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DISCLAIMER ...
There is no hard and fast answer to addressing a problem behaviour.
The following information is provided as a tool to help the Caregiver find the solution that works for situation they are faced with.

Problem Behaviours - Bathing

| Possible Causes | Coping Strategies | Other Considerations | Additional Information

Bathing is often the most difficult activity that caregivers face. Bathing is a daily activity most of us can handle by ourselves. But the introduction of another person into the bathing routine can also cause embarrassment and a sense of lost independence.

But Caregiver's cannot ignore the bath routine, At first it might be helping to get into and out of the tub. After a while it might involve the full activity of undressing, washing and dressing again. The Caregiver is always concerned about the cared for persons comfort, both mentally and physically. Bathing is the most physically challenging caregiving task, fraught with opportunities for injuries. As Alzheimer's disease affects each area of the brain, certain functions or abilities can be lost. A once peaceful, relaxing activity may be fraught with tension and fear.

The act of bathing could possibly trigger a difficult memory or experience and may react in disruptive ways, like screaming, resisting or hitting. A dislike of bathing is not uncommon for some people with Alzheimer's disease. Aa caregiver's participation in the activity can provide the comfort of another person's touch as well as an opportunity for monitoring changes in the condition of the skin. However, because it is such an intimate experience, people with dementia may perceive it as unpleasant or threatening.

Possible Causes

Physiological or Medical Causes

  • Depression, causing a loss of interest in personal hygiene.
  • Physical illness, causing a loss of interest in personal hygiene (e.g. flu, infections, etc).
  • Changed sense of perception of hot and cold water temperature.
  • This may be caused by damage to the hypothalamus region of brain which regulates "internal thermostat".
  • Different sensations of water due to brain damage.

Environmental Causes

  • Poor lighting
  • Cant find the bathroom
  • Lack of privacy
  • Room temperature too cold
  • Water to deep
  • Water too hot or cold

Other Causes

  • Fear of falling
  • Fear of water or of being hurt by it
  • Disruption to daily routine or schedule
  • Unfamiliar caregivers
  • Mechanics of bathing to complex or overwhelming
  • Purpose of bathing forgotten
  • Humiliation at being reminded
  • Embarrassment or feeling of vulnerability about being naked or having another person in bathroom
  • Agitated from an upsetting situation, such as an argument with caregiver
  • Feeling of being rushed by caregiver
  • Fatigue
  • Fear of hair washing which is no longer understood
  • Person kept waiting too long while caregiver prepares bath
  • Fear of soap, washcloth, or sound of running water

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Coping Strategies

  • Evaluate the best time of day for bathing.
  • Try to be consistent with the person's old bathing routine before the onset of the illness.
  • For example, consider time of day when person is most relaxed, type of bathing (tub, shower, sponge bath, etc.).
  • Make sure the bathroom is warm enough and inviting.
  • Pull down blinds, or close curtains and doors to create a feeling of privacy.
  • Provide adequate lighting in bathroom, especially during evening hours.
  • Try bathing instructions written by a doctor on a prescription pad. For example "Bathe 2 or 3 times weekly."
  • Prepare bath ahead of time.
  • Check water level.
  • Some people can only tolerate 1 inch of water in the tub; others 3-4 inches.
  • Lay out soap, washcloth, towel and clean clothes in sequence so that the person with dementia won't have to wait.
  • Use a quiet, calm, matter-of-fact approach. For example, "Mother, your bathwater is ready."
  • Avoid getting into lengthy discussions about whether a bath is needed. Instead tell the person one step at a time what to do to get ready for the bath.
  • Simplify task of bathing as much as possible.
  • Do one step at a time, gently talking the person through each step.
  • Combine visual and verbal cues when giving instructions.
  • Use simple, respectful language.
  • Try not to get nervous or excited or threaten the person who objects to taking a bath. This only causes additional agitation and frustration.
  • It may be helpful to wait and try again later when the person's mood is more favorable.
  • Try offering the person one or two choices.
  • For example: "Would you like to have a bath or shower?" or "Would you like to take your bath now or before bed?"
  • Encourage a bath instead of a shower if person can get in and out of tub.
  • Baths are generally safer, less frightening and easier for the caregiver to manage.
  • Try showering with the person. Sometimes this is the simplest solution, although not all caregivers are in position to do this.
  • Let person feel the water before getting into the tub.
  • Sometimes gently pouring water over hands reassures the person that the water isn't too hot. Saying something like "The water feels nice," or "This feels good," may help calm the person.
  • Don't bathe the person everyday, if bathing continues to be difficult.
  • A partial sponge bath daily and a full bath every three to four days may suffice.
  • Try using a bath chart or calendar to indicate when baths were given.
  • For example, caregiver might point to a note or a sticker on a calendar to show the person that it has been three or four days since the last bath.
  • Offer a "reward," such as a favorite food or an activity like going for a drive in the car.
  • This may be an effective way of cajoling the person into taking a bath.
  • Having something to look forward to sometimes takes the focus off the task.
  • Try separating hair washing from bathing.
  • Some people with dementia associate bathing with having their hair washed and become terribly upset, because water being poured over their head frightens them.
  • Sometimes hair washing can be done separately in a beauty shop.
  • Try a shower cap when bathing, or it may be easier to wash hair in kitchen sink if there isn't a spray attachment in the bathtub.
  • Also try dry shampoo.

