2. Why is managing continence different for people with dementia?
Key points
How are continence problems different for a person with dementia?
Continence is different for people who have dementia because they may:
- not know that their bladder or bowels are full
- not understand why they feel uncomfortable
- not remember where the toilet is, or what to do when they get there (e.g. removing clothing to use the toilet)
- not recognise the toilet or bathroom
- think they have already been and then refuse to go when asked
- have problems walking to the toilet and be unable to plan to get to the toilet in time
- not be able to hold their pee in when they stand up to walk to the toilet
- have difficulty removing their clothing in time
- be unable to plan ahead, for example, when going out shopping.
“People living with dementia have different incontinent issues than people not living with dementia. They may not recognise the appropriate place, and they’re unlikely to know how to deal with an accident when it’s happened. They just don’t recognise the signs and mechanics of it. ‘What’s that’? Is that a toilet or not? I can’t remember which of these is a toilet’. So, the mechanics of going and the appropriate place”.
Practical Tips
What you can try when...
- Your client is unable to tell you that they need the toilet
A client with dementia may not be able to tell you that they need the toilet. Instead, look for signs of discomfort, such as:- fidgeting with their clothing
- pacing around / having difficulty sitting still
- becoming distressed for no obvious reason
- frequent passing of wind
- Your client goes to the toilet repeatedly
A person with dementia may keep going to the toilet repeatedly. For example, they might use the toilet, sit back down in their chair and then immediately get up and go back to the toilet. This can happen several times. Try distracting your client to stop this pattern, especially if they are in an unfamiliar place. - Your client tells you they don’t need the toilet, but you think they do
If you think your client needs to go to the toilet but they say they don’t, try distracting them with an activity or a chat. After a few minutes, ask again in a slightly different way to see if they need the toilet.
Planning ahead
Not everyone who has dementia becomes incontinent. Also, many people with dementia manage their incontinence very well. Planning ahead and being prepared for managing future continence problems can help with this. For example, it might help to talk to the person about using pads sooner rather than later to help them get into the habit of using them.
If they are still able to recognise that they need to use the toilet and have started using pads as a precaution, encourage them to go to the toilet. This will help them to remain continent.
“Just because there is a pad, if somebody wants to go to the toilet or has that urge to go to the toilet, please take them to the toilet. We need to remember the pad is there just in case. But, other than that, it can be used as just a normal pant. It’s there in case, but if you can go to the toilet, go to the toilet”.
Things to think about when providing continence care for someone with dementia
Supporting continence in dementia requires patience, empathy, adaptability and skill. It is helpful to focus on your client’s feelings as well as the physical tasks to be done. Some of the challenges and practical suggestions of what you might try are listed below.
Supporting with empathy and dignity
Be ready to adapt your approach: every person with dementia, and every day for them, is unique. You may need to negotiate or reason gently when encouraging someone to go to the toilet, which can be tricky. Remember to:
- treat each client as an individual
- maintain their dignity and respect
- help to make them feel at ease
- be flexible – what works today may not work tomorrow.
Stigma and behaviour
Dementia affects a person’s behaviour and they may not always act in a socially acceptable way, which can make things difficult to deal with. For example, a person who has dementia may not recognise their poo for what it is and show their curiosity or concern by:
- handling it
- trying to hide it
- getting rid of it in an inappropriate place.
Try writing down places where items have been hidden before. This will help other carers and family members find used pads or any soiled clothes, bedding, or soft furnishings.
People with dementia may remember the stigma of incontinence and:
- deny incontinence to cover up their embarrassment
- hide evidence of accidents.
Homecare workers often need to be detectives, working out the reason for client behaviour in order to respond with empathy.
Time
Your visit may take longer than expected if your client has been incontinent. People can become flustered and upset, angry or uncooperative if they are rushed. You may want to let your manager know if you are likely to need to stay longer with any client.
“Some days you might go: ‘Actually, do you know what? This is a five-minute job, that’s cracking’. And, another day you’re going: ‘No, this is a whole shower. In fact, this is a whole shower and some’. It’s about the management understanding that actually, what might be a 5-minute job one day could be a 25-minute job the following day”.
Emotional impact on carers
Feelings of disgust when managing people’s poo (particularly, for example, if the client has been handling poo) are very common and a natural response. Avoid showing those feelings to your client as far as possible. Remember that their actions are a result of the disease and not a conscious choice.
You might turn an unfortunate incident into a quick pamper session. This can help encourage hand washing, followed by a gentle manicure to clean under the nails and give a hand massage. It can be a calming way for both the client and the carer to deal with a poo-handling incident.