Member of the Royal College of Nursing, Community Staff Nurse at Whittington Health, London
It is estimated that there are 850 000 people living with dementia in the UK (Royal College of Nursing (RCN), 2015), and one in every six people over the age of 80 years have dementia (RCN, 2015). It is important to view these numbers in context, because, overall, the UK population is ageing: one in five people in the UK are over the age of 65 years, and, by 2050, this number is projected to increase to one in four (Office for National Statistics (ONS), 2019). Dementia is often a condition of old age, and, with the change in the make-up of the UK population, its incidence is bound to increase.
Some 53% of people with dementia have incontinence, whereas only 13% of those without dementia experience this problem (Price, 2011). This is a large variance, especially as the prevalence of urinary and faecal incontinence is 1%in the general population (Price and Bradley, 2013; Bardsley,
2016). The nature of dementia makes assessing a patient’s incontinence needs far more challenging, as the causes of incontinence in this patient group are multifactorial.
This article looks at incontinence in those with dementia, examining how dementia can adversely affect incontinence, and it suggests some strategies for helping to manage it.
Nature of incontinence
Urinary incontinence can be classified into seven types (Bardsley, 2016), as follows:
Stress urinary incontinence: this occurs when an amount of urine is pushed out of the bladder due to exertion, for example, during sneezing, laughing or coughing
–Urge incontinence: urine is leaked from the bladder with a sudden and strong sensation to void the bladder, which cannot be deferred or controlled
–Mixed urinary incontinence: this is when a patient has both stress and urge incontinence
–Overflow incontinence: this is due to urinary retention. A patient cannot fully empty their bladder, and it becomes over-extended. This results in frequent or continuous leakage of urine
–Nocturnal enuresis: a patient will involuntarily leak urine during the night, when sleeping. Sometimes this is referred to as ‘bed wetting’. It can affect older patients and is sometimes associated with an overactive bladder, sleep apnoea or certain medication
–Reflex incontinence: this occurs when a patient has lost partial or complete control over their bladder, due to neurological damage, disease or a congenital abnormality
–Functional incontinence: this indicates that a patient is not able to reach a toilet because of physical or cognitive impairment.
In addition to these, there is also post-micturition dribble, which is when there is leakage of urine after voiding. It is not secondary to urethral stricture or bladder overflow, and it is most commonly found in men aged more than 50 years (Robinson, 2008). Although not technically a type of incontinence, it can be mistaken for the latter.
Urinary incontinence can also be due to other comorbidities, such as diabetes mellitus; heart disease; multiple births; neurological conditions, such as brain or spinal cord injury, Parkinson’s disease or multiple sclerosis; arthritis, leading to impaired mobility and dexterity; and obesity, which places
pressure on the pelvic floor and bladder (Bardsley, 2016).
Like all other body parts, the urinary system is negatively affected by age. With age, the kidneys become smaller; they filter urine at a much slower rate and their ability to concentrate urine also declines (Nazarko, 2015a). Ageing decreases the bladder’s capacity to hold urine and decreases its elasticity, leading to residual urine in the bladder after voiding. Older people become less aware of the desire to void and may only know their bladder needs emptying when it is 90% full (Nazarko, 2015a). In women, the decrease in oestrogen following menopause causes the urethra to become thin and less flexible, which causes decreased closing pressures leading to stress incontinence (Nazarko, 2015a).
How dementia can affect continence
The cognitive symptoms of dementia can affect on a patient’s ability to manage their own continence. Dening and Babu Sandilyan (2015) identified various cognitive symptoms of dementia that affect a patient’s ability to toilet themselves.
Patients with dementia may have amnesia and forget that they need to use the toilet, where the toilet is or even how to use a toilet themselves. Some may have aphasia, where they forget how to express their need to use the toilet, forget what the urge to empty their bowel/bladder is or forget how to ask for help.
Patients with dementia and apraxia have difficulty with conducting certain actions, and they may forget how to use a toilet, how to unbutton and button their clothing or even how to open a door. Lastly, they might experience agnosia, that is, they might lose the ability to recognise sensory information. A patient might forget what the physical sensory of needing to void is; their bladder/bowel maybe sending the sensation to be
voided, but the patient no longer recognises what that means.
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