excreting feces into the bag. Urine absorbable tissue 12 cm × 30 cm is places at the front of the perineum for frequent urine incontinence. After the diaper is fixed in place, to the patients trousers are put back on and the patient is moved to a chair or to their bed. Distributions of stools in diapers were compared between the new type (diaper with cushion buttock) and ordinary diapers. Stools were excreted using magnesium oxide, lactobacillus bifidus, sennoside or a combination of these medicines.3 Prescriptions for these constipation medicines were not systematic, and were dependent on the doctor’s choice. Existence of stools was observed after treatment of constipation for 2–5 days using either of laxoberon, teleminsoft or an enema in either a sitting or supine position, during which either the new type or ordinary diaper was used. A total of 25 patients (16 women and 9 men; age 82 ± 7 years, Mini-Mental State Examination 7 ± 5) with severe dementia who were inpatients at Sendai Tomizawa Hospital, a geriatric hospital, were studied.4 The diagnosis of dementia was made for a total of 25 patients according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria.5 All patients were bedbound or chairbound, and could eat food by themselves or by the assistance of caregivers. Tiapride hydrochloride (25 mg), a dopamine D1 antagonist, was used as necessary. Patients were randomly assigned to the new type diaper group (n = 12, age 83 ± 8 years) or the control group with the ordinary diaper (n = 13, age 81 ± 7 years) using a random number table. Written informed consent was obtained from participants or their families after a detailed explanation of the study. Stools were observed in approximately 40% of patients during 1 day, and stools were observed in all patients within 5 days. Stools in the new type of diaper were observed in the bag in all patients, except for a little contamination of feces to the periphery of the hole of the diaper, and a small amount of feces around the anus; whereas those in ordinary diaper stools were observed to have feces widely distributed on the ordinary diaper, and feces were observed around the perineum, including the urinary tract entrance in women and/or caudal area. In one patient with diarrhea and another patient, a large amount of feces were spread outside the ordinary diaper, whereas even diarrhea was inside the bag of the new type of diaper in one patient. doi: 10.1111/ggi.12163
| 233
A Satoh et al.
a
Figure 1 (a) Cushion buttock consists of three different rebound sponges to cover lean buttocks. (b) The cover of the cushion buttock has both lateral and front arms with an adhesive face inside the arms. (c) A new diaper is made by making a slit longitudinally in an ordinary diaper with a bag of 500 mL in capacity made by absorbable paper inside. (d) The diaper with the bag is adhered to the cushion buttock. (a) The outer surface of the cover of the cushion buttock is round and slippery.
◀
b
c
d
e
Urine was absorbed in either urine absorbable tissue or the bag. There were no patients who complained of uncomfortable feeling of discomfort with the cushion buttock during continuous use of the new type diaper. In two patients, decubitus in the caudal area subsided after the new diapers were continuously used for 1 month (man aged 82 years) and 6 months (woman aged 89 years), respectively. We have developed the new type diaper that seems to be useful for bedbound and chairbound self-dependent patients. So many diapers have been used so far, and most of them are devised to absorb urine. Until now, a diaper that separates fecal excretions from the perineum has not been developed. The extra work required for the cushion buttock diaper is troublesome compared with the ordinary diaper, because the patient needs to be turned sideways to fix the cushion buttock, but the benefits include less cleaning around the perineum after excretion of stools and relieving the pressure of ulcers. The cushion buttock lifts the lean buttocks of patients, and keeps their waists relatively flat on their beds, resulting in little harm while lying supine or sideways in bed by 20–30° while rotating position. The present study is a preliminary study to check how stools are excreted into the bag for limited periods of time and limited numbers of patients. Further work is required to understand the limitations of using the cushion buttock diapers for long periods for various patients. The new diaper is small enough to wear under usual trousers, and could be used in the same way as an ordinary one, but with advanced benefit.
Disclosure statement The authors declare no conflict of interest. Atsuko Satoh, Masahiko Fujii, Yoshiko Toukairin, Mutsuko Kajiwara, Sachiko Satoh and Hidetada Sasaki Sendai Tomizawa Hospital, Sendai, Japan
References 1 Fujii M, Ohrui T, Sato T, Sato T, Sato N, Sasaki H. Greentea for decubitus ulcer in bedridden patients. Geriatr Gerontol Int 2003; 3: 208–211.
234 |
© 2014 Japan Geriatrics Society
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Letters to the Editor 2 Fujii M, Sato T, Ohrui T, Sato T, Sasaki H. Interanal stool bag for the bedridden elderly with pressure ulcer. Geriatr Gerontol Int 2004; 4: 120–122. 3 Takahashi M, Shirai S, Sawayama C et al. Constipation and aspiration pneumonia. Geriatr Gerontol Int 2012; 12: 570–571.
