Warning: This is a graphic topic.
Learning and Procedural Memory
Today, I received a call from a good friend who was very upset. She is caring for her father and he is smearing his poop all over the bathroom. Towels, walls, any surface within reach. He is leaving the bathroom with feces all over his hands and clothing. In today’s blog, I explain how I helped her.
A common thread in all of the dementias is moving backwards in time. By that, I mean people forget or “unlearn” stuff in reverse of how they learned as they grew up. When their bodies are mature enough, children learn to hold their poop and use the potty, usually around age 2 ½ to 3ish. Some children learn earlier. Some later. They learn to properly clean themselves and to wash their hands afterwards. This behavior is reinforced by parents and teachers all throughout preschool, kindergarten, and the early grades. Pooping is also known as an overlearned behavior—every time a person poops and goes through the correct steps, neural networks in the brain fire up and reinforce the connections. Properly going to the bathroom is also known as a procedural memory. Eventually, pooping becomes an autopilot activity. We do not have to exert brain power to go through the steps. One aspect about potty training that is important to think about when dealing with dementia—children are taught that pooping in their pants or having an accident is a bad and shameful thing. This is a deeply rooted memory that is reinforced throughout one’s life. I will circle back to the shame issue in a bit.
Neuron Damage Causes Apraxia
As the nerve damage happens in dementia…and it does not matter which dementia…people start to forget how to do things. This forgetting is called apraxia. Apraxia is caused by breakdowns in complicated networks of neurons or brain nerve cells. At the start of the dementia, the brain tries to compensate or fix the problem by using detours to get the job done. You will see the person with dementia take longer to do things, but they are still successful. It just takes longer. As the dementia gets worse and more neurons die off, some of the necessary steps disappear. Apraxia is first noticeable with items that were most recently learned, like the most recent smartphone or TV remote. As the dementia worses, the apraxia becomes noticeable with common appliances, like washers, dryers, ovens, and microwaves. In the late moderate to severe stages, people living with dementia have a lot of trouble performing basic care. This is where poop accidents start and poop smearing is likely to happen.
Because of neuron damage, the person living with dementia is having trouble coordinating all of the steps needed to properly poop and cleanse. They will feel the urge and start to move toward the bathroom, but then forget where the bathroom is. They may hold in the poop until they find a safe place to defecate. This can cause constipation. Some may see a bucket or trashcan and something clicks in the brain, so they use a receptacle because of the deeply rooted and subconscious fear and shame around soiling oneself. Their family members get upset because the person living with dementia pooped in the trash can that was literally next to the toilet!!
Strategy: Spot Checking
When caring for a person living with dementia, you will need to start “spot checking” their bathroom behavior. When do you start? It depends. If the person is having trouble with urine accidents, it is time. Some families start to spot check when they find soiled underwear hidden around the house. Others start to spot check when their loved one with dementia wears the same clothes over and over again, even when the clothes are visibly soiled. Spot checking means going into the bathroom and observing the behavior or going into the bathroom and looking for signs that the person is starting to have trouble, like feces on the toilet seat.
Strategies for Assisting
The person living with dementia may need you to hand them the toilet paper when it is time to wipe. They may need you to give them simple and respectful one-step commands to pull up their pants and to wash their hands. Be matter of fact and kind. This is not the time to argue and fuss. The person living with dementia is not trying to upset you on purpose. In fact, they are likely very upset themselves.
As the dementia worsens, you will need to escort them to the toilet based on your knowledge of their bowel patterns. If there does not seem to be a pattern, the best option is to guide them to the toilet every 2-3 hours. Some people start to undress themselves, even in public, when they feel a full bladder or a bowel movement. It is not usually useful to ask, “do you need to use the toilet?” because you will likely receive a “no,” even if they have to urinate or defecate.
Preventing Poop/Fecal Smearing
Another source of fecal smearing is the use of a diaper. If the person poops in a diaper, and there is a delay in removing the diaper and cleaning off the feces, the person may experience itching or discomfort. He or she may reach into the diaper to relieve the itching, not realizing their hand is covered with feces. This is why caregivers may walk into a bedroom first thing in the morning, or after a nap, and be greeted with poop all over the place. The best way to avoid this scenario is to check the person at earlier intervals to remove the soiled diaper. Or to have them use the toilet before bedtime and before having them lay down for a nap.
Some medications have a laxative effect within a few hours of taking them. Please review all medications with your health care provider. This way, you can get the person on the toilet an hour or so after taking the medication and avoiding an accident.
What if you are trying to clean up a person living with dementia and they keep touching areas that have poop on them? Give them a towel or something to hold while you clean them up. If you have a hospital bed, tell them to hold onto the rails while you clean up. No matter how aggravated you are, and this is hard, you have to watch your tone. Yelling at them or being rough—while a very human response—is not going to make things better. It will make them upset and they may start to resist your cleaning efforts.
In some cases of dementia, the parts of the brain that tells us what is edible and what is not becomes damaged. People living with dementia may eat their own poop. I’ve encountered this behavior twice in my 35 plus years working with older adults with dementia. The best way to avoid this situation is to put the person on the toilet when the bowel movement is likely to occur. The next best way is to remove the soiled diaper immediately. Some experts advocate the use of restrictive clothing, like adult “onesies.” I understand that there are situations where the use of restrictive clothing is necessary. I’m not a fan of restrictive clothing because that means the person is sitting in feces, which can increase their risk for bladder infections and skin damage.
There are psychiatric conditions in which people “play” with poop. I am no expert in psychiatric disorders and this blog is not about those disorders. This blog is concerned with people living with dementia who are showing a new behavior.
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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.