Cleaning creatively: out-of-the-box bathing ideas for dementia care

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Cleaning creatively: out-of-the-box bathing ideas for dementia care
Cleaning creatively: out-of-the-box bathing ideas for dementia care
Resident bathing historically ranks among the most difficult caregiver tasks. It's especially challenging to tend to residents with dementia who often become fearful, agitated or combative during the process.

The source of the struggle is often multifaceted and can range from caregivers' poor technique to a failure to address residents' physical or emotional insecurities around bathing.

“Bathing is absolutely one of the biggest challenges we all face, and that's because there is no one [magic formula] to follow,” says Jamie Lopez, vice president of healthcare for Autumn Leaves, a specialized memory care assisted living provider based in Ft. Worth, TX.

“Every resident is different, so what works for one person doesn't always work for another,” Lopez explains. “And just because something worked for a resident yesterday doesn't mean it will work for that person the next time.”

While there's no one right approach, there's enough evidence—scientific and anecdotal—to suggest that certain bathing practices work consistently better than others. The secret to success, sources stress, lies in a facility's willingness to adopt a thoughtful, individualized approach to bathing.

“Now that our mission is to embrace culture change, we are steadily getting away from shuttling draped residents from their room to central bathing,” reasons Michael Ruth, president of Whitehouse Station, NJ-based Hickory Bathing and Healthcare Solutions Inc., a healthcare equipment distributor. “[It's] about time.”

Digging deeper

Ruth, who himself has bathed hundreds of residents throughout his decades-long career in the bathing and lift equipment industry, says the quest to improve the bathing process only can lead to improved skin integrity, resident dignity and staff morale. It can also reduce staff turnover and improve customer satisfaction, while rendering fewer injuries to residents and staff.

“[There is] assurance in knowing that we really do have a better way,” Ruth says.

Helping dementia residents enjoy the bathing experience, or at least not dread it, often requires sleuthing to determine the root cause of their resistance. While, in some cases, it can simply be traced to a previous negative experience or a fear of slipping and falling, many times, the source of the angst isn't so easy to uncover. But it's critical that caregivers try.

“Understanding what's really behind the person's behavior is one of the main things we teach,” Lopez notes.
“Maybe they hate being cold or feeling exposed. Maybe, in their mind, they believe they just took a shower. It's also important to look at other patterns, such as toileting.

“If there's a sudden change in bathing patterns or toileting, that's a big indication that something else may be going on, such as a urinary tract infection, which can cause irritation and pain during a bath. Regular assessments are critical because the more you know, the more able you are to make the necessary adjustments.”

With some residents, however, it's difficult, if not impossible, to determine why they oppose being bathed. Sometimes, the solution—or the path to least resistance— comes from creative options that mold the bathing process around the resident's own interests or preferences.

Lopez said one Autumn Leaves resident didn't like the sensation of water hitting him. He also was modest and didn't like to be fully undressed, so traditional showering or being immersed in a bathtub was not an option.

“Instead, we sat him on a bench [outside the shower] and brought the [shower] wand to him. We also did the bath in sections, only uncovering one part of his body at a time,” she explains. “This allowed us to bathe him, but in a way that made him more comfortable. It was a win-win.”

Training all employees

Another approach that's proven successful for Autumn Leaves is training every employee—including maintenance, housekeeping and activities staff—to bathe residents. It's proven effective, according to Lopez, because some residents “connect” more with employees who don't assume the typical caregiver role.

“They see many of these employees every day, so there's that recognition factor, but these are not the caregivers who are always asking them to do things, like use the toilet or eat their meals,” Lopez says.

One current resident, she says, will allow himself to be bathed only by a particular maintenance employee.

“Family members can also help in some cases, and we're not too proud to ask,” Lopez remarks. “If the resident prefers a family member to bathe them and the family member is okay with coming in certain times during the week to do it, then we're fine with it, too.”

Tying bath time to residents' unique interests also can work wonders. At The Manor at Bethany Village in Horseheads, NY, caregivers play carefully selected videos during resident bathing via a color television/DVD combination that is integrated into their side-entry Penner Patient Care bathing unit.

“We put the DVD in first, so it's playing before the resident is even placed into the tub,” says Cheryl Unger, The Manor's director of nursing.

Many of the videos, which are set to soothing music, were purchased at a discount retailer for just $12. Some of the more popular themes for residents include underwater sea life and video travel tours to Ireland and the Grand Canyon. Personalized family-made videos are also in the works, Unger notes.

