Bathing is a complex activity requiring cognitive and physical abilities including balance, strength, coordination, and executive function (Naik, Concato, & Gill, 2004; Rader et al., 2006). In people with Alzheimer’s-type dementia, bathing represents one of the earliest activities of daily living (ADLs) to require supervision, then assistance. In a national survey of nursing homes, at least 90% of residents required bathing assistance (Rader et al., 2006).
When people with dementia residing in an institution require assistance with bathing, the process is complicated by the culture, values, and expectations of people who assist with the bath. Seemingly simple concepts such as what is clean versus what is dirty and how one responds to what he or she perceives can trigger conflicts. Moreover, in an institutional setting there are policies, rules, and traditions of care that might trump individual needs and beliefs. There are also regulatory standards that must be followed and issues related to economies of scale. What may seem like a simple bath to assistants may be perceived as a personal attack and result in resistance due to high levels of anxiety, agitation, and aggression (Calleson, Sloane, Philip, & Cohen, 2006).
There is a large body of research and literature regarding all aspects of bathing practices. This article is a summary of selected portions of the evidence-based practice guideline Bathing Persons with Dementia (Hall, Gallagher, & Hoffmann-Snyder, 2013). This updated version of the earlier guideline (Thiru-Chelvam, 2004) is available for purchase from The University of Iowa Hartford Center of Geriatric Nursing Excellence at http://www.nursing.uiowa.edu/excellence/evidence-based-practice-guidelines. The goal is to promote therapeutic bathing experiences based on the needs and preferences of the individual with dementia that facilitate feelings of comfort, safety, autonomy, and self-esteem. The guideline addresses the long-term care (LTC) setting.
Individuals at Risk for Bathing Dependence
Individuals with dementia generally become dependent in bathing in mid-disease, yet the extent and type of disability varies with the etiology. As the diseases progress, increased time and effort are required to bathe the person with dementia (Kobayashi & Yamamoto, 2004). In people with Alzheimer’s-type dementia, the most significant disabilities were associated with using the stairs, bathing, lower extremity dressing, and issues of transfer into the bathing site (i.e., tub or shower). In cognitive domains, executive dysfunction (planning and executing the steps in sequence to reach a goal) and memory were the primary problems. However, in people with a major neurocognitive disorder (NCD) due to a vascular etiology (vascular dementia), issues with bathing, upper and lower extremity dressing, and grooming were more difficult, and the cognitive issue was difficulty with problem solving (Shiau, Yu, Yuan, Lin, & Liu, 2006).
When the person being bathed has more moderate and advanced cognitive impairment, including altered visual perception, recognition, balance, and motor planning, one may lack the context for understanding both the procedure and/or may not recognize the person assisting him or her. Thus, what may seem like a simple bath to assistants may be perceived by residents with dementia as a personal attack, sexual violation, or intended drowning. These disabilities result in resistance due to high levels of anxiety, agitation, and aggression (Calleson et al., 2006).
Physical aspects that contribute to bathing resistance include (a) pain from musculoskeletal conditions, (b) fatigue and weakness, and (c) discomfort from cold, drafty rooms/halls and sharp shower spray. Fear can develop from usual bathing practices due to (a) fear of falling, (b) being transported through noisy areas, (c) being naked in front of strangers, and (d) being hoisted high in the air on a mechanical lift (Rader et al., 2006).
A study of 107 people with dementia found 51% had previous issues with aggression. When observing residents during four direct care activities, showering was the only activity that produced significant levels of aggression. Resident factors associated with the aggression included the following:
- negative affect,
- history of premorbid aggressive personality,
- history of premorbid disagreeableness,
- lower functional and mental status scores, and
- low educational level.
Staff factors associated with aggression included negative caregiver affect and negative caregiver response to resident aggression (Whall et al., 2008).
Every individual entering a LTC setting should be formally assessed for cognitive and functional status initially and every 6 months, or if there is a change in condition. The goal of assessment is to know, as clearly as possible, the individual’s abilities and need for assistance to avoid unpleasant surprises. Functional assessments usually provide information regarding the individual’s need for help with a particular ADL and the level of assistance needed to “get the job done.” They are the initial indicators of patient needs; however, additional information is required to make the bath person-centered.
