Q. What are the special challenges posed by bathing and showering for a person who has dementia?
A. Bathing is one of the most personal activities of daily living. It’s also a complex activity requiring cognition, coordination, flexibility, balance, and a certain level of strength.
When people can no longer bathe themselves independently, they usually have declined physically and mentally, and the new symptoms can trigger emotional upset, distress, and embarrassment.
While it may not always be easy to help bathe a loved one with dementia over the full course of their illness, it’s usually possible to find ways to keep improving the bathing experience even when the challenges continue to develop.
For many people, it’s best not to ask if they want to bathe. A resounding "no" is likely to result. Rather, try to state things in a positive manner and say, “It’s nine o’clock, Harriet. It’s time to bathe. Let me help you.” A similar approach would be to say: “John, come join me, everything is ready for your shower.”
This gives the care recipient advance notice that bathing will occur in a few minutes. They will benefit from a few minutes to transition into the task. Abrupt requests often result in resistance, but occasionally they work best.
Q. When it’s time to bathe, what can a caregiver do to help a person with mild to moderate dementia?
A. People with this level of dementia can do a lot for themselves, but if you cue them, make helpful suggestions, and do some preparation for them beforehand in the bathroom, things should go even better.
For a shower, adjust the water temperature so it is at a comfortable setting. For a bath, fill the tub with just a few inches of water. This low water level will help the person feel more secure and is safer in case of slips. To help prevent those, make sure you place a protective mat in the tub first.
Here’s why you should fill the tub beforehand: If you run the water with the person in the room, the noise can lead to distress if you have to try to make yourself heard over the water cascading into the tub. The care recipient may misinterpret your raised voice as anger or think you are shouting at him or her.
Close the bathroom door to ensure privacy. Be sure that the room is warm and free from drafts. If the care recipient mentions concerns about people watching, reassure and then distract them onto another conversation. Provide them with a wash cloth they can use to cover themselves.
In more moderate to advanced stages of dementia, you will have to offer more suggestions and participate more actively in bathing. Before the care recipient walks into the bathroom, lay out the soap, washcloth, and towel. Have the robe or clothing he or she will put on after bathing neatly laid out. Doing things in this fashion ensures that you don’t have to run out of the bathroom and disrupt what you are doing at any time during the bathing process.
A person with dementia will take longer to process information than he or she did when well, and this affects his abilities, even when it comes to bathing. Take your time. Don’t make the care recipient feel that he or she is being rushed. Rushing may make him or her anxious and increase the likelihood that he will want to end his bathing prematurely.
Q. What about the water temperature. Should the caregiver be in charge?
A. You should make sure that the water temperature is acceptable. Pour a little water on the care recipient’s hand before he or she gets into the shower or bath to show him or her how nice the water is.
People with dementia can tell by putting their hand in a tub or under a running shower whether the water is too hot or cold for them. But they may not have the cognitive skills required to adjust the hot or cold water faucet. As a result, they might become very agitated and stressed and want to end their bathing. You should be the final arbiter when it comes to water temperature.
Q. Which is better for someone with dementia: Bath or shower?
A. If a person has mild dementia, a shower is fine if that is what they were used to before their illness. You can coach the person into the shower stall, set the water for them if they need help, and stand outside while they bathe in case any further help is needed.
If some assistance is needed, a hand-held showerhead is really useful. Have your loved one sit on a sturdy shower chair or bench and help bathe them that way.
Where the person needs more physical assistance, it’s better to use a bathtub. But the problem for many people is being able to raise their legs to get in and out of the tub. The bathtub is one of the most common places people will have falling and tripping accidents. Such accidents are not only common but they are oftentimes catastrophic.
In this country, most home accidents occur in the bathroom. That’s because the combination of water and slippery tile surfaces, poor balance and coordination, and limited mobility makes taking a bath or shower so risky. More than 20,000 people slip, fall, and die each year; most of these fatalities occur in people 65 and older.
Q. What can be done if a loved one has difficulty getting in or out of a tub?
A. If your care recipient cannot manage a tub alone, here are several options to consider:
1. Physically alter the tub area. Install safety rails and grab bars and strategically place them to assist getting in and out of the tub. A grab bar is a safety device that attaches to the wall and acts as a hand grip to steady the bather. These are useful near toilets or in bathtubs/showers to help people keep their balance. Constructed of plastic, aluminum, or stainless steel, they typically screw into the wall. (Towel racks are not an adequate substitute.) If there are sliding glass doors around the tub, have them replaced with a shower curtain to prevent serious injury.
2. Use a shower seat/chair. Using a shower chair in the bathtub or shower lets care recipients sit down while they’re bathing so they don’t have to worry about standing up and possibly slipping. Get a height-adjustable seat/chair with a cushioned seat, backrest, and armrests, because they provide extra support and make bathing easier and safer.
3. Use a transfer bench. Getting in and out of the bathtub or shower can be a tricky proposition as a person steps over the side of the tub. Transfer benches help minimize the risk involved. A transfer bench is basically a wide chair straddling the side of the tub, so that there are always two bench legs on the outside of the tub and then two legs on the inside of the tub.
To get into the tub, a person sits down on the bench outside the tub, scoots over, and lifts his or her legs over the tub’s side until he is sitting on the bench inside the tub. There are also transfer benches with a sliding seat that make getting in and out of the tub even easier. The benches have a seat that glides on rails in and out of the bathtub. Instead of having to scoot over on the transfer bench seat, the person simply sits on the seat and slides into the tub.
