What is the best way to approach toileting with persons with Alzheimer's disease every hour?

According to the Alzheimer's Association, incontinence is a common challenge that affects many individuals in the moderate to severe stages of the disease. Knowing what is the best way to approach toileting with persons with Alzheimer's disease every hour is crucial for maintaining dignity, preventing accidents, and reducing distress for both the individual and their caregiver.

Quick Summary

A strict hourly toileting schedule may not be the best universal approach for persons with Alzheimer's; a proactive, personalized routine based on observing individual patterns and cues often works better. This strategy reduces anxiety and focuses on adapting the environment and communication to support the individual's needs, promoting dignity and comfort.

Key Points

• Proactive Scheduling: Move beyond a rigid hourly schedule and create a personalized, proactive routine based on the individual's unique patterns to reduce accidents and anxiety.

• Environmental Modifications: Enhance bathroom visibility and safety with contrasting toilet seats, clear pathways, grab bars, and nightlights to aid navigation and independence.

• Cue Recognition: Learn to identify and respond to non-verbal signals like fidgeting or restlessness, as a person with Alzheimer's may not be able to verbally communicate their need to use the toilet.

• Simplified Clothing: Choose easy-to-manage clothing, such as elastic waistbands or Velcro fasteners, to streamline the toileting process and reduce frustration.

• Dignified Response to Accidents: If an accident occurs, remain calm and reassuring, prioritizing the person's comfort and dignity and never showing anger or frustration.

• Hydration Management: Avoid restricting overall fluid intake, which can cause dehydration and UTIs; instead, limit fluids in the evening and track patterns to adjust timing.

Understanding the Need for a Structured Routine

For many individuals with Alzheimer's disease, the ability to recognize the need to use the bathroom, find the toilet, and complete the process independently diminishes over time. This cognitive decline makes a structured, proactive approach essential for managing incontinence and preserving the person’s dignity. While the idea of toileting 'every hour' is a specific tactic sometimes used in later stages, a more holistic and flexible approach is often recommended, adapting based on the individual's unique patterns and the progression of their condition. Understanding the why behind the need for a routine, rather than just the frequency, is the foundation of successful care.

The Proactive Schedule: Beyond Hourly

Instead of adhering rigidly to an hourly schedule, the most effective method involves creating a personalized, proactive plan. This means anticipating the person’s needs based on their fluid intake, meal times, and typical daily patterns.

Steps for a Personalized Proactive Plan

1. Track Patterns: Keep a log for several days, noting when accidents or successful toilet trips occur.
2. Establish Predictable Timings: Schedule bathroom trips around key moments like waking up, before and after meals, and before bedtime.
3. Use Reminders: Offer gentle, consistent reminders at scheduled intervals.
4. Observe Cues: Pay close attention to non-verbal signals like restlessness, fidgeting, tugging at clothes, or pacing.
5. Be Flexible: While a routine is good, be prepared to adjust if the person shows signs of needing to go at a different time.

Environmental Adjustments for Dignity

The bathroom environment plays a significant role in successful toileting. A person with Alzheimer's may become disoriented or struggle with depth perception, making a cluttered or unfamiliar bathroom confusing.

Enhancing the Bathroom Environment

• Clear the Path: Ensure a clear, well-lit path to the bathroom, especially at night.
• Visible Cues: Use a clear, high-contrast sign with both text and a picture of a toilet on the bathroom door.
• Contrast is Key: A brightly colored toilet seat (e.g., blue or red) on a white toilet can help the individual distinguish it easily.
• Remove Confusing Objects: Take away wastebaskets, plants, or other items that could be mistaken for a toilet.
• Install Aids: Handrails near the toilet and a raised toilet seat can significantly increase safety and independence.
• Consider a Commode: For nighttime, a bedside commode can be a safer, less stressful alternative to a long walk to the bathroom.

Communicating with Respect and Calm

Communication during toileting must be calm, simple, and respectful. Reasoning with a person with Alzheimer's about why they need to use the toilet is generally ineffective and can increase their agitation.

Effective Communication Strategies

1. Use Simple Language: Offer clear, one-step instructions like, “Let’s go to the bathroom,” or “Time to go potty.”
2. Avoid Reasoning: Don't try to explain the logic of why they need to go. Instead, present it as a normal part of the routine.
3. Distraction: If resistance occurs, try a gentle distraction. “Let’s just check the bathroom mirror,” or “The cat might be in the bathroom.”
4. Offer Privacy: While staying nearby for safety, offer as much privacy as possible to maintain their dignity.
5. Stay Calm: Your calm demeanor will help keep the person from feeling rushed or anxious.

