From the Guidelines
Fecal incontinence in a 71-year-old patient with vascular dementia and hypertension is likely caused by a combination of neurological impairment, mobility limitations, medication side effects, age-related pelvic floor muscle weakening, and comorbid conditions like diabetes. The primary causes include neurological impairment from vascular dementia affecting the brain's control over bowel function, leading to decreased awareness of the need to defecate and impaired voluntary control of the anal sphincter, as well as mobility limitations common in dementia patients that can prevent timely access to toileting facilities 1. Medication side effects, particularly from antihypertensives, may cause diarrhea or urgency contributing to incontinence. Age-related weakening of pelvic floor muscles and anal sphincters is another significant factor. Constipation with overflow incontinence is common in older adults, where hard stool impaction leads to liquid stool leakage around the blockage. Comorbid conditions like diabetes can cause autonomic neuropathy affecting bowel control. Some key considerations for management include:
- Scheduled toileting to help manage bowel movements
- Dietary modifications to prevent constipation or diarrhea
- Pelvic floor exercises, such as those using biofeedback therapy, to strengthen the muscles controlling bowel function 1
- Medication review to minimize side effects contributing to incontinence
- Possibly medications like loperamide for diarrhea or fiber supplements for constipation
- Maintaining skin integrity through proper hygiene to prevent complications like pressure ulcers or infections. A stepwise approach to management, starting with conservative therapies and progressing to more invasive treatments if necessary, is recommended 1.
From the Research
Likely Causes of Fecal Incontinence
The likely causes of fecal incontinence in a 71-year-old patient with vascular dementia and hypertension include:
- Decreased physical activity or dietary fiber intake, which are risk factors for fecal incontinence in elderly people 2
- Postmenopausal hormonal therapy, which can also contribute to fecal incontinence in elderly individuals 2
- Colonic motor dysfunction due to decreased cholinergic function with unopposed nitrergic relaxation 2
- Vascular dementia itself, which can lead to cognitive decline and impairment in daily activities, including personal hygiene 3, 4
- Hypertension, which is associated with vascular dementia and can contribute to cognitive decline and executive dysfunction 4, 5, 6
Underlying Mechanisms
The underlying mechanisms of fecal incontinence in this patient may involve:
- Cerebral small vessel disease (SVD), which is characterized by arteriolosclerosis, lacunar infarcts, and cortical and subcortical microinfarcts, and can lead to cognitive impairment and executive dysfunction 6
- Global brain atrophy and focal degeneration of the cerebrum, including medial temporal lobe atrophy, which are features of vascular dementia similar to Alzheimer's disease 6
- Hereditary arteriopathies, which can provide insights into the mechanisms of dementia and how arteriolosclerosis promotes cognitive impairment 6
Management and Treatment
Management and treatment of fecal incontinence in this patient may involve:
- Biofeedback therapy, which can be effective in treating fecal incontinence in elderly people 2
- Loperamide and biofeedback therapy, which can be used in combination to manage fecal incontinence 2
- Vaginal or anal insert devices, which can be another option for managing fecal incontinence 2
- Addressing bowel disturbances and considering selected diagnostic tests, prescription medications, and surgical options when necessary 2