More on Incontinence

My post yesterday has proven to be very popular, so I wanted to expand on the subject a bit more today.  Maybe it’s because I’m starting to experience some stress incontinence myself, related to menopause, but this subject has been much on my mind of late.  I found a page that lists a number of different strategies, and have tried to offer my own insights here and there.

Incontinence, whether it be of bowel or bladder or both, is something that impacts tremendously on our ability to live independently.  In the early to middle stages of dementia, when the problem begins to occur, a person may fear having an accident in public, and so be reluctant to go to work or out in the community.  And this doesn’t necessarily apply just to those with dementia.  I well remember my mother, in her 40s, having to keep a mental track of where the bathrooms were located at the mall before going out shopping.  And she had a GI disorder.  I know a man who is unable to go on long trips because his bladder has been adversely affected by prostate problems.

The first step, when a person starts to have difficulty with incontinence, is to find out if there is a treatable medical reason for the problem.  A doctor may want to run some medical tests to rule out a urinary tract infection, or a bowel obstruction, a hormonal imbalance, or some other condition.  Here are some questions the doctor is liable to ask:

1.  How often is the person incontinent?

2.  Does the incontinence affect bowel or bladder function, or both?

3.  When did it start?

4.  How much does the person go?  Is it just a dribble, or are her pants soaked?

5.  Does the person seem more confused than usual?  Has she been showing any other behavior problems?

6.  Does the person have a fever?  Does she complain of pain when going to the bathroom?

7.  Is she taking any medications?

8.  Is the person passing urine in inappropriate places?

Eventually, dementia will cause the person’s brain to deteriorate to the point where she is no longer able to control her bowel or bladder.  But, more often, incontinence is due to more indirect factors, or behaviors that impact her ability to go to the bathroom.  These factors may include, but are not restricted to:

1.  Recognizing the need to go to the bathroom.  A person with dementia will develop various forms of agnosia, which prevent him from recognizing not only people and objects but also internal needs.  It’s not that he doesn’t have the urge to go, he just doesn’t realize what his body is trying to tell him.  This may result in an indefinite restlessness or anxiety.

2.  Being able to wait to go to the bathroom.  If the person is in church or riding in a car, for example, it may not be possible for the person to go to the bathroom right away when she needs to.  This can produce an anxious feeling, or repetitive questioning.

3.  Having difficulty finding the toilet.  This can happen as a person grows more disoriented with regards to her surroundings.  She may be able to know she has to go to the bathroom, and appropriately go off in search of it, but forget where it is located.  This may especially become a problem in unfamiliar surroundings, when she may have trouble remembering directions to the bathroom.  (Even if she has just been told.)

4.  Having a hard time recognizing the toilet.  At some point during the progression of the disease, a person with dementia will have two-dimensional vision, or have difficulty differentiating objects from their background, especially if they are a similar color.  Think of many bathrooms you may have seen — a white toilet in a bathroom with a light-colored floor and light-colored walls.  One way to avoid this is to paint the wall behind the toilet a contrasting color.  It may also explain the annoying tendency for some men to urinate in potted plants.  They may quite literally think the plants are urinals — so take the plants up off the floor!

5.  Forgetting how to use the toilet appropriately.  When you think about it, going to the bathroom is a rather complex activity.  A person with impaired memory skills may forget to pull her pants down before sitting on the toilet, or to raise the lid.

There are a wide variety of incontinence aids on the market.  Most of these resemble some sort of pad that fits inside the underpants, or a brief that is worn in place of underpants.  Many persons are reluctant to wear these for reasons of dignity, or because they tell themselves they should feel ashamed for being unable to control their bodily functions.  But there are a number of strategies that are quite effective for preventing episodes of incontinence, at least in part.  Here are a few:

1.  Be sure that the person is drinking enough liquids.  It may seem strange to say that a person who is incontinent should drink more, but dehydration is a significant contributing factor in a number of conditions such as urinary tract infections or constipation.  Dehydration is actually a common problem in persons with latter-stage dementia.  (I read a statistic, a while back, which suggested that it is the 2nd most common diagnosis given to people who are admitted to the hospital from a long-term care facility.)  Most persons at this stage of dementia will not remember what to do if they feel thirsty.  Or, they may no longer even recognize that they ARE thirsty.  Sadly, I have actually seen residents in long-term care facilities who don’t drink anything except what they get with meals or medications.  Caregivers need to push fluids on their charges, giving them something to drink about every hour or so.

