Catheters, old men & dementia

This, I guess, is a relatively specialist field within medicine, and within the care of people with dementia and delirium. It is however, important, and something that keeps coming-up.

By the age of 50, half of men will experience a degree of prostatic (that is, relating to the prostate, picture below) symptoms – that means,  the need to rush to the toilet, waiting a long time to pee, being unable to pee or what I am personally looking least forward to, waking multiple times in the night to pee (we call this ‘nocturia’)

As time marches on, with each passing decade, more men will develop these symptoms, until, in their 80’s and 90’s, they are almost universal.

There are treatments and medicines around to help with the symptoms, the most radical of which is urological surgery to reduce the size of the prostate.

What can happen however is that the enlarged prostate can get to a point where a man is no longer able to fully empty his bladder, we call this chronic retention. Some degree of retention is OK, although, after a certain point, when too much urine remains static, in the bladder for too long, it can predispose to urine infections which makes things worse.

Worst of all (to my mind) is when a man is suddenly unable to pee at all, this we call, ‘acute urinary retention’ and, as you can imagine can be very distressing – some people can reach a point of having litres of urine in their bladder before they are treated. This of course, doesn’t help the kidney function and most of all causes great pain.

If this were to happen to me tomorrow, I would be able to get things sorted pretty quickly, I am sure – I won’t go into the details of how…

Yet, for men living with dementia or those who become confused either because of a urine infection, or very often, another cause, communicating their needs is not always possible; acute urinary retention in this situation, can result in a change of behaviour, profound anxiety, distress, restlessness and discomfort.

If the men are lucky, a doctor or nurse will have adequate savvy to work out the cause, either by feeling their tummy or using a special device called a bladder scanner – which is an ultrasound machine (we have one on my ward donated by DonMentia). A treatment plan can then be worked-out as to how best to help the man (usually, a catheter to drain the urine, relieve the pressure and make them feel better)

There is a problem however; what do you do if that man is so confused, not only does he not understand what is causing his pain, the act of several unfamiliar people surrounding him and inserting different implements around and into his penis causes additional distress?

And, after the event, when a urinary catheter is in place, not knowing what the length of non-latex plastic is or why it is and, as often happens, pulling it our which can cause more trauma, making things worse (there is a water-filled balloon inside).

This is why, the management of this small area of continence in men with dementia and delirium is, to my mind, specialized. We, on Mallard Ward, have encountered this so many times we know what we are doing.

We rarely, or, if at all possible avoid, long-term catheters on Mallard, as they universally are associated with infections, which can make matters worse – either making the man more confused or generally unwell with fever, pain, etc.

Along with our scanner, our most common approach is to use ‘intermittent catheters’ that is, catheters which are inserted once or twice a day – depending on the individual and their symptoms, to empty the bladder, they are then removed, when urine has drained sufficiently, so that, in between times the patient doesn’t have a confusing plastic appendage and also, because it lessens the chance of infection and increases the likelihood of the man peeing normally again (we use certain drugs, and look at other aspects, but I will not go into those here)

Unfortunately, this approach is not standardized across healthcare and within that variation, many men are treated poorly, with the insertion of long-term catheters unnecessarily, given excessive and at times inappropriate sedation to manage these catheters and overall restriction of their liberty and independence, either because they have someone sit 24/7 with them, to stop them fiddling with the tube, or because the catheter bag itself interferes with their ability to walk and get around.

So there, you have a little of the complexity of catheters and water-works.

As with all these things, the solution usually is thinking person-centred, not rushing-in, thinking laterally and compassionately.