Talking Toilets: Continence and the bidet

Colm Cunningham: 0:12

Hello and welcome to today's episode of The Dementia Podcast where the conversation is toilet talk. It's very important to recognize that continence is one of the major issues that can lead to the admission to hospital or residential care for somebody with dementia. And sometimes there are things that we might be able to do to support somebody at home that may avoid that becoming an issue. So to have the conversation about what are the issues that occur and some of those tips, I'm joined again by Dr. Meredith Gresham. Now you'll have heard from her in June 2021, when she joined us to talk about design. But one of her other areas of expertise is in this area of continence management. And in particular, the reason she gets the title Doctor is because her research was on bidets. Intrigued? you will be but you won't be disappointed. It's a very important topic to talk about. But as two clinicians, we do talk about some of the fundamentals of bladder and bowel functions. So just to give you that heads up upfront, this will be toilet talk. It's great to have you back on the dementia podcast. Meredith welcome.

Meredith Gresham: 1:22

Thanks, Colm. It's pleasure to be here.

Colm Cunningham: 1:24

Look, I wanted to start with the fact that you and I know that there are some key reasons that are often tipping points to people, considering residential care or carers being unable to continue to care for at home. And one of those we know is issues with continence. So before we jump into bidets, it'd be great to talk about why it's so important to support people with their continence.

Meredith Gresham: 1:51

That's exactly right. Incontinence is one of the two key issues that will prompt that move to a nursing home or to residential care. When we unpick that problem. However, the problem is not always just that the person has an incontinence issue or an issue with incontinence. Because there are such good, shall we say, collection devices nowadays that will actually help people manage that continence issue. Really, one of the key issues is for the carer, in managing the cleanup afterwards, there are a whole lot of associated issues which we don't ever really think about associated not only with incontinence, but within managing the mechanics of toileting. It's those sorts of issues that are not well researched. But it is my hunch that a large part of that contributor to the risk factor of incontinence, to moving into institutional care.

Colm Cunningham: 2:53

I think one of the other areas that hasn't been researched as much as it should is when we think about seeking support, and we maybe have the continence nurse or that, that some of the issues that are about nighttime incontinence don't always get the attention that they need. But that again, that's often the tipping point is what's happening at night.

Meredith Gresham: 3:15

Exactly. So disturbed sleep is a huge issue for carers. If you're up, you're an elderly person, you need your rest, but you're up many times a night, you know, dealing with somebody who needs to go to the toilet needs assistance to find the toilet assistance in sitting rising and cleaning up. Big issues. And it is one of those, again, those contributing factors that just keep piling up and up and lead to that exhaustion in carers.

Colm Cunningham: 3:48

Now one of my tips is often firstly that if we stand in the hallway of your bedroom and toilet area, all the doors are often the same color. So problem one is no wonder the person might need your assistance because they can't work out where the bathroom is. Or the other classic one is the light only light that's on two door to the porch outside so of course the person would be cued to that and so they're actually making a logical decision. Sometimes people are frustrated because the outcome looks illogical. But actually the person's made probably good decisions based on the information in front of them. Any other tips from your point of view?

Meredith Gresham: 4:25

Well certainly lighting is one. I mean you have to think carefully about the lighting that using you don't want to change too radically from darkness of the bedroom to brightness of light in the bathroom. So very low wattage or soft lighting in the bathroom. People also tend to amaze me is that a lot of people tend to think that somehow it's unsightly leaving the door to the toilet or door to the bathroom open or vision of the toilet is somehow not very polite, but leaving doors open having a good nightlight having not rails but having furniture, the person is a bit wobbly on their feet, having appropriate furniture that people can actually use to steady themselves when they get out of bed and steady themselves on the way to the toilet. Plus, having an appropriate toilet rail or over toilet frame will also help the person sit and rise more safely. Again, simple things leave the toilet seat up. Now we know that urge incontinence is very common as we get older. So make it easy. You might even think about well, what are the fastenings on the pajamas if there's, you know, ties around pajama pants are they easy to undo. So consider an easy elastic around the pajama pants. So they're easy to pull down, make it easy to sit down, leave the toilet seat up, they're all very, very simple things that take a few moments thought but might mean the difference between having to clean up incontinence or making it to the

Colm Cunningham: 6:01

And we can certainly see your OT background loo on time. kicking in and that really important examples that you've given there. And I know in the previous podcast with you talking about design and how it can often appear to create behaviors that the importance of contrast, the importance of the right toilet seat, and all of that were important parts of that conversation. So I encourage our listeners to hear more from Meredith in that podcast. Dr. Meredith Gresham, I say because your PhD focused importantly on and I never say it right, bidets, which links to what we've said as important is how, do we support people to live well? and particularly to that latter point that you were just saying about? Frankly, the fact that it you know, we're often providing that continence to care to somebody we've been married to for many years. And we, you know, we haven't thought or signed up, even maybe for these challenging confronting things at changes in the dynamic of our relationships. Bidets have a role in that and I'd love you to talk about firstly, why did you study this?

