Overcoming Environmental Barriers to Incontinence Management in Dementia Patients - Diane Newman

May 7, 2024

Diane Newman addresses managing incontinence in individuals with dementia, focusing on the unique challenges faced by this population. People with dementia often cannot recognize the need to use the restroom or how to use incontinence products correctly, leading to distress for both the individual and their caregivers. Dr. Newman suggests practical environmental adjustments to aid recognition and accessibility, such as enhanced visibility of toilets, clear signage, color differentiation, and removing physical barriers like clutter and poor lighting. She emphasizes the importance of simple modifications like changing toilet seat colors to aid perception, ensuring pathways are well-lit, and maintaining privacy to facilitate easier bathroom use. These changes, while straightforward, can significantly improve the quality of life for those with cognitive impairments.


Diane K. Newman, DNP, ANP-BC, BCB-PMD, FAAN, Adjunct Professor of Urology in Surgery, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA

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Diane Newman: Now, I wanted to concentrate on incontinence and dementia because I know that's probably why you wanted to listen to this, as this can be very frustrating for individuals who have memory loss. What happens with an individual with dementia is that they don't recognize those signals anymore, so they don't recognize what the urge means. They don't remember what to do with incontinence products, or they're using them incorrectly. They don't know how to put them on, and they don't even know if they have leakage. And really, this is very distressing for caregivers, but it's also very distressing for the individual who has dementia. Even though they may not be aware of these things, I think many of them retain that, "Oh, I'm wet. What am I going to do? They have to change me." And they know from childhood what that means. That can be very embarrassing.

There are things that we can do, and I'm going to give you some key things that you can possibly do with your environment. Looking at the visibility of the toilets, signage, color differentiation, compensating for visuo-perceptual deficits in that frail, older adult who has some cognition issues. We want to make it as easy as possible for that person with dementia to really understand what to do, what that means as far as when they have to go, and then what are the cues in the bathroom? So, I want to give you some ideas that actually have some solid research in this population.

Okay. Environmental barriers. One of the studies I'm doing now is to prevent falls, and we actually have an occupational therapist go out and assess the environment. There's a CDC screening that you can look at the environment. I recently heard some presentations from her PhD students, and I cannot tell you how astute they were in looking at things like the fact that the bathroom had a step-down that was a problem for the elder, clutter, lighting. So, there are things that possibly you can do in your environment where you're caring for that individual that might help. You want to make sure the route to the toilet is lit. If they're going to get up at night, they have to go. They don't want to wet the bed. Can they find the bathroom? Is the pathway clear to the bathroom? Are the doors open? Is there signage on the doors?

I hate to say this, but in one nursing home, what we did is we put pictures of toilets and people peeing on the doors in their dementia unit, and that helped them. They knew that was what you do when you go in there. They saw a picture. Mirrors. Actually, someone with dementia, when they look in the mirror, they get scared because they don't recognize their reflection. Maybe you take the mirror away. The height of the toilet. Do you have grab bars? Because they may not be strong enough to lift themselves. They need to hold onto something. Believe it or not, changing the toilet seat cover, going from white to black, helps them identify, differentiate where the opening is to pee into. That sounds crazy, but let me tell you, this does work, just putting a black toilet seat on or something with different kinds of colors.

You want to have privacy, even though that individual has cognitive impairment. We don't really pee with people looking at us. I don't know about you, but I can't do it, and us women, we go into stalls. If you're standing around, "Okay, now go," if you have an aide standing there, they may not be able to relax or urinate, so you may want to consider what kind of privacy do they have? Will they lock themselves in? Are you worried? Well, yes, but I don't want to close the door to the bathroom. She locks herself in. Disable the locks to close that door, so they have that privacy.

Mobility aids. Again, bars in the bathroom, raised toilet seat, so that they don't have to go so far up when they rise up. If you don't want them in the bathroom, really consider portable commodes. There are beautiful ones out there now. Putting that next to the bed, a urinal for men really can help. Clothing. You want to make sure the clothes are easy to come down. Zippers don't work, really. An elastic waist is much better than, say, a belt. There are adaptive clothing with Velcro fastenings that really can help. And then again, prompted voiding. I don't know, maybe you put on an alarm every two hours. We now have these watches. Can you set the watch for two hours to remind you that I got to take mom to the bathroom? So really, a lot of these environmental barriers can be changed, and they sound simple, but they can really help.