Dementia - continence issues

Loss of continence is loss of control of bladder or bowel function, and is also known as incontinence. It may occur in people with dementia for many reasons. The brain sends messages to the bladder and bowel telling them when it is necessary to empty. Being in control of these functions depends on an awareness of bodily sensations, such as the feeling of having a full bladder, and the memory of how, when and where to respond.

When intellect and memory decline as a result of dementia, incontinence may occur. The brain changes of dementia can interfere with a person’s ability to:

• recognise the need to go to the toilet
• wait until it is appropriate to go
• find the toilet and recognise it
• use the toilet properly

Causes of incontinence in people with dementia#

Although the brain changes of dementia can lead to incontinence, other medical conditions can also cause continence problems, such as infection, constipation, hormonal changes and prostate enlargement. Many of these conditions are treatable, so the first step is always to consult a doctor for a full medical assessment and to find out why the incontinence is occurring. Talking with a continence nurse may also help.

You can help the doctor work out the cause. Useful information to give the doctor includes:

• the number of times per day the person is incontinent
• whether it is urinary or faecal incontinence
• when the problem started
• whether the person’s clothes are saturated, or whether there is just a trickle
• whether the person passes urine in strange places
• any increase in confusion or any change in behaviour
• the presence of any fever or pain when going to the toilet
• any medication the person is taking

If a medical assessment does not indicate any other reason for the incontinence, then the cause is most likely the person’s dementia.

Caring for someone with incontinence and dementia#

When caring for someone with dementia, incontinence may seem like the last straw, but there are measures that can either resolve the problem or make it less stressful. It is important for the carer to seek professional help at an early stage and not try to struggle alone. Let anyone else who helps care for the person know about the problem too.

Incontinence can be very distressing for the person with dementia.

It helps if the carer remains calm, gentle, firm and patient#

It is important that the carer tries to accept and get over their own embarrassment in having to help the person in such an intimate way. Sometimes a little humour can help.

If you are looking after someone with incontinence, it will help to:

• make sure the person is drinking enough fluids, preferably five to eight glasses of water daily (jelly, ice-cream or custard may be substituted in small amounts) – many people with dementia forget to drink or no longer recognise the sensation of thirst
• consider reducing caffeine intake by using decaffeinated coffee and tea
• observe the person’s toileting patterns and suggest they use the toilet at regular times that follow their pattern
• try toileting before and after meals, and before bed
• establish a regular routine for the person to have something to drink with and between meals

Communication#

When discussing toileting, it may help to:

• use short, simple words to give step-by-step instructions, for example, ‘sit down’
• watch for non-verbal clues, such as pulling at clothes, agitation or a flushed face
• use words that are familiar to the person, such as ‘pee’ or ‘tinkle’

Do not rush the person#

Reassure them#

The environment#

Try to make the situation as simple as possible. Some things to consider include:

• the distance to the bathroom might be too far – a commode may help
• the bed may be too high for the person to feel safe getting in and out
• the floor and toilet seat may be the same colour – try using contrasting colours
• poor lighting may make the toilet difficult to find
• the toilet might not be clearly marked – put a sign on the door, use a night-light or leave the door open

The door of the toilet should be able to be opened from the outside if the person has a fall, and the person should not be able to lock themselves inside.

The person may have difficulty undressing#

The lack of privacy may inhibit the person#

If the person is urinating in inappropriate places, try to remove any objects that may be mistaken for the toilet. When using a public toilet, the person will usually need help – accessible toilets are usually for both sexes and there is plenty of room for two people.

Clothing#

Suggestions to make getting clothes on and off as easy as possible include:

• using protective garments and disposable pads if applicable
• choosing clothing that is easy to manage and does not need ironing

Improving continence in the toilet#

Suggestions to help with continence once you are inside the toilet include:

• allowing the person to get up and down a few times if they are restless or hyperactive and will not sit on the toilet
• giving something to distract them while they are on the toilet – music may have a calming effect
• running the tap or giving the person a drink of water if they are having trouble urinating

Bathroom aids#

Bathroom aids that might help with continence include:

• a clear floor – avoid floor mats to prevent tripping
• a raised toilet seat
• wall-mounted grab-bars to help the person get on and off the toilet
• a securely fastened toilet seat to reduce the risk of slipping

Skin care#

Skin care is very important for everyone, but especially for people with incontinence. Suggestions include:

• wash the person’s skin after an accident to keep it clean and prevent rashes
• make sure the person’s skin does not come into contact with protective plastics, as this will cause soreness

Constipation#

Suggestions to reduce constipation in people with dementia include:

• a high-fibre diet
• a routine to help keep track of the person’s bowel movements – people with dementia may forget when they have been to the toilet

If constipation persists, always see your doctor#

Privacy and dignity#

It is important to respect the privacy and dignity of the person with incontinence. Losing control can be humiliating and embarrassing, so carers need to be sensitive to these feelings. There are bound to be accidents, so try not to worry too much.

Get help in managing the problem and make sure that you take adequate breaks#

Key points#

• You can help the doctor work out the cause of the incontinence
• It is important for the carer to seek professional help at an early stage and not try to struggle alone
• It helps if the carer remains calm, gentle, firm and patient
• Bathroom aids that might help with continence include a clear floor – avoid floor mats to prevent tripping
• Skin care is very important for everyone, but especially for people with incontinence