2.  Limit the person’s caffeine intake.  There are many research studies which have indicated that caffeine can have the effect of stimulating urine production.  When you consider that it can also have a mildly stimulating quality, it’s easy to see why many experts recommend with-holding caffeine from persons with dementia.  However, it’s important to remember that caffeine isn’t just in coffee and tea.  Don’t forget about that found in soda, and in chocolate.  (I am allergic to caffeine, myself, and was shocked to find that some sodas that seemingly wouldn’t contain caffeine are in fact full of it.  Check your labels.)

3.  Observe the person during to day to see what times they tend to go to the bathroom.  Then make it a point to prompt them to use the toilet at these times.  (Common times are before and after meals, before bed, and upon arising in the morning.)

3.  When helping a person to use the bathroom, keep your instructions simple.  Don’t rush the person, and make your comments as matter-of-fact as possible.  Try not to make the person feel self-c0nscious about having to be helped during such a personal act.  Try helping her take down her pants and sit down, and then step out of the room, or out of her line of sight, while she uses the toilet.

4.  Watch for non-verbal cues that may indicate a person is feeling the need to go to the bathroom, such as pulling at her pants or becoming restless.

5.  Check out the physical layout of the bathroom, and see if this may be a problem.  Is the distance from the bed/chair to the toilet too great for easy ambulation?  (If so, consider getting a bedside commode.)  Is the bed too high for the person to get out of safely?  Does she have trouble locating the toilet due to visual problems?  (If so, consider painting the wall a contrasting color.)  Does the bathroom need stronger lighting?  Does the person have trouble locating the bathroom?  (If so, consider putting a sign on the door or leaving the light on at night.)  Can the door be opened from the outside if the person falls?  Can she lock herself inside?  Public toilets will almost always have a handicapped accessible stall that can be used if you need to help your loved one while shopping, etc.

6.  Consider the person’s clothing.  Think about using Velcro fastening, instead of buttons and zippers, or have the person wear pull-on pants.  Try not to allow her to become accustomed to wearing wet clothing.  (Not only is this unhealthy/unsanitary, but it will also eventually interfere with her ability to recognize that she is wet.)  Choose clothing that is easily washable, and does not need ironing or dry-cleaning.

7.  If you take the person to the bathroom but they are unable to go, try running water or having her take a drink.  If she becomes restless, allow her to get up and walk around a bit before trying again.  Music may have a calming effect.  Try to avoid leaving her sitting on the toilet for a long time without going, or distracting her with other activities, as this may cause her to forget that this is the place for voiding/defecating.

8.  A raised toilet seat or grab bars on the wall will help the person get on and off the toilet more safely.  Consider non-skid floor mats to avoid slipping, but avoid throw rugs that might also cause her to fall.  Be sure lighting is sufficient for her to see clearly.  Be sure that the toilet lid is fastened securely.

9.  To prevent constipation, be sure that the person has plenty of fiber in her diet.  There are artificial sources of fiber on the market, that can be taken in capsule form or stirred into liquid.  Be sure that the person gets plenty of exercise.  Keep a log of the person’s bowel movements, and remember that it’s not always essential to go every day.

10.  A person with more advanced dementia will have accidents.  It is important for caregivers not to get too worried about these, and to avoid making their charges feel badly about it.  Treat them matter-of-factly, and avoid saying or doing anything that will belittle them.  Chances are that they are feeling embarrassed as well, and seeing your negative reaction will only add to that feeling.

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