Toilet (re)training.

As memory fades, they won't use the toilet if they can't remember what it's for

Just for a moment, put yourself in her slippers: you feel the urge to urinate, but you don't know where the bathroom is. When some stranger takes you into a room and says, "go," you can't find the toilet. You are trapped in a confusing jumble of zippers and buttons and pads. You're intimidated by the presence of a stranger while you try to perform this intimate task. Tensed by stress, your body doesn't respond. You are hustled out of the bathroom feeling vaguely guilty. You still have to go. You feel even more stress. Suddenly you can't hold it any longer; you're wet. "We'll just have to keep you in diapers," says the stranger. You nod meekly. Maybe that will be better than this humiliating experience. Maybe then, these strangers will leave you alone.

Incontinence in the nursing home resident with dementia is complicated. Rarely is it a medical problem. "There is nothing inherent in dementia in terms of physiology that causes incontinence," says John Schnelle, MD, director of the Borun Center for Gerontological Research at UCLA and the Los Angeles Jewish Home for the Aging. "It is a behavioral problem. The resident with dementia has a reduced motivation to want to go."

Reduced motivation applies to staff as well. "The demented resident can't ask for toileting assistance or respond in a positive way when it is given," says Schnelle, "That reduces the motivation of the staff. Why provide the service to someone who doesn't want it very much?" Given the time pressures on CNAs, it's easy to see why some give up and reach for the diapers.

Better continence for dementia residents

Yet, there are ways to improve continence among residents with dementia. "It's a mistake to say that a resident is too demented and to not bother with a toileting program," says Schnelle. "The reason they are incontinent is that they can't get to the toilet. They may not spontaneously ask to be toileted, but with prompting, many can get to the bathroom in time, use the facilities appropriately, and stay dry in between times." He suggests a two-day trial of prompting residents to toilet every two hours. "Twenty to thirty percent of people with dementia will be responsive," he says. "As long as you get their attention, remind them, and encourage them, they will go."

Once that responsive group has been established, two-hour scheduled toileting can be replaced with customized prompted voiding, building upon the individual's own pattern of need. A continence program developed by the North Carolina Healthcare Facilities Association focuses on the individual resident rather than on a rigid program. "We found that it was important to study the individual's bathroom patterns and the language used for having to urinate rather than to have one particular approach on an arbitrary schedule," says Polly Godwin, RN, director of regulatory systems for the Association. "Instead of telling Mrs. Smith it's time to go to the bathroom, a staff member uses what she knows about Mrs. Smith to talk to her and then get her to the bathroom. Demanding that residents cognate and do this activity on an arbitrary schedule can make them more confused."

As important as it is to treat those who can be treated, it is equally important to forego treatment for those who can't respond. "There are degrees of dementia where you can't do anything," says Godwin. "So you shouldn't increase the frustration for the demented resident. To continually take these patients to the toilet with no success decreases their quality of life."

Set the mood

In addition to prompting, the right environment can assist the resident with dementia to gain bladder control. "Getting the nervous system to empty the bladder is easiest to achieve in a quiet, familiar surrounding," says Niall Galloway, MD, medical director of the Continence Center, Emory University School of Medicine in Atlanta. He notes that shared living space and bathrooms often make the demented resident uneasy. Calming residents with a soft, reassuring manner, closing the door to maintain privacy, and not rushing them can go a long way toward helping their bodies work.

* Give me a sign. Simple design cues can make the bathroom easily identifiable. In some nursing homes, the sign on the bathroom door is small--a sign that demented residents can neither see nor read. "Make sure the bathroom is well marked with a symbol or drawing," says Marlene Mahn, residential care specialist for the Alzheimer's Association. "Make it large enough to be seen by failing eyes."

* Splashes of color. White toilets on white floors against white walls can look like blank rooms to the non-cognizant. Mahn suggests painting the wall and floor a strong color so the white toilet stands out. "We've learned that making the toilet a darker color to stand out against the white wall didn't work," says Mahn. "A green toilet wasn't normal to the residents and further confused them." Mahn also notes that if the bathroom is visible from the bed, residents are more apt to remember to go.

* Go toward the light. Lighting, too, can help. A night light that illuminates the bathroom door and a motion sensor light inside the bathroom can make it easier for residents to find their way.

Staff training

Nothing can take the place of a well-trained staff. Sometimes maintaining continence is as simple as a timely response to the call bell or creative prompting. "Oftentimes people with cognitive impairment will answer no if asked to go to the bathroom," says Mahn. "It's easier not to commit themselves to something they may not understand or be able to do." She suggests training staff to redirect a resident appropriately and to identify nonverbal cues, such as pulling on pants, wringing hands, or moaning. "A good approach is to ask the resident to go for a walk with you and then stop off at the bathroom," says Mahn.

Keeping staff members motivated helps keep residents dry. To that end, remind your staff of the prophylactic benefits of toileting residents. "We pride ourselves on having very good skin care," says Kathy Bartles, director of staff education at Noble Horizons, a 90-bed nursing home that's part of Church Home Villages in Salisbury, Conn. "Maintaining that type of skin integrity means keeping people dry. We teach the staff that even though it's time consuming to toilet, it's a lot more time consuming to take care of people who have skin breakdown."

Physical help

"The dementia patient is often chronically constipated," says the Continence Center's Galloway. "When the pelvis is filled with an almost always full bowel, the bladder cannot hold as much and needs frequent small emptying. That's an issue that can be addressed by diet and activity." In fact, immobility is one serious cause of incontinence. Simply keeping residents moving can help (see sidebar).