A Comparison of Toileting Schedules

Feature	Strict Hourly Approach	Personalized Proactive Approach
Focus	Frequency	Individual patterns and needs
Pros	Consistent, reduces accidents in later stages, simple to implement initially
Cons	Can be rigid, may increase agitation if not needed, doesn't respect individual autonomy
Best Used	For those in the later stages with little bladder control or recognition	As the primary strategy, adapted for all stages
Flexibility	Low	High
Caregiver Stress	Can be high if met with resistance	Lower, as it's more flexible and cue-based

Handling Accidental Soiling with Grace

Accidents will happen, and your reaction is paramount. Never show anger, frustration, or disappointment. Your goal is to reassure the person and maintain their dignity.

Steps for Responding to Accidents

1. Remain Calm: Your calm reaction helps prevent the person from feeling shame or fear.
2. Address the Immediate Need: Clean the person immediately, reassuring them that it’s okay.
3. Prepare a Kit: Keep a toileting kit with gloves, wipes, and clean clothes easily accessible.
4. Check for Cause: Could it be a urinary tract infection (UTI)? Talk to their doctor.
5. Adapt the Schedule: If you notice a pattern of accidents, adjust the toileting schedule to be more frequent around those times.

Fluid Intake and Incontinence Aids

Don’t restrict overall fluid intake, as dehydration can cause confusion and increase the risk of UTIs. Instead, manage fluid timing.

Fluid Management Tips

• Encourage fluids throughout the day.
• Reduce fluid intake a couple of hours before bedtime.
• Limit caffeine and alcohol, which can act as bladder stimulants.

Using Incontinence Products

Incontinence briefs and pads can provide security for both the individual and the caregiver. They should be used discreetly and changed regularly to prevent skin irritation. Adaptive clothing with Velcro or elastic waistbands can also make the process easier.

For more detailed information on managing incontinence in dementia, the Alzheimer's Society provides a wealth of practical advice here.

Conclusion: A Compassionate, Adaptive Strategy

While the concept of toileting 'every hour' may seem like a straightforward solution, the best approach for persons with Alzheimer's is a compassionate, adaptive, and proactive one. By observing individual patterns, creating a predictable routine, adjusting the environment, and communicating respectfully, caregivers can manage toileting challenges effectively while upholding the dignity and comfort of their loved one. Flexibility and patience are the most valuable tools in this process, ensuring that care is tailored to the person, not just the disease.

Frequently Asked Questions

Is an hourly toileting schedule always the best approach for someone with Alzheimer's?

A strict hourly schedule is not universally the best approach. A more personalized, proactive routine that considers the individual’s unique patterns and cues is often more effective, though more frequent monitoring may be needed in later stages.

How can I tell if my loved one with Alzheimer's needs to use the toilet?

Look for non-verbal cues such as restlessness, fidgeting, pulling at clothing, pacing, or specific vocalizations. Keeping a daily log can help you identify a pattern in their behavior.

What if the person with Alzheimer's refuses to go to the toilet?

Avoid reasoning or arguing. Instead, try a gentle, simple approach or a distraction. For example, 'Let’s go see the bathroom mirror' or 'Let's take a quick walk to the bathroom.' Remain calm and patient.

Should I restrict fluids to help with incontinence?

No, do not restrict overall fluid intake as this can lead to dehydration and increased confusion or UTIs. Instead, ensure adequate fluid intake during the day but limit it a couple of hours before bedtime.

What environmental changes can help with toileting?

Use contrasting colors for the toilet seat, ensure clear, well-lit pathways, install grab bars, and remove anything that could be mistaken for a toilet, like a wastebasket. Visual aids like a sign with a picture on the door can also be helpful.

How can I handle toileting accidents with sensitivity?

Remain calm and reassuring. Accidents can be embarrassing for the person, so focus on cleaning them up quickly and discreetly without showing anger or frustration. Reassure them that it's okay.

What type of clothing is easiest for toileting for someone with Alzheimer's?

Clothing with elastic waistbands, Velcro, or simple fasteners is recommended. Avoid complex buttons, zippers, or belts that can be difficult and frustrating to manage.

What if my loved one's toileting habits suddenly change?

A sudden change in toileting patterns could indicate a medical issue, such as a UTI. Contact their healthcare provider to rule out or treat any underlying conditions.