Making the bathroom/person safe:

  • As a safety precaution, adjust temperature setting on the hot water heater so that the water is not scalding.
  • Since the person may have an altered sense of hot and cold, adjust the water temperature to his/her comfort.
  • Avoid leaving an impaired person alone in the tub or shower.
  • Remove locks from bathroom door.
  • Use plastic instead of glass containers in the bathtub.
  • Make sure hairdryers, electric razors, etc., are out of reach.
  • Use a non-slip bathmat on the floor outside the tub.
  • Be sure there are no puddles of water on the floor.
  • If the person is concerned about falling while getting out of the tub, let the water drain out first.
  • If Lubriderm or other oil is used, be careful of slippery residue on the tub.
  • Put a rubber mat or non-skid decals on the bottom of the tub or shower.
  • Install grab bars so that the person can get in and out of the tub easily.
  • These bars can be mounted to the wall or they can clamp onto the side of the tub.
  • A hand-held spray attachment on a flexible hose can convert a tub into a shower.
  • The attachment can be helpful for rinsing the person thoroughly and makes washing hair much easier.
  • Adjustable safety benches or bath chairs (which have holes in the seat so the water can drain) can be used in both tub or shower.
    • These help make people feel more secure because they are sitting above the water.
    • If safety benches aren't available, try a kitchen chair.
    • These assistive devices are available through medical supply houses, large drug stores and department stores, and home health care catalogs.
    • Medicare, or major medical insurance may pay all or part of the cost of equipment if ordered by a physician.
  • Be sure that all parts of the body, especially the genital area, are thoroughly washed to avoid rashes and infections.
  • Try giving the person with dementia a washcloth to hold or something to fiddle with for distraction while bathing.
  • Play soft music in the background to create a calming and relaxing atmosphere.
  • Wrap a towel around the shoulders of the person sitting in the tub and fasten with a clothespin, if he/she is embarrassed about being undressed.
    • It is important to respect the person's privacy and dignity.
  • Try tomato juice added to bathwater, if persistent body odor is a problem.
  • Be sure the person is thoroughly dry.
  • Use a refreshing afterbath scent and dry skin lotion  to keep the skin moisturized.
    • Baby powder can also be used.
    • Remember, powder on floor can be slippery.
    • Cornstarch is an inexpensive odorless, non-allergic substitute for talcum powder.
  • While the person is undressed, check the skin for rashes or sores.
    • If any red areas or sores appear, notify the doctor immediately.
    • Pressure sores or decubitus ulcers can develop quickly on people who sit or lie down much of the time.
  • Check the person's toenails and trim them as necessary.
    • Proper foot care is essential to prevent problems such as ingrown toenails. If trimming nails is difficult, have the person seen regularly by a podiatris

In long term care settings:

  • Be sensitive to the approaches used when talking to residents about bathing.
  • Try making the bath schedule flexible to accommodate the person's mood.
  • Allow plenty of time for individuals to relax and enjoy a quiet, peaceful bath.
  • Train staff or family members who assist with bathing to allow people to do as much of the bathing themselves, whenever possible.
  • Consider making the environment in the bathroom warm, familiar and private.
    • Be aware that some people with dementia become quite upset when required to take a whirlpool bath.
    • Institutional equipment such as whirlpool baths can be impersonal and terrifying.
  • Avoid using commode chairs when giving showers... This practice encourages people to be incontinent when bathing.
  • Avoid forcing or arguing with a person to take a bath when he/she is resistant... This only causes further agitation

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Other Considerations

  • If a person is absolutely refusing a bath or a sponge bath and if his/her lack of hygiene is intolerable, consult a doctor.
    • For some people medications, such as Haldol® or Mellaril®, may ease the anxiety.
    • Use only with very careful supervision and as A LAST RESORT... Sometimes these medications have side effects and occasionally they increase the agitation.
  • In the later stages of dementia when total assistance with personal care may be needed, meticulous and careful attention to hygiene is important in preventing skin breakdown.
    • This becomes a major challenge for caregivers coping with urinary and bowel incontinence.
  • Bathing is a very personal and private activity... Many people have never completely undressed in front of anyone else and this can be an uncomfortable and vulnerable experience.
  • When a caregiver offers to help someone who is confused, it is a strong statement that the person is no longer able to do for him/herself... This loss of independence can be terribly difficult for people with dementing illnesses.
  • It is important to recognize that these feelings may be contributing to some of the resistance to bathing.
  • A generation ago, most people did not bathe and change their clothes as often as we do today... Taking a bath once a week may have been the way the person did things in his/her day.

Additional Information

Alzheimer's Association (ADRDA) chapter newsletters

Burnside, lrene. Nursing and the Aged (2nd Edition). New York: McGraw-Hill Book Company, 1981.

Gwyther, Lisa. Care of the Alzheimer's Patients: A Manual for Nursing Home Staff. American Health Care Association and the Alzheimer's Association (ADRDA), 1985.

Powell, Leonore and Courtice, Katie. Alzheimer's Disease: A Guide for Families. Massachusetts: Addison-Wesley Publishing Company, 1983.

Mace, Nancy and Peter Rabins. The 36-Hour Day. Baltimore: The John Hopkins University Press, 1981

Safford, Florence. Caring for the Mentally Impaired Elderly: A Family Guide. New York: Henry Holt and Company, 1986.

Tanner, Fredencka and Sharon Shaw. Caring: A Family Guide to Managing the Alzheimer's Patient at Home. New York: New York City Alzheimer's Resource Center, 1985.

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