A simple exercise. Because kidneys produce urine more efficiently when the body is lying down, elderly residents produce two thirds of their daily urine volume at night. To prevent bed wetting, Galloway recommends having residents lie with their legs elevated before bedtime, then be encouraged to void before going to sleep.

Better living through technology. Strengthening weak pelvic muscles decreases frequency and urgency. Unfortunately, Kegel exercises require a high level of cognition to perform and are difficult for the demented elderly, who may have decreased nerve sensation. "If your nerves have been impaired, the activity of driving the muscles to work for you is very difficult," says Galloway. "We've been working to develop technologies that actually drive the muscles for the patient."

The technology to which he refers is called extracorporeal magnetic innervation. It is currently marketed as a chair with a magnetic field generator in the base, which creates a changing magnetic field. As the patient sits in the chair, the muscles of the pelvic floor receive the magnetic stimulus to contract. "The patient doesn't have to undress, and no probe or skin contact is necessary. It doesn't involve radiation or other harmful energies, so you can treat several patients in the same environment at the same time. Because the energies are not focused at the skin, it is not uncomfortable," Galloway says.

He notes that it may be difficult to get the demented resident to sit in the chair for the required 20 minutes. "It works best if it's in a room with a television set or some other distraction," he says.

"We're beginning to see that the costs of the chair are a wash with the cost of incontinence," says Galloway. One manufacturer's representative says the cost of the chair is less than $1,500 per month.

The chair has been tested in several clinical sites and is being used in some physician practices with positive results. Orlando-Fla.-based Adventist Care Centers, a division of Adventist Health System, began the first nursing home trial in February. "I believe it has excellent potential to solve some difficult continence problems in the skilled nursing environment," says Adventist President Vann D. Camp. Various types of patients will be involved in the 90-day trial. [Editor's note: The trial concludes May 1. We will be glad to report on the results in an upcoming issue of CLTC.]

"This technology could bring some significant changes to how incontinence is dealt with in a facility," says Michelle Fetters, director of operations for Adventist Care Centers' Florida facilities.

Addressing incontinence in assisted living 

Because incontinence is a major factor in nursing home admission, addressing it in assisted living may delay transfer to the nursing home. Galloway sees a strong application for the magnetic technology in assisted living residents who cannot perform muscle exercises on their own. "We need to approach the moderately demented patient with a comprehensive plan geared toward maintaining pelvic health," he says. "The chair is not the total answer to the maiden's prayer, but it is a catalyst to bring awareness to the field."

Incontinence guidelines for assisted living are currently being developed by the National Association For Continence (NAFC), in cooperation with a dozen other groups such as the Alzheimer's Association, the Assisted Living Federation of America (ALFA), and the Wound, Ostomy, and Continence Nurses Society. "We think we'll be successful in getting facilities to adopt these guidelines," says Liv Osby, director of marketing and media relations for NAFC. She expects the guidelines to be ready by October of this year.

Theory and technology may clash when it comes to real-life situations. "The big area in incontinence and dementia in nursing homes right now is not how to treat this as much as how to get the research translated into something nursing homes can use," says Schnelle. "One of the barriers is to make sure there are enough staff resources to do it."

Resources include not only the number of staff members but also adequate training for the staff. "We get a lot of calls from families saying they have a hard time convincing the nursing home staff to schedule toileting to prevent incontinence," says Osby. "Instead, they double-diaper residents and leave them lying."

Several associations (see Resources, below) have or are working on guidelines for incontinence care. But the bottom line is the value the nursing home places on keeping residents dry. "New staff members tend to adopt the prevailing culture of a facility," says Galloway. "If it's one of neglect and reliance upon diapers, newcomers will fall into the same pattern. But if we continue to seek successful solutions, we can offer significant opportunities to improve our standard of care and our quality of life."

Upperville, Va.-based KT. Anders is a contributing writer to Contemporary Long Term Care.

Speaking from experience

Sometimes incontinence is simply an issue of immobility, A nursing assistant at Cobble Hill Health Center in Brooklyn, N.Y., reports on her experience helping a resident who needed to be transferred with a lifter because she said she couldn't walk:

"I said to her, 'You know what? You and I, we're going to try something together.' She said, 'I'm going to fall.' And I said, 'No, you're not going to fall. If you fall, I'm in a lot of trouble. Trust me. I'm not going to let you fall.' And I started walking her from the bed to the bathroom. We just did it. And every morning she'd say, 'I can't do it. I can't do it.' 'Yes, you can,' I'd say, 'without the lift.' I'd angle the chair so she could hold on to the bed, grab onto the chair, and then the next move is the bathroom. We started doing that. Pretty soon, every morning she's looking forward to using the bathroom."

--FROM COBBLE HILL'S BOOKLET, "SPEAKING FROM EXPERIENCE, NURSING ASSISTANTS SHARE THEIR KNOWLEDGE OF DEMENTIA CARE."

CNA tip sheet

* If the resident responds negatively to the suggestion to go to the bathroom, engage her in conversation and then mention the feeling of having to go to the bathroom.

* Ask the resident to go for a walk with you, and stop by the bathroom.

* Watch for nonverbal cues, such as pulling at pants, the wringing of hands, or moaning.

* If the resident cannot stay seated on the toilet, allow her to get up and down a few times.

* Use terms the resident is familiar with. "Going to the bathroom" may not be the phrase the resident uses for this activity.

* Music or other distraction may help while the resident is on the toilet.

* Do not rush the person.

* Praise the resident for using the toilet or reassure her for trying.

* Respect the resident's privacy--close the bathroom door, even if you are in the room.

SOURCE: BASED UPON INFORMATION FROM THE ALZHEIMER'S ASSOCIATION.