“Residents are so caught up with the sights and sounds that the bath is over before they know it,” she notes. “It actually has created a very peaceful experience.”

She adds that one resident with agitated dementia now enjoys baths so much that her physician has written an order to put her in the tub when agitated—even in the middle of the night.

Design a pleasant space

While adopting a resident-centric approach to bathing is essential, experts agree that abandoning sterile, institutionalized bathing areas is also critical. Today, more facilities are revamping these spaces with appealing color palettes, residential-inspired furnishings and high-end fixtures. Increasingly, sinks are adorned with fresh flowers, and both subtle scents and soothing music (which resonates with the resident, if not the caregiver) fill the air.

“Temperature is another thing that's getting a lot more attention,” according to Lopez. “If the room is too hot or too cold, that can be a source of agitation, so you need to pay attention to each resident's preference. If a person likes warmth, we'll put a bath towel in the dryer.”

Although bathing areas must be large enough to safely maneuver, Autumn Leaves opts for smaller spaces, which appear cozier and more residential, and tend to stay warmer. The Manor targets the chill in bathing areas with heated ceiling tiles.

Bathing system manufacturers throughout the country are becoming more intently focused on designing units that combine aesthetics and comfort with safety and ease of use.

“The right water temperature and pressure are essential for safe and pleasant bathing of more dependent residents,” comments Scott Maurus, PHD Product Manager, ArjoHuntleigh, Addison, IL. “The regulation works by rapidly compensating for any pressure fluctuations in the hot and cold water supply, while a thermostat ensures a constant showering and filling temperature.”

Auto-fill functions, which automatically fill the tub while the caregiver transfers the resident to the bath, also can make for more pleasant, efficient bathing experiences.

“With this feature, a resident doesn't have to wait while the bath fills,” Maurus explains.

Check equipment closely

Many facilities offer residents shower options, but some experts believe it may be unwise to place residents who become agitated or disoriented on a traditional shower chair and then wheel them into the shower stall. It's as much a dignity issue as a safety one, according to Hickory Bathing's Ruth.

“The universal use of PVC shower chairs was prompted by cost and at the expense of anything resembling comfort,” he says. “The toilet-sized opening that is needed to manually address peri-care brings with it the triggering mechanism one would anticipate in any of us.

“As distasteful and dignity-robbing as it is to be the caregiver, it is the same to the resident, and their distressed behavior often reflects it. We know [from the experts] that most of the behaviors are environmentally induced. No wonder bathing them can be a nightmare.”

Ruth's solution: a focused evaluation of comfortable chairs, preferably those with full upper body padding and cushioned head support. Range of motion is another factor that warrants careful consideration.

“The ability to accommodate resident range of motion limitations plays a major role in avoiding triggers,” Ruth continues. “Reclining seat backs satisfy all those who find sitting at 90 degrees uncomfortable, or worse. Elevated lower leg support will also matter to many of them.”

Sometimes, even the smallest changes can make a big difference. At Autumn Leaves, thick, soft towels are layered on top of tub and shower seats.

“We do this each time and it does seem to help make bathing more comfortable,” healthcare VP Lopez explains.
Tub transfers also require careful consideration and should not involve disorienting triggers, such as lifting, turning or pivoting, adds Ruth.

“Nothing will have as much impact as choosing equipment wisely,” Ruth says.

When selecting lifting and bathing equipment, Ruth recommends inviting a short list of vendors to bring their products and then evaluating the products' effectiveness with the most challenging residents.

“You will quickly determine which is preferred by your caregivers,” he says. “It will be the reaction of those residents that shapes their opinions.”

Don't force the issue

When it comes to bathing residents with Alzheimer's and other forms of dementia, it's important that long-term care providers understand that sometimes even the most award-worthy bathroom designs, high-end equipment and patient caregivers won't be enough.

If, at any point, bathing becomes a struggle, it's important not to force it. In her book “Bathing without a Battle: Person-Directed Care of Individuals with Dementia,” dementia care nurse-turned consultant and renowned bathing expert Joanne Rader and co-editors stress that one of the worst things caregivers can do is force a resident to bathe. It's advice that Lopez says is recognized and embraced by every staff member at Autumn Leaves.

“If a bath isn't going to happen today, that's okay. We can try again in the evening or tomorrow,” Lopez says.

“Just as it's important to understand which bathing method each resident prefers—whether it's a bath, shower or sponge bath—it's just as important to recognize when it's time to stop. Dignity and quality of life are what's more important.”