Brain function and bladder control

Dementia can cause bladder control problems due to changes in brain functioning, such as not recognising the need to pass urine or suffering from confusion. However, other causes may also be involved, such as urinary tract infection or medication side effects. General measures such as preventing constipation and giving toilet reminders may improve continence. Incontinence aids such as pads may also be helpful in people with dementia.

Dementia interferes with toileting process

People with dementia suffer memory loss and may be confused and disorientated. This can cause a breakdown in the mechanisms necessary for bladder control.

Dementia causes changes in the brain which may interfere with their ability to:

• recognise the need to pass urine
• 'hold on' until they get to the toilet
• find the toilet
• recognise when the bladder is completely empty.
• adjust clothing appropriately.

Incontinence may develop or worsen in unfamiliar surroundings, or during episodes of depression, anxiety or stress.

Medical causes may also be found

People with dementia, just like other adults, are susceptible to other causes of incontinence such as urinary tract infection, constipation, atrophic vaginitis (vaginal irritation and inflammation after menopause), an enlarged prostate gland or side effects of certain medications.

Seek help from their doctor

Can anything be done for dementia sufferers with incontinence? Yes! While their dementia may prevent them from participating in some treatments, much may be possible to ensure maximum comfort and dignity.

Seek help from their doctor, who may be able to treat them directly or will refer them on to a continence advisor for a continence assessment. (See end of article for details of continence resources and services available).

Assessing the problem

Assessment involves a physical examination and taking a history of relevant information.

Difficulties encountered by the patient may include:

• forgetting to take down clothes when going to the toilet
• having difficulty finding the toilet
• urinating in inappropriate places
• passing urine more often than usual
• saturating clothing/bedding without warning
• wetting on standing up from a chair or bed
• suffering from constipation, diarrhoea, faecal incontinence.

Record bladder and bowel function

It is often necessary to rely on the carer to provide this important information and to record bladder and bowel function. That is:

• what time the person goes to the toilet and/or wets
• how wet the person is, for example:
  - minor = dampness underpants;
  - moderate = wets through to skirts/pants;
  - severe = floods chair/floor/bed.
• how often they open their bowels.

Ways to minimise episodes of incontinence

1. Treat underlying conditions: Underlying conditions such as urinary tract infection, constipation or atrophic vaginitis (inflammation of vagina and surrounding tissue after menopause) often respond to treatment and the incontinence may possibly subside.

2. Monitor medication effects: In some situations, medications may help, but they can also worsen incontinence and increase confusion. Therefore, medications must be closely monitored and altered if any side effects occur.

3. Encourage sufficient fluid intake: Where possible, encourage the person to drink six to eight glasses of fluids a day, unless otherwise advised by their doctor. This helps to prevent urinary tract infection and constipation and to maintain good bladder health. Avoid excessive amounts of coffee, tea and cola as the caffeine in these drinks may irritate the bladder and can cause frequency and urgency to pass urine.

4. Good bowel habits: Maintain regular bowel habits and prevent/treat constipation.

5. Toilet reminders: The person may need to be reminded to use the toilet at regular intervals - at the times when they usually need to go or before they are likely to be wet.

6. Take to toilet at regular intervals: If they are no longer able to recognise the need to use the toilet they should be taken to the toilet at regular intervals. This may be every 2 to 3 hours, depending on how much they drink and their wetting pattern. It may be necessary to stay with them to help them and remind them why they are there. Frequent toileting (eg, hourly) is not encouraged.

7. Use easy-to-manage clothing: Adjust clothing, if appropriate, to make it easier for them to manage. For example, Velcro fastening instead of zips and buttons. Easy-to-manage clothing such as tracksuits may make undressing easier.

8. Keep walkways clear and well-lit: Keep the way to the toilet clear and free of clutter and use a night-light if required. Make the toilet door easily identifiable.

While the above measures may or may not overcome the incontinence, they may reduce the incidence or severity of the problem.

Pads and incontinence aids

Quality of life for the person with dementia and the carer may also be improved by the use of incontinence aids such as pads. It may be possible to receive some financial assistance with the cost of incontinence aids.

Advice on eligibility and the types of aids available can be sought from:

• your local continence advisor
• Alzheimer's New Zealand
• Needs Assessment Service coordinator
• local hospital (check with GP).

You can also consider utilising community resources to assist with the demands of caring for a person with dementia. Home help or district nursing may be available in the local area. Consult their doctor or a continence advisor for help.

Review medication use

In the first instance, the person's doctor should review all medications being taken as some of these may actually be causing or aggravating the incontinence.

In some cases, medications can be prescribed by their doctor to help them overcome their incontinence, eg:

• antibiotics may be prescribed to treat a recognised urinary tract infection
• hormone replacement therapy (tablets, patches or vaginal creams) may help post-menopausal women by reducing the frequency and urgency caused by atrophic vaginitis
• bladder relaxant tablets may be given to help calm an irritable bladder and thus improve its capacity. This may reduce the urgency and frequent need to go to the toilet
• tablets may occasionally be given to help pass urine when there is obstruction or blockage in their outlet.

Side effects of medication

Be aware that these medications may produce side effects such as a dry mouth, constipation, impaired balance and lethargy. In the person with dementia there is also a risk of increased confusion. Medication use requires careful professional monitoring.

Where can help be found?

There are many health professionals qualified to assist you with bladder control problems. You may seek assistance from your doctor, who may offer treatment directly or refer you to a specialist, or to a qualified continence advisor.

You may also seek help and obtain information directly from the following sources:

• NZ Continence Association (details below under 'Further Information and Support')
• GP
• continence nurse advisors
• Disability Resource Centre
• district nursing services
• independent living centres
• Alzheimer's New Zealand (details below under 'Further Information and Support').

Original material provided by the New Zealand Continence Association, and edited by everybody, August 2005. Reviewed by everybody, September 2011.