Knowledge of the individual’s history of bathing practices and preferences will assist in determining the time of day (morning or later in the day) and the type of bathing process (tub, shower, or bed bath) to be used initially for that individual (Thiru-Chelvam, 2004). In a study of 18 health care assistants from 12 different facilities, all participants agreed it was important to know the resident to ensure the bathing experience was successful (Gaspard & Cox, 2012). Direct caregivers should be asked if there are any issues with bathing such as resistance or agitation, and what measures they used to prompt bathing, such as saying the person could not go to lunch without bathing. In one study, more than 90% of individuals with a major NCD became agitated as soon as they were told it was time to bathe (Rasin & Barrick, 2004). Facility staff also need to know the new resident’s behavioral issues:
- What does the individual do when upset or fatigued? How often does this occur? What do the behaviors entail and how intense are they? How long do the behaviors last? What time of day are they likely to occur? Are the behaviors triggered by anything? What do you do to avoid or resolve them?
- How often did the individual previously bathe? What time of day? Was there anything in the past that might affect frequency of bathing (e.g., growing up without indoor plumbing)? How does the individual bathe now (tub, shower, at sink, not unless prompted)? Does the individual use any special products, robes, towels, or equipment during bathing (e.g., bubble bath, scented soaps, music, back brush, sponge) to make the experience more enjoyable? Is the individual especially modest?
Behavior monitoring can be achieved through observing and recording the individual’s response in certain situations and using the patient record for a historical perspective on behaviors. If the bathing method established is accepted by the individual, it should be documented so that other caregivers will follow the same routine. If it is not accepted, then further exploration into other methods would be necessary until a bathing process is found that is accepted by the individual (Thiru-Chelvam, 2004). Every attempt should be made to avoid bathing people against their will. Assessment is the only way to gather enough information about the person to individualize care and be person-centered (California Workgroup on Guidelines for Alzheimer’s Disease Management, 2008). The Table summarizes practice recommendations from the workgroup (2008, p. 10).
Evidence-Based Recommendations for Practice Assessing People with Dementia
The California Workgroup on Guidelines for Alzheimer’s Disease Management (2008) lists the following practice guideline for functional assessment:
The Bathing Process
Bathing should never be forced on a person or treated as a life or death, win/lose situation. Gaspard and Cox (2012) point out the need to use policies and guidelines that are consistent with a culture of caring and respect for the resident, staff, and families. In addition, careful documentation of methods and outcomes will assist future caregivers in providing appropriate accepted practice to individual care recipients.
Why Reactions Occur
Bathing involves multiple stressors, and individuals with dementia have a decreased threshold for tolerating stress in their environment. If a large group of residents needs to be bathed each day, employees may work quickly, often in the early morning, to accomplish the goal. This can cause stress, agitation, and even aggression as a resident might feel a loss of dignity and control. Being undressed and washed by a stranger may be a humiliating, frightening, and potentially traumatic experience. Agitated behaviors are more likely to occur with providing care in feeding and bathing. Negative verbal responses were more likely to be treated with benzodiazepine agents and neuroleptic medications (antipsychotic agents), but both have limited efficacy and pose risk to residents (Ramadan, Naughton, & Prior, 2003).
Showering an individual with dementia was the ADL most likely to provoke patient-to-staff physical aggression (Schreiner, 2001; Schreiner, Yamamoto, & Shiotani, 2000).
Resistive behaviors are normal responses to the following perceived threats:
- Unfamiliar activities.
- The presence of strangers.
- Unpleasant sensations (e.g., cold, pain).
- Fear of catching cold.
- Feeling confused, dominated, insulted.
- Misinterpretation as a sexual assault.
- Impaired ability to recognize staff as being helpful not harmful.
- Unwanted touch or invasion of personal space.
- Frustration from declining abilities.
- Anticipation of pain.
- Perceived loss of control.
- Lack of attention to personal needs.
Caregivers report the most common physical aggression while bathing includes hitting, punching, and slapping followed by pinching and pushing. The most common needs the resident has during bathing are control and an absence of cold, pain, and fear (Rasin & Barrick, 2004). ADLs, including bathing, are not improved with the addition of a cholinesterase inhibitor; however, they may delay additional functional decline (Desai, Grossberg, & Sheth, 2004).
Many caregivers possess intuitive skills to assist in understanding and caring for individuals with dementia. There are, however, many skills that can be learned by motivated staff to provide quality care for all individuals who may require assistance in performing ADLs. When bathing is seen as a treatment it carries the same compelling necessity as a medication order and caregivers feel pressured to carry out the order with little discretion. As a result, the bathing process may continue on a regular basis without either the resident or the caregiver achieving a positive experience (Corber, Siberfeld, & Feldman, 1998).
