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Tips to Reduce Bathing and Showering Challenges—A Therapist's Role

By Kim Warchol | Posted on 10.29.2010 | 6 comments
Tips to Reduce Bathing and Showering Challenges—A Therapist's Role

Professional and family caregivers often report bathing as one of the most challenging areas of dementia care. People with dementia often refuse, withdraw, or fight during a bath or shower. There are many things that can trigger these responses, and many of these triggers can be controlled.


A CNA or family caregiver often does not have the advanced expertise to identify the trigger, a prevention strategy, or a helpful response. This then becomes an intervention need for a dementia trained therapist. Reimbursement for therapy services designed to reduce difficult behaviors can be obtained by clearly connecting the behavior to a decrease in the patient's function or safety. We must clearly document how the causative factor, which is the recurring behavior, impacts the person's level of independence and/or safety.


How to identify the behavior trigger


Once the therapist receives orders and begins intervention, it is critical for the therapist to allocate some evaluation time to observation of the patient with the caregiver in the actual bath/shower environment. This is the only way that the trigger and other problems can be identified. We call this a "push in" approach in which the therapist is teaming with the caregiver and the patient in the normal day-to-day environment. An accurate problem list can not be formulated unless we use this "push in" approach.


In my experience, I have seen the following as common difficult behaviors exhibited during the bath or shower experience:

  • Physical resistance including hitting, pushing, kicking, and biting
  • Verbal agitation such as "leave me alone," crying out, yelling, or cursing
  • Withdrawal and fear in which the person may shake, cry, or hold themselves tightly and rock
  • Refusal

The role of the therapist is to discover, with the help of the CNA or family member, the cause of a behavior problem as named above. Some likely causes/triggers include:

  • Unmanaged pain
  • Being cold
  • Feeling frightened, vulnerable, and exposed
  • Feeling embarrassed
  • Feeling a loss of control
  • Not understanding what is happening, misperceptions, and poor communication

The therapist should observe the patient in their usual shower or bath environment and observe the typical interaction between the caregiver and the patient. The therapist should document all the probable triggers. Next, the therapist will devise a plan that will seek to reduce the triggers and the frequency and severity of the behavior.


There can be a place for OT, PT, and ST to intervene as the triggers and problems are vast and spread across the expertise of all disciplines. Also, the therapist must remember to partner with nursing in order to obtain behavior log information that includes recording of the frequency and type of behavior the patient exhibits each day. These reductions and the link to improvement in function and safety are necessary documentation elements for therapy reimbursement. Remember to gather information from all shifts.

Strategies to make it better for the person


I have found the following interventions to greatly reduce the frequency and severity of the behavior:

1. Reduce pain by:
  • Change PRN pain meds to routine.
  • Make sure the person's body is positioned comfortably.
  • Provide a gentle touch.
2. Keep the person warm by:
  • Keep the person's body covered as much and often as possible with warm towels.
  • Maintain a comfortable temperature of both the room and water.
  • If transporting to a central tub area, make sure the person is fully clothed or wearing a warm robe.
3. Reduce fear by:
  • Increase safety in the environment by adding secure grab bars, bath mats, or other non-skid surfaces. Make sure the person's feet are firmly placed on the floor and not dangling.
  • Caregivers should build a relationship with the patient and changes in caregivers should be minimal.
  • Avoid water spraying on the person's face and consider using non-rinse soaps; the water spray can be painful or frightening for some people.
  • Change the bathing/shower environment to look and feel homelike and inviting.
  • Communicate what's about to happen during each step of the activity.
  • Make the bath/shower fun or relaxing by setting the tone through music, lighting, adding bubbles or candles, etc. (always remember safety codes).
  • Make certain the caregiver is patient and waits the adequate amount of time for a patient to process and respond.
4. Reduce embarrassment by:
  • Keep the person's body covered as much as possible.
  • Make certain the person feels safe and comfortable with the caregiver. For example, a caregiver of the opposite sex may upset a patient.
5. Maintain the patient's sense of control by:
  • Always ask for permission instead of saying "it's time to take a shower."
  • Provide choices throughout the experience.
  • Facilitate independence.
  • Honor the person's preferences for shower or bath, products, time of day, etc. If the person is unable to communicate their needs and wants, gather their life story from their family or significant others.
6. Reduce the risk for misperceptions and miscommunication by:
  • Communicate what you are there to help the person with and what's going to happen throughout each step of the activity.
  • For those who are lower functioning (Allen Level 3 or lower) consider using sensory bridging techniques such as providing a favorite/familiar soap or shampoo to smell before engaging the patient in the activity. This can help the person connect to a memory related to the activity and it can help you facilitate a higher level of understanding and independence.
  • Use the proper cueing strategies and communication techniques to increase understanding. Match to the person's cognitive level.
  • Closely observe the patient's responses and adjust the approach as needed.