A surgical supply store or Internet supplier will have a good selection of bars, rails, seats, and chairs to keep a person safe and steady in the tub or shower.
Be sure to have non-slip suction mats or rubber silicone appliqués in the tub to help prevent falls and a non-skid, latex-coated bath mat on the floor beside the tub to provide safe footing.
4. Sponge bathe. It’s not always possible for the care recipient to get into a tub. In that case, a sponge bath has to suffice. Have the care recipient sit on a comfortable chair near the sink. Fill the sink with warm water, and give him or her a sponge bath with a washcloth.
Q. What is the best way to make headway with a resistant patient who disagrees with all attempts at bathing?
A. If a person has mild to moderate dementia, try to reason with them. At this point in the illness, they still have quite an ability to listen, think, and make decisions for themselves. Think of reasoning as your first bargaining chip. Also think about their old patterns of bathing. Did they use the shower or bath? Did they bathe at night before bed or early in the morning? Try to maintain the old patterns. Don’t try to schedule a bath during a favorite TV show.
If the caregiver thinks the person needs to bathe with the same frequency as when they were well, the expectation of the caregiver has to change. We Americans bathe daily, but people in other cultures don’t do that. Once a week may be adequate for some people.
Still, bathing is not just about smelling good. If care recipients do not wash frequently enough, they put themselves at risk for a skin infection or other skin problems. At the bare minimum, hands should always be washed after using the toilet, before each meal, and before handling food. The face should be washed daily to keep the skin clear, and the genitals and bottom should be washed daily to ward off infection.
Refusal to bathe is a common problem. When it is time to bathe and the care recipient flat-out refuses, it’s time to change tactics and be more creative in how you get someone to wash.
Some people simply react badly to the word “bath” or “tub.” You may find that whenever you say either word, the person shows annoyance. Therefore, not saying those exact words may prove to be more palatable. Instead, say something like, “Mildred, I want to run a washcloth across your face. You’ll feel fresher." Or, “You might feel better if you soaked that painful knee (back, neck) in warm water. Let’s go do that now.”
For some people in nursing homes, the sign outside the bathroom can cause them to react badly at bath time. By covering up the sign and telling the person at bath time, “I want to take you in here, warm you up, and use some soap and water,” you should be able to get the person to begin the bathing process.
Distractions help as well. Sometimes when you want to give a bath and have a distraction present—their favorite show tunes playing, for instance, or favorite pictures hanging on the wall—you can go in the bathroom and chat the whole time with them about a grandchild, a favorite pet, or recent family news as you are washing them. This way, the music, the chat, and reminiscing become the primary activities while the washing becomes secondary.
1. Help care recipients remove their clothing. Drape them with a bath towel or robe to keep them warm and protect their dignity and right to privacy by not exposing their body.
2. Turn on the water and have the care recipient check the water temperature.
3. Assist the care recipient into the shower. If using a shower chair or bench,make sure that the wheels are locked.
4. To help maintain independence, let your loved one wash himself (or herself) as much as possible.
5. When finished with the shower, hand the care recipient a towel and help them to pat themselves dry. This helps reduce chafing.
6. Help them apply body lotion, and help them to dress and comb their hair.
7. Everyone loves flattery. Tell the care recipient how great he/she looks.
Washing the “private parts”
Whenever possible, a person with dementia should be encouraged to attend to his or her own perineal care as part of the bathing process. (The perineum is the area of tissue from the pubic area to the anus in men; in women it is often an overlooked part of patient care.)
When stool or moisture from urine are allowed to remain on the skin in the perineum, redness, blisters, and pain are likely to follow. This area should be cleaned daily to protect the delicate skin from breakdown or injury, prevent infection and odor, and promote patient care.
If you have to provide this highly personal care, start by explaining to your loved one exactly what you are going to do. This prepares the person for the upcoming task.
If the perineal area cannot be adequately cleaned in a tub or bath, here is an effective way to provide care when the person is sitting down.
1. Gather latex gloves, a towel, a washcloth (or premoistened disposable wipes), a waterproof underpad, a bath robe or ample towel, gentle cleanser, and a basin of warm water.
2. Offer the person a urinal or bedpan, or bring them to the toilet. This will reduce the chance of urination during the procedure, which may cause discomfort and embarrassment.
3. Place a waterproof pad on the bed and have the person sit on it.
4. Expose the perineal area by having care recipients gently spread their legs and lift one knee at a time, if possible.
5.Dampen a folded washcloth and add soap, or use a premoistened disposable wipe.
6. Wipe from front to back and from the center of the perineum to the thighs. Change the washcloth if necessary.
• Separate the labia. Wash the urethral area first.
• Wash between the inside and outside labia in downward strokes, alternating from side to side and moving outward to thighs. Use different parts of the washcloth for each stroke.
• Wash and rinse the tip of the penis using a circular motion beginning at the tip of the penis. (If uncircumcised, pull back the foreskin of the penis.)
• Continue washing down the penis to the scrotum and inner thighs.
7. Change the water in the basin. Use a clean washcloth or wipe to rinse the area thoroughly.
8. Gently pat the area dry.
9. Help the care recipient to turn onto his or her side and away from you.
10. Wet a clean washcloth and add soap, or use a premoistened disposable wipe.
11. Clean the anal area from front to back.
12. Rinse the area and gently pat dry.