Smearing, Hiding, and the Toilet That Isn't

It has a name, it is not aimed at you, and about a quarter of people with dementia do some version of it. Here is why it happens and what reduces it.

First, the name

It is called scatolia, and telling you that is itself part of the help.

Almost every family who meets this believes two things: that their person has invented something uniquely awful, and that it means something has gone morally wrong.

Neither is true. It is documented, it is named, and clinicians who work in memory care see it regularly.

A survey of 246 people with dementia found smearing occurred frequently in about 2%, sometimes in 8%, and rarely in 15% — roughly a quarter at some frequency, and 75% never at all. So it is not universal, and it is far from rare.

The same work found something more useful. Smearing was associated with lower cognitive scores, with more negative mood, and — like wandering — with insomnia.

Why it happens

The usual sequence is discomfort, then not recognizing what it is, then trying to deal with it, then trying to put it somewhere.

Reconstructed from the inside, it goes something like this.

• Something is uncomfortable. A soiled brief, itching, dampness, constipation, a skin problem, a urinary infection.
• They reach. Which is what anyone does.
• They do not recognize what is on their hand. This is agnosia — the loss of the ability to identify what the senses are reporting. The same failure that makes a fork unfamiliar makes this unidentifiable.
• They try to get rid of it. On the sheet, the wall, the chair — whatever surface is available. Not as a statement. As disposal.

Other threads feed into it: hands looking for something to do, a texture that is oddly absorbing to someone with little other stimulation, and simple restlessness at the times of day when nothing is happening.

None of it is aimed at you, even when it is very hard to believe that.

When the toilet stops being the toilet

A caregiver described finding a bowel movement in the trash can with the toilet directly beside it. That is a perceptual failure, not carelessness.

By the middle stages, several things can break at once:

• The toilet is not recognized as a toilet. A white bowl among white fixtures in a white room. Visual agnosia and reduced contrast sensitivity make it genuinely hard to pick out.
• The bin is the right shape. An open container at roughly the right height. Substituting a plausible object is exactly what a brain reaching for a category does.
• The bathroom cannot be found in time. By the time the signal registers, there is not enough warning left to get anywhere.
• The sequence falls apart. Find the room, manage clothing, sit, wait, wipe, redress, flush, wash. That is an eight-step task for someone who can no longer hold three.

What helps, concretely:

• Contrast. A colored toilet seat — red or dark blue against a white bowl — is one of the highest-value pounds you will ever spend. It makes the target visible.
• Leave the door open and the light on. A closed door removes the cue entirely. A nightlight along the route matters more than one in the room.
• A sign with a picture, not just a word, at eye level — which is lower than you think for someone who is stooped.
• Remove the plausible substitutes. Lidded bin, no open wastebasket in the bedroom, nothing bowl-shaped within reach at night.
• Clear the route. Nothing on the floor between bed and bathroom.
• Prompt on a schedule rather than waiting to be asked — after meals especially, when the bowel is most active. See the companion piece on constipation for why timing around meals works.

Hiding soiled clothing

This is almost always shame, and shame is the thing to manage.

Soiled underwear behind the radiator, in a drawer, under the mattress, in a bag at the back of the wardrobe. Families find it and read it as deceit.

It is usually the opposite. The person knows something has gone wrong, feels humiliated, and solves the problem the only way still available: put it where nobody will see. That takes a degree of self-awareness, and it means the humiliation is real and current.

Which is why the response matters enormously.

• Do not confront them with it. Nothing is gained and a good deal is lost. Remove it quietly and say nothing.
• Never make it a moral issue, however tired you are. If they learn that accidents produce shame, they will hide more, not fewer.
• Reduce the hiding places rather than policing them — and check the usual spots on a routine, unremarked schedule.
• Make the right option easier. A lidded laundry basket in the bedroom, in plain sight, with a towel in it. Somewhere to put things that is not a secret.
• Make accidents ordinary. "Let's get you comfortable" rather than any sentence containing the word again.

Taking the brief off

Check for a reason before you treat it as a behavior.

Someone removing a brief, undressing, or getting dressed and undressed repeatedly is usually reporting something.

• Is it wet? The most common answer and the easiest to fix, with more frequent checks.
• Does it fit? Too tight at the leg, riding up, or the wrong absorbency for the load. A great many "behavioral" problems here are sizing problems.
• Is the skin sore underneath? Look. Redness, a rash, thrush, or breakdown from being damp. Barrier cream and a clinician's eye.
• Are they too hot? Layers plus a brief plus a warm room is genuinely uncomfortable.
• Is it constipation? Fullness and pressure produce fidgeting and pulling at clothing. See the companion article.

If the physical causes are covered, reduce access rather than argue: adaptive clothing that fastens at the back, a one-piece garment, pants without an easy waistband, or a bodysuit under normal clothes. These are ordinary products and they are not restraints.

Restraint is not an option — not physically, and not by tying or binding clothing in a way the person cannot undo. Beyond the legal position in most care settings, it produces distress and injury.

The sudden start

If this began in the last week or two, look for a medical cause before you accept it as a new stage.

Behavior that appears suddenly is usually reporting something, and dementia rarely changes overnight. Ask about:

• Constipation or impaction — including the overflow leakage that looks like diarrhea
• Urinary tract infection, which reliably produces behavior change in this population
• Thrush or skin infection under the brief
• A new medication, or a dose change
• Pain anywhere — including teeth, which is routinely missed
• Sleep that has collapsed, since smearing and insomnia travel together

A sudden change in alertness or confusion alongside it is a same-day call. That may be delirium, which is treatable and urgent.

The practical side, honestly

Some of this is not solvable, only survivable, and it is worth being told that plainly.

• Cut the nails short and keep them short. It reduces what gets carried and makes cleanup faster.
• Set up a kit and keep it stocked where the problem happens: gloves, wipes, bags, an enzymatic cleaner, a change of clothes, a spare set of bedding. Fumbling for supplies mid-incident is the part that breaks people.
• Enzymatic cleaners, not ordinary disinfectants. Enzymes break the residue down. Everything else masks it and it returns in a warm room.
• Waterproof means sealed backing, not "water-resistant" fabric. Several caregivers have bought three covers before learning this. Washable pads under the sheet save more work than they cost.
• Soft furnishings are consumable. Odor that has reached the foam of a chair or the core of a mattress does not come out. Replacing it is a practical decision. If the chair belongs to a facility, expect to be billed and ask what their policy is before it happens.
• Two hands are better than one. Where a second person is possible for the worst of it, take it. This is one of the tasks that most reliably exhausts a solo caregiver.