Continence and toileting

The principles

Continence requires several functions to work together: feeling the urge to go, recognising what the urge means, getting to the toilet, undressing, sitting down, voiding, dressing, and washing. Dementia can affect any link in this chain, alongside age-related changes (overactive bladder, reduced capacity, prostate symptoms in men, pelvic floor weakness in women).

What is treatable

Several causes are reversible and worth investigating:

• Urinary tract infection (a common cause of new incontinence);
• Constipation (can cause urinary urgency and overflow incontinence);
• Diuretics, sedatives, anticholinergic medication (may need review);
• Restricted fluid intake (paradoxically worsens incontinence);
• Mobility impairment (cannot reach the toilet in time);
• Environmental factors (poor lighting, complicated route to the bathroom).

A continence assessment by an NHS continence service or specialist nurse identifies which factors are at play.

Practical strategies

Environment

• Clear, well-lit path to the bathroom;
• Contrasting colour for the toilet seat;
• Signage with picture and word;
• Night light in the hall and bathroom;
• Raised toilet seat for those who struggle to lower and rise;
• Grab rail beside the toilet;
• Bedside commode where mobility is significantly limited.

Routine

• Prompted toileting every 2 to 4 hours (an established intervention);
• Toilet visit before going out;
• Last drink earlier in the evening (but not so restricted that hydration suffers);
• Bowel routine (most people have a regular daily time).

Clothing

• Easy-fastening clothes (elastic waistbands, Velcro);
• Avoid complex belts and small buttons.

Continence products

• Pads, pull-up underwear (Tena, Attends and others);
• Bed protection;
• Convenes for men in some situations;
• Catheters reserved for specific indications (urinary retention, severe skin breakdown);
• NHS continence services often supply pads free.

Constipation

Constipation is very common in dementia, exacerbated by reduced fluid, low fibre, immobility and some medications. It contributes to behavioural symptoms and Delirium. Treatment:

• Adequate hydration (1.5 to 2 litres a day);
• Fibre in the diet (whole grains, fruit, vegetables);
• Physical activity;
• Laxatives where needed: bulk-forming (Fybogel) and osmotic (Macrogol, Lactulose) first; stimulant laxatives (Senna) for additional support.

When to seek help

• Sudden new urinary incontinence (may suggest UTI or Delirium);
• Acute urinary retention (cannot pass urine, painful abdomen) - emergency;
• Faecal impaction;
• Skin breakdown from chronic incontinence.

For Carers

Continence problems are often the symptom that most increases carer burden. Practical help is available:

• NHS continence services (referral via GP);
• Continence nurse specialists;
• Equipment supply through occupational therapy;
• Help with the personal care from social services;
• Respite to give carers a break.

For some families, continence problems are the point at which residential care is considered. This is a reasonable response to a substantial caring demand.