Saturday, January 9, 2010

Understanding difficult behaviors in Alzheimer's: Bathing, Wandering

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Part three of our series is about problems with bathing. Bathing is almost universally a dreaded caregiver chore. I have never seen the slightest bit of research to prove this next statement, but I believe hydrophobia is a real symptom of Alzheimer’s. I say that because I cannot recall a single Alzheimer’s patient that did not fight taking a bath or a shower, tooth and nail. Starting even in the early stages they make excuses like; “I just took a bath”, “I don’t need it”, “I don’t need help”. In the later stages they don’t even bother to make excuses, they just refuse. Even if you are able to get them into the shower, it’s not unusual for them to physically resist by yelling, scratching, punching and even biting.

Nevertheless, it is possible to get your loved one peacefully into the shower. It’s just a matter of taking your time and figuring out what about getting in the bath or shower is affecting them and then developing some unique tricks that will make the process manageable. However, the key to this whole problem is realizing that it you need set aside a lot more time than you would expect.

You are about to read one of the most comprehensive reports I have ever seen on the topic. I got this from a booklet in my library called “Understanding Difficult Behaviors: Some Practical Suggestions for Coping with Alzheimer’s disease and Related Illnesses”. However, before we get started, did you sign up yet to be included in my FREE mail list? Please go to and you will find a sign up in the upper left corner. Additionally, you will get a FREE stress management download as soon as you sign up!

Problems with Bathing
I have a theory that Alzheimer’s sufferers are hydrophobic; afraid of water. I’ve never seen any literature talking about this, or any research to prove it. However, in all my years working with Alzheimer’s I have never seen a person that didn’t kick, scream and bite to avoid taking a shower. They will tell you that they just had one, or that they don’t need it. But never ever have I seen somebody look forward to taking one.


Physiological or medical causes:

* Depression, causing a loss of interest in personal hygiene.
* Physical illness, causing a loss of interest in personal hygiene (e.g. flu, infections, etc.).
* Changed sense of perception of hot and cold water temperature. This may be caused by damage to the hypothalamus region of brain which regulates “internal thermostat.”
* Different sensation of water due to brain damage.

Environmental causes

* Poor lighting – unable to see the bathtub or shower.
* Can’t find the bathroom.
* Lack of privacy (especially in facilities)
* Room temperature too cold.
* Water too deep.
* Water too hot or cold.

Other Causes

* Fear of falling
* Fear of water or of being hurt by it.
* Disruption in daily routine or schedule.
* Unfamiliar caregivers.
* Mechanics of taking a bath too overwhelming.
* Purpose of bathing forgotten.
* Humiliation of being reminded to take a bath.
* Agitated from an upsetting situation, such as an argument with caregiver.
* Reeling of being rushed by caregiver.
* Feeling embarrassed and vulnerable about being naked or having another person in the bathroom.
* Fatigue.
* Fear of hair washing, which is no longer understood.
* Person kept waiting too long while caregiver prepares bath.
* Fear of soap, washcloth, sound of running water, etc.


* Evaluate the best time of day for bathing. Try to be consistent with the person’s old bathing routine before the onset of the illness. For example, consider time of day when person is most relaxed, type of bathing (tub, shower, sponge bath, etc.).
* Make sure the bathroom is warm enough and inviting. Pull down blinds, or close curtains and doors to create a feeling of privacy.
* Provide adequate lighting in bathroom, especially during evening hours.
* Try bathing instructions written by a doctor on a prescription pad. For example “Bathe 2 or 3 times weekly.”
* Prepare bath ahead of time. Check the water level. Some people can only tolerate 1 inch of water in the tub; others 3-4 inches.
* Lay out soap, washcloth, towel and clean clothes in sequence so that the person with dementia won’t have to wait.
* Use quiet, calm, matter-of-fact approach. For example, “Mother, your bathwater is ready.”
* Avoid getting into length discussions about whether a bath is needed. Instead tell the person one step at a time what to do to get ready for the bath.
* Simplify task of bathing as much as possible. Do one step at a time, gently talking the person through each step. Combine visual and verbal cures when giving instructions. Use simple, respectful language.
* Try offering the person one or two choices. For example: “Would you like to have a bath or shower?” or “Would you like to take your bath now or before going to bed?”
* Try not to get nervous or excited or threaten the person who objects to taking a bath. This only causes additional agitation and frustration. It may be helpful to wait and try again later when the person’s mood is more favorable.
* Encourage a bath instead of a shower if person can get in and out of tub. Baths are generally safer, less frightening and easier for the caregiver to manage.
* Try showering with the person. Sometimes this is the simplest solution, although not all caregivers are in a position to do this.
* Let the person feel the water before getting into the tub. Sometimes gently pouring water over hands reassures the person that the water isn’t too hot. Saying something like “The water feels nice,” or “This feels good,” may help calm the person.
* Don’t bathe the person every day, if bathing continues to be difficult. A partial sponge bath daily and a full bath every three to four days may suffice.
* Try using a bath chart or calendar to indicate when bathes were given. For example, a caregiver might pint to a note or a sticker on a calendar to show the person that it has been three or four days since the last bath.
* Offer a “reward,” such as a favorite food or an activity like going for a drive in the car. This may be an effective way of cajoling the person into taking a bath. Having something to look forward to sometimes takes the focus off of the task.
* Try separating hair washing from bathing. Some people with dementia associate bathing with having their hair washed and become terribly upset, because water being poured over their head frightens them. Sometimes hair washing can be done separately in a beauty shop. Try a shower cap when bathing or it may be easier to wash hair in kitchen sink if there isn’t a spray attachment in the bathtub.
* Also try dry shampoo.