Two other care aspects that play a key role in the mood and behavior of the patient are promoting best ability to function and gaining agreement.


Promoting best ability to function


A sense of control, accomplishment, and privacy can all be facilitated by the person doing as much of the bathing activity for themself as possible. The therapist must alter the activity demands, environment, and care approach to facilitate the greatest degree of patient participation and independence. This activity modification plan is taught to the caregivers until competency is achieved.


Gaining agreement


Some time ago a highly regarded colleague, Sharon Roberts, RN, performed a small study on bathing challenges in persons with dementia. She informed me that she learned one of the greatest methods to reduce resistance or refusal was simply to gain agreement from the patient. This often means the caregiver must get creative in order to identify a situation that might encourage patient agreement.


Examples include:

  • Telling the patient they will/might have a family or clergy visit later in the day and therefore it would be nice to get freshened up.
  • Taking the patient into the kitchen or garden, having fun, and getting obviously dirty. This blatant dirt can trigger the client to ask for the bath or shower.
  • Honoring the preferences of the patient based upon their individual life story. For example, a patient might have always preferred a tub bath at night to relax and therefore will value the activity of bathing versus the task of getting clean.




One of the most frequent concerns we hear from therapists is lack of follow-through from those who have been trained by therapy. I can almost guarantee that if a therapist takes the "push-in" approach in which we work side-by-side with the patient and the caregiver to truly make a daily experience go more smoothly, we will obtain follow-through. One of the secrets of follow-through is making certain our maintenance programs are realistic and meaningful for both the patient and the caregiver. If you can prevent the caregiver from getting beaten up and verbally abused on a daily basis, you will gain a friend and follow-through.


Adapt your approach


Assisting a person with dementia to take a bath or shower does not have to be a horrific experience. Remember that many of the behaviors are triggered. ALWAYS stop and ask yourself, Would I be agreeable to bathing or showering at this time of day or in this environment or with this approach? This perspective helps us identify some of the changes that must be made. In addition, we must factor in all that we know about the patient's life story and cognitive level. Each has a direct relationship on the triggers, prevention strategies, and environmental modifications that the therapist will design.


Recently, I heard a terrible account of how a private-pay nursing home was creating their patient shower/bath schedule for the convenience of the facility. A CNA I was interviewing told me that at the nursing home where she was currently working she had baths and showers scheduled over her midnight shift. She therefore needed to awaken the patient in the middle of the night in order to accomplish this task. She was uncomfortable with this direction and when she questioned her supervisor she was told the patients who were being showered and bathed at night were the dementia patients and they wouldn't know any better.

Oh my gosh! What have we become? What have we reduced these individuals to? Nothing more than a check on a task list. We should be ashamed and we must never let this happen again.


Dementia Care Training: Read more about dementia care training on our Knowledge Base page and gain access to our free eBook, Communication Tips for Serving Individuals With Dementia.

Dementia Care Specialists (DCS) is the premier dementia training and consulting company. With nearly 60 years of cumulative experience in dementia care training, DCS provides state-of-the-art dementia products, training, and program consultation.

