Contents

Incontinence

Incontinence is distressing, embarrassing and a considerable burden for carers and occurs sooner or later for several reasons:

Causes
1. Lack of foresight.
The Duke of Wellington is credited with the remark that “A man should piss when he can, not when he has to”. Most adults may not consider the matter in such colourful terms but routinely relieve themselves in anticipation of any situation in which it may not be convenient to get to a lavatory: before going for a walk, taking their place in a cinema etc. A person with frontal lobe damage shows a loss of forward planning, affecting even such simple matters as emptying the bladder at a convenient time; consequently they are liable to be caught short.

2. Apathy
The general apathy affecting many people with Pick’s disease may cause them to ignore the sensation that they need to go to the lavatory, leading to incontinence, particularly at night.

3. Use of inappropriate places as lavatory.
Damage to both temporal lobes of the brain may lead to the so called ‘Kluver-Bucy syndrome’, one feature of which is an inability to recognise the appropriate use of objects in the environment. The sufferer may, for instance, try to eat things that are inedible and, similarly, may use a wardrobe as a lavatory or a wastepaper basket as a WC.

4. General debility.
In the late stages of any dementing disease the patient becomes incapable of doing anything for themselves, including attending to their sanitary needs

5. Specific urinary problems.
Pick’s disease occurs generally in an ageing population and it is important not to overlook specific urological problems unrelating to dementia. Middle aged and elderly men may have prostatic problems, and women, inconitnence related to coughing, stress, or vaginal prolapse. Most of the literature on incontinence in dementia focuses on these incidental physical causes, rightly so, as specialist advice may be necessary to ensure that these treatable conditions are not overlooked.

Management
The first two of the above may to some extent be managed by insisting that the patient relieves themselves regularly and before going out or going to bed, and by limiting drinks in the evening. Excessive fluid restriction is unhelpful, however, leading to concentrated urine and urgency of micturition (urination).

Specific problems affecting the urinary system require specialist medical and nursing advice. Assessment is difficult as diagnosis depends to a considerable extent on accurate reporting of the symptoms, of which the patient may be incapable. Specialised continence clinics may be orientated chiefly towards the needs of those who are aware of their problem and eager to co-operate in finding a solution.

Continence aids are readily available from the larger retail chemists and supermarkets or, more conveniently and at lower prices over the Internet. Several well-known manufacturers of sanitary towels have Internet sites offering a range of aids. Unfortunately, the lack of insight typical of Pick’s disease may cause the sufferer to refuse to wear incontinence pads, waterproof knickers etc. At the least, a washable mattress protector and disposable draw-sheets may reduce the soiling or wetting of bed linen. Re-usable absorbent knickers or underpants resemble conventional garments and may be more readily accepted by the patient than disposable pads – but their use creates a lot of laundry.

Without the co-operation of the patient, there is no solution to urinary incontinence by day, which may seriously limit and eventually put an end to, social activity outside the home.

Faecal incontinence, if it amounts to more than light soiling of underwear, presents an even more serious problem. Patients may appear indifferent to the soiling of their persons and of the surroundings, or may panic and try ineffectively to remove contaminated clothing and clean themselves, often making matters worse.

The difficulties of cleaning the patient, their clothes and the surroundings can be distressing to all concerned and may be manageable only with continuous nursing care. Incontinence is often a major factor leading to admission to a nursing home, but it is important that any physical, urological causes should be diagnosed, as these are treatable.

Professor Colin Binnie