Dementia bathing: How to keep a bath from becoming a battle

Bathing and hygiene tasks are often disturbing and frightening for those with cognitive decline, and nothing about them is routine for caregivers, either.
Bathing is a deeply intimate and a sensory experience, and for residents who have dementia, a tubful of paranoias and miscues, said Denise Scruggs, CDP, CADDCT, ADC/MC, director of the Beard Center on Aging, Lynchburg College, in a breakout session at this week’s Memory Care Forum in Austin, Texas.
Many residents come from generations that had demure views of nudity, and the simple act of being naked in front of someone else can be a massive stressor. And, since those with dementia may have “time-shifted” in their minds to a much younger age, the process can even be misconstrued as sexual if the caregiver is the opposite gender, she explained. 
Caregivers can avoid spoiling the bathing experience by understanding how the dementia brain can misinterpret the stimuli and translate a bath into a battle. The combination of the vulnerability of nakedness and the struggle to recognize/identify those involved in the bathing process can escalate stress to volatile levels, Scruggs explained. “That person with dementia might be thinking, ‘They’re trying to drown me’ or ‘They’re trying to hurt me.’ And, since the brain’s reaction time has slowed down, they may not be able to tell you, ‘That shampoo is burning my eyes.’” Any bad experience can affect future bathing, making everyone’s day harder later, she added.
One of the biggest mistakes? Caregivers who chat with each other while preparing the resident for bathing instead of interacting with the resident, Scruggs said. The sense of being “stripped” or treated like a task object instead of a person will frustrate residents further and add the element of humiliation.
Caregivers also should never underestimate the power of their own non-verbal cues, Scruggs warned. Bathing shifts are often challenging, but letting your emotions show—impatience, anger, frustration—almost always prompts behavioral responses in people with dementia.
Residents’ individuality needs to be respected—bathing shouldn't be viewed as an “assembly line” process, Scruggs added. For each resident’s turn in the tub, use hygiene products that are familiar and liked by that resident. Learn what soothes each person and use it consistently. Individualized music selections, colorful towels, individualized routines and storytelling can all be effective as comfort cues.
The thin nature of elder skin and proximity of nerves to the skin surface mean what seems envigorating or soothing to a younger person could be painful for an older adult. Both water temperature and water pressure can be factors here, Scruggs said. And, pay attention to temperature differentials, such as the nice, warm bath water and that chilly bathing seat.
Taking the time to learning a bit from the family on what causes bathing stress or enjoyment can go a long way. Sometimes a life experience from the distant past can be a factor, especially for residents who are veterans or victims of abuse or other crimes. Scruggs relates the experience of one resident, who had survived the WWII concentration camps and had watched her friends go into the gas chambers, crafted to look like showers. Once in a nursing home, “She came to the shower every day, thinking this would be her day to die,” Scruggs said. “We never know what someone’s past experience has been.”
Scruggs offers these tips and strategies for providing a positive bathing experience:
  • Warmth is innately soothing. Warm the water, the bathing seat and the lotion for afterward. If possible, heat the towels.
  • One seat doesn’t fit all. Bathing chairs or stool that are too high can cause a resident’s feet to dangle, a sure trigger for feelings of insecurity. Find a seat that allows the resident’s feet to fully touch the bottom surface.
  • Lighting is tricky. Bright, harsh lights can startle or unnerve a resident, but too-dim lighting can create scary shadows or a subversive atmosphere.
  • All-white isn’t right. All-white bathrooms might look crisp and appealing to others, but the lack of contrast and color distinction becomes a muddled blur for people with dementia and can affect their sense of security.
  • Nix the mirrors. People with dementia often cannot recognize their own faces in a mirror and may think there’s a stranger watching them undress.
  • Consistent caregiver assignment strategies work. The more times a resident works with a particular caregiver who can provide a positive experience, the less resistant the resident will be to the bathing process.
  • Fragrance choices should not be random. Who wants to bathe in a room that smells like someone else’s favorite fragrance? Choose scents that are familiar and soothing to that particular resident.
  • Watch the pressure. Some residents may enjoy being sprayed with the massage setting on the shower head, but many older adults find it painful—and people with dementia may interpret this stimulus with fear or panic.
Scruggs made one final suggestion to caregivers: “Have you ever been in a Hoyer lift? Get in one and see what it’s like to be hanging and how vulnerable that makes you feel—especially with no clothes on,” she said. “It should be a ‘must’ in your training.”

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