* As a safety precaution, adjust temperature setting on the hot water heater so that the water is not scalding (between 120 – 130 degrees F.).
* Since the person may have an altered sense of hot and cold, adjust the water temperature to his/her comfort.
* Avoid leaving an impaired person alone in the tub or shower.
* Remove locks from bathroom doors.
* Use plastic instead of glass containers in the bathtub.
* Make sure hairdryers, electric razors, etc., are out of reach.
* Use a non-slip bathmat on the floor outside the tub. Be sure there are no puddles of water on the floor.
* If Lubriderm or other oil is used, be careful of slippery residue on the tub.
* Put a rubber mat or non-skid decals on the bottom of the tub or shower.
* Install grab bars so that the person can get in and out of the tub easily. These bars can be mounted to the wall or they can clamp onto the side of the tub.
* A hand-held spray attachment on a flexible hose can convert a tub into a shower. The attachment can be helpful for rinsing the person thoroughly and makes washing hair much easier.
* Adjustable safety benches or bath chairs (which have holes in the seat so the water can drain) can be used in both tub or shower. These help make people feel more secure because they are sitting above the water. If safety benches aren’t available, try a kitchen chair. These assistive devices are available through medical supply houses, large drug store and department stores, and home health care catalogs. Medicare, Medicaid, or major medical insurance may pay all or part of the cost of equipment if ordered by a physician.
* Be sure that all parts of the body, especially the genital area, are thoroughly washed to avoid rashes and infections.
* Try giving the person with dementia a washcloth to hold or something to fiddle with for distraction while bathing.
* Play soft music in the background to create a calming and relaxing atmosphere.
* Wrap a towel around the shoulders of the person sitting in the tub and fasten with clothespin, if he/she is embarrassed about being undressed. It is important to respect the person’s privacy and dignity.
* Try tomato juice added to bathwater, if persistent body odor is a problem.
* Be sure the person is thoroughly dry. Use a refreshing after-bath scent and dry skin lotion to keep the skin moisturized. Baby powder can also be used.
* Remember, powder on the floor can be slippery. Cornstarch is an inexpensive odorless, non-allergic substitute for talcum powder.
* While the person is undressed, check the skin for rash or sores. If any red areas or sores appear, notify the doctor immediately. Pressure sores or decubitus ulcers can develop quickly on people who sit or lie down much or the time.
* Check the person’s toenails and trim them as necessary. Proper foot care is essential to prevent problems such as ingrown toenails. If trimming nails is difficult, have the person seen by a podiatrist.


* Be sensitive to the approaches used when talking to residents about bathing.
* Try making the bath schedule flexible to accommodate the person’s mood.
* Allow plenty of time for individuals to relax and enjoy a quiet, peaceful bath.
* Train staff or family members who assist with bathing to allow people to do as much of the bathing themselves, whenever possible.
* Consider making the environment in the bathroom warm, familiar and private.
* Be aware that some people with dementia become quite upset when required to take a whirlpool bath. Institutional equipment such as whirlpool baths can be impersonal and terrifying.
* Avoid using commode chairs when giving showers. This practice encourages people to be incontinent when bathing.
* Avoid forcing or arguing with a person to take a bath when he/she is resistant. This only causes further agitation.


* If a person is absolutely refusing a bath or a sponge bath and if his/her lack of hygiene is intolerable, consult a doctor. For some people medications may ease the anxiety. Use only with very careful supervision and as A LAST RESORT. (Sometimes these medications have side effects and occasionally they increase the agitation.)
* In the later stages of dementia when total assistance with personal care may be needed, meticulous and careful attention to hygiene is important in preventing skin breakdown. This becomes a major challenge for caregivers coping with urinary and bowel incontinence.
* Bathing is a very personal and private activity. Many people have never completely undressed in front of anyone else and this can be uncomfortable and vulnerable experience. Also, when a caregiver offers to help someone who is confused, it is a strong statement that the person is no longer able to do for him/herself. This loss of independence can be terribly difficult for people with dementing illnesses. It is important to recognize that these feelings may be contributing to some of the resistance to bathing.

Finally, don't let your personal habits dictate what is normal. A generation ago, most people did not bathe and change their clothes as often as we do today. Taking a bath once a week may have been the way the person did things in his/her home.

Now, since you didn't do it the previous two time asked - here's one final request: if you are a caregiver, if you nothing lose, a lot to gain from signing up at and go find some great information on
see you soon, Donahue

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