4 Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–198. 5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington DC: American Psychiatric Association, 1994.
COMMENTS
Incident delirium from interdisciplinary team care Dear Editor, The article by Yoo et al.1 is a valuable addition to the delirium literature. I applaud the authors for searching medical records for a past diagnosis of dementia or mild cognitive impairment. The authors did not mention prevalent delirium as an exclusion factor – could they clarify whether they excluded prevalent delirium? They recruited patients over a period of 20 weeks in 2007. Recruitment 6 years ago might in part explain the unexpected high rate of incident delirium (94/518 or 18.1%). A more likely explanation is that behavioral and psychological symptoms of dementia (BPSD) were counted as delirium. From January 2011 to March 2013, I admitted 896 age ≥65 years acute geriatric admissions: 69 (7.7%) had prevalent Confusion Assessment Method (CAM)+ delirium and 23 (2.6%) had incident CAM+ delirium. Could Yoo et al. report the number and proportions of patients in each group who went to permanent highlevel care as opposed to skilled nursing homes? The authors could improve their study if they had measured the following: (i) hearing, assessed with the whisper test;2 (ii) if hearing was impaired despite hearing aids, to use a portable amplifier with headphones3 (cost US$100 with no consumables other than replacing batteries); (iii) inattention, by formal tests, such as five and six digit span forward;3 (iv) serum albumin, leukocyte count and neutrophil counts, as powerful predictors of discharge mortality; (v) instrumental activities of daily living (IADL).4 This is a better measure of cognitive recovery than ADL;4 and (vi) serial cognitive testing at discharge, 6 and 12 months. I recommend the Montreal Cognitive Assessment over the Mini-Mental State Examination.
© 2014 Japan Geriatrics Society
I am the principal investigator in the Central Coast Australia Delirium Intervention Study (CADIS). This is a prospective randomized controlled trial registered with Clinical Trials.Gov NCT01650896. CADIS compares CAM+ and CAM– subjects, as well as subjects positive and negative by a new diagnostic criteria I devised. CADIS also compares management of prevalent delirium by geriatricians in an acute geriatric unit with that of general internists outside the geriatric unit.
Disclosure statement The authors declare no conflict of interest. Paul Regal University of Newcastle, Lake Haven, New South Wales, Australia
References 1 Yoo JW, Nakagawa S, Kim S. Delirium and transition to a nursing home of hospitalized older adults: a controlled trial of assessing the interdisciplinary team-based “geriatric” care and care coordination by non-geriatrics specialist physicians. Geriatr Gerontol Int 2013; 13: 342–350. 2 Regal P. Hearing impairment, amplifiers and digit span. Am J Geriatr Psychiatry 2013; 21: doi:10/1016/j.jagp.2012.08.019. 3 Regal P. Confusion Assessment Method (CAM) indicators when CAM positivity in 647 patients has good outcome. J Am Geriatr Soc 2013; 61: 173. 4 Regal P, Hetherington E. Baseline IADL and incident dementia. J Am Geriatr Soc 2012; 60: 1189–1190.
