“My mother-in-law keeps peeing in the laundry room trash can.”
People come to be with a variety of dementia-related behaviors. I was only surprised that this problem had not come up in prior conversations this other clients!
Whenever I’m helping a family member with a dementia-related behavior, I first ask a lot of questions:
“Does your mother-in-law pee in the laundry room trash can during the day? What is her evening routine? Please describe the layout of the house. Tell me about the lighting.”
Environmental and Behavioral Contexts
I learned that my client was the primary caregiver for her mother-in-law during the day. Vanessa (not her real name) would take her mother-in-law, Janet, to the bathroom immediately after getting her out of bed. Janet rarely sat down and would walk from room to room. Vanessa would escort Janet to the bathroom when she noticed Janet tugging on her pants. Vanessa also reported that Janet had a “worried” look on her face when she needed to urinate. Vanessa provided very important information: Janet was aware of her need to urinate but could not find the commode without assistance. Janet’s husband had also put a bedside commode in the bedroom, but Janet walked right past the commode on her nightly journeys.
Janet’s husband was the caregiver once Vanessa left in the evening. He was a heavy sleeper. He would discover the pee in the laundry room trashcan every morning and was frustrated with the behavior. Sometimes, there was also pee around the laundry room trashcan and he was concerned that Janet may slip in the urine and fall.
Vanessa described the layout of the house. Everything was on one floor. The master bedroom was at the north end of the hallway. The laundry room was at the south end of the hallway. The bathroom was in the middle of the hallway, on the western wall. The eastern side of the hallway led into the living room. Vanessa mentioned that her father-in-law had installed night lights in the hallway to prevent Janet from stumbling in the dark. No lights were left on in the living room after bedtime.
Vanessa’s description also “shed light” (no pun intended) on the situation. The hallway was well lit, unlike the living room. It made sense that Janet would stay in the well-lit hallway. I was curious why Janet did not try to open any of the other doors, and why she would open up the laundry door. Vanessa supplied an important detail: the two outlets where the night lights were plugged in were at opposite ends of the hallway—one near the master bedroom, and one near the laundry room. The other doors were in shadow.
Strategies Informed by Behavioral Neurobiology
Based on Janet’s needs, I figured out that she was in the late moderate/early severe stage. At this stage, her cerebral cortex probably had a lot of damage. The cerebral cortex is the outermost layer of the brain and one of its jobs is to process information from the five senses. Janet likely was having trouble understanding that there were multiple doors in the hallway. Because of the lighting pattern, she honed in on the two doors nearest the nightlights. I had a mental picture of Janet walking up and down the hallway, puzzled, until the need to urinate was so great that she urinated in the laundry room trashcan. Janet had no previous experience with a bedside commode, and she was unable to learn new things, which is why she was walking past the bedside commode.
As I mentioned in the blog about poop smearing, learning to hold one’s urine and feces is an overlearned skill. As infants, we start out with a strong dislike of sitting in wet or soiled garments, which is why babies cry when they have a wet or poopy diaper. When we start to learn to control our urine and feces, usually around age 2 ½-3ish, we also learn that there is deep shame associated with soiling ourselves. These memories and learned behaviors persist until the severe stage of dementia.
I explained all of this to Vanessa, and put together a plan: the night light at the far end of the hallway would be moved to the outlet closest to the bathroom doorway; the bathroom lights were to be kept on all night; and the toilet lid was to be left up. The bathroom trashcan was also removed. All hallway doors were to be left closed. I explained to Vanessa that by keeping the north end of the hallway well-lit, Janet would be unlikely to wander to the dark end of the hallway. People in the moderate-to-severe stage also have trouble recognizing familiar objects, so keeping the toilet lid up—and exposing the toilet seat—may help her notice the toilet. Keeping the lid up would also remove one additional step from successfully using the commode. The well-lit bathroom would act like a beacon to attract her into the bathroom. I suggested removing the bathroom trashcan because Janet may use the trashcan instead of the toilet.
The result? Success! At least for now.
Dr. Rita Jablonski
Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.