Dementia and urinary incontinence Q&A

Dr Amanda Cross is a researcher from Monash University who is currently working with Dementia Australia to create user-friendly information and resources. This will help people with dementia and their families understand the risks and benefits of medications for managing bladder control. We caught up with her to see what the latest research has to say.

What is functional incontinence?

Also known as disability associated urinary incontinence, is leaking wee because you can't get to the toilet in time due to physical impairment (rather than bladder dysfunction). This is due to either not recognising the need to wee (mental capacity/cognition) or not having the physical ability to get to the toilet and perform the necessary steps for toileting in time such as removing clothes or locating the toilet.

Q: What symptoms of urinary incontinence do people with dementia typically experience?

A: Urinary incontinence is common among older adults and may range from small, occasional leakage of urine (wee) to total loss of bladder control. People with dementia often experience incontinence more frequently due to the cognitive, behavioural, and physical changes associated with the condition.

This can mean that some people with dementia may not feel when they need to go to the toilet, they may not be able to find and use the toilet, they may not be physically able to get to the toilet in time, or they may not be able to communicate that they need to go to the toilet.

Everyone is different, and it is important to understand the specific symptoms a person is experiencing to develop a person-centred tailored management approach.

Q: How do you diagnose the cause and treat the symptoms of urinary incontinence in people with dementia?

A: When a person is experiencing new or worsening symptoms of urinary incontinence, it is important that they work with their healthcare professional to explore any potential contributing factors and identify the type of urinary incontinence that is being experienced.

Common contributing factors can include:

current medications
existing medical conditions
infections
constipation
reduced mobility
lifestyle factors
behavioural changes.

Typically, a general practitioner is the first healthcare professional that a person will speak to, and then depending on the symptoms and discussion they may be referred to a specialist medical practitioner, continence nurse or perhaps a pharmacist for a comprehensive medication review.

Q: What medications may cause or worsen symptoms of urinary incontinence?

A: There are a number of medications including:

Medications for dementia (eg cholinesterase inhibitors such as donepezil) can increase bladder contractions and the urge to urinate (wee).

Medications for diabetes (eg empagliflozin, dapagliflozin) can increase urine production, urgency and frequency.
Diuretics for excess fluid (eg furosemide, hydrochlorothiazide) can increase urine production, urgency and frequency.
Sedative medications (eg benzodiazepines, zolpidem, zopiclone) can relax the bladder and reduce awareness of a full bladder.

It is a good idea to discuss with your doctor or pharmacist if any of your current prescription or over-the-counter medications may be contributing to your incontinence symptoms.

Your doctor can request a comprehensive medication review from a pharmacist, which can help to identify medications that may be causing harm and provide recommendations for alternative doses or medications where appropriate.

Q: What medications are available to help treat urinary incontinence?

A: There aren’t really medications available over the counter to treat the cause of urinary incontinence unless the cause is related to something like constipation. However, even then, we recommend speaking with your healthcare professional first before self-treating with over-the-counter medication. Constipation may be a side effect of a current medication, and it may be more appropriate to review that medication or other underlying causes of the constipation.

The main over-the-counter options for minimising the impact of urinary incontinence symptoms are continence aids such as pads and liners, and barrier creams to protect the skin from irritation or infection caused by urine.

Many people with dementia may self-select continence products from the supermarket or pharmacy, but it is really important to have the discussion with your healthcare professional first as there may be contributing factors that can be addressed or non-medication strategies that could be used that would help to reduce symptoms.

Medications prescribed by a doctor generally address underlying bladder trouble. The two most common classes of medications are:

Anticholinergic medications (eg oxybutynin) help to calm an overactive bladder and can reduce the sudden need to go to the toilet and associated leaking (urge incontinence).
Beta-3 agonists (eg mirabegron) help to relax the bladder so that it can hold more urine and thus help reduce the sudden or frequent trips to the toilet that are common in urge incontinence.

“Another common problem is over-the-counter vitamins and supplements that can interact with medications, ensure you consult your doctor or pharmacist before adding any vitamins or supplements to your routine.”

