8For Student

An 82-year-old man with advanced Parkinson’s disease and dementia is cared for in a nursing
home. His nursing needs are usually fairly predictable. Of late, he has become more agitated than
usual. He seems uncomfortable and has started to shout and rattle the bedsides, and occasionally
he hits out at the nurses. The on-call GP has prescribed a sedative to settle the patient at night.
The patient is continuously wet with urine and, unusually for him, he is now incontinent of liquid
faeces too. He has no fever and other vital signs are normal.

Tasks:

1. What are the likely causes of urinary incontinence in this patient? -diappers
2. How should the problem be investigated?
3. What can be done to help?
Student’s name
For examiner
An 82-year-old man with advanced Parkinson’s disease and dementia is cared for in a nursing
home. His nursing needs are usually fairly predictable. Of late, he has become more agitated than
usual. He seems uncomfortable and has started to shout and rattle the bedsides, and occasionally
he hits out at the nurses. The on-call GP has prescribed a sedative to settle the patient at night.
The patient is continuously wet with urine and, unusually for him, he is now incontinent of liquid
faeces too. He has no fever and other vital signs are normal.
Task 1 (3.5)Urinary and faecal incontinence are not uncommon in the setting of dementia and
relative immobility caused by conditions such as Parkinson’s disease. Nevertheless, regular
toileting and maintenance of a daily bowel habit by appropriate diet, simple laxatives and, when
necessary, suppositories are usually sufficient to maintain control of the situation. In this
scenario, it is very likely that faecal impaction has supervened, with overflow of liquid stool.
This is a most uncomfortable situation for the elderly man, who is unable, as a result of
confusion, to draw attention to his predicament. Urinary retention with overflow of urine is also
very common in this setting, particularly if there is pre-existing urinary outflow obstruction as a
result of prostatic enlargement. Anticholinergic drugs, sometimes used (inappropriately) in older
patients with Parkinson’s disease, and opiate-based analgesics can also precipitate this problem.
Urinary infection is not infrequent in this setting but would usually be associated with fever and
offensive urine. Infective diarrhoea would tend to produce profuse liquid stool associated with
fever, abdominal tenderness and dehydration, and there may also be other affected residents in
the home. Clostridium difficile enteritis should be considered, especially if the patient has
received a broadspectrum antibiotic.
Task 2 (3.0)A careful clinical examination (even if difficult) is essential, with particular
reference to fever, hydration, abdominal tenderness or distension, bladder enlargement (often
non-tender in chronic retention) and rectal examination (prostatic enlargement or impaction with
hard stool). Urinalysis and, if appropriate, stool culture should be done for evidence of infection.
A bladder scan should be done to assess for urinary retention. Plasma U&Es should be sent if
obstructive uropathy or dehydration is suspected.
Task 3 (3.5)Faecal impaction should be relieved by regular enemas, with attention to regular
bowel care as outlined above. Once constipation is relieved, urinary retention may resolve
spontaneously, especially if the patient is able to sit or stand to pass urine. Failing this, temporary
urinary catheterization (with measurement of residual urine to confirm the diagnosis) should be
performed until the bowel function has normalized. Anticholinergic and opiate-based medication
should be withdrawn whenever possible. Treatment for UTI should be guided by antibiotic
therapy. Infectious diarrhoea will require ‘barrier nursing’ precautions to prevent the spread of
infection. Clostridium difficile enteritis will require oral metronidazole or vancomycin.

Final score: