Taking Action to remain Continent of Urine and Faeces
Incontinence is the involuntary leakage of urine or faeces or flatus (wind). Incontinence is not a normal part of ageing.
Changes to memory and brain function in Alzheimer’s Disease and other dementias can cause reduced independence with toileting and also incontinence. However, incontinence may have treatable causes e.g. urine infections, constipation, englarged prostate, side effects of medication, anxiety, depression, cancer. It is important to have your doctor medically assess the person living with dementia and also review their medications.
Some of the actions below may support the person with dementia to remain continent for longer, promote quality of life and dignity and ease carer stress. Effective management of incontinence reduces the likelihood of falls and fractures and early residential care admission.
Observe, support and preserve the person’s normal pattern or familiar routine for passing urine or faeces
Observe and record the times of passing urine for 24 hours and bowels for 7 days. This information will inform the carer but also provide valuable information to the doctor if needed.
- Going to the toilet at night 1-2 times is not unusual for older people
- Going to the toilet frequently, urgently, having a weak stream of urine or being slow to start to pass urine may indicate an enlarged prostate
- Incontinence or constipation that commences after the introduction of a new medication may be related to a side effect of the medication
Maintain toileting at a time and place that is familiar.
- Scheduled toileting prompts by the carer may be needed e.g. every 2-3 hours; toileting before showering; toileting before bed
- Be flexible – after morning diuretics when more urine is passed, more frequent toileting may be needed. If the normal routine for bowel action is 5a.m. it may require a 5a.m. escort to the toilet when the person is no longer independently initiating this
- Prompt toileting for bowels ½ to 1 hour after a meal if unsure of the normal pattern
- Use terms which are meaningful and culturally appropriate to the person e.g. poo, wee
- Support a diet to aid bowel function – fruit, vegetables, grains daily e.g. finger foods if appetite reduced; comfort foods related to cultural background
- Fluids 1.5-2 litres daily unless medically contraindicated – to aid both bowel and urinary function – may include soup, ice blocks, yoghurt, custard, milk
- Exercise will assist with maintaining mobility, strength, independence, well-being and also continence
- Be aware that the person may find it difficult to wait and may ‘need to go now’
- Identify if environments like crowded, noisy areas on outings increase incontinence
Identify early signs of changed behavior and respond early to change
Difficulty with zips, belts, buttons.
- Provide clothes with elasticised waist or velcro not zips or buttons
- Respect privacy but assist or prompt if needed to start or complete pulling pants down or up
Rushing to get to the toilet and not getting there on time – leaking some urine
- Prompt scheduled toileting times
Presence of additional chronic illness with slow mobility e.g. arthritis and not getting to toilet on time.
- Prompt scheduled toileting times
- Ensure aids in place such as over toilet seat & grab rails to promote independence
- Simple clothing – easy to take down and pull up
Not going to the toilet before going out.
- Prompt to toilet
- Model/show the behavior yourself
- Point to toilet
- Use positive expressions – eye contact, touch, smile, do not rush
Not recognizing toilet signs or being able to toilet independently when out.
- Plan ahead and ensure toilets are easily accessible
- Accompany into disability toilet
- Take change of pad/clothes if needed to reduce carer’s anxiety
Fearful of entering the toilet
- Try to identify why e.g. is a dark toilet mat may be interpreted as a hole in the ground and dangerous
- If toilet space is small – try using an ensuite that is larger, leave door open, turn on light
- Fear loss of privacy – remove mirrors in case it is interpreted as someone else being present
- Fear loss of privacy – no longer recognizes the carer
- Toilet may feel cold in winter or have an unfamiliar, confusing smell e.g. from a deodorizer
- Toilet locks may become confusing – remove or disarm locks if there is a risk of becoming locked in the toilet
- Inability to maintain their own hygiene
- This can contribute to urinary infection by inadequate cleaning or poor technique after bowel motions. Assist to clean in a front to back direction (i.e. clean to dirty)
Forgetting the routine for toileting or not being able to find the toilet or short attention span
- Replace toilet seat with a contrasting, coloured seat e.g. black, dark blue
- Paint the toilet door a contrasting colour to the walls
- Prompt to locate toilet – use simple words, break task down into smaller tasks – ‘let’s go for a walk’; as you walk past the toilet – ‘there is the toilet’, do not rush, reassure
- Prompt to follow the steps of taking pants down and sitting on toilet – place picture on back of door showing steps to take
- Run water to encourage passing urine
- Distract, talk, play music, give magazine or newspaper
- Place picture on toilet door (at eye level when seated) to encourage sufficient time on toilet to pass bowels or pass urine. Never restrain the person.
