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
The