Incontinence in dementia: what helps family carers

Key facts at a glance

• According to the guideline, behavioural interventions are the first measure – because they have no side effects
• There are four forms of toilet training; which one fits depends on cognitive abilities
• Bladder training is expressly not recommended in organic brain disease
• For people with dementia, prompted voiding is suitable – a procedure in seven steps
• Family members can be trained by a nursing professional and carry out the training themselves

As dementia progresses, incontinence is one of the changes that burden family carers most. The geriatric guideline devotes a whole chapter to it – with an insight that makes many things easier: not every training suits every person, and the wrong training inevitably fails.

Why training comes first

The German S2k guideline on urinary incontinence in geriatric patients is clear on this point:

“Due to the absence of side effects for the person concerned, behavioural interventions are the primary intervention in the presence of urinary incontinence in geriatric patients.”

These programmes were developed specifically for frail older people with cognitive and physical impairments. So they do not presuppose that someone learns new patterns of behaviour – they take into account precisely that this is no longer possible.

The price: they mostly require the active participation of carers – family members, partners or nursing staff.

The four forms – and who they are intended for

1. Scheduled voiding

The person concerned is accompanied to the toilet by a carer according to a fixed schedule, for example every two hours during the day.

Suitable for: cognitively impaired and functionally dependent people. Easy for carers to implement – the prerequisite is a motivated carer.

2. Individual voiding times

As above, but with an individually drawn-up toilet schedule instead of a rigid grid.

Suitable for: the same group – but only if a voiding pattern can be identified at all. This first requires a few days of observation.

3. Prompted voiding

This is the form for people whose cognitive abilities are no longer sufficient for more complex behavioural interventions. All that is required is that someone can feel the urge to urinate and respond to a prompt – and is able to use the toilet or an aid such as a commode.

The guideline describes the procedure in seven steps:

1. At regular intervals, about every two hours, attention is drawn to the bladder by asking whether wet or dry.
2. After checking, feedback is given.
3. Then a visit to the toilet is offered – and if initially declined, encouraged up to three times.
4. The person is accompanied to the toilet only if this is wanted or at least not refused.
5. After a successful toilet visit or if the person was dry: positive verbal feedback.
6. A drink is offered.
7. The time of the next toilet visit is named, combined with the request to wait until then.

Three points deserve a second look. Steps 3 and 4 take the coercion out of the situation: it is offered, not ordered, and a no is respected. Step 5 relies on praise rather than reproach – even when there is only “stayed dry” to report. And step 6 counteracts the most common mistake in home care: reducing drinks to avoid wetness.

4. Bladder training

Here the person concerned must go to the toilet independently at set times, keep a voiding diary and actively suppress the urge to urinate.

Suitable for: cognitively competent, motivated people capable of learning and with a high degree of initiative. The guideline expressly states: not recommended in organic brain disease.

This is the most important sentence for family carers. Anyone who attempts classic bladder training in advanced dementia is working against the disease – and experiences a failure that is not due to the person but to the choice of method.

Where toilet training is not indicated

The guideline clearly names the area of application and the limits:

• The domain is overactive bladder and mixed incontinence; for stress incontinence it is also an option
• Contraindications exist for overflow incontinence and extraurethral incontinence

Which form is present is therefore not an academic question. What distinguishes the individual forms is explained in our article on stress and urge incontinence.

In principle, a behavioural intervention can be carried out at any degree of severity – but the chances of success decrease with increasing severity. The same applies to cognitive and physical impairments: the prospects are better the less pronounced these are. So it pays to start early.

Why the conversation has to go through family members

A practical point that the guideline deals with specifically: the usual questionnaires presuppose adequate cognitive performance. It follows that information about urinary incontinence in people with dementia can only be obtained through a third-party history – i.e. via carers or family members. The guideline also notes that the established questionnaires are not validated for this setting.

For you as a family carer, this means: your observations are the data basis. What you write down determines the assessment.

What you should bring to the appointment

• at what times of day wetting occurs – noted over several days
• whether a warning sign is recognisable, such as restlessness or fidgeting
• whether the toilet can be found and used independently
• how much is drunk and when
• which medicines are taken – diuretics change the picture considerably

Who leads the training

It is the task of nursing professionals – preferably with a specialisation in continence advice – to select, carry out and evaluate the appropriate form on the basis of a differentiated assessment.

Decisive for home care is the guideline's addition: the supporting person can also be a family member trained by the nursing professional. So you do not have to work it out alone – but you may carry it out.

In geriatric patients, toilet training expressly also includes targeted bladder emptying by offering toilet aids such as a urine bottle or commode. The way to the toilet is often the real obstacle, not the bladder.

Frequently asked questions

Should I give less to drink in the evening?

Reducing drinks is not part of the recommended programmes – on the contrary, offering a drink is part of the prompted voiding procedure. How the amount of fluid is distributed in the individual case should be discussed with a doctor.

My relative refuses to go to the toilet. What now?

The guideline provides for encouraging up to three times – and then not accompanying if it is refused. Refraining from coercion is part of the method, not its failure.

From when do medical aids make sense?

The two are not mutually exclusive. Training aims at fewer wet episodes, care secures the time in between. Which product type fits when is explained in our article on pad, pants or brief.

Who pays for what?

With a care level, consumable care aids via the long-term care insurance fund are added to the medical aids from the health insurance fund. The distinction is explained in our article on health insurance and long-term care insurance.

Does this also work in a nursing home?

Yes. The guideline names hospital, nursing home and home environment equally – but requires staff with sufficient time resources and suitable premises.

Your next step

We stock absorbent products in all absorbency levels from TENA, HARTMANN and SENI – including versions that can be changed lying down. With a care level, the monthly care package is also an option; how this works is explained in our article on the care package.

Sources

• S2k guideline “Urinary incontinence in geriatric patients – diagnostics and therapy”, AWMF register number 084-001, version January 2024 (in German)
• S2k guideline “Advice on medical aids for urinary incontinence”, AWMF register number 043-054, version February 2025 (in German)