Causes of Dementia-Related Incontinence
Confusion is the main reason why people with dementia may develop incontinence and the confusion can make existing bladder and bowel problems worse. However, even though many people with dementia develop incontinence as their condition worsens, not all will experience the problem.
Many people with dementia can’t always recognise their need to pass urine or faeces and some are not able to hold on long enough to get to the toilet. Many have trouble identifying the toilet and forget to remove their clothes when they get there. These issues can be even worse when the person is not in surroundings which are familiar to them because they may not be able to identify where a toilet is. This can result in them toileting in places which are inappropriate. Further problems can also occur if the person has an underlying depression, anxiety, stress or illness.
While people with dementia may not be able to completely participate in bladder treatment programs such as pelvic floor exercises or even bladder training there are some strategies which can assist to provide some comfort and dignity.
The first step is to diarise the person’s toileting behaviours. To do this carers need to watch and write down the person’s bladder and bowel habits and look for any patterns which identify toileting needs (eg. pulling at their clothing, restlessness, pacing). If these signs can be identified the person can be taken to the toilet before they have an accident.
Many people with dementia do not always know they need to go to the toilet so they should be taken at regular intervals. A very common time for people to have their bowels open is after meals, particularly breakfast so this is a good time for them to be taken to the toilet. A bladder and bowel diary will assist carers to assess if the toileting program assists.
Sometimes particular signage can assist people with dementia to identify a toilet (eg. a picture of a toilet, a sign with familiar language – toilet, even ‘dunny’ may be language familiar to the person. It’s a good idea to ask their family members if they know what the person used to call the toilet. Sometimes the toilet door can be painted a bright colour rather than the same as other doors – this may assist the person to identify where the toilet is located.
Although some people with dementia might need to have toilet paper and other distractions removed while they are sitting on a toilet, others may need something to do (eg. a book or magazine). This is also a topic which may need to be discussed with family members who may be able to suggest the person’s individual toileting habit (eg. some people used to read the paper – or particular sections of the paper such as the racing guide while they were sitting on the toilet while having their bowels open).
Ensure the areas the person with dementia frequents are not too cluttered. This can make the identification of the toilet easier. Keep the area around them uncomplicated and familiar and consider the use of a night light which might make the toilet door easier to see. The reduced clutter and light also makes it safer for them to negotiate their way to the toilet when lighting is reduced.
Always listen to their conversation and respond to their concerns while showing respect and care. Do not dismiss the person’s concerns as this will only make them more frustrated.
Bladder and Bowel Assistance
Fluids are important. Ensure the person with dementia drinks sufficient fluids each day. It is generally accepted that most people need 1½ to 2 litres of fluid per day (unless otherwise instructed by their doctor). Although water is the best, other fluids such as milk, juice, jellies and liquid soups are helpful.
Fluids are helpful for helping bowel management. Good fluid intakes ensure faeces remains soft and easier to pass. They also help to keep the bladder healthy by keeping the urine well diluted and good fluid intakes assist in the prevention of bladder infections.
The intake of caffeine should be minimised because it can irritate the bladder. Caffeine is mainly found in coffee and cola drinks but there is some, in lesser concentrations, in chocolate and tea.
Constipation can cause pressure on the bladder and reduce bladder size. When a person has constipation they often try to bear down to have their bowels open and this can adversely affect their ability to hold on to their urine.
To avoid constipation ensure the person eats regular amounts of fruit and vegetables. Nutritional specialists suggest the intake of 2 pieces of fruit and 5 serves of vegetables daily. The person should also be encouraged to drink well (see above) and be encouraged to be as mobile as possible through walking.
Encourage good toilet posture – sitting straight while on the toilet and, if agreeable, place their feet on a foot stool.
Should constipation occur it should be treated promptly. Watch for signs that the person needs to toilet and record them on a chart along with any regular times, whether they successfully toilet of if they experience any wetting or soiling. These records can also be useful for establishing an individualised toileting program which is aimed at avoiding accidents.
Clothing - If the person has trouble removing their clothes to toilet look for ways to modify their clothing. This can be through the use of tracksuit pants or trousers with elastic or Velcro rather than zips and buttons if the person has problems with them. Women who like to wear panty hose may be better with stockings.
If these suggestions do not help there may be a need to seek further assistance from a qualified health professional such as the person’s doctor, a continence nurse, a physiotherapist familiar with continence issues, an occupational therapist or even a dietician.
The person’s doctor can review the person’s medications and health issues. Other health professionals can assist with things like mobility, mobility aids, diets and products to assist with the management of incontinence. Many of these products can improve the person’s quality of life and reduce the carer’s burden.
A comprehensive bladder and bowel control check-up should include a physical check and the health professional should ask about when, where and why problems happen.
The carer is often needed to give the required information as he/she may be able to provide information about when the person is more likely to use the toilet or have accidents. They can usually give an idea about how much incontinence occurs, when and how often the person has their bowels open, and, where this may occur (e.g. toilet, pad etc.)
Many people are eligible for assistance to purchase continence products so should also be discussed with the health care professional.
Any medications need to be discussed with the person’s doctor. Antibiotics can be used to treat bladder infections and there are medications for people with overactive bladder or bladder storage problems. The medications for overactive bladder may reduce the number of times the person goes to the toilet (normal is about 4-6 times/day and once a night during an 8 hour sleep). Men who have large prostate gland problems, with can squeeze the urethra (urine tube), can often have medications to which can assist.
However, doctors will usually only prescribe any of these medications for people who have mild dementia because some of these medications can cause increased agitation and confusion. As always, many medications can also cause unwanted side effects or cause new problems such as a dry mouth, constipation, poor balance or a lack of energy. There are also many medications which can worsen bladder and bowel control problems so all medicines should be checked and reviewed by a doctor as some may need to be changed.
Much of the information in this article has been obtained through the Continence Foundation of Australia – Dementia and Bladder and Bowel Control