Expert: Mary Gordon - 9/6/2010

Question
Hi Mary, I am looking for help suggestions with behavior problems with my brother who lives in a memory care unit.  He has reached the stage where he is urinating anywhere and everywhere despite tolieting him every half hour, putting a commode next to his bed and so on.  He also is being to become combative and is resisting being taken to the bathroom.  We are taking him back to see his Doctor but I know that they know alot about behavior and medicine but as much as someone who deals with this on a day to day basis.  The memory care unit he is in is new and a really wonderful place, with lots of caring workers and I don't want to have to move him if possible.  Need help!!!!

Answer
Dumb question, but surely a memory care unit - that deals with dementia patients - can deal with incontinence ? Is the problem the urinating in strange places?

I'd get the doctor to check him out to make sure he doesn't have a urinary tract infection that would cause a very frequent urge to urinate. Very often, when people with dementia have a UTI, they show no symptoms other than urinating very frequently.  They don't seem to be in pain, don't complain about anything, and may not run a temperature (or if they do run a fever, it's so low it might not be noticed). Sometimes an undiagnosed UTI will contribute to being less "with it" than usual, or unusually combatative. He might even have an enlarged prostate, which can cause an increase in the urge to urinate frequently.  

Certainly, urinating every half hour is NOT normal for anyone. Normal frequency would be once every two to three hours.

So, first thing is to make sure there is no undiagnosed medical problem.
It is useful if the doctor can be provided with the following information:
When did the problem start?
How often does he urinate during the day or at night - both number of times and time between.
Is he saturated or is it just a trickle?
Has there been an increase in confusion or any change in behaviour?
Has there been any fever or does he appear to find it painful to go to the toilet?
Is he taking any medication that might impact his bladder?
Is there any pattern to the places he chooses to relieve himself - is there any chance he may be mistaking things for a toilet? Does he always urinate into a corner?

He's getting combatative because he doesn't understand what he is being asked to do or is not capable of complying. He's feeling pressured and stressed and he's confused - which causes the kind of reaction you are seeing. He may have forgotten what a bathroom is for, where it is, how to use it on his own -and may have no idea why people would not want him urinating everywhere. He may have lost the ability to wait until he gets to the bathroom. He certainly seems to have lost his sense of modesty and hygiene privacy. He probably can't think through the connection between the physical sensation of needing to urinate and seeking a bathroom. Prompting and pushing isn't working. It's just making him upset.

If there is no medical reason, and its purely behavioral, maybe time to stand back a bit. Has the team tried brainstorming around this subject to try and figure out what is going on? Think about his past patterns and current behavior, and really look at the routines and the physical environment.

Some suggestions
Be sure he is drinking adequate fluids, preferably water (5 to 8 glasses daily – jelly, ice cream or custard may be substituted). Many people with dementia forget to drink or no longer recognise the sensation of thirst. Adequate fluids will keep his system flushed out and reduce the odds of UTIs.
Consider reducing his caffeine intake by using decaffeinated coffee and tea.
Observe his patterns and suggest he use the toilet at regular times that follow his natural pattern rather than try and impose a pattern.
For example, for most people what works is toileting before and after meals, and before bed (again, I'd ask the doctor about what is going on, since urinating every half hour suggests a medical problem to me).
Try to establish a regular routine for him to have something to drink with and between meals.

When discussing toileting, it may help to:
Use short, simple words to give step-by-step instructions. For example, ‘sit down’.
Watch for non-verbal clues, such as pulling at clothes, agitation or a flushed face.
Use words that are familiar to the person, such as ‘pee’ or ‘tinkle’.
Do not rush the person. He can read physical and verbal anxiety and will "catch" it - he will know the caregivers are not happy with him, and he may react to that.
Reassure him.

Try to make the situation as simple as possible. Some things to consider include:
What happens during the night? Is it different than what happens during the day?
Is the distance to the bathroom too far?
The floor and toilet seat may be the same colour. Try using contrasting colours. Sometimes a colored toilet seat helps.
Does he have difficulty undressing?
Is he at all inhibited by lack of privacy?
Is there good lighting to make the toilet easy to find?
Is the toilet clearly marked? Put a sign on the door, use a night-light or leave the door open.
Is he upset by anything in the bathroom? Believe it or not, mirrors can be very confusing and upsetting, since they may not recognize themselves, and may think there is a stranger in there with them who won't leave.
Can the door be opened if he falls? Can he lock himself in?
A raised toilet seat and wall grab-bars may help the person get on and off the toilet.
Make sure the seat is fastened securely to the toilet to reduce the risk of slipping.
Avoid floor mats to prevent tripping.
If there is any pattern or trigger to his urinating in inappropriate places, try to remove anything that might be causing him confusion (i.e.  objects that may be mistaken for the toilet). Again, look for patterns to where and when he is urinating inappropriately.

Clothing
Try to make getting clothes on and off as easy as possible.
Use Velcro tape instead of buttons or zippers.
Try elastic waistbands for trousers or wraparound skirts.
Try not to let the person become accustomed to wet clothes.

If nothing else works, it might be time to try adult diapers or pads or even a  condom catheter. These are a better idea than a foley, since they are much less likely to be pulled out and less likely to cause infection.  If part of the problem is disrobing in public, you can buy "strip proof" clothing to keep him from pulling his pants down or pulling off a diaper or catheter. Here is an example
http://www.silverts.com/show.cfm/product/50880-alzheimers-anti-disrobing-suit

Start with the doctor and see where that takes you. This kind of behavioral issue can be very hard to manage. However, you know that no matter what anyone does, eventually, he will be completely incontinent as he will lose all control.

I'm thinking of you. I know this is very hard to watch, especially in a relatively young person like your brother. It's painful to think of them losing control of such a basic function we learn from early childhood.

Mary