Before considering a medication, it is important to discuss with your healthcare professional the possible benefits and harms of the medication to ensure it aligns with your health goals. These two medications are mainly used for urge incontinence and are unlikely to help if a person with dementia is experiencing functional incontinence.

Furthermore, anticholinergic medications are associated with a range of possible side effects, including constipation, dizziness, dry mouth, increased falls and increased confusion. Beta-3 agonists are newer medications and there is less research to guide their use for people with dementia. They may have fewer side effects but can still raise blood pressure and can also be quite expensive.

Shared decision making between health professionals, patients and carers should be used to identify if medication is appropriate, and if so, which medication is likely to be most beneficial for you and your circumstances.

Q: What are the non-medication alternatives?

A: Non-medication alternatives should be tailored to the individual, the urinary incontinence symptoms they are experiencing and their level of physical and cognitiveability. Even if taking medication, it is recommended to use non-medication strategies as well for maximum results.

For example, if a person living with dementia is having trouble finding or recognising the toilet, then clearer signage, visual cues and a coloured toilet seat such as red or black, may be helpful. Other people may benefit from a carer prompting them to use the toilet at regular intervals rather than waiting for or relying on the urge to go to the toilet. Adaptive clothing, night lights, dietary modifications and pelvic floor exercises are all strategies that can be effective in people with dementia.

Q: Which symptoms can be side-effects of urinary incontinence medication?

A: When you start a new medication you should be provided with information about risks, benefits and possible side effects as well as what to do if they occur. Any new symptom should be potentially considered a side effect of a medication, especially if you are taking multiple medications, and you should discuss this with your healthcare professional. Specific symptoms to look out for will depend on the medication.

Some symptoms, such as dry mouth, constipation, dizziness, tiredness or confusion, can be difficult to identify as they may be associated with other medications, medical conditions, dementia or ageing. Regular check-ups help you to notice and manage potential side effects before they get worse and ensure that the medication is still a good fit.

Q: How will patients, families and carers know if the urinary incontinence medication is helping?

A: This is a great question, and sometimes something that can be overlooked when a medication isn’t causing any side effects. Medication for urinary incontinence should be proactively monitored to ensure the medication is still contributing to meaningful benefits and is aligned with the person’s health goals.

As dementia progresses the goals of care may change, and the benefits of the medication may reduce over time. Families and carers should monitor the symptoms for which the medication is being used. For example, if the medication was started to reduce the number of leakages occurring at night and there has been no change or the number of leakages are increasing, then it might be time to review the ongoing need of that medication with your healthcare professional.

Q: How often should incontinence medication be reviewed in people with dementia?

A: Regular reviews are important for monitoring benefits and harms of urinary incontinence medication to determine the ongoing need for it. When a medication is first started, you may be monitored daily or weekly to help get the right dose and to identify any side effects.

However, even after the initial period, it is still important to regularly discuss with your healthcare professional to ensure the medication is still right for you. If the medication is not helping or is no longer helping, if there are potential or actual risks to using the medication that outweigh the benefits, or if other health changes occur, then it may be time to consider lowering the dose or stopping the medication.

Dr Cross worked with Dementia Australia to develop an easy-to-follow PDF with information on urinary incontinence medication and dementia. It supports shared decision-making when considering starting, monitoring and stopping medications.

"We received funding from Dementia Australia via a Dr Stuart and Bonnie Bartle Project Grant to support this important work," Dr Cross tells Bridge. "We have integrated the latest evidence, expert-consensus advice and question prompts to support conversations with healthcare professionals."

"My top tip for people with dementia and their families and carers is to reach out and talk openly with your healthcare professional to find strategies that best fit your needs. Urinary incontinence (leaking wee) can have a huge impact on both the individual and their families and carers, and every person will experience symptoms differently. There is no one size fits all approach, and having early and regular discussions and engaging in shared decision making can ensure the person with dementia receives care that truly fits them.”