There is a positive correlation between increased activities of care and caregiver burden, including direct tasks such as bathing. One study explored educating certified nursing assistants (CNAs) in person-centered approaches for residents who experienced agitation and aggression while bathing (Hoeffer et al., 2006). When CNAs incorporated learned techniques using gentleness and verbal support, symptoms improved for both types of bathing and changed the CNAs’ perception of bathing activities. Nursing practice rituals such as bathing need to be rethought in terms of who really benefits from this activity. The prerequisite for putting the resident’s needs first and adjusting nursing care to individualize approaches cannot be overemphasized.
Shifting the caregiver’s perspective from task-focused to person-focused is one way to change the psychosocial environment under which a successful bathing process can occur. One study of antecedents to assaultive behavior during bathing found that caregiver behavior, especially 5 seconds prior to the assault, triggered the behavior (Somboontanont et al., 2004). Caregiver behaviors included calling the resident by first name; confrontational communication; invalidation of the resident’s feelings; absence of personal restraint; spraying water without telling the individual; touching feet, axilla, or perineal area; non-bath–related communications; and failing to prepare the resident for the bath. Additional training and less invasive bathing measures are recommended.
Preparing for the Bath
Time spent preparing both the individual and the environment for the bathing process may have a positive effect on the final outcome. Only by listening to, and carefully observing the individual, and by speaking with family members, can the individual’s expectations and perceptions of bathing be appreciated (Sloane et al., 2004). By interviewing the family members and discovering the past personal habits of each individual, the nurse has a framework for how to approach the individual in terms of which bathing methods are acceptable for each person. For example, the caregiver should not expect that an elderly woman who always bathed at the sink would respond favorably to a tub or shower bath.
Goals can be developed in relation to identifying the specific function the bath is to serve, the frequency needed, and what form can be used to achieve that function. Regarding form, a bed bath can also be considered in addition to a tub or shower. Bed bath variations resulted in approximately 50% fewer agitated behaviors and less discomfort than tub or shower (Dunn, Thiru-Chelvam, & Beck, 2002). The bed bath also showed reduction in behaviors regardless of degree of cognition and physical mobility.
Creating a list of reasons the caregivers can use to explain to the individual why he or she should bathe may be helpful. For example, the following are a few “approach” techniques to use in gaining the individual’s cooperation:
- Preparing for the day.
- A special occasion.
- To get ready for a meal (e.g., breakfast, lunch).
- They have worked hard and need to “freshen up” (Dougherty & Long, 2003).
Persuasion, not coercion, should be used. The individual should not be pressured, as this will increase agitation. In addition, the individual should be allowed to remain in control.
Privacy can be ensured by closing the door and not undressing until absolutely necessary (Mickus et al., 2002). The time the person is unclothed should always try to be minimized. Avoiding a series of distasteful tasks in succession is also recommended. If undressing agitates the individual, bathing him or her in the morning when only pajamas or a nightgown need to be removed, or undressing only a little at a time, such as keeping the shirt on while washing the legs or covering the lower body when removing trousers, is suggested. The person’s perceptions are always valid—cold is cold, pain is pain. Pain associated with increased range of motion is a common trigger for resistive behaviors, so the need for analgesic medications should be considered and sufficient time allowed for them to be effective before beginning the bath (Rader et al., 2006). It is important to stay attuned to responses and validate their experiences.
Whether it is performed in a tub, shower, at a sink, or in bed, there are a number of principles and guidelines to follow in each situation for the process to be pleasant and therapeutic. In a review of outcomes of past interventions using the Treatment Routes for Exploring Agitation approach for non-pharmacological treatment of agitation in residents with dementia, findings to improve practices suggested four major factors that contribute to agitation during bathing: (a) resident’s needs, (b) caregiver’s needs, (c) the physical environment of the bathing area, and (d) institutional factors (Cohen-Mansfield & Parpura-Gill, 2007).
The interventional care practice model resulted in positive behavioral changes in care practices by staff, along with increased knowledge and understanding of the residents including factors required to create a favorable bathing experience. Although the duration of bath time initially lengthened as new bathing techniques were implemented, over time, the duration was comparable to pre-intervention times. Staff need to feel educated, supported, and provided with all the necessary materials to achieve success (Cohen-Mansfield & Parpura-Gill, 2007).
