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Promoting continence in people with dementia

Watch this video from the Scottish Care Inspectorate to find out about continence promotion in people with dementia.
The promoting continence resource has been developed to be used by people living with dementia and other long-term conditions as well as their families and staff working across Health and Social Care. So whether you are a nurse working on a busy NHS Ward, part of the Care at Home team, support worker in a day centre or a manager of a care home, there are valuable messages in this resource. It’s one of those resources that is good for everybody. So it can be used by people popping into their GP surgery and thinking, “you know what, maybe this is something I need a bit more information about”, or for people working in frontline services.
If we get the little things right we know that we can keep people continent for much longer which actually has a huge impact on their health and well-being. The reason for the resource is for the information that we’re gathering as part of our electronic annual return ever year was showing that there was a really high prevalence of incontinent within our registered care home services so it made me then question, why is that? and look behind to see what maybe the barriers to promoting continence and good continence care. Continence care is about helping people control their bladder or bowel functions.
This can include: suggesting ways how to keep the bladder and bowel healthy, undertaking a detailed lifestyle assessment and knowing what matters to an individual, identifying the right treatment, and where cure is not possible, giving emotional support and advice around products that support people to lead active lives. Making the first step to contact the continence services is as big I think than somebody making the first step to contact a sexual health clinic, or a mental health team. Because, it’s as traditionally as societal to do, to talk about bowel and bladder. People suffer alone, they buy pads that are not appropriate. They deal with symptoms for years and years and years without even telling their nearest and dearest.
They leave work because they have a perception that people at work know that they have a problem. So it’s about, I think breaking the barriers down, and the more comfortable we are to talk about it and the more comfortable we are to acknowledge that we all potentially at some time will either have a continence issue or be caring for somebody with a countenance issue I think those barriers will start to go. It’s absolutely central to everything, promoting continence. It’s the biggest impact they can have on somebody’s quality of life, if it’s not managed properly.
How we keep it moving is to keep it actually built into people’s training needs part of people’s induction, staff induction, and just basically revisiting that every single time when you’re doing that whole assessment process is to put continence there as a key indicator of quality of life.
Talk to me. Make sure you’re talking to me and a language that I can understand. Don’t use acronyms or anything like that. Tell me what’s available. Tell me what the latest thing is in continence. You need a person there to actually talk to you, to run you through it. To take the embarrassment out of it. To make it all alright. And if that professional - they’re speaking to you, telling you about it the whole time, relaxing you, that’s the whole point. And they can. The one that came that here was brilliant, she was absolutely brilliant. We had a laugh about it, so you that’s a good thing if you can laugh about incontinence, you can laugh about anything.
The assessment’s really important, as it really brings in the focus to the individual person. It’s really about making sure the person’s central to that assessment, ensuring that we’re actually picking up the issues that impact in that person’s life in a day to day basis. Which will ultimately involve improving their quality of life, and ensure that they still feel that they have a purpose to play in life, and that they are actually key to the whole process.
There some things that we never share with our loved ones and toileting is one of the things I think people very rarely share and that actually at end of life, that has huge implications, and I would urge people to share those things with their loved ones while they’re healthy. Because perhaps one of the really important things that I look back on now which I wouldn’t have been able to tell a care home is what my mother’s normal toileting routines were. And I realise that if those are not addressed then someone’s day-to-day comfort is impaired.
Assisting a person to the toilet should not be seen as a task but an opportunity to engage and connect with the person. Being aware of any changes to mobility or mood for example. Seeing the whole person. How important are the details, they’re the key aren’t they? That’s the key that opened the door to whether somebody’s going to be continent or incontinent. Communications very important when we’re supporting residents and that would include communication skills with the residents and their families. Sometimes residents might have impaired communication, so it’s really important that we obtain some information from the families.
I think the biggest thing for my mother is that she wouldn’t realise she needed the toilet, and you would ask - “are we going to the toilet?”, and she would say “I’m no needing it”, and you say, “okay let’s go and try”, and it was still “I’m no needing it”. And then we would just say, “right okay then - a pound to pee”, because that’s how she said it, and she would say, “I’ve no money”, and we’d take her through. So we came at it like a little situation that worked for us. Our experience in the home - some of them will ask, verbally - “I need to go, and I need to now”.
