Everyone poops. Perhaps due in part to all the psychological and societal hang-ups associated with toileting, incontinence care for aging or injured adults is a topic avoided by even the most dedicated family members. But, let’s face it, everyone poops, everyone pees, and sometimes folks need a little assistance with one or both of these natural bodily functions.
Toileting is one of the activities of daily living (ADLs) that can be central to the individual’s sense of dignity and control, so it is imperative that a caretaker be well-versed in toileting assistance as well as how to manage urinary and/or bowel incontinence. Toileting assistance is an area in which family caregivers appreciate the competence and support of an experienced caregiver more than most, and this article will walk through the basics of toileting assistance as well as methods for adapting to bladder and bowel control issues.
Note: If incontinence is a new or worsening issue, a physician should be consulted to evaluate possible treatment plans to assist with or alleviate incontinence.
In many cases, getting to the toilet in time is the main part of the patient’s issue, and this may be a natural extension of problems with other activities of daily living like ambulation, bathing, grooming, and dressing (or undressing). A few tools and assistive devices can help with this process, as can careful planning. Raised toilet seats make it easier to move from standing to sitting (and vice versa), and grab bars on the wall can help the individual transfer to the commode. For nighttime needs, a bedside commode or bedpan may be in order.
Potty time: One of the most successful ways to avoid accidents is through observation and planning. Most of us have potty patterns, meaning we tend to go to the bathroom at around the same time every day. Observing an individual’s natural elimination pattern is a good way to create a bathroom schedule. Much like working with potty-training children, certain occasions may be indicators of good times for a bathroom break. In particular, upon waking, whether after a nap or in the morning, after meals, and before leaving the house are all times that the caregiver may wish to encourage their charge to attempt to use the toilet. Beyond those times, a potty break every two hours will help to reduce urgent bathroom needs.
Being watchful: For certain patients, such as those with dementia or those who have difficulty communicating, the caregiver should also be on alert for signs that indicate the individual needs to use the bathroom. These signs may vary, but they can include tugging on clothing (especially around the crotch area), fidgeting, pacing or foot tapping, and general displays of agitation. Being aware of and reacting in time to these kinds of signs can prevent unnecessary accidents.
This way to the toilet: A clear, well-lit path to and in the bathroom can help the person ambulate as quickly and smoothly as possible to the toilet when the need strikes, and leaving the bathroom door open will help the person zero in on where they need to go. Another factor that can help with finding and getting to the toilet on time is removing obstacles, such as potted plants or throw rugs, that can impede progress to the bathroom.
You can do it: As with other activities, the caregiver should demonstrate patience and encouragement when they are helping someone with toileting. They may need assistance pulling down pants and underwear, or they may need a gentle reminder to actually pull down their pants before sitting down. House dresses and pants with elastic waistbands are good choices for individuals who may need assistance with toileting.
Take your time: Once the person is on the toilet, the caregiver must be careful not to rush them. Bladders and bowels move at their own pace, and what seemed urgent only seconds before can be a long time coming once in position. Rushing the person or showing frustration can cause the individual to feel shame, and it also increases the risk of constipation and accidents.
I’ll be right out here: If possible, give the individual some privacy by waiting outside the bathroom. If they need assistance cleaning up, consider using wet wipes in addition to standard toilet paper to make sure the skin is fully clean before pulling pants or underwear back up. Ensuring that the person has properly adjusted and zipped up clothing afterward reduces potential embarrassment and fall risks.
There are several types of incontinence, and knowing a little about the different types can help the caretaker and the family make the best decisions about what levels of toileting assistance should be included in the care plan of their loved one.
Overflow Incontinence: This refers to the urine leakage that occurs when the bladder is full, and it generally involves only a small amount of urine. This type of incontinence can usually be managed with a combination of regular trips to the bathroom, limiting fluid intake at bedtime, and using incontinence pads on the bed or in underwear.
Transient Incontinence: This term refers to temporary problems with urine retention. This type of incontinence goes away when the root cause is identified and treated, and this is one of the reasons new or worsening cases of incontinence need to be medically evaluated. Urinary tract infections, surgeries, or new medications are often the culprits for this type of incontinence.
Functional Incontinence: When a patient experiences this type of incontinence, their urinary tract is normal, but external factors may affect their ability to get to the toilet on time. Common external factors include difficulty with ambulation, trouble removing clothing, or forgetfulness. In the case of functional incontinence, the caretaker is essential to helping the individual maintain their dignity by developing a potty schedule and physically assisting with toileting activities.
Stress Incontinence: Many women become familiar with this type of incontinence after childbirth or during pregnancy. Stress incontinence occurs when a small amount of urine is released due to intra-abdominal pressure caused by actions like sneezing, climbing stairs, exercising, or laughing.
Urge Incontinence: Also referred to as overactive bladder, this manifests as a strong, sudden urge to urinate even though the bladder may not be full. This may occur more frequently among people who have had extensive chemotherapy or radiation treatment as well as those who have sensation loss or nerve damage.
Individuals may also experience mixed urinary incontinence, which is a combination of stress and urge incontinence. Regardless of the type of urinary incontinence an individual is experiencing, the respectful response of the caretaker is key to helping them through the process. Assisting with toileting, developing a bathroom schedule or routine, and cleaning up accidents with compassion are all considered to be part of the duties of the in-home caretaker.
Bowel incontinence can be much more problematic, frustrating, and embarrassing for individuals, not to mention messy. Like urinary incontinence, it is important for the person to undergo a medical evaluation for new or worsening symptoms of bowel incontinence.
