Different types of incontinence and possible causes

Urinary incontinence can present in different ways. People living with dementia may have an overactive bladder. They may experience:

• Urge incontinence: This is an inability to retain urine until reaching the toilet.
• Stress incontinence: This is a leakage of urine when coughing, sneezing, or when exercising.
• Overflow: This causes leakage when the bladder is full.
• Nocturnal enduresis: This is leakage of urine during sleep.

Faecal incontinence is less common. The types are:

• Passive incontinence: This is where there’s a lack of awareness of discharge of faeces.
• Urge incontinence: This is where the person is unable to retain faeces despite attempts.
• Seepage: This is leakage after emptying the bowel.

There are certain things that we need to take into consideration in relation to dementia and maintaining continence.

These are normal ageing changes, brain changes due to the disease process of dementia, frailty and multiple health issues and medication.

Dementia causes multiple brain changes. Over time this can have a major impact on daily functioning.

Most older people are dealing with more than one health condition. The older the person, the more likely it is that they will have multiple conditions.

Dementia and incontinence can be part of a syndrome called frailty. Frailty can mean that someone experiences muscle weakness, problems with endurance, balance, mobility and nutrition.

Other common conditions that can impact on continence in older adults are diabetes, cardiac failure, joint disease and arthritis, chronic lung disease such as COPD or emphysema, Parkinson’s disease, depression and stroke.

Up to 45% of medications are prescribed for people over the age of 65, and about a third of older people have five or more prescribed medicines.

Due to the high prescribing in this age group, it’s essential for a person developing urinary problems to have a full medication review, preferably by a pharmacist.

In terms of continence issues, there are some medications that may contribute to incontinence.

Some of the more common are diuretics or water tablets, antihypertensives for treatment of high blood pressure, antipsychotics which are major tranquilizers, anti-Parkinson’s medication and some antibiotics for treatment of urinary tract infections in women can have a side effect of cystitis.

Drugs prescribed for Alzheimer’s disease can cause or worsen incontinence and can cause particular problems with control of the bowel.

The main type of drugs used to treat urinary incontinence have been shown to impact on cognitive impairment.

As well as dealing with normal ageing changes, the person with dementia will be experiencing brain changes due to the disease process. These changes can lead to accidents.

Visual changes may affect someone’s ability to recognise a space or facilities, read signs or distinguish colour.

The person may have expressive difficulties where they struggle to communicate the need to use the toilet. They may have receptive difficulties and are not able to understand a bed will prompt to use the toilet or understand they need assistance.

Sensory changes can affect the person’s ability to recognise the message from the bladder to the brain that would alert them that they need to use the toilet.

Memory and orientation are often affected in the early stages of dementia. This can mean the person is unable to remember where the toilet is and how to navigate to get there.

Changes to someone’s mobility and just judgement can lead to problems. They may not be able to determine distance or the time they need to get to the toilet, which can lead to accidents.

Dark patches or shadows may be perceived as steps or holes deterring the person from moving forward.

The person’s spatial awareness changes. They can have difficulty in understanding how things fit into a space and how to coordinate body parts. For example, sitting on a toilet or putting a leg into a trouser.

To complete the process of toileting, a person requires to retain the motor skills needed to open, lower, raise, replace and fasten clothing. This is quite complex and any part of that process can be affected by brain changes.

The person may be unable to recognise objects in the toilet or how to use them.

They may urinate in inappropriate places like the sink or the waste paper basket, mistaking it for a toilet.

They may not clean themselves properly, because they no longer recognise toilet paper and what it’s for.

This may lead to the person trying to dispose of faeces, when they may not recognise it or what to do with it.

They may try to hand it to the person caring for them.

They may use objects in the toilet to wipe faeces from their hands, smearing surfaces such as sinks, walls and floors.

Loss of motivation and volition to use the toilet can be related to depression. It’s not always due to dementia.