Selecting continence products for people with dementia should be based on a holistic assessment. An evaluation found that pant-style products promote dignity and independence in patients with mild-to-moderate dementia
Incontinence is a common problem in people with dementia and can be due to a complex combination of physical and functional issues. This article reports on a product evaluation of pant-style continence pads, which found they could help promote dignity and independence in care home residents who had mild-to-moderate dementia.
Citation: Brown J et al (2018) Selecting absorbent continence pads for people with dementia. Nursing Times [online]; 114: 5, 26-29.
Authors: Jayne Brown is professor of nursing (older people) and director of the Leicester Academy for the Study of Ageing, De Montfort University; Chris Knifton is senior lecturer in dementia, admiral nurse; Katie Bell is research assistant both at Leicester School of Nursing and Midwifery.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
- This article is funded by an educational grant from TENA, an Essity brand
The word ‘dementia’ describes a set of symptoms that may include memory loss and difficulties with problem solving or communication, and it occurs because of damage to the brain caused by disease. There are many different types of dementia, of which Alzheimer’s disease is the most common.
Gibson and Wagg (2014), state that continence requires “a functional lower urinary tract and pelvic floor, but also sufficient cognition to interpret the desire to void and locate a toilet, adequate mobility and dexterity to allow safe and effective walking to the toilet, and an appropriate environment in which to allow this”.
Symptoms of incontinence are common in people who have dementia due to their deteriorating mental and physical abilities (Wai et al, 2010). Incontinence may be either:
- ‘True incontinence’ – the inability to control the excretion of urine or faeces;
- ‘Functional incontinence’ – the inability to get to a toilet for physical or mental reasons.
As an example, individuals with dementia may:
- Forget to go to the toilet;
- Forget how to use the toilet;
- Forget where the toilet is;
- Fail to recognise the toilet;
- Be unable to communicate their need for the toilet;
- Be unable to adjust their clothing.
A comprehensive continence assessment is essential to understand the underlying causes of incontinence. Box 1 outlines the components of a continence assessment. While it is important that people with dementia have opportunities to remain continent and that the environment supports continence (Box 2), some may need continence aids, such as body-worn pads.
Box 1. Components of a continence assessment
- Medical history including a review of medication
- Physical examination to exclude causes of incontinence such as:
- Vaginal atrophy
- Abdominal mass
- Prostate enlargement
- Post-void residual volume assessment
- Bladder and bowel diary:
- 3 days for urinary symptoms
- 1–2 weeks for bowel symptoms
- Mobility and dexterity, including the need for, and availability of, carer assistance with activities of daily living
- Diet and fluid intake
- Psychological consequences, including:
- Effects on the person’s daily life
- Quality of life
- Attitude to incontinence
- Relative/carer assistant experience
- Suitability of clothing
- Severity of cognitive impairment and behavioural disturbances that may affect continence
Source: adapted from Payne (2018)
Box 2. Strategies to promote continence
- Use walking aids, handrails, commodes, urinals or carer assistance as appropriate
- Keep the toilet environment uncluttered and accessible
- Use clear visual signs with written and pictorial labels to help people identify the toilet
- When not in use, leave the toilet door open to make it obvious when the toilet is vacant
- Cover or remove mirrors – these can confuse people with dementia as they may think there is someone else in the bathroom
- Use plain colours to identify and differentiate between the toilet and other bathroom furniture to reduce the effects of visual disturbances and disorientation (Barrie, 2016)
- A black toilet seat and white pan can make the toilet easier to see
- Consider altering clothing and replacing zips and buttons with Velcro (Bardsley, 2013)
- Give regular verbal reminders to establish a routine, such as toileting regularly (Ouldred and Bryant, 2008)
Selecting continence products
There are three common styles of pad:
- Wrap-around products (Fig 1a);
- T-shaped pads (usually worn underneath net pants);
- Pull-up pant-style products (Fig 1b) (Fader et al, 2003).
Box 3 lists the key features of continence pads identified in the literature. Although they can be important in promoting dignity, it is not always clear which is the most appropriate pad for people with dementia. When possible, the patient should be supported to make decisions about their care – in cases when capacity to do so is lacking, carers need to understand and use the Mental Capacity Act (2005) during continence assessment, product selection and continued use.
Box 3. Key features of continence pads
- Support of skin integrity (Trowbridge et al, 2016)
- Fit and comfort, and ease of disposal (Simpson, 2000)
- Discreetness and odour control (Chartier-Kastler et al, 2011)
- Product absorbency (Clarke-O’Neil et al, 2004)
- Storage, ease of application and removal of the pad (Fader et al, 2003)
- Incorporate other products, such as barrier creams (Vinson and Proch, 1998)
Research on pant-style products
We undertook a study to explore the experience of using a pull-up pant-style continence product (TENA pants) compared with that which was currently used (the majority used a wrap-around pad) in seven care homes with people with dementia. The study had three phases:
- Phase 1 – care home staff (n = 61) completed a questionnaire based on key features of continence pads, giving their views on continence products they currently used (Table 1);
- Phase 2 – we introduced the pull-up pant product to staff in training sessions, and provided a month’s supply for use with those residents who have dementia.