Evaluation of a restorative care model, Res-Care, used CNA training and oversight from an advanced practice nurse to help residents engage in functional and physical activities. At the start, 60% of residents were unable or unwilling to stand or ambulate. At the end of 4 months, significant improvements were seen in levels of self-efficacy with bathing (Resnick et al., 2009).
A clinical randomized controlled trial comparing person-centered showering and towel baths studied 73 residents with histories of agitation while bathing (Sloane et al., 2004). Measures of agitation, aggression, and discomfort declined significantly in both groups, although the towel bath was significantly more comfortable than the shower. The length of bathing activity with showering increased by 3.3 minutes but did not increase for the towel bath. Skin condition improved equally with both methods. Thus, although advantages exist to both the towel bath and person-centered shower, the towel bath was the least time consuming and uncomfortable. The procedure for the towel bath has been well studied. A film associated with the towel bath is available at http://bathingwithoutabattle.unc.edu.
Speaking in a low, pleasant voice and giving information before and all through the bathing process is a strategy that can help keep the individual calm and in control. Repeated reassurance that the person is safe and not alone should be given. Calm behaviors from the individual are the result of engaged verbal communication from the caregiver. If agitation occurs, distraction (e.g., a pleasant topic) should be used. It is important to focus on how the individual is responding, including if the timing of the bath was appropriate (Mickus et al., 2002).
It is also important to concentrate on the person’s feelings and reactions, and watch for warning signs by staying alert to non-verbal behaviors such as facial expressions, mood, or raising fists (Dunn et al., 2002). If agitation escalates, the plan should be modified and a partial bath should be given or hygiene delayed altogether. There is always tomorrow. The individual’s request to stop must always be acknowledged. “Rescuing” can be used if necessary to reduce agitation. A negative response to one caregiver can be “solved” by the second caregiver. However, two people should not bathe different parts of the individual at the same time. Stimulation should be kept singular and focused. Residents who listened to music while bathing had a decrease in 12 of 15 identified aggressive behaviors (Clark, Lipe, & Bilbrey, 1998). Caregivers also frequently reported improved affects in the bathed resident and a general increase in cooperation with the task, thus decreasing stress for residents and caregivers. It is important to maintain eye contact, provide emotional support, and use soothing speech. Wash only what is necessary, be mindful to slowly and gently manipulate movement of joints, and keep actions brief.
Use of towel or thermal baths reduced 14 types of agitated behaviors when compared to tub baths. Marginal behavioral differences were noted in noisy breathing, facial grimacing, and negative vocalizations (Dunn et al., 2002; University of North Carolina [UNC], 2008).
After the Bath
Sometimes it is impossible to eliminate all negative behaviors. Sometimes a reduction is only what can be achieved. No solution works all the time. The caregiver needs to reevaluate moment to moment. Documentation is critical for evaluating and planning additional bathing modifications (Rader et al., 2006). When bathing is stressful, discussion and evaluation are required at report and care planning sessions. The health care team should brainstorm to explore every avenue for possible solutions to problems encountered while bathing.
Environmental and Administrative Considerations
In attempting to manage negative behaviors associated with the bathing process, the actual room in which this activity occurs plays a major role in the outcome and plan of interventions. In older facilities, the challenge is to make the bathing room a place that does not contribute to negative behaviors by alarming the individual who may interpret a large, sterile, cavernous room as threatening. Because of the frailties and physical limitations of individuals requiring care, the tubs and accompanying bathing equipment required for facilities do not resemble anything the individual would remember from his or her past.
Much can be done so that this equipment does not become the focal point of the room. It is helpful to look at the room from the other person’s point of view. What is the first thing he or she sees when entering the room? What does he or she see when entering or leaving the tub or shower?
Lighting needs to be sufficient enough for the caregiver but also subdued enough not to startle the individual being bathed. Lights shining off ceramic tiles cause a glare that is distressing to the person with dementia (Calkins, 2002). Offensive smells can be eliminated by making sure that soiled clothing is removed immediately, hampers are cleaned, and scented air fresheners are used. Flooring needs to be examined from the aspects of cold and safety when wet. Washable non-slip rugs should be considered. Stable grab bars are of prime importance where individuals who require assistance are moving into the tub or shower, and it is important that they be visible and strategically placed for safety (Brawley, 2001; Calkins, 2002).
