We still have a taboo about discussing pee and poo. There are so many words to describe these functions and some of them are regarded as rude by some people, and the other words are so scientific that you might not recognize them at once. (“Micturition” anyone? What about “Piss”?) That precisely why when incontinence happens, people are confused about where to get help. Recently someone wrote to ask me about this very thing.
“My mum Avril is in care and wears a pad, and when I went to visit it was loaded with poo, and she was just lying on her bed. I thought it might have been like that for an hour.”
If a person with dementia develops problems with continence they need to have a thorough assessment from a continence nurse specialist. The staff caring for her need to have training on these issues.
My first question is why Avril has a pad on in the first place. Is it for urine? Did they give her that for urine problems and then just stop taking her to the toilet because they think they don’t need to? So she ends up opening her bowels in the pad because she never got to the toilet. Or perhaps because of not eating the right things, drinking enough fluid and getting enough exercise she is now constipated, and the uncontrolled faeces being produced is “overflow” that is bypassing a constipated mass that is stuck.
There are lots of factors to assess. Why can’t Avril go the toilet as she once did? Has she got a urine tract infection (UTI) that means she needs to go very suddenly and can’t get there in time? Has she got an undiagnosed medical condition like diabetes that would make her go very often to pee? Does she not completely empty her bladder when she goes to pee, resulting in dribbling later? Has she got one of the common gynaecological or “women’s” problems like a prolapse of her uterus? Has she not voided her urine completely because her bowel is loaded with faeces and that is stopping the urine coming out efficiently? Did they just stick her in incontinence pads without assessment? Were they using them at night to allow her to sleep, and then drifted into using them in the day?
Staff who an unsympathetic or uneducated attitude towards toilet needs cause problems in many cases that could be reversed. Good staff can make a fantastic difference. They can also explain what they are doing, and why, even if they have reached the stage of using pads appropriately.
- if Avril is mobile, can she take herself to the toilet; is it easy to find and use, can she get out of her seat or bed, is it well signposted?
- Do they remind her to go and guide her there regularly?
- Are her clothes easy to manage, with pants and trousers that can slip off easily to get to the loo quickly when needed?
- When she is taken to the toilet (which should happen regularly even if they have her in pads) is she given enough time to sit quietly and perform? Some of us can read the entire daily newspaper there…or does someone hover over her and shout her to hurry up?
- Does the toilet need adaptations for her to be balanced there; is it quiet warm and welcoming?
- If there are any problems does the occupational therapist or physiotherapist get involved in the issue?
Incontinence is something that happens at end stages of life, but it is not automatic in dementia. Medication, depression, confusion, fear - of these things can make the person less efficient at caring for themselves. And all of these can be addressed.
- Have the staff put Avril on laxatives, so that she has to void really urgently, not giving time to go to the toilet?
- Could medication be given at a different time of day?
Final note. Everyone has a different bowel habit. Some go many times a day, others once a day and some people even less than that. There might be a pattern. Some people need to go as soon as they wake. Others do it after a hot coffee and some breakfast. Some can’t do it easily in a strange place. Faecal incontinence requires specialist advice and treatment. You need good skin care because it can make the person’s skin very sore. Any change in bowel habit should be reported to medical staff.
So the first step is a really good assessment which may require.
- A bowel diary (including urgency, straining, consistency of stool, faecal leakage and pain)
- A urine diary (including urgency, frequency, smell, colour, infection, blood and pain)
- And there may be a medical exam including urinalysis, internal and examinations
There is more about this, including how to get poo stains out of soft furnishings in the International edition of “Dementia; What You Need to Know.”