People with Alzheimer's disease commonly experience loss of bladder or bowel control for many reasons. They may lose their ability to recognize natural urges telling them when to go to the bathroom, where the bathroom is located or what to do when in the bathroom; or they may be adversely affected by medical problems, physical conditions, or environmental factors. Consult the patient's physician to rule out any existing medical cause of incontinence such as a urinary tract infection, bladder or prostate problems, or medication side effects.
Understandably, because bodily functions are very personal and private matters, assistance with toileting is distressing for both the person with dementia and the caregiver. Family members often experience awkward or embarrassed feelings when helping with toileting. This is normal and in time these feelings can be overcome. Although you can manage urinary incontinence and fecal incontinence for a time by making adjustments and changing the person's routine, clothing or environment, at some point you will probably need to accept it as part of the disease process.
To better help the Alzheimer's patient with toileting and diapering, it's important to be matter-of-fact, reassuring and as calm as you can when confronted with these duties that are probably unpleasant for both of you. It's important to help the person retain a sense of dignity and privacy despite incontinence problems by conveying a supportive attitude that will help lessen feelings of embarrassment.
The following sections offer tips for caregivers to assist Alzheimer's patients with toileting and to manage incontinence.
If incontinence is a new problem, promptly check with the patient's physician to determine if there are medical reasons. Although some people with Alzheimer's will eventually lose independent control of their functions in the middle or later stages of the disease, many causes of incontinence can be controlled. Do not let a doctor dismiss incontinence without carefully exploring all treatable causes. Schedule physical examinations to answer the following questions.
- In the case of urinary incontinence, could the patient have a urinary tract infection? A chronic or acute bladder condition? A prostate problem?
- In the case of bowel incontinence, does the patient have a fecal impaction? Constipation? Diarrhea?
- Does the patient have diabetes or Parkinson's disease? Has the person had a stroke?
- Is the patient on tranquilizers, sedatives or diuretics that can cause incontinence?
- Is the patient adversely affected by stress? The environment? Weak pelvic muscles? Clothing?
- Do movement difficulties make it hard for the patient to get to the bathroom in time?
It's important to distinguish incontinence from urinating or defecating in inappropriate places such as closets and wastebaskets. Whereas incontinence causes loss of control on oneself wherever the person may be, cognitively impaired individuals who urinate or defecate in inappropriate places may be unable to remember the appropriate place or locate the bathroom.
Note that using a catheter as a continuing way to manage urinary incontinence should be avoided if possible. Also, the medications used to treat incontinence can cause side effects such as dry mouth, eye problems and confusion. So continue to consult the physician and pharmacist.
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Do not withhold fluids when the person starts to lose bladder control
Giving less fluid can be dangerous. Limiting fluids can cause dehydration, which could lead to a urinary tract infection and incontinence. Even minor dehydration can cause confusion, particularly in older people and of course those with dementia. Make sure the person is getting enough fluid to adequately stimulate the bladder to work.
Try to give the person six to eight glasses of liquid a day
For variety, consider introducing decaffeinated herbal teas, decaffeinated coffee, Jell-O and fruit juices. (Cranberry juice has a therapeutic effect on the urinary tract.)
Reduce or eliminate beverages that might produce a diuretic effect
Any such drink that might lead to increased urination — coffee, cola, tea, alcohol and grapefruit juice — should be limited or eliminated. Such diurectics tend to activate incontinence.
Limit the person's intake of liquids after dinner
The last drink of the day should be two hours before bedtime unless there is some medical reason for continuous fluids. To compensate, be sure the person has been drinking plenty of liquids throughout the rest of the day to prevent dehydration.
Encourage a high-fiber diet
Avoid using laxatives. Instead, increase the amount of fiber and water in the diet. You can achieve this by increasing vegetables, fruits, juices, whole-grain cereals and salads.
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Set up a schedule for toileting
Toileting the first thing in the morning, after meals and at bedtime should be standard procedure. If cognitively impaired individuals cannot recognize or communicate their natural urges, try taking them to the bathroom at periodic intervals. A good policy is to toilet every two hours to three hours. Be sure not to toilet every hour, however, because that can cause bladder damage.
Determine a schedule for bowel movements
Since elimination is tied to the body's circadian rhythms, monitor bowel movements and plan accordingly. Try to determine a regular bowel habit and remember to take the person to the bathroom daily at the determined time.
Keep a log noting when the person uses the bathroom
Keep a record for at least one week of the times the individual is wet and dry. Also keep a record of medications and liquids that are taken. From this information, you can find a pattern; for example, if the person with Alzheimer's is wet every four hours, schedule bathroom visits every three and a half hours.
