Bathing is often the most traumatic personal-care activity for people with Alzheimer's — and thus the most difficult facing their caregivers.

Because bathing is such an intimate experience, a person with dementia may perceive it as embarrassing, unpleasant, threatening or painful and, in turn, may exhibit disruptive behavior such as screaming, resisting and hitting. This behavior often occurs because the person doesn't know what bathing is for or doesn't have the patience to endure such unpleasant aspects as lack of modesty, being cold or experiencing discomfort.

Bathing ourselves is a very private activity and a statement of our independence since the time we were small children. As the disease progresses and people with Alzheimer's increasingly neglect personal hygiene, they need more and more help at the expense of their privacy and independence. It is the caregiver's responsibility to help them maintain hygiene while respecting their dignity, privacy and anxiety. The following sections offer caregiver tips for helping people with dementia to bathe.

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Make the bathroom safe.

To prevent falls, install grab bars on the walls of the bathtub or shower and the tub edge. Place non-slip rubber mats and non-skid adhesive decals on the bottom surface of the tub. Outside the tub or shower, use a non-slip bathmat to keep the bathroom floor free from puddles. Consider installing wall-to-wall carpeting in the bathroom.

Enhance safety in the bathtub and shower.

To increase safety in the bathtub or shower, use a tub bench or bath chair with a back and adjustable heights. In addition to installing grab bars and non-skid adhesives to prevent falls, be sure that all soap dishes, towel bars and hand rails are secure to hold the weight of the person's pulling power.

Prepare the bathroom in advance.

Do everything you can in advance to make the process easier. Gather bathing supplies such as towels, washcloths, shampoo and soap in advance so that you and the person can focus on the bathing task. Have the towels ready; pre-measure the shampoo; develop a soap pocket in the washcloth so the person can wash. Check the bathroom temperature to make sure it's not too cold, and raise it if necessary to make it extra warm

.Create a safe water environment.

Use only two to three inches of water in the bathtub: Maintaining such a low water level helps people with dementia feel more secure and is safer in case they slip. Test the water temperature in advance to prevent burns. Always check to make sure the water is neither too hot nor too cold. In addition to non-slip adhesive mats in the tub and non-slip bath mats outside it, make sure that the bathroom floor is free from puddles. Avoid using bubble bath and bath or shower oils that would make the tub or shower stall slippery. Tighten bathtub faucets so that the person cannot manipulate them while bathing. Install a stall guard or preset water temperature regulator (you can get them at a hardware store).

Never leave the person unattended.

Never leave the person alone in the bathroom. Never even turn away from the person. Many accidents occur in the bathroom. Be particularly careful when helping the person in and out of the bathtub or shower stall. In preparing the bathroom for the bath or shower, also plan ahead for skin care, dressing and anything else that might distract your attention from the person. If the phone rings, let the machine answer it.

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Help the person feel in control.

Involve and gently coach the person during each step of the bathing process. You may need to experiment to determine if the individual prefers tub baths or showers, depending on the person's lifelong routine. Keep in mind that showers are often more frightening to cognitively impaired individuals than baths; on the other hand, a hand-held shower hose in the tub may be less frightening than being immersed in water and the controlled flow of water may be less upsetting than a regular shower.

Include the person in the process.

Simplify the bathing process, and be sure the person has a role in it. Break down the task into simple steps, and give instructions for one step at a time. Discuss each step with cognitively impaired individuals, using phrases such as "Now it's time to get into the bath" and handing them items such as the soap or the washcloth. This will help them focus on each step of the task instead of whether or not they want a bath. Be specific: Instead of the general "Time for your bath," say things like "Take off your shirt."

Be gentle and calm.

Take care in giving the bath. The person's skin may be very sensitive. Avoid scrubbing the skin, and pat dry instead of rubbing. Avoid using harsh deodorant soaps. Make sure that the person washes the genital area, as well as within folds of flesh and under the breasts. Consider installing a hand-held shower hose with a nozzle to wash hard-to-reach areas.

