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Focus on Incontinence in Dementia We have reviewed a number of types of dementia, including the potential causes, diagnosis, consequences, and treatment options. We have also discussed the limitations of diagnostic criteria used to clearly and definitively determine the presence of, and type of, dementia. Researchers continue to strive to estimate the prevalence and incidence of dementia, which is crucial to determining the allocation of resources and appropriate patient care.
There are a series of physiologic, neurologic, and cognitive reflexes required to maintain continence. The natural process of aging can lead to occasional and eventually chronic incontinence associated with weakening bladder muscles and which can be impacted by the presence of dementia. Intact cognition is an important feature to assure the ability to perceive the sensations associated with bladder fullness and the ability to postpone the process of urination after the first sensation; the motivation and desire to urinate, mobility, coordination; general ability to locate, reach, and access the toilet; and the manual dexterity and mental capacity to remove clothing items and complete the toileting process. Patients with Alzheimer’s and other forms of dementia progress to declines beyond memory and include functional abilities that affect overall health, quality of life, and the ability to live independently. These functions are typically measured using the basic activities of daily living (ADLs) necessary for proper self-care, and specifically self-hygiene and toileting practices. At the first signs of incontinence, patients and their caregivers are encouraged to get medical attention to rule out treatable causes, such as urinary tract infections. The presence of incontinence and its progressive worsening as people living with dementia become more dependent on others for activities of daily living place increasing burdens on caregivers. Incontinence is not considered an inevitable symptom of dementia, but it is relatively more common in patients living with dementia. For instance, urinary incontinence is a common condition in the general population, and more so in older adults. About 10-20% of all women and more than 75% of women living in nursing homes may experience urinary incontinence. Several studies have documented higher rates of urinary incontinence in people living with dementia compared to those without dementia. Among the elderly with dementia, about 22% that may be community dwelling and 84% living in nursing homes experience urinary incontinence. Similarly, the prevalence of fecal incontinence is higher in people living with later stage dementia and tends to increase with age.
Now this is important. Incontinence has been cited as the second most common reason for the decision to move an elderly patient to a assisted living facility or long-term care setting because of the extraordinary burden placed on caregivers. Data suggests that such institutionalization is also a risk factor for the development of urinary and/or fecal incontinence. While treatment options concentrate on the treatment of underlying causes, incontinence may remain due to dementia-related changes that reduce the patient’s physiologic, psychologic, and independent toileting ability. Considering that a large part of care-giving for people living with dementia is taken on by the family, the burden can be considerable.
Types of Incontinence in Dementia Let’s start here with a brief review of the types of incontinence that may be experienced by the general population--and specifically by people living with dementia. There are several types of incontinence, each of which may have different etiologies or causes.
Functional incontinence is the type that is usually faced by patients with cognitive deficits. In this case, the urinary and/or digestive system may work normally, but there may be a loss of bladder and/or bowel control because of the inability to get to, or use, the bathroom properly. Some dementia patients don’t recognize the urge to urinate or defecate or may not be able to communicate their need to use the toilet. In some cases, the deficits may include the inability to remember the process of toileting and hygiene. In cases of dementia, urinary incontinence may develop first with fecal incontinence developing as dementia progresses to later stages. Urinary incontinence may be categorized as stress, urge, mixed, overflow, functional, and reflex. While any of these types may be experienced by a person living with dementia, functional incontinence is specifically associated with physical or cognitive impairment, such as immobility and dementia. Urge incontinence, which can be associated with neurologic diseases such as Parkinson’s, may also come into play. Because the prevalence of urinary incontinence is relatively high in the elderly and particularly those in institutional settings and/or with dementia, several reasons for urinary incontinence may be present and should be taken into account when planning management strategies. Fecal incontinence may be categorized as urge incontinence, the most common form described as a sudden need to defecate, the inability to stop defecation in time so that they can get to a toilet. The second form, passive incontinence or the lack of awareness of the need to defecate, leads to the inability to sense when the rectum is full and may result in leakage without knowing it. Fecal incontinence may also happen in cases of diarrhea, constipation, and gas or bloating. More common in older adults, fecal incontinence may affect 7%-15% of community dwelling adults, 18%-33% of adults in hospitals, and 50%-70% of adults in nursing homes. Fecal incontinence has been cited as often present in 60%-70% during late-stage dementias, such as Alzheimer’s.
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