DIMENSIONS Spring 2000

INCONTINENCE: PROMOTING FUNCTION & DIGNITY

by Catherine D'Ambrosio, R.N., M.S.N.

Incontinence is the inability to control one's bowel and/or bladder, resulting in urinating and/or defecating in one's clothing. Experts estimate that a significant percentage of all dementia patients suffer from urinary or fecal incontinence during the course of their disease process. Incontinence, agitation, and violence are among the most commonly cited reasons a family chooses to place their loved one outside of their home.

When incontinence occurs, it can rule the lives of nearly everyone in the household. Incontinence can cause embarrassment, anger, resentment, and even violence as patients become frustrated, or as caregivers make unsuccessful attempts to discipline the patient's unruly toileting habits. Often both the patient and the caregiver become increasingly isolated, ashamed, and quite vulnerable to depression and other illnesses.

Incontinence among people suffering from dementia is different from other forms of incontinence because often there is no structural or nerve fiber damage causing the incontinence. Dementia-related incontinence is caused by the loss of intellectual capacity to recognize what the sensation of a full bladder or bowel means, and what steps need to be taken (find a toilet, disrobe, etc.) to get rid of the sensation. As the sensations of needing to go to the bathroom grow more intense, dementia patients often grow increasingly upset and frustrated because they know something is very uncomfortable, but they can't figure out what has to be done to stop that feeling.

Incontinence in many cases can be prevented, postponed, made less severe, or managed reasonably. It is best to begin the following steps long before incontinence becomes an issue, but they can also be attempted at later stages as well. Keep in mind that while some of these recommendations may seem fairly rude and intrusive, once incontinence becomes an issue you will be forced to face these issues frequently.

1. Over a week or so, observe and write down the times of day your family member normally goes to the bathroom. It is much easier to maintain your family member's existing routine than it is to start a new one.
• Observe and write down the frequency, amount, color, odor, and stream of urine.
• Observe and write down the frequency, amount, color, and consistency of stool and the effort required to produce it.
2. Take note of any subtle signs your family member gives before he/she needs to go to the bathroom. For example, some people get fidgety, anxious, or appear to be looking for something.
3. Once your family member's routine is known, it is important to assist them to maintain it by taking some version of the following steps:
• Remind your family member to go to the bathroom if he/she is forgetting to go at the regular times. Walk with him/her to the bathroom when they seem uncertain about how to proceed.
4. Listen outside the bathroom door. Is your family member remembering why he/she is in the bathroom and what they need to do?
• Give gentle, but simple verbal cues on disrobing or actions such as, "Undo your belt Frank" or "Go ahead and sit down on the toilet Mary." Offer to assist, but avoid routinely doing things for your family member if they seem able to do them independently.
5. If your family member is disrobed and appropriately situated to urinate or defecate, but seems to be having difficulty initiating their stream there are a couple of measures you can try.
• Turn the tap water on gently. Sometimes the sound of running water helps one to urinate.
• Fill a plastic cup with warm (not hot or cold!) water and gently pour it over their urethra.
6. Some things that can cause, or make incontinence worse include, but are not limited to:
• Sleep deprivation: Assist your family member in getting to sleep in the evening. A warm bath, clean sheets and pajamas, reading a story aloud, a warm cup of milk or tea, or music may help relax your family member.
• Dehydration: Not getting enough water can cause constipation and urinary problems that make incontinence more likely. Monitor how much your family member drinks every day and remind him/her to drink often by offering liquids. Drinking with your family member can also serve as a subtle reminder. Avoid alcohol and caffeine.
• Infection: As we age, our body develops different ways of expressing infection. Frequently infections are found in the elderly when they are brought to the hospital with acute confusion (delirium) caused by a urinary infection or pneumonia. Delirium typically clears within several weeks after the infection is effectively treated.