Why is Bathing Such a ProblemProblem?

&

How to Help!

TeepaSnow.com

1© 2010 Teepa Snow. All rights reserved. Use only with permission. Presentation at Home Instead Senior Care of Sonoma County sponsored Dementia and Alzheimer’s event, March 22, 2010, at the Scottish Rite Masonic Center in Santa Rosa, CA.

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Why Is Personal Hygiene a Problem?

• Physical Health issues

• Psychological Health Issues

• Social issues

• Family concerns

• Regulator issues

• Caregiver stress

• Others…2

With Dementia…

• Problems with hygiene frequently are an indicator of…– A need for closer supervision and assistance

needed with other ‘complex’ task completion – toileting, OTC meds, diet restrictions…

– The beginning of loss of ability to organize time during a week or day – more down time

– A need for more structure and guidance in how the day goes – appointments & activities

3

Common Issues

• No sense that bathing is needed• Sense that bathing has already happened• Need for privacy• No sense that assistance is needed• Dislike of the space – size, temperature, look, echo, emotional

memory, wet/slippery surfaces

• Dislike of caregivers – personal or general• Fear of… falling, water, experience, cold• No understanding of what is happening

4

THE GOAL IS…???

• Getting CLEAN – NOT –– Taking a bath– Taking a shower– Having a traumatic experience

• Keeping everyone safe – NOT – – Hurting the person – physically & emotionally– Hurting the helper – physically & emotionally

5

SIX Pieces to the Puzzle

• Personal history and preferences

• Level of dementia

• Other conditions & sensory losses

• Environmental conditions

• Care partner approach and behaviors

• What happened – full day & all players

6

If it is A PROBLEM…

• Describe the behavior – OBJECTIVELY & SPECIFICALLY!!!– WHO?– WHAT?– WHERE?– WHEN?– WHAT helps… WHAT makes it worse?– Frequency & Intensity?

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BEFORE YOU EVEN START…For EACH PERSON…

• Get a ‘getting clean’ history & preferences… – How have they been getting clean?– History of hygiene practices– How frequently did they get clean?– What about hair?– Where did they do get clean?– When did they get clean?– Temperature sensitivity?– Privacy issues?– Gender issues? Racial issues?

8

Before You Even Start…

• Check on medical, physical, psychological, & sensory status and conditions– Pain - Stiffness– Mobility - Contractures– Sensation - Fear of others– Vision - Need for

control– Hearing - Body fat– Balance - Circulation

9

Level of Dementia

• Diamonds – Using OLD Routines and Habits• Emeralds – Just Get It Done & I Can Do IT! or

I already did it!• Ambers – Its Not a Task Its an EXPERIENCE –

Busy hands & If I don’t like it I leave or hit• Rubies – Got to GO or Out Like a Light –

gross movement – sensitive spots• Pearls – Stuck in Glue – Immobile & Reflexive

stiff and tight – hard to get to & low weight 10

• Uses Routines & Old Habits to function• Can complete personal care in ‘familiar place’• Follows simple prompted schedules - mostly• Misplaces things and can’t find them• ‘Resents takeover’ or bossiness • Notices other people’s mis-behavior & mistakes• Territorial – refusals!• Varies in lack of self-awareness

Level 5 - Diamond

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Personal Care Issues

• IADLs– Money management

– Transportation - Driving

– Cooking

– Home maintenance & safety

– Caring for someone else

– Pet maintenance

– Med administration

• Unfamiliar settings or situations– Hospital stay– Housing change– Change in family– Change in support

system – MD visits– New diagnoses– Traveling or vacations

12

Help?

• Apologize! - “I’m SORRY!” – “I didn’t mean to…”

• Friendly NOT bossy

• “Let’s try” – temporary…

• Share responsibility not take over

• Use as many ‘old habits’ as possible

• Give up being ‘RIGHT’

• Go with the FLOW

• Give other ‘job’ when taking away another13

Level 4 – Emerald

• Limited awareness of time sensitive needs

• Needs some “HELP” – not doing for or to

• Wants the familiar … hard to find it

• Asks a lot about “What…? Where…?”

