1. Incontinence? Or just the disabling impact of dementia?
Colin MacDonald
Associate Trainer and Nurse Consultant
The Dementia Services Development Centre
University of Stirling

2. Dementia in Scotland Projected number of people with dementia in Scotland
(Alzheimer’s Scotland 2007)
Currently 71,000 in total
- 60% in community
- 40% in institutional (long stay) care
Projected to rise to 127,000 by 2031 (Alzheimer’s Scotland 2010)

3. Some scary stats... “Dementia costs the UK £23 billion a year” and....
“On present trends the UK’s approach to managing
Dementia is unsustainable”
(Alzheimer Research Trust 2010)

4. Dementia – an overview
Definition:
“Dementia is a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple cortical functions, calculation, learning capacity, language and judgement. Impairment of cognitive functions are commonly accompanied, and occasionally preceded by deterioration in emotional control, social behaviour or motivation.” (W.H.O.)
The difficulty with this definition is….

5. How Dementia is framed... Focuses on inevitable neurological decline
- ‘a series of deficits and symptoms…a by-product of the inevitable neurological and
cognitive decline’ (Jacques and Jackson 2000)
- a sense of nihilism - ‘you can’t do much with dementia patients’ (MacDonald 2007)
“Traditional” methods of managing people with Dementia – based on “control”
- psychotropic medications
- restraint
- care practices
Our ‘care’ often focuses solely on what the person can’t do
- ‘problem-orientated care plans’ (Packer 2000)
- paternalism (Adams and Clark1999))
- routines and models of care - ‘the culture of care’ (Kitwood 1997) and the ‘hard culture’ (Lee-
Treweek 1997)
Urealistic expectations of safety and risk

6. The disabling impact of Dementia..?
Being in hospital:
“Had a significant negative effect on general physical health”
“Had a significant negative effect on symptoms of dementia – with increased confusion
and dependency”
“Increased length of stay”
“More likely to be prescribed anti-psychotic drugs”
“Increased prevalence (34%) of being admitted to a Care Home”
(Counting the Cost - Alzheimer’s Society 2009)

7. Does our care and treatment contribute to incontinence in people with Dementia....?
“Wide prevalence (11 – 90%) of incontinence in people with dementia in care settings”.
74% in hospital + care homes vs 32% at home (Hellstrom 1994)
“Urinary incontinence in nursing home increased from 46 – 81% after 6 months” (Specht et al
2002)
Risk factors for incontinence in people with Dementia include:
Poor mobility and transfer (Bravo 2004; Nelson and Furner 2005)
Clothes fasteners (Nelson and Furner 2005)
Medications – including diuretics, sedatives and ant-psychotics (Skelly and Flint 1995)
Laxatives (Brockenhurst et al 1998)
“There is a lack of evidence based nursing intervention related to incontinence care for
people with dementia ….. But prevention is still the best cure” (Hagglund 2010)

8. A systematic process © Colin MacDonald
The Dementia Services Development Centre
This tool may be reproduced without formal permission for the purposes of non-commercial research,
private study and review provided that the material is appropriately attributed.

9. What’s going on for the person?
Declining cognitive abilities
Declining emotional control, social skills and motivation
Impaired reasoning
Increased susceptibility to stress
For the person with dementia – their behaviour may become their main
form of communication and expression of need!
This will affect the person’s current reality and experience

10. Physical illness and treatments
- PAIN and discomfort
- Infection
- constipation
- medications (side effects/toxicity)
- endocrine or metabolic disorders
- many others!

11. The disabling impact of the environment?
Does it make sense to the person?
Does it lack crucial information?
Sign and cues?
Areas of importance not highlighted?
Inappropriate lighting?
Too much noise and conflicting stimuli?
Patterned carpets and shiny flooring?

13. Reduce the impact of the environment
Good signage
Large size
Right height
Use of strong contrasts
Yellow highly visible
Symbol and text
On doors, not beside

14. Decoration
Enable access
Restrict access
Burnett Pollock Associates

15. The Iris Murdoch Building
Purpose-built, opened in 2002
Design exemplar for dementia-friendly public buildings
The Iris Murdoch Building opened in 2002, named after Iris Murdoch, who had Alzheimer’s disease.
It was purpose-built as a design exemplar to demonstrate how a public building can be dementia-friendly and compensate for the deficits of cognitive impairment. It is the first of its kind to extend the thinking of the Disability Discrimination Act, which allows for physical and sensory impairment, to include cognitive impairment.

16. - Colour and contrast - Conceal the unnecessary

17. Our impact on the person?
Attitudes, views, and beliefs about older people…..
An ageist society? Stereotypes?
Perceptions of behaviour
Negative and nihilistic views?
Care models and approaches
authoritarian and “expert” attitudes
Inflexible routines
Focus on safety and physical care only 17

18. Case study
Mr I. P. Squint is a 67 year old man with Dementia. He was a professional football player with long-standing alcohol problems. He is fully mobile and physically active. Since his admission to a Community hospital a few weeks ago he has been urinating inappropriately in the ward – often at the “hairdressers sink” in the main corridor. He has also defaecated here. Staff are “disgusted” with this behaviour and are convinced that it is “sexually motivated” – in full view of visitors to the ward.
He is also becoming increasingly “violent” towards staff when stopped from indulging in this behaviour. He has been on Quetiapine for some time – this has now been increased to100mg TID.
What might be some of the reasons for this man’s behaviour?
What actions could be taken?

19. Reasons for behaviour? Disorientation reduced inhibitions
- new environment
- lack of cues / signs
- misinterpretation of cues (hairdressers sink)
reduced inhibitions
Medications - 10am diuretic. ? Quetiapine + Lactulose
Past history / lifestyle
Personal response - ?embarrassment at reduced abilities / control
Staff approach – reactive /aggressive – seeking to control “deviant” behaviour (lack of understanding)

20. Actions.... Adapt environment - Improved signage / orientation
- removed sink (trigger)
Screen for physical reasons / causes:
- test urine sample
- check / monitor bowels
- check / review medications
Behaviour and continence assessment
- familiar patterns (times, places)
- means of communication (of needs)
- timed prompts
Adapt our approach – less confrontational
?? Incontinence management products

21. Result…?
REDUCED number of episodes of inappropriate urination / defaecation
REDUCED episodes and severity of aggression and violence

22. Final Point
Dementia as a disability is something that CAN be compensated for.
The person with dementia can’t adapt to us – we need to adapt our social and built environment around the person.
At the very least - don’t disable the person further!

23. Thank you Iris Murdoch Building, University of Stirling, FK9 4LA
Tel
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