Dementia is a broad term used to describe a variety of neurocognitive disorders characterized by a decline in cognitive function that affects a person’s ability to perform everyday activities. One of the behavioral and psychological symptoms that can present in some forms of dementia is fecal smearing, where a patient spreads or plays with their feces. This understandably causes distress for caregivers and families. Fecal smearing, while not very common, is most prevalent among dementia patients in long-term care facilities. Let’s explore some of the reasons why dementia patients may engage in this behavior.
Loss of Inhibitions
One of the hallmark symptoms of many types of dementia is a gradual loss of inhibitions. Societal norms and manners that were previously automatic become hazy and difficult to recall or implement. This loss of inhibitions is due to the breakdown of pathways in the brain that regulate behavior, impulse control, and proper social conduct.
As their condition progresses, the filter between thought and action becomes weaker. Where once there existed an automatic sense of “this is not appropriate,” now there is simply thought turned immediately into action, without the intervening check. Smearing feces, playing with feces, and using feces for art projects are behaviors that in the healthy brain would be automatically discarded as unacceptable. But for the dementia patient with lowering inhibitions, the impulse arises and is acted on before the check can kick in.
Regression
Some experts posit that fecal smearing represents a regression to infantile behaviors. In infancy and early toddlerhood, playing with feces is not uncommon. This behavior naturally ceases as cognition and self-awareness grow.
However, as dementia strips away higher functioning, patients can regress to these earlier developmental stages. Smearing feces becomes akin to a toddler’s exploration of the world through their senses. The dementia patient loses awareness of societal norms and may find the textures and smells of feces pleasant or soothing in some way reminiscent of infancy.
Loss of Communication Skills
Many dementia patients suffer from aphasia, the inability to produce or comprehend language. As their ability to communicate declines, patients may resort to fecal smearing as a mode of expression. They may use feces to draw pictures or “paint” the walls with their fingers. Smearing feces becomes an outlet for creative impulses when language function fades.
Loss of Control Over Bowel Function
Some dementia patients lose control over their bowels as their condition advances. Constipation and fecal impaction are common issues among the elderly and immobile. Liquid feces can then leak out around the impacted stool.
Rather than being able to recognize and address their soiled undergarments, the dementia patient may act out and spread the feces out of frustration over their loss of continence. What begins as an accident can lead to purposeful smearing behaviors.
Attention-Seeking Behavior
Dementia patients require higher levels of care and attention as their cognition declines. Caregivers are often stretched thin among many patients. A dementia patient who craves more social contact or feels neglected may resort to fecal smearing to force interactions with staff who must then come clean them.
While the smearing itself is non-social, the aftermath usually involves one-on-one attention in the form of getting cleaned up, changed, and moved to a new room or area. For patients desperate for human interaction, this can become a learned behavior even if the action itself is inappropriate.
Confusion and Disorientation
Many dementia patients suffer from episodic confusion or delirium. During these bouts of worsening cognition, they may smear feces simply out of profound disorientation. Just as they may mistake a closet for the bathroom, they may fail to recognize feces as something that should not be touched and played with. What appears to be purposeful smearing may in fact be accidental in some cases.
Frustration and Anger
Coping with the anxiety, depression, and fear that often accompany dementia can lead patients to act out in frustration. Loss of bowel control can be frightening and embarrassing. Outbursts of temper or aggression may manifest as inappropriate behaviors like smearing feces as a form of lashing out. Patients may feel angry over their declining health and loss of function, which gets expressed through fecal smearing.
Sensory Stimulation
Different types of dementia attack different areas of the brain. In some patients, sensory areas of the brain are affected. This can lead to both decreased and heightened sensitivity to sensory stimuli.
Fecal smearing may provide visual, textural, and olfactory stimulation for patients whose sensory perception is dulled. The pronounced smells and textures of feces could provide a stimulating sensory experience patients are seeking in order to feel more engaged with their surroundings.
Paranoia or Hallucinations
Many dementia patients suffer from disturbing hallucinations like seeing bugs crawling on their skin. Paranoia over caregivers poisoning their food is also a known phenomenon.
In severe cases, patients may smear feces on themselves or others as a defense against imagined external threats. Spreading feces could be an attempt to repel what they see as an infestation or to “ward off evil spirits” through the use of a prized bodily excretion. While illogical, this behavior stems from a perceived need for protection against their hallucinatory tormentors.
Self-Harm
Repetitive fecal smearing that causes skin breakdown, infections, or illness may be a form of self-harm in some dementia patients. Just as some patients scratch themselves, pull out their hair, or self-mutilate, fecal smearing to excess can be a manifestation of self-injurious impulses brought on by the stress and agitation of dementia. The behavior elicits negative feedback from others which feeds into a sense of low self-esteem and worthlessness that the patient expresses through further self-harm.
Attention-Seeking from External Environment
Some dementia patients in long-term care facilities smear feces to elicit negative attention from the external environment. They may feel isolated, neglected, or uncared for by families who rarely visit. Acting out with fecal smearing forces facility staff to interact with them while also potentially driving away visiting families who are disgusted or embarrassed by the behavior. The end result is a warped version of the attention and social interaction the patient craves. While negative, it still provides human contact.
Lack of Meaningful Activities
The bleakness of the “institutionalized” long-term care environment often provides little cognitive stimulation or meaningful activities for patients. Lack of enrichment leads to boredom, restlessness, and frustration. Fecal smearing becomes an outlet for expression, creativity, and experimentation in the absence of more appropriate and engaging options. Providing activities, sensory engagement, and socialization opportunities could curb the urge to make art with feces.
Side Effects of Medications
Some psychiatric medications used to control the behavioral and psychological symptoms of dementia list fecal smearing or elimination problems as potential side effects. Medications like antipsychotics that affect cognition, mood, or brain chemistry can possibly inhibit inhibition or provoke primitive behaviors in already confused patients. Doctors may need to adjust medications if they appear to be worsening fecal smearing behaviors.
Coexisting Psychiatric Illnesses
Dementia patients frequently have coexisting problems like major depressive disorder, schizophrenia, obsessive compulsive disorder, and other psychiatric conditions. These illnesses create symptoms and behaviors of their own that may “blend” with dementia to provoke increased incidents of fecal smearing. Treating any underlying psychiatric issues could alleviate some fecal smearing behaviors in dementia patients.
Conclusion
Fecal smearing in dementia patients, while disturbing and distressing, generally arises from factors related to cognitive decline that are beyond the patient’s control or comprehension. Dementia creates a perfect storm of lowered inhibitions, primal regression, loss of faculties, sensory deprivation, fear, paranoia, aggression, and hopelessness that can lead to this behavior in some individuals.
Rather than punishment, rehabilitation should focus on addressing root causes of the behavior through therapy, activities, changed routines, anti-psychotic medication, and increased caregiver interaction. Families can help deter fecal smearing by providing enrichment care packages, spending more face-to-face time, and advocating for oversight of their loved one’s daily mood and activities in a long-term care setting. With advanced psychiatric intervention, functional analysis-based training, activity engagement, and devoted caregiving, fecal smearing can often be curtailed or redirected to more appropriate actions that improve the patient’s quality of life.