Dementia Gateway: The environment

Case study: Incontinence: how design solutions can help

It seemed that Ishtar was incontinent – but was she really?

It is difficult to know which one of the actions made the biggest difference – the key thing was to put in practice everything that is known about dementia friendly design.

Read the full case study:

• Understanding the situation - 1. Research and development findingsOpen

  A range of evidence supports the case for making changes to a building to help a person with dementia find the toilet.

  First, there is research done with people with dementia. This is the best kind of research because it helps predict what the problem might be for Ishtar. That research shows, for example, that a person with dementia will walk better over a smooth, matte floor surface of the one colour (and without a pattern).

  Second, we can learn from research into the needs of people with sensory and physical impairments. As most people with dementia are older, they experience the normal changes of ageing, such as reduced eyesight and hearing (and they also have less capacity to compensate for these problems). In Ishtar's case, learning from research on visual impairment tells us that an older person is more likely to notice a toilet door if certain details about the sign – say, its position and use of colour – are right. For example, yellow and black are known to be a really good colour contrast and therefore easier for people with a visual impairment to see.

  Third, there is anecdotal evidence (where no serious research has been done), but people with experience can suggest some helpful responses. For example, people with dementia may not recognise their own reflection and might find a bathroom or toilet with lots of mirrors quite scary for that reason.

• Understanding the situation - 2. Views collected from key peopleOpen

  Ishtar said nothing, but she would get angry and resist the staff when they tried to help her to wash after episodes of incontinence. If she did find the toilet herself, she tended to flush incontinence pads down the toilet.

  Ishtar's daughter Lee was very embarrassed by the incontinence.

  The care home manager and care workers were anxious to make life as pleasant as possible for Ishtar, but they were also concerned about the smell and infection risk. Costs were mounting too from the extra washing and cleaning. Medical staff were concerned that a urine infection would make Ishtar more confused and likely to have a fall.

  Ishtar was becoming an unpopular resident, and people were voicing this. Other residents and relatives seemed to think that Ishtar was 'dirty'. One agency worker said, 'I know her type. She does it for attention. She's just lazy. There's no excuse for her.'

• ActionsOpen

  The care team asked for support from a continence nurse, who suggested they keep charts to record when and where Ishtar was having accidents. This exercise showed that in fact there was no medical cause for Ishtar's incontinence. It was clear that she never knew where the toilet was.

  The aim then was to encourage Ishtar to use the toilet herself as much as possible, and to put in place things that would support her to do that.

  The continence nurse also lent the care home an enuresis mat, which alerts care staff or carers when the person is wet. This was really useful for working out the most common times when Ishtar needed the toilet. Based on this, staff made a plan to encourage Ishtar gently and discretely at those times to make her way there.

  In a well designed care home, if a person forgets where basic things are – such as toilets – hopefully they can still find and see them easily. In Ishtar's case, the staff rearranged furniture in her room so that she could see right into her ensuite toilet when she was lying in bed.

  They changed the lavatory pan seat from white (on white porcelain) to one in a contrasting colour – black. Lee told staff that this was the colour in Ishtar's toilet in the family house many years ago.

  Ishtar preferred to sleep in complete darkness so a small passive infrared beam was placed at the side of her bed. If she moved to leave bed during the night, the broken beam would switch on the toilet light, making it more likely that she would go in there.

  The mirror in Ishtar's ensuite toilet was removed. Other washrooms around the care home still had mirrors, so these were fitted with neat little roller blinds, to be covered when not in use.

  The floor covering between the bathroom and the bedroom was already the same colour, which is good for people with dementia. However, the cleaners (who prided themselves on making the bathroom floor shiny) were encouraged to get some products that cleaned the floor just as well, but with a non-reflective finish. Care staff removed the bath mat from the floor as it was confusing matters and Ishtar was stepping around it rather than standing on it.

  In the day room, the toilet doors were already able to be seen, but the colour of the doors was changed to bright green to contrast with the pale walls. Large signs were put on the doors with pictures of a toilet as well as the word 'Toilet'. The signs were set lower than standard height, so Ishtar could see them even though she stooped.

  The light level in the day room was already high, but the electrician fitted a spotlight just above the toilet door, so that it could be spotted easily.

  Ishtar always preferred to wear trousers held up with a knotted sash, and if possible a pair of tights underneath. Staff encouraged her to wear socks instead and Lee altered her trousers so that they all had elasticised waistbands. This meant that, when Ishtar reached the toilet, she could undress quickly to use it.

  Staff provided Ishtar with plenty of fresh drinks, clearly visible at all times, as dehydration could make incontinence worse. Colouring the water in her glass – for example by adding cordial – made her more aware that there was a drink in it, so she could help herself.

• ResultsOpen

  Ishtar became far less agitated, as now she was able to find the toilet before she got uncomfortable and desperate. Staff rarely had to struggle to get wet clothes off her, and her new trousers looked better for longer, not needing to be washed so often.

  Lee was surprised that the incontinence was reversible. She could see the logic of many of the changes, as they were so simple. She was pleased that she could help, advising on what kind of soap and toilet paper her mother preferred and the colour of the toilet seat. She was also glad to be involved in the practicalities of adding to her mother's wardrobe. She just said, 'Anything that works, we'll try!'

  Some other residents' relatives seemed to find the big obvious toilet signs off-putting, but staff became quite expert at persuading them how practical and useful they are, and how important it was to avoid the alternative (in terms of smell and accidents).

  Once Ishtar was using the toilet, it was important to go to the next step and make sure she washed her hands. She always looked to do that, but didn't recognise the wall mounted soap dispenser and paper towels. Her daughter told staff that Ishtar loved the little perfumed bottles of soft soap with a pump on top, and these were obtained. A contrasting coloured hand towel was always available on a hook by her own ensuite toilet (though it never got approval in the communal areas because of infection control rules).

• Advice for othersOpen

  The outcomes were an improved quality of life for Ishtar, her daughter, the care workers and everyone who lived in or visited the care home. It is difficult to know which one of the actions made the biggest difference – the key thing was to put in practice everything that is known about dementia friendly design.

  What was surprising was that these changes made a difference in the level of continence across the whole group of residents, although afterwards it seemed obvious.

• Financial implicationsOpen

  For the most part, these changes are inexpensive and sustainable. The basic design features should be built in as standard to every new building for older people.

  Traditional plumbing styles can be a really helpful visual cue to older people, although it is expensive to introduce these to an established building. Lots of low-cost things, such as signage, can be done at any time. And while some of the costs for making changes might be higher you only have to make these changes once and they will help promote the continence of any subsequent residents. The cost of incontinence is high, both in social and financial terms, so it is a balance.

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