One of the most challenging behaviors caregivers face when supporting a person with dementia is fecal smearing, clinically known as scatolia. This behavior is a symptom of progressive neurological decline, not a deliberate or malicious act. Understanding that scatolia is a manifestation of unmet needs, confusion, or physical discomfort is the first step toward a compassionate response. The goal is to implement practical, person-centered strategies that address the underlying triggers to reduce the frequency and severity of this behavior.
Identifying the Root Causes of Fecal Smearing
Determining the reason behind scatolia is essential, as the correct intervention depends entirely on the cause. Caregivers should investigate acute medical or physiological triggers, which often cause discomfort the patient cannot verbalize. Constipation is a frequent culprit, as the discomfort or the urge to “dig” at impacted stool leads to manipulation of feces. Other sources of pain, such as hemorrhoids, anal fissures, or a urinary tract infection (UTI), can also increase agitation and lead to the person reaching into their brief or clothing.
A second category of cause relates directly to cognitive impairment and sensory changes. As dementia progresses, the brain’s ability to process sensory input declines, and the person may no longer recognize feces as waste. The substance may simply represent an interesting texture to explore, similar to mud or clay, satisfying a need for tactile stimulation. This loss of recognition is compounded by apraxia, meaning the person forgets the multi-step process of using the toilet and cleaning themselves.
Confusion and disorientation, particularly during the night, are significant contributing factors. Many people with scatolia experience insomnia, waking up confused and disoriented in the dark. They may attempt to remove soiled undergarments due to discomfort or a feeling of uncleanliness, inadvertently leading to smearing. Delayed responses from caregivers, where a soiled brief is not promptly changed, can create an opportunity for the behavior out of frustration or a desire to alleviate the unpleasant sensation.
Immediate Interventions and Redirection Strategies
When a smearing incident occurs, the caregiver’s immediate response must prioritize calm, non-judgmental redirection over confrontation. The person with dementia is already confused or distressed, and an agitated reaction from the caregiver will only increase their anxiety and reinforce the negative behavior. Instead of scolding or lecturing, approach the person with a soothing tone and a relaxed posture to de-escalate the situation.
Non-verbal redirection is often the most effective tool for immediately interrupting the behavior. Offer a safe, preferred object for the person to hold, such as a soft towel, a favorite stuffed animal, or a stress ball, which provides an alternative tactile focus. This simple distraction can divert their attention away from their hands and the soiled area, allowing the caregiver to initiate the cleanup process.
The goal is to transition the person to a wash-up area using minimal, clear instructions. Use simple, one-step commands like, “Hands down, let’s go wash up now,” rather than complex questions or explanations. Avoid asking them why they performed the action, as they are often unable to articulate the reason or may not even remember doing it.
During the cleanup, maintain a matter-of-fact and compassionate demeanor to avoid shaming the person. While cleaning, quickly check for other immediate needs that may have been the trigger, such as pain, hunger, or being too hot or cold. Caregivers must wear gloves and use disposable materials for the cleanup to minimize infection risk. If the person exhibits coprophagia—the act of consuming feces—the immediate removal of the soiled brief or clothing is necessary to prevent ingestion, which carries a high risk of infection.
Proactive Environmental and Clothing Management
Implementing structural changes to the environment and managing clothing can significantly reduce the opportunity for scatolia. Specialized clothing, often called anti-strip garments or adult onesies, prevents the person from easily accessing their brief or diaper. These one-piece garments typically feature secure zippers or fastenings located in the back, making them difficult for a person with compromised manual dexterity to remove.
Scheduled toileting is an effective preventative measure that addresses both physiological and behavioral triggers. Establishing a predictable routine, such as taking the person to the toilet every two to three hours, upon waking, and before bed, ensures that waste is evacuated before it can accumulate in the brief. Monitoring the person’s typical bowel pattern and timing the toileting session to coincide with their expected bowel movement can drastically reduce the number of soiled episodes.
Environmental modifications within the bathroom can also limit potential smearing tools. Removing items like toilet paper, which is often used for smearing, and securing the toilet lid can help prevent access to waste. Ensure the person is provided with sensory substitution activities throughout the day to satisfy tactile needs. Providing a fidget blanket, a texture board, or water play can channel the urge to explore textures into a safe outlet, reducing the likelihood they will seek tactile stimulation from their own waste.