doi: 10.1111/ggi.12120
| 235
Letters to the Editor
Diaper with cushion buttock
Dear Editor, Diapers are widely used for fecal and urinary incontinence in self-care-dependent older adults; in particular, treatment of fecal incontinence is difficult for both patients and caregivers. Diapers should be changed as soon as possible after excretion of stools, but it is sometimes difficult for self-care-dependent older patients to let caregivers know when they have excreted.1 A shortage of caregivers is another limitation to the ideal treatment of fecal incontinence. Stools and/or urine around the perineum for a longer period of time might have many consequences of not only discomfort of patients, but also skin reactions, which exacerbate decubitus and urinary infection.2 Furthermore, lean buttocks in these partients would accelerate decubitus in the perineum and caudal area. In the present report, we have developed a new type of diaper with a big hole around the perineum. The new diaper is supported by a cushion buttock in order to separate direct contamination of excretion, and to compensate for lean buttocks. A cushion buttock might reduce pressure ulcers around the perineum and caudal area. Figure 1a, shows a round cushion buttock with an outer frame of 32 cm in length × 34 cm in width 6 cm in thickness, and an inner hole of 26 cm in length × 13 cm in width, which is made of a combination of three different sponges for enabling the patients to attach it comfortably to their buttocks for a long time. Both the front and rear of the round buttock are relatively thin (3 cm in thickness) in order to remove pressure for the caudal area. The cushion buttock is compressed to approximately 2 cm in thickness to allow for 50 kg in bodyweight sitting on it. The cushion buttock is covered by a thin waterproof bag, and can be detached with a fastener for laundering (Fig. 1b). The cover of the cushion buttock extends laterally with front arms. Figure 1c show an ordinary paper diaper, except for a hole covered by a bag. The hole is made by cutting longitudinally by 28 cm in the center of the diaper, which is covered by a bag of approximately 500 mL in capacity, which has absorbable paper inside and is waterproof outside. The diaper is adhered to the covered cushion buttock (Fig. 1d). The diaper with the cushion buttock is fixed so the hole of the diaper, which is 24 cm in length × 11 cm in width and 5 cm in depth in the final shape, does not dislodge from the anus (Fig. 1e). The diaper with the cushion buttock is inserted beneath the hips of patients lying down in the supine position, and is rotated laterally and adjusted to © 2014 Japan Geriatrics Society
the position of the perineum by pulling the diaper from the opposite side of the patient. Dislodgment of the diaper from the anus a few cm in any direction would not cause trouble for excreting feces into the bag. Urine absorbable tissue 12 cm × 30 cm is places at the front of the perineum for frequent urine incontinence. After the diaper is fixed in place, to the patients trousers are put back on and the patient is moved to a chair or to their bed. Distributions of stools in diapers were compared between the new type (diaper with cushion buttock) and ordinary diapers. Stools were excreted using magnesium oxide, lactobacillus bifidus, sennoside or a combination of these medicines.3 Prescriptions for these constipation medicines were not systematic, and were dependent on the doctor’s choice. Existence of stools was observed after treatment of constipation for 2–5 days using either of laxoberon, teleminsoft or an enema in either a sitting or supine position, during which either the new type or ordinary diaper was used. A total of 25 patients (16 women and 9 men; age 82 ± 7 years, Mini-Mental State Examination 7 ± 5) with severe dementia who were inpatients at Sendai Tomizawa Hospital, a geriatric hospital, were studied.4 The diagnosis of dementia was made for a total of 25 patients according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria.5 All patients were bedbound or chairbound, and could eat food by themselves or by the assistance of caregivers. Tiapride hydrochloride (25 mg), a dopamine D1 antagonist, was used as necessary. Patients were randomly assigned to the new type diaper group (n = 12, age 83 ± 8 years) or the control group with the ordinary diaper (n = 13, age 81 ± 7 years) using a random number table. Written informed consent was obtained from participants or their families after a detailed explanation of the study. Stools were observed in approximately 40% of patients during 1 day, and stools were observed in all patients within 5 days. Stools in the new type of diaper were observed in the bag in all patients, except for a little contamination of feces to the periphery of the hole of the diaper, and a small amount of feces around the anus; whereas those in ordinary diaper stools were observed to have feces widely distributed on the ordinary diaper, and feces were observed around the perineum, including the urinary tract entrance in women and/or caudal area. In one patient with diarrhea and another patient, a large amount of feces were spread outside the ordinary diaper, whereas even diarrhea was inside the bag of the new type of diaper in one patient. doi: 10.1111/ggi.12163
| 233
A Satoh et al.
a
Figure 1 (a) Cushion buttock consists of three different rebound sponges to cover lean buttocks. (b) The cover of the cushion buttock has both lateral and front arms with an adhesive face inside the arms. (c) A new diaper is made by making a slit longitudinally in an ordinary diaper with a bag of 500 mL in capacity made by absorbable paper inside. (d) The diaper with the bag is adhered to the cushion buttock. (a) The outer surface of the cover of the cushion buttock is round and slippery.
◀
b
c
d
e
Urine was absorbed in either urine absorbable tissue or the bag. There were no patients who complained of uncomfortable feeling of discomfort with the cushion buttock during continuous use of the new type diaper. In two patients, decubitus in the caudal area subsided after the new diapers were continuously used for 1 month (man aged 82 years) and 6 months (woman aged 89 years), respectively. We have developed the new type diaper that seems to be useful for bedbound and chairbound self-dependent patients. So many diapers have been used so far, and most of them are devised to absorb urine. Until now, a diaper that separates fecal excretions from the perineum has not been developed. The extra work required for the cushion buttock diaper is troublesome compared with the ordinary diaper, because the patient needs to be turned sideways to fix the cushion buttock, but the benefits include less cleaning around the perineum after excretion of stools and relieving the pressure of ulcers. The cushion buttock lifts the lean buttocks of patients, and keeps their waists relatively flat on their beds, resulting in little harm while lying supine or sideways in bed by 20–30° while rotating position. The present study is a preliminary study to check how stools are excreted into the bag for limited periods of time and limited numbers of patients. Further work is required to understand the limitations of using the cushion buttock diapers for long periods for various patients. The new diaper is small enough to wear under usual trousers, and could be used in the same way as an ordinary one, but with advanced benefit.
