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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 - Dressing

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

Alzheimer's BenchWhen you got dressed this morning, you probably didn’t think much about all the little movements involved that require dexterity, flexibility and a bit of strength. You most likely didn’t give it a second thought when you pulled your shirt over your head, zipped a zipper, fastened buttons or pulled on your socks and shoes. As an individual's dementia progresses, dressing and grooming can become more and more challenging. For millions of our elderly, those simple acts can also be painful, frustrating and nearly impossible because of physical limitations resulting from frailty, illness or disability.

As a Caregiver, by encouraging and complimenting your loved ones in their efforts to dress and groom, you can help them to continue with the daily ritual of dressing and boost their esteem and mood at the same time. For the dementia sufferer, without the caregiver, The person may wear a sweater in the summer, or he or she may wear a shirt backwards. Eventually, your loved one may not know when to change clothes or what article goes where.

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)
  • Changes in gross motor skills (unsteady balance, problems with walking or arm movements)
  • Changes in fine motor coordination skills (zippers, buttons)
  • Memory loss from dementing illness.
    • Sometimes people with dementia no longer have the ability to remember if they are getting dressed or undressed.
    • Or they may forget to change their clothes.
  • Side effects of medications causing dizziness, stiff joints

Environmental Causes

  • Poor lighting ... unable to see clothes in closet or drawer.
  • Too many distractions ... such as noise, people, clutter in the room
  • Lack of privacy (especially in institutional settings)
  • Room temperature too cold.

Other Causes

  • Task to complicated.
  • Caregiver not giving simple or clear enough instructions.
  • Attention span too short for task.
  • Person no longer able to make decisions about what to wear.
  • Fatigue
  • Person no longer understands how to get dressed
  • Feeling of being rushed by caregiver
  • Fear or anxiety
  • Feeling embarrassed about having to dress in front of caregiver
  • Humiliation of being reminded to get dressed.
  • No longer being able to recognise parts of body

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Coping Strategies

  • Have a good medical work-up to discover any possible causes or medical reactions contributing to problems with dressing.
  • Have vision or glasses checked
  • Have an evaluation for depression, particularly if person is frequently unwilling to get up or dressed in the morning.
  • Show the person the dress or shirt he/she is going to wear when introducing the idea of dressing.
  • Keep the morning routine as familiar to the person as possible.
  • Help the person to eat breakfast, wash and dress in the same order the person has done these activities throughout his/her life.
  • Avoid delays or interruptions in the morning routine. These can cause the person to forget the activity which he/she may be involved in.
  • Make sure the room is warm enough for the person.
    • Remember that some older people, and especially those with dementia, often have different temperature needs.
    • Sometimes a caregiver may feel that it is oppressively hot inside the house, while the impaired person finds the temperature comfortable.
  • Provide adequate lighting in bedroom... Also make sure the light in the closet is at the same level of intensity as the light in the room, so that the person won't have to get used to different light levels.
  • Close door to room and pull down blinds to create a feeling of privacy.
  • Make sure the room looks familiar to the person... Try and make it as much as possible like the room in which the person has dressed throughout his/her life.
  • Keep the bedroom free of clutter or of the appearance that things are out of place and need straightening up before dressing can take place.
  • Choose a suitable spot in the room for the person to dress (to prepare for the day)
    • and a different spot for the person to undress (to get ready for bed).
    • Try and use these same spots every time the person dresses and undresses.
  • Put away rarely worn clothes or out-of-season clothes to make the selection of clothing easier.
  • Encourage person to select his/her own clothes ... but make it easier by simplifying the number of choices.
    • For example, offer two outfits to choose between or ask the person if she/he wants to wear a white blouse or a pink one.
    • For some people with dementia, it may be too difficult to make even these simple decisions.
  • Label dresser drawers describing their contents (shirts, underwear, socks).
    • For some people, it may be helpful to group all the items that are the same color and that go together (e.g., blue shirt, blue sweater and blue socks).
  • Hang ties, belts or other accessories on hanger with the matching dress or shirt.
  • Lay articles of clothing out in sequence on the bed... That is, they should be stacked or arranged in the order they are intended to be put on.
    • For example, shoes might be on the bottom with stockings inside, and the dress, slip, bra and underpants on top of each other.
  • Make sure that all articles of clothing are right side out.
  • Try laying out lightly colored clothing on a dark bedspread... For someone with visual problems ... contrasting colors may help the person to distinguish articles of clothing from the background color of the bedspread.
  • Try putting a poster on the wall above the person's bed and above the laid out clothes... The poster could list the sequence of clothing.
    • For example:
      • underpants
      • bra
      • dress
      • stockings
      • shoes
    • If the person is no longer able to read ... use pictures of items of clothing to remind the person of what to put on next.