Some will be kinda fidgety, and kinda get distracted, and you need to prompt them and say, “are you needing the bathroom”, cuz they’re get embarrassed and they don’t want to say “I need the toilet”. Everyone’s just got different wee tell-tale signs. So you just kinda to watch it. But it’s just you’re practice, knowing your resident.
People coming into a new environment will need time and support to orientate themselves so that they can find the toilets, and know how to ask for help. Staying active and having a good choice of healthy food and drinks will promote a healthy bowel and bladder. I have a plea, that when you have a new admission come in to your service who are deemed incontinent, that you actually just you don’t accept that. You look beyond that and see with 24-hour care whether you can improve that person’s life. It is important to know if the person you are supporting has any sensory loss. This could be as simple as making sure that glasses are clean, and hearing aids are working.
Sensory is kinda a bee in my bonnet, and often I think there is a lack of understanding of different sight conditions, and so older people and the predominance of macular degeneration nowadays in older people and how that sight is interpreted - and lack of maybe central vision. And often staff don’t know what the specs are for. If a person is taking any form of medication we want to make sure that it does not stop them from engaging in their usual activities, or from going out and enjoying themselves. Medication’s obviously something you have to assess properly to ensure that if you actually going to make any alterations to the medication it’s also done in line with discussion with the general practitioner.
The times the medications can vary. It depends on, for instance, maybe going out with their family. If they’re going to, say a church service, or going to a family gathering. Then we can look at what’s the best thing for the resident, to ensure they have the confidence to go out with the family. That they feel safe and can go out with the family, but also that their continence needs are met within that new environment they’re going to.
We need to think about the environment and some of the barriers that may cause people to be incontinent. These might include lack of signs showing the way to the toilet, poor lighting, or not being able to reach a walking frame to walk safely to the toilet. Take time to think if there are barriers within your service that do not support continence, and how you could remove them to get better outcomes for the people you support and care for. When we’re looking at the physical environment within care homes, we would be reviewing the signage within the care homes, we would review the that the contrasts, we would be looking at the lighting.
The most important thing when a new resident comes into a care home is ensuring that the environment, and the environment they are going to be in, and that they are orientated to that environment. It’s very important because obviously they’re coming into somewhere where they haven’t been before, and as care staff have to give them the opportunity to settle within this new environment that they’re in.
Continence can be promoted in a number of ways It should not be stressful, embarrassing or ignored. The staff have to appreciate exactly what continence is. We provide a very robust training schedule with regards to how we promote continence within the home. What we try to do is get the staff to put themselves in the position of the resident because continence is something that can be so debilitating for somebody. Sometimes there’s a culture that becoming incontinent is just the accepted way of being, and we know that’s not true. So we want to have staff, relatives, really thinking about what can we do to keep the person that we’re supporting, continent for as long as possible.
I think the key message that I would have to support this resource is think about the individual, and not about their age or their abilities, or their disabilities. To be creative, to look at the actual person and what they’re going through, and even if they can’t verbalise that they’re embarrassed, or they feel that their dignity has been compromised, we know that they do. It’s not normal to be incontinent and I think the key message is just that. I’m hoping that the resource will lead to people actually question their own beliefs and their service culture in their organisational culture about bowel and bladder health.
And ask the question why if they have a high prevalence of incontinence, go back to the drawing board and ask the question why. Is it staff understanding? Or is it the barriers I’m putting in place within the service that are stopping people from getting to the toilet? Or are people truly incontinent? Well that’s fine - we get them the right product that’s best for them, that helps them with a better quality life.

Watch this video made by the Care Inspectorate for Scotland to raise awareness of the continence needs of people with dementia, and to highlight that promoting continence with this group of people is as relevant and valid as it is for people with any other long-term condition diagnoses.

People with dementia may experience challenges to their continence as a result of:

True incontinence – the inability to control the excretion of urine or faeces.

They may equally experience functional incontinence when they do not have the inability to get to a toilet for physical or mental reasons.

Incontinence of urine or faeces is as distressing and embarrassing for a person with dementia as it is for any other person, and they are entitled to seek and receive evidence-based continence promotion to help them to manage the condition and minimise the impact on them and their families.

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Understanding Continence Promotion: Effective Management of Bladder and Bowel Dysfunction in Adults

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