held November 19, 2007
Incontinence and the Individual with Alzheimer’s Disease
by Terri Decker, RN, CWOCN
Incontinence: Scope of the Problem
Incontinence is a significant health care problem, and can lead to a host of other problems including skin rashes, pressure ulcers, falls and fractures from slipping on urine-wetted floors as well as sleep deprivation, depression and withdrawal from social outings. There are a variety of causes of incontinence as well as types of incontinence. The added issues which Alzheimer’s disease and dementia place on the individual as well as their caregivers are the topic of this article.
Bladder and Bowel Control
In order to understand better what happens when there is loss of control of urine or bowel movements, let’s first look at what is necessary to have control of them.
Nerve fibers which sense bladder and bowel fullness as well as those which control sphincter muscles to delay urination or bowel movements until the appropriate time are critical to maintaining continence. The bladder, a hollow muscular organ, must also have the ability to stretch and store urine as well as the ability to contract and release the urine at the appropriate time. Sphincters muscles work to “hold back” the flow of urine when necessary as well as “relax” in order to allow for urination. Any difficulties in these “filling” or “releasing” activities can result in urinary incontinence or other bladder issues.
For bowel control, in addition to nerves which send messages to the brain sensing fullness and muscles to “hold off” the bowel movement, the rectum must be able to stretch and hold the stool for a time until a toilet can be reached.
Loss of Bladder and Bowel Control
There are also normal changes which can occur as we age that can lead to bladder or bowel problems. Yet loss of bladder or bowel control is not a normal consequence of aging and should be discussed with a healthcare professional. There are many treatment options available which can help.
Some of the changes which may occur as we age include less of an ability to “delay” urination or bowel movements as well as slower mobility which can increase the length of time needed to get to a commode. After menopause, women may experience lower estrogen levels which can affect the ability of the urinary sphincter and pelvic muscles to work effectively. This can lead to leaks of urine during times of laughing, coughing, sneezing or lifting, also known as stress incontinence. As men age, the tendency for enlargement of the prostate gland can affect the ability to properly empty the bladder. This can also lead to urine leakage as the urine “spills out” of the very full bladder. This condition, overflow incontinence can be dangerous to the health of the kidneys and should be brought to the attention of the healthcare provider.
Other bladder problems such as “overactive bladder” where the individual has “Gotta go right now!” and has a tremendous urgency to urinate can lead to incontinence. In this case, the bladder muscle contracts at an inappropriate time and usually a larger amount of urine or more noticeable “accident” occurs. Again, a healthcare professional should be consulted as there are medications and treatment options available. In addition, certain foods and beverages can act as bladder irritants and contribute to “overactive bladder”. Use of a diary to record food and beverage intake as well as urine and bowel output, including the times and approximate amounts of successful trips to the restroom as well as “accidents” can help the healthcare provider and caregiver piece together a better idea of the problem as well as map out any strategies that may help with management solutions.
There are also times when a person may experience temporary incontinence of urine due to a bladder infection, or bowel incontinence due to explosive diarrhea. Other common causes of incontinent episodes include side-effects of certain medications as well as cases of severe constipation. Constipation can put pressure on the bladder and cause urine incontinence as well as lead to bowel incontinence. These transient or temporary types of incontinence should also be reported to the healthcare provider.
The chart below describes the various types of Urinary Incontinence.
The table below illustrates how to choose the right product for each situation.
|Types of Urinary Incontinence*|
|Stress||Leakage of small amounts of urine during physical movement (coughing, sneezing, exercising).|
|Urge||Leakage of large amounts of urine at unexpected times, including during sleep.|
|Overactive Bladder||Urinary frequency and urgency, with or without urge incontinence.|
|Functional||Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevents a person from reaching a toilet.|
|Overflow||Unexpected leakage of small amounts of urine because of a full bladder.|
|Mixed||Usually the occurrence of stress and urge incontinence together.|
|Transient||Leakage that occurs temporarily because of a situation that will pass (infection, taking a new medication, colds with coughing).|
* National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health
Effect of Alzheimer’s Disease on Continence
Now let us turn our focus to the individual with Alzheimer’s disease. The complex brain activity involved in receiving the signal of bladder or bowel fullness, then deciding what to do about it and executing that action plan can be affected by Alzheimer’s disease or dementia. Since toileting and hygiene are hugely personal issues, the loss of control in these areas are particularly devastating for the individual affected as well as their caregivers.
People with dementia may feel ashamed of their incontinence and try to hide the evidence. They may take off their soiled clothes and try to hide or discard them. They may also become confused as to their surroundings and try to urinate in a paper basket for example, instead of the toilet. They may have difficulty at night, unable to realize the need to urinate and get up and out of bed to get to the toilet, and wet the bed, thinking they were on the toilet. In more advanced stages, the person confined to bed for example, may lack any ability to sense and communicate the need for toileting.
The individual with Alzheimer’s disease who develops problems with incontinence should be checked by the healthcare provider to rule out any transient problems such as bladder infection, fecal impaction, as well as other factors which may contribute to the incontinence.
Use of the Bowel and Bladder Diary as mentioned previously becomes an important means of guiding helpful interventions. For example, if bladder leakage is occurring mostly late morning, it could be coffee contributing to the problem. A switch to decaf coffee or an extra reminder mid-morning might help avoid a mishap. To help with regulating bowel movements, a schedule of breakfast, walk around the yard, warm beverage and then sit on the commode with a magazine might help.
After looking at the typical daily patterns of the individual, a scheduled toileting time, often every 2 hours or so, can be set up by the caregiver to help remind or assist the individual to the restroom. The caregiver may encourage: Mom, let’s get to the bathroom now before ‘The Price is Right’ starts so we won’t be interrupted during the show.”