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Coping Strategies (cont)

When choosing clothing:

  • Select clothing that is washable and doesn't need ironing.
  • Choose clothes that fit comfortably ... Stiffness and muscle tension can make dressing very difficult for them.
  • Try purchasing clothes that are one size larger... This may make it easier to get clothes on and off.
    • Tightly fitting blouses, for example, may be very difficult to put on.
  • For some people, buttons, snaps, hooks, zippers and belt buckles are too difficult to manage... Replace them with Velcro tape which can be purchased in a fabric store.
  • When buying new clothes,
    • Choose clothes with simple patterns.
    • Bright, busy patterns can sometimes be distracting.
    • Also, select solid contrasting colors.
    • These tend to be easier for older people to distinguish.
  • Slip-on shoes are easier to put on than shoes with laces and ties.
    • Make sure the shoes have non-skid soles.
    • Some people prefer tennis shoes with Velcro closures; they are also washable.
  • Make sure that trousers or robes aren't too long... This might cause the person to tnp or clothing might get caught in the spokes of a wheelchair.
  • Try using cardigans rather than pullovers, and garments with front closings rather than back closings

Clothing for men:

  • Try using suspenders or pants with elastic waistbands.
  • Try tube socks, which are easier to put on because they don't have heels.
  • Consider buying T-shirts... They tend to look okay even if worn backward

Clothing for women:

  • Try slip-on blouses, wrap-around or elastic waistband skirts or slacks.
  • Buy loose fitting underpants.
  • Consider using a cotton vest if person has a lot of difficulty with putting bra on.
  • Try short cotton socks, knee high or thigh high stockings.
  • Panty hose are difficult to put on.
  • Stockings with garters and knee highs with wide elastic bands may be bad for people with circulation problems.
  • Avoid using a slip unless person feels uncomfortable without it.
  • Wash-and-wear reversible gowns with Velcro closures are available through home health care catalogs.

General:

  • Try jogging suits or sweat pants and shirts which can be easy to get in and out of for the person who has difficulty dressing... They are also warm, good looking and easy to care for.
  • Try using the task breakdown technique.
    • For a person with dementia, getting dressed can be a very complex and overwhelming task because there are many steps involved.
    • Task breakdown involves breaking the task of dressing down into simple, manageable steps.
  • The goal is to help the person do as much as possible for him/herself without getting frustrated... One example of the steps involved in dressing is:
    • Person chooses what to wear selects clothing from closet and dresser.
    • Person takes nighttime clothes off.
    • Person puts clothes on in the sequence that is most familiar to him/her ... underpants/bra; dress; knee high stockings;shoes or slippers
    • Grooming - person looks at self in mirror;puts jewelry on (if chooses to do so); puts on make-up, perfume; combs hair
  • For one individual with dementia, getting dressed may still be a fairly familiar and simple task.
  • With some careful prompting or reminding of what article of clothing goes next in sequence, the person may be able to independently do most of the steps... For others, it may involve a much more detailed and specific breakdown of the task with many more steps. For example:
    • A person may no longer be able to step into his trousers and pull them tip.
    • In this situation the caregiver will need to provide a great deal of help.
  • Also it may be necessary to experiment with the breakdown of steps in order to determine which steps the person is still able to do successfully and which steps he/she may need help with.
  • Make sure you are only doing one step at a time. Sometimes caregivers have a tendency to group or combine several small steps together not realizing that the impaired person may no longer be able to do two or three steps at one time. For example,
    • a caregiver might hand the person a pair of underpants to put on; not realizing the complexity involved in this particular sequence of steps.
  • It may be that the person is no longer able to distinguish the front from the back of the underpants;
    • or he/she may no longer be able to put the right or left leg into the correct hole;
    • or he/she may not be able to pull the underpants up to waist without some assistance - In this situation, the caregiver may have to gently remind or prompt the person with each step.
  • In some cases, the caregiver may have to do several of the steps him/herself.

