How to Manage Incontinence in Dementia

Incontinence is common in old age by itself and occurs in the majority of patients with dementia at some point. Although not as problematic as anger, aggression, agitation, or falls, incontinence is upsetting both to you and your loved one and is a major reason individuals with dementia end up leaving home and going into a facility.

There are many different types of incontinence that older adults may experience. Some types are related to anatomical and medical causes; these types are best evaluated and treated by a urologist or other physician. For this reason, if these recommendations fail to significantly address the incontinence, it is important to discuss the problem with a physician. (Note, however, that often medications prescribed can worsen thinking and memory!)

If your loved one has a leakage of urine when they cough, sneeze, or laugh, they may have stress incontinence. Stress incontinence is more common in older women and results from weakening or damage to the bladder muscles that hold in the urine. Overflow incontinence occurs when the bladder does not empty completely. It is common in men with an enlarged prostate, although it can occur in women as well. The bladder muscle becomes stretched and can either leak or spasm. Lastly, if your loved one has a strong, sudden urge to urinate, needs to run to the bathroom, and doesn’t always make it on time they have urge incontinence (also called overactive bladder). Sometimes individuals have a milder form of this problem leading to urinary urgency or frequent trips to the bathroom without actual incontinence. And, some individuals have a mixture of these different types of incontinence.

In dementia, four main problems can either cause or worsen incontinence. One is that, as the individual’s frontal lobes and white matter connections become damaged from dementia, their ability to control their bladder is impaired, and they are simply less able to hold their urine regardless of how hard they try. The second is that, due to memory problems, they may forget to use the toilet before going on a long walk or car ride, or they may forget to adjust their intake of fluids prior to such an event. They also may forget or misjudge how long they can hold their urine, particularly if their ability to hold their urine has diminished over the years. The third is that some individuals with dementia simply aren’t bothered if they urinate in their clothes or other inappropriate places. This lack of concern for hygiene may be seen early on in those with frontal lobe dysfunction such as frontotemporal dementia, or in the severe stage of any dementia. Lastly, if your loved one cannot move quickly for any reason, it will make it all the more difficult for them to reach the bathroom in time.

Bowel incontinence may be due to problems that anyone can have, such as diarrhea, but it is common in dementia in the moderate and severe stages for the same reasons that urinary incontinence is common. The control of the bowels is impaired and individuals with dementia are less able to hold in their feces. They may forget to use the toilet to move their bowels prior to going on a trip. Due to frontal lobe dysfunction, they may not care if they soil their clothes. And again, if their walking is impaired, they will be less likely to make it to the toilet in time.

Key Question:

I don’t mind cleaning up when she doesn’t make it to the bathroom in time and soils herself, but now she’s fighting me when I try to get her washed up.

• Incontinence is common in dementia. When the individual does not want to get cleaned up it generally indicates problems with frontal lobe function.

© Andrew E. Budson, MD, 2021, all rights reserved.