Other practical measures include placing a picture of a toilet on the bathroom door, good lighting in the hallway and bathroom, and use of a bedside commode or urinal. Clothing styles such as pants with stretch waistbands can also help ease toileting struggles.
Helping the individual following an episode of bowel or bladder incontinence can be disturbing especially if the caregiver is very close to the person. It’s important to try to overcome feelings of embarrassment or distaste as well as anger. Approaching the person with a calm, matter-of-fact attitude or perhaps a bit of a sense of humor can sometimes ease those first few interactions.
Approaching care such as assisting with changing of clothing or pads from behind the individual can help lessen the embarrassment for both parties.
Absorbent Incontinence Products
When absorbent incontinence products become necessary, use of bladder control pads or pull-on style briefs are usually better tolerated than the tape-tab style briefs. There are a wide range of absorbency levels within the bladder pad and pull-on categories and newer technology allows for moisture to be pulled into the disposable product keeping the skin drier. There are also reusable, cloth underwear products which can be well-tolerated as they closely resemble regular underwear.
For persons confined to bed, those with heavy urine loss, or bowel incontinence, the tape tab style brief or “adult-diaper” is the most absorbent product designed for these situations. Heavy night-time wetness is also best contained by the higher absorbent tape tab style briefs.
Disposable as well as cloth chair and bed pads are also very useful for the home situation. For example, the washable cloth bed pads can be used to help lift or turn a bedridden person more safely and easily.
Skin Care Basics
Care of the skin after an incontinent episode is important since moisture, ammonia from the urine, as well as enzymes from the stool can all affect the skin and contribute to rashes, skin breakdown, and other complications. Mild, pH-balanced skin cleansers are designed to gently cleanse the skin. Protective barrier products are also useful to protect the skin and prevent skin breakdown. High quality absorbent incontinence products are also effective in preserving skin integrity as they effectively wick away wetness to help reduce trauma to the skin (review more information on this topic in our Skin Care: Problems and Solutions for the Individual with Alzheimer’s Disease).
Expert Help with Product Selection
With so many styles of incontinence products, levels of absorption, and sizes to consider, it can be a daunting task to select the best product for a loved one’s needs. The people at Home Care Delivered (1-800-565-5644 or www.homecaredelivered.com) are experts in incontinence product selection. Home Care Delivered’s sampling program helps ensure patients choose the right size and style to meet their incontinence product needs. Convenient home delivery of supplies frees up time and allows for discreet purchasing. There is also easy, online ordering, as well as telephone ordering assistance. Where there is insurance coverage of absorbent supplies (certain state Medicaid programs), Home Care Delivered can file claims on patient’s behalf, which reduces paperwork hassle.
Caring for someone with Alzheimer’s disease and incontinence is a challenge. It is hard work; but help is available. The first step should be to contact the patient’s healthcare provider to see if treatment options are available. Resources are available to help ensure that their needs are managed in the most comfortable, dignified way possible.
Terri Decker, RN, CWOCN is the Clinical Director for Home Care Delivered, Inc. based in Richmond, VA. She received her Bachelor of Science degree in Nursing from Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio. She is Board Certified in the Specialties of Wound, Ostomy and Continence Care Nursing, and has extensive experience with Diabetes Self-Management Education. Terri has many years of experience as a Home Health Nurse and understands the demands on those supporting patients in the home setting. As the Clinical Director for Home Care Delivered, Terri provides support and education to caregivers and patients regarding incontinence, diabetic, urological, ostomy and wound care supplies. Founded in 1996, Home Care Delivered, Inc. provides an extensive offering of quality, name-brand medical supplies delivered directly to one’s home. Deborah H. Perkins, MS, APRN, BC, GNP earned her BS in Nursing from Duke University and graduated with a Masters in Nursing from Virginia Commonwealth University. She is a board certified Gerontological Nurse Practitioner and Gerontological Clinical Nurse Specialist experienced in Comprehensive Senior Assessment and Nursing Education. She co-facilitates an early stage Alzheimer’s support group, serves on committees for the Greater Richmond Alzheimer’s Association, and is a Board Member of the South Richmond Adult Day Center. As a Geriatric Clinical Nurse Specialist consultant and president of Gero Care Advocate, PLLC, Debbie strongly believes in the preservation of dignity for all older adults throughout the health care continuum. Through comprehensive assessment, she discerns individual strengths, needs, and preferences. She empowers individuals and families with information to make well informed health care decisions. She assists with interpretation of personal health care information and provides direction with beneficial questions to ask health care providers while guiding individuals and families as they navigate the health care system and resources. As an advocate, her vision is that all older adults experience optimal health, function, safety, and care excellence.
Dr. Ayn Welleford is Chair, VCU Department of Gerontology, Associate Professor,VCU Department of Gerontology, and Associate Director, Virginia Geriatric Education Center. Dr. Welleford received her B.A. in Management/ Psychology from Averett College, M.S. from the Department of Gerontology and Ph.D. in Developmental Psychology from VCU. She has taught extensively in the areas of Lifespan Development, and Adult Development and Aging. As an educator, researcher, and previously as a practitioner she has worked with a broad spectrum of individuals across the caregiving continuum. As a gerontologist she currently works extensively with formal and informal caregivers to improve elder care through education. Outside of the classroom and working with various community agencies, Dr. Welleford provides community education on a variety of topics, including: Steps to Aging Well, Building Successful Mother-Daughter Relationships, Intergenerational Programs, and Family Caregiving. Dr. Welleford conducts research, through mixed methodology, in the areas of caregiver burden, coping with distress, adult mother-daughter relationships, successful aging, and geriatric education.