Care Advocate Newsletter  

Past Issues | Download PDF   June 2013

Calming the Waters at Bathing Time

As we advance in years, we all experience the frustration of having to slow our pace, cut back on some activities or modify them due to physical deterioration or infirmities. For those of sound mind, these limitations are annoying and challenging, but there are normally ways that can be found to cope with them.

For people with dementia, however, particularly those residing in nursing homes or long-term care facilities, activities we take for granted, such as bathing, can become painful, confusing, invasive and even terrifying experiences. This in turn causes them to respond accordingly with behaviors ranging from distress (crying, moaning, shaking) and avoidance (pulling away or trying to leave) to verbal and physical aggression (cursing, striking and biting). What could be a pleasurable activity instead becomes something to be dreaded by both residents and their caregivers.

It doesn’t have to be that way, however. Many facilities have found that making sense of the person’s behavior, selecting possible solutions tailored to the individual and testing and adjusting these solutions will pay off in more positive outcomes for all concerned.

We have to begin by realizing that when your friend or family member loses the ability to clearly express feelings, needs or desires verbally, they communicate through their behavior. By analyzing these actions, caregivers can identify certain causes or triggers. Some of the most common include:

  • Pain
  • Feeling cold/more sensitive to water and room temperatures
  • Embarrassment
  • Fear and exposure
  • Feeling a loss of control
  • Other physical conditions/limitations
  • General confusion and lack of understanding

The key to interpreting these behaviors is understanding the person, specifically his or her personal history, physical and mental status (including level of dementia and overall mood), personality traits and bathing preferences. As a friend or relative, you can be an essential help to the staff by providing background information and your insights. You may already have been involved in some information gathering if you were asked by the facility about your relative or friend’s customary routines and activities (such as when they like to get up in the morning, and when they like to go to bed). Customary routines are taken very seriously by nursing home regulators, and nursing homes are expected to ask these questions and to incorporate the resident’s preferences into their care plans.

It is widely known that bathing can be a particularly tough time for residents, and especially so for people with dementia; therefore, nursing homes are also expected to honor the bathing preferences of residents by asking them and/or their families: “How important is it to you to choose between a tub bath, shower, bed bath or sponge bath?” The nursing home may also use a Personal Information Data Sheet or Bathing Preferences and Practices Form. An excellent reference source for this and bathing issues in general is Bathing Without a Battle—Personal Care of Individuals with Dementia (See sidebar for details.).

As you can see, an individualized and flexible approach is the best way to resolve bathing issues. This begins with the bathing method—shower, tub bath, sponge bath, washing hair at the same time—where the resident may have very strong preferences that should be recognized, and the best time of day so that schedules can reflect that as much as possible. A consistent and familiar caregiver is also a definite advantage, so take the opportunity to discuss your friend’s preferences, best ways to communicate with them and little touches that could make a difference, e.g. singing or playing music that they like, giving them a comforting object to hold, telling stories or jokes. The bathing environment should be kept warm, quiet and private, and the process should never be rushed, particularly if the person needs physical assistance.

Another major factor to consider when bathing someone is pain, especially because the resident must move around so much. Persons with Alzheimer’s often cannot describe what is bothering them but will express it nonverbally. Make sure the resident is being monitored for pain, and that appropriate medication is being administered at the right times and adjusted as necessary. Again, your input can be most valuable.

To preserve your relative’s modesty, speak with the caregiver about keeping her body covered as much as possible, particularly when she is being transported. Using a gentle tone and touch and keeping the bath area warm enough will also help. In addressing loss of control issues, your friend or relative should be encouraged to maintain as much independence as they can handle during bathing, assisted by the caregiver’s patient prompting and demonstrating. Perhaps they could even give the person a small reward (lollipop, chocolate) at the end of the session. This can all help preserve their dignity and improve their mood.

If your friend or relative is reaching the stage where taking a full bath or shower is becoming uncomfortable, a few different solutions can be implemented. For instance, as long as pressing concerns (incontinence, bed sores) are being addressed by the staff, it is not necessary to have frequent bathing. Even twice a week might be sufficient. There are also very effective ways to perform bed and towel baths. In addition, it is possible to provide bed and towel baths and to clean hair with no-rinse or dry soaps and shampoos. Although it is often assumed that water must be used in order to get someone properly clean, this is not the case.

The bottom line is that proper bathing of persons with dementia requires considerable knowledge and skill and a realistic, individualized care plan that includes the person’s preferences, needs and capabilities. It should also be flexible enough to adapt to changes in cognitive and physical abilities as time goes on.

It may always be a challenge to calm the waters at bathing time, but working with your relative or friend and a supportive caregiver and staff can result in more satisfying and successful experiences for everyone.

We wish to acknowledge Forest Laboratories, Inc. for making this newsletter possible.
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Resources & Events

To obtain the book, Bathing Without a Battle, please visit:

For information about bathing issues, equipment needs and resources, and how to purchase a training video, please visit:

CMS (Centers for Medicare & Medicaid Services) has available for all nursing homes in the country a training program that, among other things, specifically addresses the issue of bathing: “Hand in Hand: A Free Training Series for Nursing Homes.”