Disclosure statement The authors declare no conflict of interest. Atsuko Satoh, Masahiko Fujii, Yoshiko Toukairin, Mutsuko Kajiwara, Sachiko Satoh and Hidetada Sasaki Sendai Tomizawa Hospital, Sendai, Japan
References 1 Fujii M, Ohrui T, Sato T, Sato T, Sato N, Sasaki H. Greentea for decubitus ulcer in bedridden patients. Geriatr Gerontol Int 2003; 3: 208–211.
234 |
© 2014 Japan Geriatrics Society
bs_bs_banner
Letters to the Editor 2 Fujii M, Sato T, Ohrui T, Sato T, Sasaki H. Interanal stool bag for the bedridden elderly with pressure ulcer. Geriatr Gerontol Int 2004; 4: 120–122. 3 Takahashi M, Shirai S, Sawayama C et al. Constipation and aspiration pneumonia. Geriatr Gerontol Int 2012; 12: 570–571.
4 Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–198. 5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington DC: American Psychiatric Association, 1994.
COMMENTS
Incident delirium from interdisciplinary team care Dear Editor, The article by Yoo et al.1 is a valuable addition to the delirium literature. I applaud the authors for searching medical records for a past diagnosis of dementia or mild cognitive impairment. The authors did not mention prevalent delirium as an exclusion factor – could they clarify whether they excluded prevalent delirium? They recruited patients over a period of 20 weeks in 2007. Recruitment 6 years ago might in part explain the unexpected high rate of incident delirium (94/518 or 18.1%). A more likely explanation is that behavioral and psychological symptoms of dementia (BPSD) were counted as delirium. From January 2011 to March 2013, I admitted 896 age ≥65 years acute geriatric admissions: 69 (7.7%) had prevalent Confusion Assessment Method (CAM)+ delirium and 23 (2.6%) had incident CAM+ delirium. Could Yoo et al. report the number and proportions of patients in each group who went to permanent highlevel care as opposed to skilled nursing homes? The authors could improve their study if they had measured the following: (i) hearing, assessed with the whisper test;2 (ii) if hearing was impaired despite hearing aids, to use a portable amplifier with headphones3 (cost US$100 with no consumables other than replacing batteries); (iii) inattention, by formal tests, such as five and six digit span forward;3 (iv) serum albumin, leukocyte count and neutrophil counts, as powerful predictors of discharge mortality; (v) instrumental activities of daily living (IADL).4 This is a better measure of cognitive recovery than ADL;4 and (vi) serial cognitive testing at discharge, 6 and 12 months. I recommend the Montreal Cognitive Assessment over the Mini-Mental State Examination.
© 2014 Japan Geriatrics Society
I am the principal investigator in the Central Coast Australia Delirium Intervention Study (CADIS). This is a prospective randomized controlled trial registered with Clinical Trials.Gov NCT01650896. CADIS compares CAM+ and CAM– subjects, as well as subjects positive and negative by a new diagnostic criteria I devised. CADIS also compares management of prevalent delirium by geriatricians in an acute geriatric unit with that of general internists outside the geriatric unit.
Disclosure statement The authors declare no conflict of interest. Paul Regal University of Newcastle, Lake Haven, New South Wales, Australia
References 1 Yoo JW, Nakagawa S, Kim S. Delirium and transition to a nursing home of hospitalized older adults: a controlled trial of assessing the interdisciplinary team-based “geriatric” care and care coordination by non-geriatrics specialist physicians. Geriatr Gerontol Int 2013; 13: 342–350. 2 Regal P. Hearing impairment, amplifiers and digit span. Am J Geriatr Psychiatry 2013; 21: doi:10/1016/j.jagp.2012.08.019. 3 Regal P. Confusion Assessment Method (CAM) indicators when CAM positivity in 647 patients has good outcome. J Am Geriatr Soc 2013; 61: 173. 4 Regal P, Hetherington E. Baseline IADL and incident dementia. J Am Geriatr Soc 2012; 60: 1189–1190.
doi: 10.1111/ggi.12120
| 235
![[Diaper dermatitis].](/assets/img/hold.png)
