Approach with Caution -- and Compassion
Miss Peggy was off to herself in a comfortable chair with her walker placed in front of her. Unlike the other residents, she was not asked to participate in music or, as I had noticed, most of the other activities. When I asked one of the caregivers why Miss Peggy was not encouraged to participate, the carer simply responded, “She’s mean.” Since I was the volunteer, I wondered why she said this and ventured over to Miss Peggy.
I have no idea how Miss Peggy was usually approached, but I went over to her slowly enough that she wasn’t startled and got directly in front of her. I spoke softly to her, told her good morning, who I was, and after a few minutes, asked her if she would like to come and listen to some music with me. To my utter amazement, she did!! Beginner’s luck, I was assured by the care staff.
But there are a few elements here that improved my chances of success. The first was that I approached slowly, so I did not abruptly interfere in what she was watching or thinking. I also approached from the front. As we have mentioned previously, the visual field of a dementia client (and the visual field of the elderly in general) decreases peripherally with age. She might not have seen my approach if I came to her at an angle. In addition, I did not appear rushed in my mission. I told her good morning first with a smile. What is that saying about how you can get more with honey? My objective (to get her to join the group) was the LAST thing I mentioned, not the first. I had an agenda, but I wasn’t going to reveal it ahead of time.
I am sure Miss Peggy could be difficult if she was asked to do something she did not want to do. The caregivers told me bathing was at the top of her agitation list, and if you wanted to be hit, scratched, or even bitten, tell her she was going to take a shower. How could this be approached in a manner where she might be more compliant? How could she be convinced she wanted to do something, too?
Bathing is a source of tremendous anxiety for most dementia clients, and this is understandable. I am nice and warm in my clothes, and you want me to be naked, cold, and wet? Not so fast! That doesn’t sound much fun to me, either. I think of those days when I am ill and not feeling well. It can hard to garner enough enthusiasm just to brush my teeth. Those with balance issues may fear falling; unsteadiness and slippery surfaces pose safety concerns. Adapt the environment to address these issues by using a non-skid bathmat, grab bars, and color differentiation of surfaces, tile, and tub so the area can be seen. If tub, tile, and shower curtain are all similar in color, the bathroom may look like a white abyss. Use bright stickers on the tub, shower floor and doors, and provide a colorful, contrasting shower curtain.
There are strategies that can be implemented for improved results when addressing bathing reluctance. First, establish how often bathing needs to occur. Some caregivers report less resistance to bathing when it is part of the daily routine. Others may spray a favorite perfume or scent in the room prior to announcing ‘spa’ time which cues the patient as ‘time to get ready for work’ or to go somewhere like dancing or to school if the client insists they need to leave. Dim lighting somewhat to reduce glare on smooth, shiny surfaces.
Choose the most appropriate time to provide care. Previous routines established earlier in life (showering at night, etc.) can sometimes decrease resistance to care if continued. Approach from the front, ask permission before beginning, and explain the steps involved if that is reassuring to the client. As always, the client should know the person extending care. Provide reassurance and positive feedback for cooperation. If aggression occurs, pick another time of day to provide services.
Mirrors can be frightening to dementia clients. Those with dementia may not recognize themselves (or others) in the reflection. Cover the mirror with a sheet, put a picture there instead, or just turn the client so he/she doesn’t see the reflection.
All items should be ready for bathing prior to undressing the client. Disrobe the client in stages. There is no need to hurry the process as this can add anxiety and cause behavior to escalate. A portable heater can be used to keep the bathroom warm if a ceiling heater is not available. A reassuring tone of voice is helpful to encourage the person to approach the shower. If hair washing is a particular battle, use dry shampoo or wash hair at a separate time.
An electric razor and hands-free hairdryer may be helpful. Likewise, electric rather than hand-held toothbrushes or disposable oral sponges may be easier to utilize. If the client does not like toothpaste or dysphagia is an issue, decrease the amount of paste to the size of a pencil eraser or just eliminate it and use water instead if necessary. Good oral hygiene can reduce the infectious nature of nasal secretions and may decrease risk of aspiration pneumonia (Zimmerman et al, 2014). When a shower is not possible, a sponge bath can work just as well. A towel or blanket can be used to cover the client’s shoulders or lap, whichever is undressed first. Use warm wipes (or a wipe warmer) and washcloths if possible. Uncover only the part of the body being washed. No -rinse shampoos can also be used for hair.
There are publications available on bathing an individual who is not mobile. A highly recommended source for bathing techniques is Bathing without a Battle. A summary can be found on the web; online training and DVDs are available for purchase (Bathing without a Battle, n.d.; The Cecil G. Sheps Center for Health Services Research UNC. Retrieved January 30, 2017 from http://bathingwithoutabattle.unc.edu/bathing-techniques).
For dressing, consider adaptations to buttons such as Velcro or snaps. Larger zipper pulls and reaching aids may be helpful. Many clients do not like clothing pulled over their head. Consider clothing that opens to the front or back if this is an issue.
Sources:
Zimmerman S, Sloane P, Cohen L, Barrick A. Changing the culture of mouth care: Mouth Care Without a Battle. The Gerontologist, 2014:54(51):525-534.