NURSING IN THE CASE OF ALZHEIMER'S DISEASE: INCONTINENCE
Nearly all those suffering from a dementing illness will eventually lose control of their bowels and their bladder. When this problem first arises, with bed- or seat-wetting, it is essential that it is brought to the attention of the general practitioner as there are many causes of incontinence apart from dementia that older people in particular are prone to. These range from urinary tract infections, such as cystitis, to more important physical problems, such as an enlarged prostate gland, which can be rectified. Although incontinence is most likely to be the result of dementia, it may not be, and this possibility needs to be carefully examined. It is also important to differentiate between incontinence, which is the inadvertent passage of urine or faeces, and inappropriate behaviour, such as evacuating the bowel or the bladder into the wastepaper basket or the sink. The latter is a behavioural problem rather than true incontinence and can often be helped by making access to a toilet easier or by taking the person concerned to the toilet frequently, so that they don't have to try to find it urgently when they are on their own.
Some people become incontinent because they can't get to the bathroom quickly enough. Again, this is sometimes caused or aggravated by medical conditions which the doctor may be able to treat. If not, easy access to the bathroom and frequent visits to it may also avoid accidents, as described above. At night, leaving a light on, clearly labelling the bathroom door, or providing a chamber pot or commode may be helpful.
It is impossible for a person to be incontinent of urine if the bladder is empty. The need to pass urine is often regulated by the pattern of intake of fluid - drinking habits and mealtime routines - and also sometimes by the medication that a person is taking. By carefully charting the times when an incontinent person goes to the bathroom and those when he or she is wet, it may be possible to establish when and how frequently the bladder will need to be emptied. This pattern can then be used to indicate the most appropriate times to take the sufferer to the bathroom to try to avoid the full bladder and consequent incontinence.
Incontinence at night can sometimes be limited by restricting the amount of fluid that is available during the evening. Most people can manage as long as fluid is unrestricted during the remainder of the day. Before adopting this routine, however, it is probably best to check with the sufferer's doctor.
There are also many non-verbal clues that indicate when people need to empty their bladder. The most obvious of course is restlessness, but men may begin to fiddle with their clothing or women to raise their skirts. Keeping a look-out for such signs is often helpful.
Inability to control bowel function can also be caused by medical problems, some of which can be rectified quite easily.
Most common of these is severe constipation, with a 'paradoxical' leakage of fluid bowel contents to the outside, rather as if the bowel is overflowing. If, however, the incontinence is the result not of a medical problem, but rather of the dementing process, it can be more difficult to manage. Nevertheless it can be managed even if it can't always be prevented. Sometimes it is necessary to use a combination of different medicines to prevent the bowel being emptied when this would be inappropriate, but on the other hand stimulating a bowel movement at a convenient time. A simpler approach which works in some people is to rely upon what is known as the gastro-colic reflex. If the stomach is distended by a large quantity of food or fluid this sometimes causes contraction in the large bowel, the colon, resulting in a bowel movement. This is why many people have a normal daily routine which involves emptying their bowels after a particular meal. If a person with Alzheimer's disease or a similar condition is given a reasonable breakfast with at least one large mug of tea, this may well be sufficient to stimulate the evacuation of the large bowel shortly afterwards. The timing varies from person to person, but in some people it is possible to use this natural reflex to help control bowel function.
Unfortunately many people will continue to lose control both of their bowels and of their bladder, despite the best care and attention from their medical attendants and those looking after them. Under these circumstances it is important to try to minimize the workload that this causes and also to try to make sure that the sufferer's skin is kept as clean and dry as possible. There are many varieties of incontinence pants, pads, and nappies that can be used in different combinations to protect outer garments, chairs, and beds. The best are generally those that soak up any moisture in such a way that it is not in contact with the skin for very long.
In many parts of the country, the community services will provide these aids and so an inquiry, probably first of the district nurse or the health visitor, will let you know what is available locally. It is also possible to obtain protective sheets and pads that prevent urine soaking into a chair or a bed if other means of containing it are somehow unsatisfactory. If there is an incontinence laundry service in your area this will be a great boon. They will regularly take away bed-linen and launder it. Unfortunately this service isn't available in all areas. If laundering linen proves to be a major problem, ask your district nurse to advise you about locally available alternatives which will often consist of a combination of disposable pads and special draw-sheets to protect the bed.
There are many types of urinal that can be strapped on to a man's penis to collect his urine. Some of these are quite effective in the daytime but in general they are not much help at night as they tend to leak. There are no satisfactory appliances of this type for women. For this reason, many medical or paramedical professionals may consider the use of a catheter. This should be avoided if at all possible, but in the last instance it may be necessary. If it makes the difference between a person being able to stay in her own home or having to live in an institution, it is probably better to accept a catheter. It is not necessary for anybody other than the patient and her carers to know that this decision has been taken as the bag into which the catheter drains can be discreetly strapped to a thigh or suspended from a belt within the outer clothing. It is very easy to empty a catheter bag, but necessary to remember that this task should be undertaken as carefully as possible to avoid introducing bacteria into the system.