Tips On ... Toileting

by Edyth Ann Knox
More About Edyth Ann…

Individuals affected by Alzheimer’s Disease will become incontinent – unable to control urination or bowel movements – as the disease progresses. This is both saddening and anxiety-producing for the caregiver. Too often, the caregiver (and other family members) see incontinence as a reason for institutionalization – but you should know that many people still maintain their loved ones at home after coping with this new aspect of the disease.

1) Protective products: There are many kinds of products out there to help protect from leakage for your Loved One. Different ones have different advantages according to the stage of awareness and incontinence that the individual affected by Alzheimer’s Disease is at:

  • Pads: Pads are often used in the earlier stages of incontinence, where you are dealing with only a little leakage or smearing. Many women will find them acceptable to use as they resemble a feminine pad that they are used to. There are protective pads that are specially designed for men too and have a cup like depression in front of the pad. I suggest using the pads designed for urinary leakage rather than a feminine pad as they are more absorbent and designed better for incontinence use. These pads, like feminine napkins, have a sticky strip to help attach to the underwear and are very easy to change.
  • Specially designed underwear: Many individuals affected by dementia are very aware of their incontinence in the beginning and find it embarrassing to use a pad or any obvious type of product for urinary leakage. For them there are regular underwear designed to help with light urinary leakage. The two I have seen are put out by Wherever and Compose. One type has a built in washable padding that is highly absorbent. The other type has a hidden pocket to slip in a changeable absorbent pad. Both look like regular underwear for a man or a woman.
  • Disposable protective underwear: These are fairly new products and are excellent. They have a cloth like outer covering but are very absorbent and prevent leakage onto the outer layer of clothing. They have an elastic top and can be easily pulled up and down by your loved one. This makes them excellent products to use while a Loved One is still able to take themselves or with only occasional assistance to the bathroom. They are not very bulky so they are not noticeable under the clothing like some of the older products were. They generally have a soft cloth like exterior which is less irritating and allows for better air circulation. Most have tear away sides for easy removal but to put on fresh ones the pants have to be removed to place a new one on.
  • Protective undergarments: These are generally wide pad-like pieces that go from the waist in front to the waist in back. They generally have an elastic band that attaches from the front to the back with either a button or velcro. These are easier for the caregiver to change, especially when your loved one needs more help or is still wearing pants. The caregiver only has to undo the elastic to slip the old one off, attach the elastic band to a fresh one, place the undergarment on, and attach the elastic to the other side of the garment.
  • Full Adult Diapers: Most are not well designed and are covered with plastic. They tend to be bulky, especially between the legs because of their poor design. The plastic outer covering can be irritating and cause heat build up within the diaper itself. This can cause a hastening of adult diaper rash and skin breakdown. However they can be useful when the individual is at the stage that they are no longer able to bear weight and are in the bed more often when needing to be changed. In this case, you may not need to attach the front to the back with the adhesive strips.

2) Make sure they can get to the bathroom: Not being able to get to the bathroom or recognize it is generally one of the first problems they will have. Leaving the bathroom door open may be helpful at times. Most houses now have two bathrooms and you want to leave the bathroom most familiar to your loved one free as much as possible.

4) Reminding your loved one: Once your loved one starts to lose a sense of the location of the bathroom they may need redirection towards the bathroom and possible cuing as to the chain of events. Because incontinence begins in the middle stages so must our assistance for our loved one. Watch your loved one’s body language and behaviors because they may indicate that they need to find the bathroom.

5) Observing their normal bathroom habits: Make mental or physical notes of when your loved one normally uses the bathroom and when they have bowel movements can be of great assistance later when you have to take over taking them to the bathroom.

6) Conditioning: As the disease progresses and daily structure becomes more important, you may have to develop a toileting schedule. Once my mother-in-law got to the point that she needed me to take her to the bathroom, I had a good idea of her normal bathroom habits. I then would take her to the restroom when she was most likely to go, even if she was already wet. I would then sit her on the toilet when she was most likely to go. This way I began to condition her for results every time I sat her on the pot. It is very much like toilet training a small child. This helped a great deal in the later years when she was no longer aware of her needs.