Meredith Gresham: 7:11

A lot of people ask that. Okay, as an OT, I've always been interested in basic self care, and supporting people to carry out their own basic self care independently and with dignity. The second thing was way back about a decade ago, I was involved in an Assistive Technology Demonstration Project in the community. In this project, we took off the shelf newer or novel technologies, and tried them out to see if we could alleviate some of the burden or physical or psychological stress that carers were actually experiencing. There were two standout pieces of technology in that project we trialed about 16 different types of technology. And one was the electronic wash and dry toilet top bidet. Now I say that very carefully. Because the word bidet, apart from being an archaic breed of small French horse,

Colm Cunningham: 8:13

are they right? Okay.

Meredith Gresham: 8:16

The earlier bidets earlier basins sort of on a wooden stand had a little um, a neck and a soap dish and townhall towel holder. And so it looks like you're sitting astride a small French horse. That's where the name came from. But bidets are simply the name applied to any apparatus that is used for water washing after using the toilet.

Colm Cunningham: 8:40

Well look, that's really helpful because I'm thinking about our international listeners. And I would simply go oh, this makes sense. To me. You're talking about those things I see when I'm in France, but you're not actually

Meredith Gresham: 8:50

No. The sorts of bidets that I've done in my research are a Korean bidet which is a toilet seat replacement, so you actually unscrew the toilet seat, and you replace it with this electronic toilet seat. Well, the electronic toilet seat that provides firstly a heated toilet seat which is great for those cold winter mornings. It has two sprays, one for front cleaning and one for rear cleaning. The sprays have adjustable width and pressure and temperature of water. And then it actually has drying jets so gently blows warm air to dry you after actually having a wash. So that's a sort of bidet I'm talking about, not the standalone pedestal type of bidet or any other sort of bidet.

Colm Cunningham: 9:41

Now, to ask the question I do know the answer to which is people are going to assume there's no way somebody with dementia is going to adapt to this Meredith to what are you on about thinking about this as appropriate.

Meredith Gresham: 9:54

Going back to that assistive technology project, we installed our first bidet And we were waiting with great trepidation to see what the outcome was. When we had a call from the carer following his first couple of uses of that. We said, How did it go? This was a woman who screamed when somebody tried to attend to her personal care, absolutely screamed. So we didn't hold high expectations. And the carer told us, she actually giggled, wow, the, the actual water washing, yes, is an unusual experience. But if you prepare the person, even if they have quite severe dementia, if you prepare the person in some way, communicating to them, that's something different is going to happen. It's a matter of days to about a week for people to get used to the actual bidet

Colm Cunningham: 10:57

It makes sense to me, because it is also a bit more private than actually having a human get involved in things here. So this is one of the ones where I go yep technology absolutely has a role. But I'm not surprised that people would go this is not going to work. Did you get some resistance from cares?

Meredith Gresham: 11:16

Absolutely. After the Assistive Technology Project, we got such good feedback from the majority of users of these bidets, I thought there is something in this, we really need to investigate this more. I then went to a nursing home got permission and started to develop a feasibility study. And we installed a bidet in the staff toilet, my raison d'etre was that you've got to use this piece of technology to understand what it feels like and how it functions. So carers need to be confident about how you use it, and helping coach somebody through those initial experiences. Well, one of the carers came up to me and said, It'll never work. And she made between her thumb and forefinger a tiny little circle and said, the bidet cleans that. And then she held both hands out coming to buttocks and said, We clean that. End of story. What eventually happened was I said, Oh, dear, the study's not going to work. If I don't get the support of the care workers. I don't have a study. Yeah. Is that the bidet that I had installed was in the staff toilet adjacent to the staff training room. Now they used to run Saturday afternoon at the movies in the staff training room, and cares started experimenting with the bidet in the staff toilet because it was the closest toilet to take residents to eventually, I got a call from the manager who said, you know that study with the bidets? Do you still want to do it? Ooh yes, I said and went back. What had happened was just through the experimentation, carers were finding it so much easier. It was useful. And it was acceptable to the residents, which was the big ticket items. Such a surprise. Indeed. So we ran a feasibility study, we had 14 residents involved. To cut a long story short, it was a raging success.

Colm Cunningham: 13:26

Of course, on of the other things that we know, is not good for older people, people with dementia is when they get urinary tract infections, because it can create delirium, it can create an infection that causes them to be even further confused, and worse still. Were there any benefits from a hygiene and infection point of view?

Meredith Gresham: 13:45

Yes, bidets were marvelous in terms of the hygiene, the cleanliness, and potentially the reduction of urinary tract infection.

Colm Cunningham: 13:57

So the potential so to draw on the fact that you are a researcher, a quite rightly, you're saying, Look, we haven't studied this in a detail, but I can say you to you conclusively. But I guess in the context of this podcast, common sense would even suggest to me as a nurse that actually this is probably going to be useful for some people in ensuring that their continence hygiene reduces the risk of infections.

Meredith Gresham: 14:24

Yep, we've got great anecdotal evidence, we don't have the hard evidence yet that research needs to be done.

