Toileting: Promoting personal hygiene and coping with incontinence
Managing personal hygiene (and the bowel and/or urinary habits) of a loved one with later stages of dementia is unquestionably one of the most difficult challenges facing caregivers. As the disease progresses and cognition diminishes, a loved one is likely to lose the ability to recognize his/her bodily cues such that the need for assistance in the bathroom will increase. For someone with dementia, the vague discomfort of a full bladder or the need to defecate is not always going to translate to “I need to get to the bathroom now.” If your loved one does recognize the cues (i.e., knows precisely when it is time to go), he/she may not recall where the bathroom is, nor the sequence of steps that are necessary for a successful trip (recognize the toilet, remove clothing, sit down, know when finished, wipe properly, replace clothing, wash and dry hands, etc.). Accidents may result; however, their frequency and impact can be minimized with special attention to some critical basics.
Why is this happening?
There are several reasons that someone with dementia might have difficulty with toileting tasks:
- Those suffering with dementia can lose the ability to recognize and associate physical urges with the need to get to the bathroom. Instead, their behavior can be that of someone who is agitated or restless (e.g. pacing, odd facial expressions, tugging on clothes).
- Not only is there confusion about bodily cues; dementia robs individuals of insight, as well. That is, they lose the ability to understand why it is important to remain clean (and how to do so). While it would be of no value at this point to discuss why to remain clean, your loved one will become increasingly dependent upon you or others for assistance in actually performing the necessary tasks.
- It is also important to recall that people with Alzheimer’s and other forms of dementia are susceptible to the same health issues that the rest of us might experience that can cause incontinence (e.g. urinary tract infection, loss of muscle tone, diabetes, enlarged prostate, excessive caffeine intake, certain types of medications, and constipation).
How should you respond?
Since incontinence can threaten the dignity and physical health of your loved one—as well as your own peace of mind—a number of considerations must be made for promoting personal hygiene and coping with incontinence.
An important goal will be to minimize the occurrence of accidents by taking the following steps:
- Inform the physician of your concerns and ask to rule out any health issues that may be causing or exacerbating the incontinence (sometimes incontinence is correctable, but you won’t know unless you engage the doctor.)
- Keep a dietary and toileting journal for a period of time (e.g. 3-6 weeks). List all foods and fluids consumed throughout the day (with times taken), and document the frequency of all urination and bowel movements, being sure to note every “accident” by date, type (bladder or bowel), and time of day. This documentation can help you to identify certain foods as irritants to your loved one’s system that have diuretic, laxative, or constipating effects. Also, writing down these specific toileting habits will help you to establish an appropriate routine, e.g. with frequently scheduled trips to the bathroom to empty the bladder.
- Ensure that your loved one is consuming a sufficient amount of (non-caffeine) fluid every day. Six to eight glasses of water spread over the day (until 7:00 pm) are recommended unless the physician advises another amount. Although it might seem sensible to reduce fluid intake in order to reduce urinary incontinence, you can be certain that doing so will have the opposite effect and actually carries risk for urinary tract infection and constipation.
- Allow your loved one to independently manage as much as possible. Begin with verbal cues, “Dad, let’s make a bathroom stop before we go out,” and later lend additional support only as the need becomes apparent.
- Set up for success!
- Watch for non-verbal cues of the need to go to the bathroom and do not delay.
- Simplify the wardrobe with elastic waistbands for fast removal.
- Remove obstacles in pathways to the bathroom and toilet. Consider duct-taping a “path” to the bathroom and/or hanging a sign on the door for easy recognition.
- Since a waste can might be confused with the toilet, keep the waste can out of sight.
- Consider the use of a bedside commode if mobility is a problem.
- Many types of incontinence products are available, including adult briefs, plastic sheets, baby wipes, and disposable mattress pads. These can reduce stress and the amount of clean-up time required in coping with incontinence.
- Finally, in the immediate moment of a urinary or bowel accident, never scold or attempt to “teach”; such actions can only produce exasperation for yourself. Accept that this situation is common to the disease process. Responding with patience and matter-of-factly assuming responsibility for ensuring that your loved one is clean will go a long way toward preserving your loved one’s health and dignity (and reducing anxiety for both of you).