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
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.
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.
- 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.
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!