- Phase 3 –at the end of the trial month, the same questionnaire was completed by staff (n = 72), this time giving their views of the trial product. Staff who volunteered (n = 9) were interviewed about their experience. All staff who had used the trial product were involved in the evaluation.
Staff were asked to rate the products on a scale of 1-10, with 1 indicating least satisfaction. In total, 54% rated the pant product 7 or higher for overall satisfaction and 28% rated it 10. It also gained higher scores on every factor than the original products used by the care homes, particularly with regard to comfort, fit and reduced skin irritation (Table 1).
Qualitative data supported these findings: for example, participants commented on problems they had experienced previously regarding the fit of pads:
“For residents that would wear an incontinence pad inside their underwear we sometimes found they would remove them due to being uncomfortable.”
“They are not so bulky – they fit better because they are pull-ups – other products don’t fit as well.”
The pull-up pant replicated the look and feel of ‘ordinary’ underwear, and was perceived to support people in remaining continent:
“They were able to toilet themselves without getting confused. We found they kept them on rather than taking them off which, in turn, reduced stress caused by incontinence.”
There were also comments about the retention of dignity and independence:
“Pull-ups are easy to use; seems like pulling up underwear, taking away the embarrassment of using them for residents.”
“They are able to use the toilet as and when, being able to pull up the pants, giving them a bit of independence.”
Findings also demonstrated the importance of considering residents’ individual needs:
“They are easier for residents with skirts but harder for residents wearing trousers.”
However, pants were seen as unsuitable for those people who had more advanced dementia, less mobility and in whom awareness was lower:
“When they are wet, you have to literally take all their clothes off to change them, which was the only thing, because some of the residents … don’t understand why they’re getting changed in the middle of the day, they don’t want to take their clothes off.”
“Ideally pull-ups would be a better alternative for people who are still mobile.”
As dementia progresses, continence products may need to be changed more frequently; changing pant products becomes increasingly labour intensive for staff and potentially distressing for the resident so alternative products need to be considered.
When tested by staff working with care home residents who have dementia, compared with the original products used, the pull-up pant product was rated more highly on all of the key features required to give an individual the best experience of using continence products. The pant was also considered to promote dignity and independence in people with mild-to-moderate dementia. For those with more severe dementia and less mobility a wrap-around product was perceived to be more appropriate. More research is needed to explore the promotion of continence in people with dementia.
- Continence problems are common symptoms experienced by people with dementia
- People with dementia may experience problems with functional incontinence
- Assessment and continence promotion are an essential part of care
- Pull-up pant-style continence pads can help promote dignity and independence in people with mild-to-moderate dementia
- Wrap-around products were perceived to be more appropriate for people with advanced dementia
Bardsley A (2013) Maintaining continence for people with dementia. Nursing & Residential Care; 15:11, 716-723.
Barrie M (2016) Dealing with patients with concurrent dementia and urinary incontinence. Journal of Community Nursing; 30: 3, 37-46.
Chartier-Kastler E et al (2011) Randomized, crossover study evaluating patient preference and the impact on quality of life of urisheaths vs absorbent products in incontinent men. British Journal of Urology International; 108: 2, 241-247.
Clarke-O’Neill S et al (2004) A multicenter comparative evaluation: disposable pads for women with light incontinence. Journal of Wound, Ostomy, and Continence Nursing; 31: 1, 32-42.
Fader M et al (2003) Management of night-time urinary incontinence in residential settings for older people: An investigation into the effects of different pad changing regimes on skin health. Journal of Clinical Nursing; 12: 3, 374-386.
Gibson W, Wagg A (2014) New horizons: urinary incontinence in older people. Age and Ageing; 43: 2, 157-163.
Ouldred E, Bryant C (2008) Dementia care. Part 3: end-of-life care for people with advanced dementia. British Journal of Nursing; 17: 5, 308-14.
Payne D (2018) Managing urinary incontinence in patients living with dementia. British Journal of Community Nursing; 23: 1, 24-28.
Simpson L (2000) Management of urinary continence in older men. Elderly Care; 12: 2, 36.
Trowbridge MM et al (2016) A randomized, controlled trial comparing skin health effects and comfort of two adult incontinence protective underwear. Skin Research and Technology; 23 :2, 202-211.
Vinson J, Proch J (1998) Inhibition of moisture penetration to the skin by a novel incontinence barrier product. Journal of Wound, Ostomy, and Continence Nursing; 25: 5, 256-260.
Wai APP et al (2010) Implementation of Context-aware Distributed Sensor Network System for Managing Incontinence in Patients with Dementia. International Conference on Body Sensor Networks 7-9 June 2010. Networking Protocols Department, Singapore. 102–5. DOI 10.1109/BSN.2010.15