7) Getting a resistant person to sit on the pot: The bathroom is a small closed in area and at some time when the individual affected by Alzheimer’s Disease is most confused they may resist being directed in the bathroom. They do not understand what you are doing, being pulled and tugged on and can become very anxious over the whole procedure, sometimes resulting in fighting back. Here again conditioning can help. In getting my mother-in-law, Milly, to sit anywhere I would stand on the same side of her when she was standing in front of where I wanted her to sit. I would back her up till the chair would hit the back of her legs. In some cases like with the toilet, I found it was better to place my foot at where I wanted her to start sitting down. Then when her heels hit my foot or the back of her legs hit the seat edge, she would stop. I would place one hand on her back by her shoulders and one hand on her belly. I would gently put pressure on her tummy and her shoulder which would start her in the sitting motion and help ease her to the pot of seat. Doing it the same way each time with what method works for you and your loved one helps make it less confusing. You can also give simple verbal directions at the same time. Give any verbal direction as one step at a time until that step is completed and the next step is ready.

8) Cleaning up after using the bathroom: Make sure your loved one is cleaned up properly after having a bowel movement to avoid infection, skin damage and unpleasant odors. The ease of this will likely depend on your loved one’s state of mind. I found with Milly that I had better luck if I stood her up facing the sink (our sink was right in front of the toilet). I would then either let her have a wash cloth or hold on to the sink, while I stood to one side and slightly behind her and then I would wash her off with a wet, warm wash cloth with one end soapy and the other end wet enough to rinse her off with. If I was out of her direct line of site and especially when she was holding a wash cloth, I think that she felt as if she were the one doing the cleaning. It is best to clean from the front to the back to avoid infection from the fecal matter that may be there.

9) Setting up a regular routine: Setting up a regular bathroom routine is essential as the disease progresses. This does not mean taking your loved one to the bathroom at an exact time but at regular intervals that you know will work for your loved one. For instance at a certain length of time after eating, a certain time before bed or even during the night after going to bed. This not only helps to get to the bathroom before they have an accident but also allows you a regular time to help keep them clean. The object is not so much to keep them from using the protective product but allowing them to be able to eliminate as much as possible in the pot and also allowing for clean up when they need it the most.

10) Identifying environmental problems in the bathroom: Here are some items that can also cause problems for person using the bathroom:

  • Toilet paper: Who would think that something as simple as toilet paper could cause so many problems? Finding it can be a problem especially if the walls are white and so is the paper. Colored toilet paper can be easier to see when hanging on the wall. Your loved one may begin to have difficulty understanding where to deposit the paper after use. Many times when they are sitting on the toilet they do not see the toilet as an option of where to place the soiled paper. Place a small trash can with an easy to remove plastic lining beside the toilet to dispose of the soiled paper rather than getting frustrated that the paper ends up on the floor or in a pocket. Avoid toilets overstuffed with too much paper by leaving out a pre-measured amount of toilet paper and checking the supply often.
  • Mirrors: At some stage the mirrors and pictures will cause problems. This is especially true in the bathroom. Many times the individual affected by dementia is reluctant to go in the bathroom or use it because to them there is a stranger already in there watching them. Removing and covering the mirrors is often helpful and the easiest way to get rid of unwanted strangers.
  • Lighting: Keeping a light on in the bathroom is also helpful. At night you want to make sure that the path to the bathroom is also lighted so that your loved one will be more likely to safely make it to the bathroom.
  • Simplify: Keeping the bathroom as free from clutter is better. Keep the lid up on the toilet and keep the bathroom as open as possible helps to reduce anxiety and confusion, as well and limit the number of things that can get knocked over and broken.

Additional Resources:

- To Diaper or Not to Diaper: Is That a Question?
- Toileting and Incontinence Skill Builder

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