- Assist or prompt if needed with personal hygiene (disposable gloves may assist). Take opportunity to observe for abnormalities that may suggest urine infection, constipation e.g. reduced volume of urine, dark coloured urine, unusual smell to urine, reduced amount and type of faeces passed, anal itching. Constipation, urine infection, dehydration and pain can result in delirium e.g. an increase in confusion, agitation, reduced balance and alertness. Note if there are any skin changes e.g. rash, broken skin – medicated creams prescribed by the doctor or barrier creams may be required
- Give the person something to hold if they are trying to ‘help you’ unsuccessfully to clean up after a episode of incontinence e.g. small bowl of water or washer. Distract with unrelated conversation. Intervene early before the person tries to remove the pad/pants.
- Caution: do not block up toilet with wet wipes or excessive toilet paper – have plastic bags and bins nearby in toilet/bathroom. Change in the shower recess. Use combined toilet/shower chair where bulk of faeces may drop into pan for ease of disposal and to stop blockage of shower outlet.
- Remove pot plants, waste bins, laundry baskets that may be mistaken for toileting places.
Not being able to communicate the need for toileting
Signs of needing to go to the toilet may include:
- Starting to undress in inappropriate places
- Agitation e.g. pacing up and down, calling out, plucking at clothes, frowning, looking lost, standing up and down, standing in a corner, word-finding difficulty
- Men may need to sit to pass urine if balance is impaired
- Consider wearing a continence aid/pad when travelling or on longer outings
- Feeling shame and embarrassment – reassure if incontinence occurs
Hiding soiled pads/pants in their cupboard or drawers.
- Check regular hiding places
- Change pads/pants before leakage occurs or pads are heavy with urine.
- Reassure and prompt to toilet regularly
- Provide plastic bags or rubbish bin in bedroom, bathroom, toilet with sign in large print at eye level e.g. ‘Put dirty pads or pants in bin please’
Waking the carer to go to the toilet at night
- Ensure bed and toilet are not too low or too high to independently get on and off. Alzheimer’s Queensland can arrange an occupational therapist to assess the home for aids to promote independence
- Leave the toilet light on at night
- Provide sensor lights along the route to the toilet if it is not near the bed
- Leave the toilet door open so that the toilet is visible
- Keep walkways clear of clutter or distractions
- Toilet before going to bed
- Avoid caffeine drinks before bed
- Avoid fluids for 2 hours before bed
- Trial use of commode beside bed or spill proof urinal
- Maintain good sleep hygiene practices
- Impaired balance or sight may require that the carer escort the person at night
Actions to avoid
Do not assume incontinence is a normal part of ageing.
- In the middle or late stages of dementia the incidence of incontinence may increase
- Do not blame the person living with dementia
Do not demonstrate anger or try to rush the person.
- This is humiliating, embarrassing and distressing for the person with dementia and often results in carers feeling guilty
Do not use incontinence aids/pads unnecessarily (if person is still continent)
- This can have negative social, psychological and physical consequences
- Substitute decision-makers should consider the potential preferences of the person e.g. to trial medication, scheduled toileting
Do not reduce or limit fluid intake.
- This can result in concentrated urine irritating the bladder wall and increase the risk of dehydration and constipation
Do not toilet frequently ‘just in case’.
- This can train the bladder to have a reduced capacity
Do not think that people with reduced food intake do not need to move their bowels.
- Constipation can increase confusion
Do not assume the same size continence pad will meet both day and night time needs if continence aids are being used.
- Larger amounts of urine are usually passed at night and a larger pad will be required to reduce leakage, protect skin integrity and reduce laundry!
Do not reduce social outings.
- Social needs coexist with physical needs and reduce anxiety, produce positive emotional responses, increase alertness, provide distraction and exercise
Do not use strong soaps, deodorants or talcum powder after an incontinent episode or excessive washing as this increase the risk of skin breakdown.
- Use cleansers that are pH 5.5, avoid excessive rubbing, pat dry and apply a moisturizing barrier cream (this preserves the skin integrity and does not increase the pH of the skin)
- Change faecally soiled pad/pants as soon as possible to reduce tissue irritation and alkalinity
Do not use an indwelling catheter as the first choice to maintain continence.
- Complications are associated with this including infection, trauma, psychological distress and reduced mobility
- Catheters may be a choice at the end of life if pain, reduced mobility, reduced intake or pressure sores are issues of concern.
- Catheters used at the end of life may ease agitation for some and increase agitation for others
Resources to assist the carer and the person living with dementia
If incontinence occurs continence pads, pants or aids can be organized through Alzheimer’s Queensland. Incontinence will add to the workload and stress of carers. Alzheimer’s Queensland provides Home Care Packages and can assist carers with showering, laundry, bed making and housekeeping and other flexible, individualized services. We can also arrange day and overnight respite at Alzheimer’s Queensland respite centres in Brisbane, Ipswich and Toowoomba.
In Brisbane Alzheimer’s Queensland operate Aged Care Homes which provide safe and stimulating environments for people living with dementia.
The Alzheimer’s Queensland 24 hour Advice Line also provides support and education for carers, friends and community members and people with dementia. Please phone 1800 639 331 with any general enquiries or for further discussion in relation to his article.
The National Continence Helpline can be contacted for additional advice on incontinence Phone 1800 330 066.