Wet skin feels cold and therefore the room needs to be maintained at a higher temperature than other areas the individual may frequent (Brawley, 2001; Calkins, 2002). Hand-held showers are easier to control and more versatile than wall mounted. They can usually be attached to a bracket to use in the traditional way if the individual is more independent (Brawley, 2001). How the individual with dementia enters the tub is the most important consideration when choosing a tub. Those systems where the person has to be raised a considerable height were shown to cause the largest degree of negative behaviors (Namazi & Johnson, 1996).
An educational video containing research-based, person-centered showering and towel bath techniques to reduce agitated behaviors in individuals with Alzheimer’s disease (UNC, 2008) was mailed (at no charge) to 15,453 nursing homes. Researchers evaluated outcomes data based on dissemination, use, and short-term results collected by LTC surveyors in three states. The surveys were given to 114 administrators. Only 45% of administrators acknowledged their facilities received the training video. Those facilities that used the training materials reported high ratings for quality and effectiveness. An evaluation of training materials completed by participants resulted in 95% of nurses, 94% of nursing assistants, and 92% of administrators agreeing or agreeing strongly that the materials achieved the program’s goals. Short-term outcomes of increased knowledge were achieved as demonstrated by an overall mean for participants’ test scores of 93% (Calleson et al., 2006).
A small convenience survey of dementia care providers was used to examine autonomy versus safety as it relates to wandering, access to outdoor spaces, restricted diets, and bathing options in people with a major NCD. Although no participant stated he or she would force a resident to bathe, most expressed that the baseline acceptable standard for all residents would be to bathe or shower once per week. Most would notify the family and physician if the individual missed two baths. Providers were evenly divided among those who would provide the resident with options for cleansing each time or base it on the individual’s standard preference. It is suspected, however, that facilities may “strongly recommend” and guide a patient’s preference (Calkins, 2007).
Although much research has been conducted on evidence-based methods, they are not universally accepted by facility administration who continue to perceive bathing as an essential task. It is necessary to explore and establish methods that respect the wishes of the person with dementia when actions do not threaten. Individuals with dementia continue to tell us what they want even when their verbal abilities decline (Calkins, 2007).
Conclusions and Implications for Nurses
Bathing people is an essential nursing responsibility, yet bathing individuals with dementia is one of the most troubled activities in LTC settings. Traditional practices are fraught with difficulties; however, the procedure is so ingrained that change has been resisted. The need for changed methods is well-documented in resident outcomes and behaviors, yet change is slow.
There is abundant research that focuses on person-centered bathing and bed bathing. It is well received by residents and caregivers, resulting in significant declines in suffering. These methods focus on the needs and preferences of the individual with dementia rather than facility priorities about speed and efficiency (Barrick, Rader, Hoeffer, Sloane, & Biddle, 2008). Focusing on facility factors results in a “factory mentality” instead of person-centered care. Residents are treated as products and the research is filled with descriptions of how we make individuals with dementia suffer needlessly.
“Bathing people routinely against their wishes—‘for their own good’—should become a part of nursing history” (Rader et al., 2006, p. 42). In bathing, person-centered care and creative thinking should become the norm.
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Evidence-Based Recommendations for Practice Assessing People with Dementia
The California Workgroup on Guidelines for Alzheimer’s Disease Management (2008) lists the following practice guideline for functional assessment:
|Conduct and document an assessment and monitor changes in:
Daily functioning, including feeding, bathing, dressing, mobility, toileting, continence, and ability to manage finances and medications
Cognitive status using a reliable and valid instrument
Comorbid medical conditions, which may present with sudden worsening in cognition, function, or as change in behavior
Behavioral symptoms, psychotic symptoms, and depression
Medications, both prescription and non-prescription (at every visit)
Living arrangement, safety, care needs, and abuse and/or neglect
Need for palliative and/or end-of-life care planning
|Reassessment should occur at least every 6 months, and sudden changes in behavior or increase in the rate of decline should trigger an urgent visit to the primary care physician.
|Identify the primary caregiver and assess the adequacy of family and other support systems, paying particular attention to the caregiver’s mental and physical health.
|Assess the patient’s decision-making capacity and determine whether a surrogate has been identified.
|Identify the patient’s and family’s culture, values, primary language, literacy level, and decision-making process.