• Increasing mistakes and errors

• Likes to ‘stay busy’ with familiar tasks

• Fears being seen as ‘incompetent’14

Personal Care Issues

• Doesn’t do care routinely – thinks did

• Makes mistakes in sequence – unaware

• Repeats some care routines over & over

• Resists or refuses help

• Gets lost – can’t find where to do care

• Limited awareness of ‘real needs’ – – Hunger, thirst, voiding, bathing, grooming…

• Has other ‘stuff’ to do…15

How to Help

• Learn about “SO WHAT!”… is it worth it?

• Provide ‘subtle’ supervision for care

• Provide visual prompts to do– Gestures, objects, set-up, samples, show

• Hide visual cues to ‘stop’/prevent– Put away, move out of range, leave

• Use the environment to cue – SHOW

• Use ‘normal’, humor, friendliness, support16

What NOT to DO…

• DO NOT point out errors – or focus on ‘wrong’

• DO NOT offer – physical assist 1st

• DO NOT offer “Let me HELP you”

• DO NOT try to ‘go back and fix it…

• DO NOT continue arguing about ‘reality’

• DO NOT treat like children…

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Level 3 - Amber

• LOTS of touching, handling, mouthing, manipulating

• Focus on fingers and mouth

• Get into things

• All about sensation….

• Invade space of others

• Do what they like AVOID what they do NOT

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How to Help

• Provide step-by-step guidance & help

• Give demonstration – show

• Hand-under-hand guidance after a few repetitions, uses utensils (not always well)

• Offer something to handle, manipulate, touch, gather

• Limit talking, noise, touch, other activities

• SUBSTITUTE don’t SUBTRACT 19

Level 2 - Ruby• Big movements – walking, rolling, rocking• Hand actions – not fingers• Tends toward movement unless ‘asleep’• Follows gross demonstration & big gestures

for actions• Limited visual awareness• Major sensory changes• Major movement skill loses• Fine motor skill lost – mouth & hands

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How to Help

• Hand under hand

• Move with first – then guide

• Learn about patterns of ‘needs’

• Gradual transitions - go to stop

• Use music and rhythms – help get or stop movement

• Use touch with care

• Combine cuing & do SLOW21

Level 1 - Pearl

• Immobile – can’t get started• Bed or chair bound• Has more time asleep or unaware• Has many ‘primitive’ reflexes present -Startles easily• May cry out or mumble ‘constantly• Increases vocalizations with distress• Difficult to calm• Knows familiar from unfamiliar• Touch and voice make a difference in behaviors

22

How to Help

• Hand under hand help & care

• Check for reflexes – modify help and approach to match needs

• Guide movements

• Use calm, rhythmic movements and voice

• Come in from back of extremities to clean

• Stabilize with one hand and work with other

23

Before you start…

• Flow of the Day

• TIMING!!!

• Routine, habit, patterns

• Fit into the rest of the day

• Cues and clues

• What else is happening?

• Time to recover…

24

Before you start…

• Check out the Environment…– Physical– Sound– Lights– Equipment– Surfaces– Temperature– Privacy– Materials

25

Before You get started

• Caregiver Skills– Preparation of the space– Preparation of supplies and equipment– Preparation of self– Approach– Words– Actions– Reactions– THANKS!– BACK OFF!

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How can we help… better?

It all starts with

your approach!

27

Positive Physical Approach

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How you talk…

• How you say it…

• What you say…

• How you respond…

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Use empathy&

Go with the flow

Reality Orientation

Telling Lies

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How you help…

• Sight or Visual cues

• Verbal or Auditory cues

• Touch or Tactile cues

31

Hand-Under-Hand Assistance

32

Believe -

People with dementia

Are doing

The BEST they can!

33

Courtesy of Life Enrichment Center, Kings Mtn“It beats a cold creek!” 34

What shouldn’t we do???

• Argue

• Make up stuff that is NOT true

• Ignore problem behaviors

• Try a possible solution only once

• Give up

• Let them do whatever they want to

• Force them to do it

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So WHAT should we do???

Remember

who

has the healthy brain!

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www.bathingwithoutabattle.unc.edu

Training CD for facilities

37© 2010 Teepa Snow. All rights reserved. Use only with permission. Presentation at Home Instead Senior Care of Sonoma County

sponsored Dementia and Alzheimer’s event, March 22, 2010, at the Scottish Rite Masonic Center in Santa Rosa, CA.