Because cognitively impaired individuals may forget to use the bathroom, you may need to remind them periodically by encouraging them and asking them if they have to go.
Watch carefully for signals the person may exhibit
Always be on the lookout for visible cues that the person needs to use the bathroom. Common signs include restlessness, anxiety, agitation, pacing, unusual sounds, facial expressions, sudden behavioral changes when no other cause is evident, pulling at clothes, dropping pants, suddenly stopping eating for no apparent reason. This tip is particularly important because cognitively impaired individuals may be unable to ask for help or are embarrassed to ask for it.
Identify when accidents occur and plan accordingly. For example, if they happen every three hours, get the person to the bathroom every two and a half hours. To help control incontinence at night, limit the intake of liquids after dinner and in the evening or schedule bathroom visits when the person awakens in the middle of the night. Change the person's diapers as many times as necessary.
Don't hesitate to consult the patient's physician
If the person doesn't have a bowel movement every two or three days, consult the physician. Constipation can be not only a sign but a cause of other problems. Constipation can cause discomfort or pain, which in turn can lead to a worsening of the person's confusion. Constipation can lead to a bowel impaction, in which the bowel becomes partially or completely blocked and the body is unable to rid itself of wastes. Similarly, failure to urinate can be a sign of dehydration or a medical problem.
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Help the person with Alzheimer's retain a sense of dignity. A reassuring attitude will help lessen feelings of embarrassment. Always bear in mind that even when the person has lost independent control of bodily functions, there is much you can do to reduce embarrassment.
Respect the privacy of the person
Keep in mind that issues of modesty often play a role in toileting. Be prepared to "look the other way" for a few moments if the person appears to be uncomfortable by your presence.
Dress the person in manageable clothing
Keep the person's dress simple and practical. Choose easy-to-remove and easy-to-clean garments, such as sweatpants with elastic waistbands instead of clothing with zippers and buttons.
Calmly talk the person through each step
Give people with dementia cues if they do not know what to do.
Assist the person in going to the bathroom
As the situation dictates, assist with the removal or adjustment of clothes and with wiping and flushing. Help the person get into the correct position if needed. If people with dementia are hyperactive, allow them to get up and down from the toilet a few times while you tell them and show them with gestures that they are to sit on the toilet. Give them a distraction such as a magazine or a knotted pair of socks to occupy them while sitting. Sometimes urination can be stimulated by giving the person a drink or by running water in the sink.
Praise successful performance in the bathroom
Do not punish failure or inappropriate urination.
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Make sure the bathroom is easily accessible
Leave the bathroom light on and maintain a clear, visible pathway. Use nightlights in the bedroom and hallway leading to the bathroom. Clear the pathway of any obstacles, such as furniture, walkers, shoes, throw rugs. Avoid having items nearby that could be mistaken for a toilet, such as a trashcan.
Adapt the bathroom to the person's needs
Install a grab bar on the wall or an aluminum arm frame to the back of the toilet. These items are available through home health equipment companies. You could also install side brackets so you could place a bar across the front of the toilet to help keep the patient seated with something to lean on. (To find information on the web, enter the keywords "Home Health Equipment" or "Medical Equipment.") For more temporary solutions, try placing a commode atop the toilet to elevate the seat while providing arms to hold onto.
Enhance bathroom safety
Take safety measures to lessen the danger posed by tile floors and by porcelain toilets and sinks. (To find information on the web, enter the keyword "Bathroom Safety.")
Provide visual cues
To help locate the bathroom, consider using reflective tape on the floor leading to it and around the bathroom door or painting the door a brighter color than the walls around it. To help identify it in the early stages of the disease, consider posting a large sign on the door with a picture of a toilet or block letters saying "BATHROOM." In addition, securing non-slide colored rugs on the bathroom floor and lid covers on the toilet may help it stand out.
Bring the toilet to the person
If the problem is that the person is immobile or moves too slowly to get to the bathroom on time, keep a portable commode or urinal bottle nearby during the day as well as at night. Consider placing them strategically around the house.
Place a commode beside the person's bed
Older people may awaken many times at night to urinate and find themselves unable to get back to sleep. Placing a portable commode or urinal bottle by the bed is less dangerous and sometimes less upsetting than a nighttime walk to the bathroom. As Alzheimer's erodes short-term memory, be sure to point out the commode, urinal or bedpan to the person every night as many times as necessary. Avoid having items nearby that could be mistaken for a commode, such as a wastebasket.
