Dementia - continence issues

Loss of continence is loss of control of bladder or bowel function, and is also known as incontinence. Incontinence may occur in people with dementia for many reasons.

Our brains send messages to our bladder and bowel telling them when it is necessary to empty them. 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 there is a decline of intellect and memory as a result of dementia, incontinence may occur.

The changes in a person’s brain that occur with dementia can interfere with a person’s ability to:

• recognise the need to go to the toilet
• be able to wait until it is appropriate to go to the toilet
• find the toilet
• recognise the toilet
• 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 in people with dementia, 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 to obtain a full medical assessment and find out why the incontinence is occurring. Talking with a continence nurse may also be helpful.

Information to tell the doctor

You can help the doctor to work out the cause of the incontinence. Information about the continence problems you can give the doctor include:

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

If medical assessment does not indicate any other medical reasons for the incontinence, then the cause is most likely to be 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 be taken either to resolve the problem or to make it less stressful.

It is important for the carer to seek professional help at an early stage and not try to struggle alone. They should let anyone else who is helping to care for the person with dementia 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.

Suggestions for managing incontinence

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

• Make sure the person is drinking adequate 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 the person’s 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.
• Try to establish a regular routine for the person to have something to drink with and between meals.
• There are many aids and appliances available to help in managing incontinence.

Communication and incontinence

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.

Environment and incontinence

• 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.
• The person may have difficulty undressing.
• The lack of privacy may inhibit the person.
• 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 if the person has a fall.
• The person with dementia should not be able to lock themselves inside the toilet.
• 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 – toilets for people with disabilities are usually for both sexes and there is plenty of room for two people.

Clothing and incontinence

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

• simplifying clothing – use Velcro tape instead of buttons or zippers
• trying elastic waistbands for trousers or wraparound skirts
• trying not to let the person become accustomed to wet clothes
• selecting clothing that is washable and does not need ironing
• using protective garments and disposable pads if applicable.

Improving continence in the toilet

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

• running the tap or giving the person a drink of water if they are having trouble urinating
• allowing them 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.

Bathroom aids and incontinence

Bathroom aids that might help with continence include:

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

Skin care and incontinence

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

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

Constipation

Suggestions to decrease constipation in people with dementia include:

• a high-fibre diet and at least five to eight glasses of water a day
• plenty of regular exercise
• a routine to help keep track of the person’s bowel movements – people with dementia may forget when they have gone to the toilet.

If constipation persists, always see your doctor.

Respecting privacy

It is important to respect the privacy and dignity of the person with incontinence. Losing control can be humiliating and embarrassing, so caregivers 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.

Where to get help

• Your GP (doctor)
• Your local council
• Your local community health centre
• National Dementia Helpline, Dementia Australia Tel. 1800 100 500
• Aged Care Assessment Services Tel. 1300 135 090
• My aged care Tel. 1800 200 422
• Cognitive Dementia and Memory Service (CDAMS) clinics
• Carers Victoria Tel. 1800 514 845
• Carer Gateway Tel. 1800 422 737
• Dementia Behaviour Management Advisory Service (DBMAS) Tel. 1800 699 799 – for 24-hour telephone advice for carers and care workers
• Continence Foundation of Australia
• Continence Aids Payment Scheme (CAPS), Department of Health and Ageing, Australian Government.