I am hopeful that a dementia trained therapist can have a positive impact in all work environments. Your reimbursable outcomes will be improving the function or safety of the patient or preventing patient decline and injury. Your reward will be making life better for those with Alzheimer's and their caregivers. It is possible!


Note: A wonderful training resource is "Bathing Without a Battle." Please refer to this month's product/resource review for a description of this training tool and information on where to order.

Erin Harris
Thank you, Paula! It's certainly true that trust is THE most important thing, and that the caregiver adapting to the individual person and the individual situation is essential too. If you'd like to share more from your experience, please email me at eharris at crisisprevention dot com. We'd love to feature your voice here on our blog. :)
2/29/2016 12:38:08 PM
Paula Welter
Some helpful info but after being a caregiver for 30 yrs with dementia patients including my own mom I find each person is different- trust is key and difficult to develop if caregivers are constantly different or not patient!I had to soak my moms feet and sponge bathe her because of her not wanting to shower and changing her depends was a ritual. She did most things in her own time!
I had much better cooperation from other people I cared for but I did teach the cnas how to approach my mom in her last few months when she was in a skilled nursing facility !I have learned That bathing the person can be isolated to hand washing -haircare- incontinence care and foot soaks- Full body showers not necessary all the time! Sitz baths and bidet type cleaning is tolerated better by some people!Toileting those people who will allow it should continue despite incontinence I tried to toilet all the residence in a dementia secure unit I worked in it made changing easier for them and kept some folks dryer and cleaner! Face and hand washing after every meal also helped Still continuing to learn :)
2/28/2016 11:58:24 AM
Erin Harris (CPI)
Thank you, everyone, for sharing your experiences and ideas! Best wishes to all of you in caring for your loved ones and advocating on their behalf to raise the standards for their care. I know it's not easy, but your efforts are invaluable.
1/18/2016 5:32:22 PM
Hi. Great article. BUT. I really must ask you to reconsider a couple of references:

"unhealthy responses" in the first paragraph,
"problem behavior" in the second.

Both of these references contain combative components. That is, these are fighting words, reducing the situation to "Us vs THEM (the enemy)."

What on earth is unhealthy about the natural response by normal people to what has become a traumatic experience, one that they feel robs them of independence and dignity? And it does, however natural it is to have a bath or a shower. Even the sufferers of Dementia, Alzheimer's are "still in there."

A Problem? Yes, maybe, in the sense of a challenge, which I think is the meaning you meant to convey; but unintentionally as may be, to label someone a problem is not in my mind good care giving. Again, it is combative.

On a personal level, I see this behaviour in my wife at her care home; she is simply defending herself, standing up for her rights. Respect that.
Otherwise, your overall approach seems sound to me, a spousal care giver.

Thank you for listening. But please change these offensive references before you allow you article to be re-posted on Facebook, which is where I found it.

I am H. W. Bryce and you can find me at http://hwbrycewrites.com/blog

I am working on publishing my book of poetry about my and my wife's experience with Alzheimer's.

1/17/2016 3:48:27 PM
This was very interesting, we have our father in a assisted living home with Dimentia, it has always been a struggle to bathe, but he has not had a bath or changed his cloths in a month. None of the caregivers have been able to get him changed or bathed, I have spent hours on end trying with him. Unfortunately I am not a trained caregiver and try to research and find ways to get him to this point. We are frantic with the caregivers and the facility, they should be finding a way to get him there. We are afraid that he may have sores and other problems at this point. any suggestions please help.
10/31/2015 2:32:21 AM
A privacy garment designed for showers and bathing can solve the most embarrassing problem of assisted bathing. The accessory covers the private body areas and the patient can enjoy a shower without feeling embarrassed. Here's the nonprofit site that explains the unique and valuable product. www.dignityrc.org
7/19/2015 4:32:04 PM