Bathing: Eliminating Fear and Turning Refusals into Agreement

By Pamela D. Wilson CSA, CG, MS, BS/BA

Bathing can be a challenge in childhood and a similar experience when we age into older adulthood. I recall many evenings as a young child, when it was challenging if not impossible for my mom or sister to convince me that taking a bath was a good idea. The bribe of creating a fun experience using Mr. Bubble became the tipping point between my agreement or refusal.

When we age, bathing becomes difficult due to physical frailty, poor balance, general weakness, poor physical stamina, or fear of falling, rather than the idea that we really don’t want to bathe. As many caregivers know, a shift from physical frailty to a diagnosis of dementia changes the bathing game. Many older adults with a diagnosis of dementia simply refuse to bathe.

The day I helped my father in and out of the tub shower at my home was a day of lost dignity. Not lost dignity for me, but for my father who had balance concerns and difficulty stepping safely over the high bathtub rim without someone standing by. He was a World War II veteran, proud and independent and his daughter was having to help him “in this condition.” The activity of requiring assistance with bathing was embarrassing for a man who all of his life had been very independent and who took great pride in his appearance.

Unknown to my father was that over the years in my caregiving profession, I learned to assist many older adults with bathing. I’d learned ways to protect dignity while accomplishing hygiene tasks. I’d learned how to bathe clients with dementia who refused or were extremely resistant to the idea of bathing because of fear or prior experiences that were not positive.

As we age, the ability to bathe safely is important because of the risks of falling and potential fractures, broken hips, and other injuries. The consequences of a fall, until experienced, are not considered to be significant. “Forty percent of adults living at home fall once a year and 1 in 40 are hospitalized. Of those admitted to a hospital, only about 50% will be alive one year later.”1 Many older adults returning home will eventually move to a care community or nursing home as the result of fear of falling and purposely limiting physical activity which results in further weakness and balance concerns.

Bathing supports a positive appearance, and self-esteem. Bathing is one of the 5 activities of daily living that become more difficult for older adults. The other 4 activities of daily living are the ability to dress, the ability to eat or feed oneself, the ability to toilet and manage continence, and transferring. Transferring, means moving from a sitting to standing position whether rising from a chair, transferring from bed to a wheelchair, or moving in and out of a car.

How many of you have experienced a slip or fall in the bathroom? Reducing fall hazards and installing preventative equipment is one of the most effective ways to prevent falls, serious injuries, or being forced to move prematurely to a care community. Fall hazards include: rugs, extension cords, slippery floor surfaces, low toilet seats, unsafe showers or bath tubs, and poor lighting. Preventative equipment and modifications to prevent falls include: raised toilet seats, shower chairs, grab bars, non-slip surfaces, hand held shower heads, roll in showers, high rise toilets, high counters and sinks, and bright but soft lighting.

Beyond our own bathing or showering is acting in the role a caregiver for a loved one who requires assistance with hygiene. How many family caregivers experience refusals from loved ones who simply refuse to bathe? The replies and refusals are common: “I’m not dirty. I don’t need a bath. I bathed yesterday (when a bath hasn’t occurred in a month). I don’t work anymore so I don’t sweat and don’t need to bathe.” Shock or surprise is often expressed when the loved one is asked about bathing as if the inquiry is an insult to their ability and dignity to care for themselves.

Let’s take the idea of bathing one step further to being a caregiver for an individual with dementia. How many caregivers, when attempting to assist or to bathe a loved one experience yelling, hitting, kicking, hair pulling, pinching, biting, or verbal abuse? Does your loved one become agitated upon hearing the word shower or bath? How many caregivers dread the experience of bathing as much as the person you are attempting to bathe? This is a common experience.

Research by Gozalo confirms that bathing is an important but often difficult task.
Bathing is the personal care task most commonly associated with such behavior, with 20 to 40% of persons with dementia manifesting aggressive or agitated behaviors such as hitting, kicking and screaming while bathing. Moreover, many remain upset for hours after the bath.2

What solutions exist? What if you were able to reduce behaviors by at least 50% by attempting to use a different bathing technique? What if you were able to reduce bathing time? What if a previous traumatic bathing experience could be transformed into a pleasant bathing experience? Are you interested in learning techniques to make this happen?

Over a decade ago, research completed at the University of North Carolina at Chapel Hill resulted in a program called “Bathing Without a Battle”. The program was developed to help professional caregivers and family caregivers learn techniques that result in a more positive bathing experience.3

An important technique pre-bath or shower is changing the approach to the activity. This means refraining from using the words bath or shower but instead using the term wash-up or a similar non-threatening term. Maintaining dignity and comfort is also important.

Comfort is important. Some individuals will be more willing to participate if they are kept warm by being covered with a blanket, sheet or towel. Placing a towel on a bath chair for comfort is another technique. Sitting naked on a hard, plastic shower seat is uncomfortable. Warming towels or a bathrobe in the clothes dryer also improve comfort. For concerns about being cold, a space heater or a heated towel rack support warmth.

Verbal distractions are also important during the task of bathing. Singing or talking about family, hobbies or activities will distract so that the task of bathing may be completed more easily. Playing music is another option that adds distraction. After the bath, using a pleasant-smelling aftershave or skin lotion may add to a create positive experience. Foot massages are also an activity that few refuse.

Other techniques to ease bathing challenges include different types of bathing experiences that include no rinse soap or using shower caps with soap that can be heated in the microwave. There are other options for baths that do not include stepping into the tub or shower. For example, bathing while a loved one is sitting on the toilet, a bed bath, or bathing different body parts each day. When all else fails, shared showers are an option.

Do these techniques work? Yes. Research by Gozalo conducted with residents at six nursing homes in the state of New York proves positive results. Along with differences in the bathing processes, significant reductions were found in aggressive, agitated, verbal and physical behaviors including decreased use of anti-psychotic medications after staff were trained how to administer person centered care with residents diagnosed with dementia. Family caregivers can use this research in their own bathing situations.

The most important aspect to support bathing success is incorporating these techniques into a daily routine. The benefit is improved hygiene, positive self-esteem and a decrease in urinary tract infections also common in older adults. The addition of safety equipment and bathroom modifications reduces the likelihood of falls, serious injuring, and having to leave the home permanently to reside in a care community.

Sources:
1 Rubenstein, Laurence Z. (2006) Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing. 35-S2: ii37-ii41, doi:10:1093/ageing/afl084
1 Gozalo, P., Shivaani, P., Qato, D., Sloane, P., Mor, V. (2014) Effect of the bathing without a battle training intervention on bathing-associated physical and verbal outcomes in nursing home residents with dementia: A randomized crossover diffusion study. JAGS 62: 797-804, 014 doi: 10:1111/jgs.12777.
2 Bathing Without a Battle. http://www.bathingwithoutabattle/unc.edu

©2014, 2018 Pamela D. Wilson, All Rights Reserved.

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