Try these communication techniques:

  • Speak in a calm, friendly tone of voice... Use short words and short, simple sentences.
  • Avoid complicated phrases.
  • Use, when needed, very specific concrete verbal and visual cues... For example: "Here are your blue trousers," while pointing to the trousers on the bed.
  • Give praise and encouragement as the person completes the steps of the task... A warm "good" or "you are doing well" conveys the message that the person is being successful.
  • In trying to communicate clearly, be careful not to talk down to people with dementia or to treat them like children... After all, they are adults, entitled to be treated with dignity and respect

In long term care settings:

Train staff, family members and volunteers who are assisting with dressing:

  • To be sensitive to the fact that dressing is a personal activity ... one that should be done in the privacy of person's room with the door closed.
  • To allow people to do as much for themselves as possible... For example, staff might assist with putting a stocking on over a person's heel and then encourage the person to finish the step by pulling the stocking up;
  • To break tasks down into simple and manageable steps;
  • To encourage people when they are dressing to look at themselves in a mirror
    some nursing homes don't have mirrors in every room;
  • To be flexible and willing to modify the steps involved in the dressing task with different people.... The extent to which people can manage these tasks varies greatly;
  • To be sensitive to grooming.
  • Jewelry, make-up, hair and nail care and shaving are important in helping people feel better about themselves and their appearance;
  • To recognize the daily rituals of getting washed, dressed and properly groomed are important activities in the morning routine.

This can be a time when staff can socialize and perhaps spend more time individually with residents rather than hurriedly running through the routine

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Other Considerations

  • A generation ago many people did not change their clothes as often as we do today.
    • It is important not to impose our values about how often we change our clothes on those we care for.
  • Being reminded to change your clothes can be a very embarrassing and humiliating experience.
    • It is important for caregivers to recognize these feelings if there is some resistance to getting dressed.
  • Getting dressed is a very personal and private activity.
    • Many people have never completely undressed in front of anyone else before (especially an unfamiliar caregiver), this can be an uncomfortable and vulnerable experience.
  • When a person needs some assistance with dressing, this conveys a message that the impaired person is no longer able to care for him/herself.
    • This loss of independence can be terribly difficult for people with dementing illnesses.
  • It is important that staff encourage residents in nursing homes to get up and get dressed for the day.
    • Staying in a bathrobe or bedclothes all day does little to enhance morale.
    • It also conveys the message that people are sick and are no longer able to do much for themselves.
    • If staff perceive a resident to be bedridden or ill, one's expectations of what that person may still be able to do for him/herself will probably be minimal.
  • Many times caregivers are tired or are in a hurry to get everyday tasks done.
    • Caregivers often tend to perform the task themselves rather than giving the person with dementia a chance to get involved.
    • It takes more time to assist the person with getting dressed, rather than doing it yourself, but the extra time is well worth it.
    • Being able to dress one's self can make a person feel less dependent and can also enhance feelings of pride and self-esteem.
  • Some people with dementia are no longer able to make decisions about how to dress appropriately for the weather because of impaired judgment,
    • some people may no longer be able to know what to put on, for example, if the weather is cold.
    • Don't assume that they necessarily will tell you if they are too hot or too cold.
  • Some people with dementia tend to undress themselves frequently.
    • This can be embarrassing and inconvenient, but it is important to remember that they no longer understand what is appropriate, and usually are not doing this to be provocative.
    • Evaluate each situation... Is the person dressed too warmly? ... Does he/she need to go to the bathroom? ... Is he/she tired and trying to get ready for bed? ... Is he/she bored?
    • Try putting clothes on backwards, or purchasing clothing that is difficult to remove, such as jump suits that fasten in the back.
  • Some people with dementia develop a habit of putting many layers of clothing on, regardless of the weather.
    • You may begin with a cotton dress, and soon there are several slips and sweaters on top of this.
    • This habit can be frustrating but needs to be evaluated:
      • Is there any reason why the person should not wear the extra clothing? ... Is it really too hot or is it just embarrassing the caregiver?
    • Try moving clothes that are often put on, and substituting more appropriate items.
      • Patiently remove extra clothing and replace it ... knowing that you may have to repeat this many times
  • Some older women are uncomfortable in short sleeves, having always worn long sleeves.
  • Sometimes people with dementia want to continue wearing the same outfit day after day and refuse to consider any variation ... Don't argue with the person (even though this may be irritating). Instead, buy a couple of duplicate outfits.

Additional Information

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.

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

Misplon, Frank and Lena Metzelaar. Task Breakdown: Teaching/Learning Techniques Designed for Working With the Elderly. Ann Arbor: The University of Michigan, 1980.

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

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

Robinson, Anne, Beth Spencer, Shelly Weaverdyck and Susan Gardner. Helping People with Dementia in Activities of Daily Living. Video and slide tape production. Ann Arbor:PhotoMotion Productions, 1987.

Weaverdyck, Shelly. Neuropsychological Assessment as a Basis for Intervention in Dementia. In Nancy Mace (ed.) Dementia Care: Patient, Family and Community. Baltimore: The Johns Hopkins University Press, 1989

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