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Use adult briefs and protective pads as needed
Adult briefs are specially designed for older people with incontinence problems. They are disposable and are available for daytime use or overnight use depending on absorbency. Use protective pads inside diapers. You can also use medium-sized or large-sized baby diapers inside adult briefs or panties to promote effectiveness and comfort. However, in deciding to use diapers, take into account how that might affect the person's self-esteem as well as health, especially in the earlier stages of the disease.
Choose clothing that is easy to remove and care for
Use clothing that is more easily accessible (that is, pants with elastic waistbands for men as well as women and dresses rather than slacks for women).
Buy adaptive clothes specially designed for impaired adults
Specialized, adaptive and protective clothing can provide ease of care that is not always available in standard clothing. Adaptive clothing can provide easier access to diapers. Several products consist of an outer washable pant that holds a disposable pad; the ideal is a soft, cool material in which the absorbent pad draws urine away from skin. More and more catalogs are offering adaptive clothes specially designed for cognitively impaired adults.
Sleep clothes should be functional as well as comfortable
Nightgowns and nightshirts are easier to work than pajamas. If there is a problem with a confused person with Alzheimer's trying to remove diapers at night, consider getting the person in a one-piece outfit for sleeping or cutting the legs off a pair of pantyhose and place the panty portion over the diaper.
Use incontinence bedding
Disposable incontinence pads are made to protect bedding. You can also try rubber sheets or rubberized flannel sheets. Also use a draw sheet on the bed. This is a regular sheet folded in half lengthwise and tucked in across the bed to hold a plastic sheet in place between it and the bottom sheet. Should the person then have an accident, you only have the draw sheet and the pad to change. Absorbent bed pads used in combination with a draw sheet and rubber pad will help keep the bed dry.
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Never let an individual remain in wet or soiled diapers
Changing and diapering needs to be done immediately to protect from skin breakdown. A person who remains in wet or soiled clothing can quickly develop skin irritations, sores and painful rashes. It is important to watch for these. Keeping the skin clean and dry is really the best protection against skin problems. Promptly clean the skin after each incontinence occurrence.
Keep sensitive skin areas clean and healthy
Clean the skin with mild soap and water, or skin cleaners specifically designed to cleanse without excessive dryness or irritation; rinse thoroughly and gently pat dry. Consider using a skin sealant or moisture barrier to protect the skin if there is constant exposure to urine or stool. In addition to toilet paper, use adult wipes or baby wipes free of chemicals, perfumes and alcohol. Just be sure to dry the skin afterward to avoid irritation and rashes. (To find cleansing products on the web, enter the keywords "Incontinence Products" or "Incontinence Supplies.")
Prevent diaper rash through proper care
Here are some specific tips to help reduce the risk of diaper rash:
- Change the person's diaper frequently to reduce exposure to irritating urine and stool
- Use plain water with a soft cloth to wipe the person's backside. Avoid wipes with chemicals, perfumes or alcohol. Expose the person's buttocks to air whenever possible. Avoid tight-fitting disposable diapers or plastic pants over cloth diapers
- Apply petroleum jelly or barrier ointment (such as Desitin, A&D or zinc oxide) after cleaning with a moist cloth to protect the person's skin
- Avoid talc. If the person breathes it in, this powder irritates the lungs and may cause pneumonia. Cornstarch should also be avoided, since it may increase the growth of yeast
- Avoid unnecessary antibiotics. Overuse of antibiotics may lead not only to diaper rashes, but to other complications such as diarrhea, more-drug-resistant "superbugs" and other serious problems
Treat skin problems immediately
If sore spots occur, use moisturizing creams and avoid products that contain alcohol. For skin problems caused by urine burns, consult the patient's physician or nurse.
Don't hesitate to consult a doctor or nurse
Consult the person with dementia's doctor if the skin becomes inflamed. Skin problems with incontinent Alzheimer's persons can develop easily, and quickly escalate into bedsores if untreated. Similarly, since Alzheimer's patients are at high risk for urinary tract infections, consult the physician if they exhibit symptoms such as fever, frequency, odor, signs of painful urination, dark-colored urine.
For more information, contact the National Association for Continence, formerly known as Help for Incontinent People, on the web www.nafc.org or by phone at 1-800-BLADDER.
Sources: the Alzheimer's Disease and Related Disorders Association website (www.alz.org) and Action Series brochure "Steps to Assisting with Personal Care"; the National Capital Area Chapter of the Alzheimer's Association website (www.alz-nca.org); Nancy L. Mace and Peter V. Rabins's book The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life (1999, Third Edition, Johns Hopkins University Press).
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