Find the best time of day.

Experiment to find the person's good time of day. Also experiment to find the caregiver with whom the person feels most comfortable, from a family member to a professional aide. Bathing should be a regular routine, performed the same way at the same time. Try to follow as many of the person's old routines as possible, notably preferences between bath or shower and between morning or evening.

Respect the person's dignity.

Some individuals may be self-conscious about being naked. Letting the person hold a towel in front of the body, both in and out of the bathtub or shower, may ease anxiety. Try wrapping the person in a robe or a towel and washing under it. Let people with dementia do as much as possible, assisting them only as necessary.

Never argue or struggle.

Avoid arguments and power struggles. Avoid getting into discussions about whether a bath is needed. Instead of trying to convince people with dementia, simply ask and assist them to begin the first step (for example, by saying something like "Let's take off your shoes now") and then guide them through the process one step at a time. If the person resists or becomes agitated, back off and try again. Try distracting the person with conversation. Above all, never try to force a shower or tub bath at the risk of injury.

Don't worry about the frequency of bathing.

It may not be necessary for individuals to bathe every day. Sponge baths can be effective between tub baths or showers. When all else fails, you could give partial baths or sponge baths. If the person is resisting, try to understand why the person is upset. Are they embarrassed? Is the water too cold? Does the person not like to be touched? Once you get to the cause of the problem you can develop strategies to deal with it, like putting a towel over the person to respect their modesty, correcting the water temperature, and having the person do much of the washing themselves. However if the person is very agitated, stop trying to bathe them and approach them at a different time.

Be flexible.

Maintain realistic goals and remain flexible. Strive for a level of cleanliness that will prevent skin breakdown and offensive odors. You goal should be to keep the person reasonably neat and clean, so don't worry if baths are occasionally missed or if you can't accomplish every task of the routine. In addition to attempting to distract the person with conversation, you might try to make bathing a game with the promise of a specific reward afterward.

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Stress skin care.

Make sure that the creases or folds of the skin and under the breasts are dry. Ask your doctor if you should apply baby powder or corn starch, however, be aware that some elderly people are sensitive to these products. Use body lotion on dry skin. If the person resists deodorant, try baking soda. Before the person dresses, always check closely for red areas of skin, rashes and sores. (Keep in mind that pressure sores and decubitus ulcers develop quickly on people who sit or lie down much of the time.) If any red areas or sores appear, consult the patient's physician to help you manage them.

Be prepared to take on increasingly more responsibility.

As the disease progresses and people with Alzheimer's increasingly neglect personal hygiene, they need more and more help until, eventually, they need total help. Assist them as necessary. Let people with Alzheimer's do as much as possible for as long as possible. But if they become incapable, then you must do it all.

Be sensitive to difficult tasks like hair washing.

Plan to do a project such as hair washing at a time of day when the person is well rested. Washing the person's hair may well be one of the most difficult tasks. Hold a washcloth over the person's forehead to keep the water from running down their face and use a cup to rinse the soap out of their hair. Consider using tearless baby shampoo. If normal hair washing is too difficult, try using dry shampoo. Consider calling in a professional hairdresser for a wash and set. Keep hairstyles simple and short.

Use sponge baths as a last resort.

Sponge baths can be effective between baths or showers. If really necessary, sponge baths can be used in lieu of baths or showers. Rather than struggle with a confused or agitated person in the bathtub, try using the sink and a washcloth for a sponge bath. If the person must be washed in bed, use a wash basin and washcloth for a sponge bath. If the person is not taking regular baths or showers, hygiene requires that sponge baths be administered daily.

Sources: the Alzheimer's Disease and Related Disorders Association website ( www.alz.org ) and Action Series brochure "Steps to Assisting with Personal Care"; the National Capital Area Chapter of the Alzheimer's Association website ( www.alz-nca.org ); Nancy L. Mace and Peter V. Rabins's book The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life (1999, Third Edition, Johns Hopkins University Press).

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