Colm Cunningham: 14:31

Gotcha. So, why, given what you have found are bidets not used widely across aged care?

Meredith Gresham: 14:41

I think with anything new, it's quite difficult to change practice. So in Australia and in quite a lot of Western countries, we are wedded to the toilet paper. As we evidenced during the pandemic the run on toilet paper was incredible. Why I'm not quite sure. But there is a prejudice against water washing, although half the world's population actually use water washing after the toilet. So it's just habitual, we've grown up with toilet paper we're used to toilet paper. That's how things are done. It is somewhat mystifying when we have staff who were very resistant to trying out a new method, because as you pointed out earlier, wiping somebodies bottom with a toilet paper is incredibly invasive. And we do know that most episodes of aggression actually occurred during personal care. toileting, being one case in point. I think, in my two nursing homes in which I did a controlled study, one nursing home had a bidet in the staff toilet, as I used in my feasibility study. The other one had a bidet one did not have a bidet, in the nursing home that had the bidet available for staff use. The uptake by staff was great, you know, there were really no problems. The other nursing home that did not have a bidet in the staff toilet, there was a considerable amount of resistance. So I think that ability of staff to try out the technology themselves understand what it feels like, how to use it, experiment is utterly invaluable.

Colm Cunningham: 16:28

So changing the culture, in societies that are not used to or comfortable with this is probably one of the things because we wouldn't be having this conversation if we were for example, in Japan.

Meredith Gresham: 16:39

Exactly. Japan, Korea, the Asian countries have had a high uptake of bidets. I can't comment on bidet use in nursing homes in those countries. But I would expect that because it's normal, you just keep doing the normal thing.

Colm Cunningham: 16:55

Yeah. So Meredith. Are there other advantages we haven't talked about?

Meredith Gresham: 17:00

Absolutely. Let me tell you about two. The first is a heated toilet seat. Now, some people commented that when they sat on the toilet seat, the first time round, they thought, ooh! somebody has been sitting here before me. But what we actually found is that, you know, taking a resident to the loo, on a cold winter morning and asking them to sit on a cold toilet seat is not a particularly pleasant experience. So I had some lovely stories that came out in the qualitative part of my research around residents who previously would not sit on the toilet or stay on the toilet, were quite happy to do so. The bidet that I used had a slightly contoured seat, which actually gave a slightly better posture for elimination. The other thing that I want to talk about, let's go back to that idea of managing incontinence. Increasingly, in the trials that I ran, and these were 2 12 week trials, we examined on how staff were actually using the bidet. And one of the repeated comments that kept coming back to me is that there were more useful than just for cleaning. staff would say that they would take a resident to the toilet, they would not get any product, shall we say? They would run the bid for cleaning. Then they found that there isn't one either urinate or defecate right? Then they'd run the bidet again. And lo and behold, they'd get a little bit more they were able then to say Mrs. Such and Such used to always be incontinent of feces around morning tea time, and it was always a big issue to actually manage, you know, the morning tea and clean up. They were finding that the bidet would actually encourage defication in particular or urination. And going back into the very limited literature around this. There are a couple of studies that say for people with spinal cord injury, so paralysis, they can't feel what they're doing. The use of one of these electronic wash and dry bidets actually relaxes the perianal sphincter and encourages peristalsis and peristalsis is this squeezing motion of the lower the lower gut to help actually eliminate so the cluey nurses that were trialing out these bidets really started to hook into the fact that they could help prevent incontinence of urine and incontinence of feces. And that, again, I think is an area that is wide open for research. At the moment, we just tend to think of incontinence equals some sort of pad or collection device. But I think we can get much more intelligent about this. And we know that residents even who are quite far down the track with their dementia, often being incontinent, especially incontinent of feces is uncomfortable, undignified and embarrassing. So I think We have some marvelous findings, waiting.

Colm Cunningham: 20:05

And look, it's one of the reasons why I thought this conversation was really important. I'm sure there's people who will have gone Gosh, this, as you know, was quite personal what we're talking about. But I think it's so important because having known the research you've done on how important it is. I'm hoping people from other countries and even here in Australia, will be listening, thinking about how they consider these as opportunities, because I think the best is yet to come in terms of the importance of this as part of advancing care for people and choice. So thank you so much for firstly, being passionate about such an area. And thank you for joining us in the dementia podcast. Meredith.

Meredith Gresham: 20:48

It's been my pleasure Colm.

Colm Cunningham: 20:50

A big thanks to Dr. Meredith Gresham for joining me on this episode. You can hear more from Meredith and her bidet research by following the link in our show notes to our web pages. It includes three informative videos and a lot of practical tips on installing and using a bidet that can be applied at home or in care. You can also find some useful practical tips on supporting incontinence. As we've included a free download of Toilet Talk a book by Professor Mary Marshall, part of our Dementia Design Essentials series. And of course, a thank you to you for listening. If you've any feedback, comments, or any other ideas for future episodes, we'd love to hear from you via our email hello@dementiacentre.com Bye for now