Common contributing factors to bowel incontinence include nerve injury, injury or weakness of the anal muscles as is common after some surgeries, reactions to medication, reaction to food or fluids consumed, or simply confusion and forgetfulness. Certain conditions, like paralysis or gastrointestinal illnesses, can also cause bowel incontinence. Issues like diarrhea, constipation, and fecal impaction may cause or be a result of ineffective bowel function.
Part of the responsibility of the caretaker is to monitor bowel movements so that they can ensure the person in their care is voiding their bowels on a regular basis and so that they are aware of changes in bowel patterns.
Some types of in-home treatments for incontinence and toileting may be covered by health insurance, long term care insurance, disability insurance, Medicare, Medicaid, government benefits (like VA benefits), and/or local community programs. Caretakers may wish to encourage families to explore the options for covering the costs associated with incontinence care.
There is a common misconception that aging inevitably leads to incontinence. This assumption is false, but many of the conditions that affect older adults may contribute to the inability to control one’s bladder or bowels. Aging bladders may have reduced urine capacity or the inability to completely void the bladder, and urinary incontinence is more common among women than it is among men. Nonetheless, a few key behaviors can help improve bladder and bowel control.
Eat, Drink, and Be Regulated: Diet and fluid intake can affect urination urgency and bowel incontinence, so incorporating high fiber foods, such as whole grains, bran, beans, nuts, fruits, and vegetables, into a person’s diet while encouraging sufficient fluid intake is the first step in managing bowel and bladder irregularity. Drinking six to eight glasses of water a day is recommended for most people, but, in some cases, individuals are reluctant to drink water or take in a lot of fluid for fear of peeing on themselves. However, dehydration can lead to more serious problems, so it is imperative that the person receiving care drinks enough fluid. The color of urine can be an indicator of hydration levels. Clear or yellow urine is fine, but orange or brownish urine can be a sign of dehydration.
Caffeine, alcohol, citrus, and sugary drinks can contribute to increased urgency with urination, so it may be helpful to limit those types of beverages in general. In contrast, cranberry juice helps with urinary tract health and it also reduces the odor commonly associated with urine-dampened clothing or bedding. As a caretaker, it is critical that you ensure the person you are caring for is consuming appropriate levels of fluids and high-fiber foods throughout the day, though it may be helpful to limit fluid intake at night in individuals with urinary incontinence.
Move for Better Movements: People who are bedbound or sedentary are more likely to experience problems with regular bowel function. If possible, encourage your charge to take a walk or participate in other exercises and physical activities to keep things moving through the digestive system.
It’s Poop O’Clock: Bowel retraining is one method that some caretakers and individuals find useful in managing bowel movements. After determining the approximate times each day a person uses the bathroom, the caretaker can establish a potty routine that mimics the person’s natural patterns. Individuals with Alzheimer’s or dementia can especially benefit from routine potty breaks, and incorporating a regular bathroom schedule for seniors suffering from these conditions can help train their body to void waste at more predictable intervals.
Catheters: Catheters are often the last resort for incontinence treatment, and improper use can increase the risk of infections and damage to the urinary tract. If the individual uses a catheter, the caretaker should monitor the catheter for signs of irritation or infection as well as report on any changes in urine output.
Planning for accidents can help mitigate the embarrassment and messiness that inevitably accompanies a missed toileting opportunity. When accidents occur, the caretaker should move swiftly to help the person clean themselves and get into clean clothes. If accidents occur frequently, the family may need to invest in additional tools for incontinence and other health care needs.
Some of the items that can assist with toileting and incontinence care include the following:
Personal care and personal hygiene support activities expected of caretakers may include the following:
Some people may try to hide their accidents due to their own embarrassment at their situation, but a good caregiver should be able to break down these barriers by clear, direct communication and swift action. Thoughtful and regular communication is key to improving or maintaining a good quality of life for the person receiving in-home care, and this is especially important with an activity like toileting that is central to a person’s independence.
Be direct and proactive. Make sure the individual knows that incontinence or difficulty toileting in a common but often treatable problem. Reassure them that reporting or asking for help when accidents occur is the best way to get appropriate treatment and deal with the situation.
Stay calm. An individual who urgently needs to get to the bathroom or who has just soiled their clothes may become angry, fretful, or just plain anxious. Using phrases like, “It’s okay” or “These things happen,” can put the person at ease. A matter of fact, “I’ve been through this before and it’s no big deal” approach is especially useful for addressing the problem at hand and moving the person past the incident.
Never reprimand or yell. No one enjoys losing control of their bladder or bowels, and caretakers should make sure they are employing all of the strategies at their disposal to prevent accidents from occurring. When accidents do happen, remember that most older adults have likely been toileting independently their whole lives and, as such, they know when they have missed the mark. Fear of recrimination only worsens the problem.
Pay attention and adapt the assisted toileting process to the individual’s preferences. One of the many things younger or fully able-bodied people takes for granted in that we all have our own unique habits in the bathroom. How much toilet paper does the individual person tend to use? Do they stand to wipe? Do they prefer briefs or boxers? Do they like to take a book or magazine with them for longer potty sessions? Learning and responding to these habits can make the person receiving toileting assistance feel a little more relaxed about needing help.
For caretakers providing live-in care or working in an assisted living facility, approaching toileting behaviors with knowledge, respect, and compassion can make all the difference in the world for the person receiving care.
After all, everyone poops.