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Bathing disability and bathing persons with dementia.

Bathing disability, an individual's inability to wash and dry the whole body without personal assistance (Gill, Gahbauer, Han, & Allore, 2010; Gill, Guo, & Allore, 2006), has been assessed by nurses for decades. It has challenged nurses who care for older adults or persons with dementia or disabilities to achieve maximal performance of self-care. Bathing disability is a functional health problem. Its existence is implied in acute care agencies by nursing judgments and the extent of personal assistance patients require with bathing, whether full or complete, self-help bath, partial (abbreviated), bag bath, tub bath, or shower (Berman, Snyder, & McKinney, 2011). Persons with bathing disability have lost control of one aspect of everyday life and, with that, some of their autonomy. In addition to examining the literature addressing bathing disability as a predictor of functional decline and institutionalization in older adults (Barnes et al., 2012; Nelson, 2004), nurses need to explore its connection to the hygienic care of persons with dementia.

Bathing is one of the first activities of daily living (ADLs) to become impaired when older persons become increasingly frail (Theou, Rockwood, Mitnitski, & Rockwood, 2012). Its portrayal as a sentinel event for the aging community brings it to the forefront for nurses and others serving older adults (Mehta et al., 2011; Rozzini, Sabatini, Ranhoff, & Trabucchi, 2007). Bathing disability, as a new-onset phenomenon for older adults admitted to acute care agencies, may be a crucial factor in decisions to place individuals in long-term care facilities. It is also a sentinel event in the disabling process (Gill et al., 2006) and a slippery slope often ending in death (Barnes et al., 2012; Rozzini et al., 2007; Smith, Walter, Miao, Boscardin, & Covinsky, 2013).

Cognitive impairment also predicts functional dependence in community-dwelling persons age 65 and older (Millan-Calenti et al., 2012). Inability to perform hygienic care activities represents an important loss for older persons (Gitlin, Winter, Dennis, Hodgson, & Hauck, 2010; Pound, Gompertz, & Ebrahim, 1998). Bathing independently is a very personal and complex ADL. Inability to perform this self-care function is associated with emotional and physical discomfort (Rader et al., 2006). As quintessential elements of nursing care, cleanliness and personal hygiene involve interpersonal processes for nurses and patients and are complicated by behaviors associated with dementia diagnoses (Downey & Lloyd, 2008). Consequently, in this article bathing disability is explored from the perspectives of its prevalence and assessment, and nursing interventions for bathing persons with dementia are identified.

Related Literature: Bathing Disability

Search terms for this literature review included bathing disability, nursing, long-term care, nursing home, activities of daily living, elderly, and older persons. The databases Proquest Medical and Nursing, Medline, Cumulative Index to Nursing and Allied Health, and Proquest Dissertations and Theses Global were searched for years 2000-2014 because initially few citations were found. Some of the citations can be considered classic, in that they called attention to bathing disability as a public health problem.

Gill and co-authors (2006) noted bathing disability requires personal assistance from caregivers, is costly, and is related to the risk of long-term nursing home admissions. Investigators quantified the burden of bathing disability over time; determined if the burden of bathing disability differed according to age, sex, and physical frailty; and evaluated the relationship between disability in bathing and disability in the performance of other ADLs. They conducted a longitudinal study of community-living persons (N=754) age 70 and older who required no personal assistance for four ADLs (bathing, dressing, transferring from a chair, walking inside the house). Home-based assessment occurred at baseline and every 18 months; telephone assessments of bathing disability were completed monthly for up to 6 years. Deaths were measured initially by obituaries and followed up by telephone interviews with informants (community-living persons) conducted by research staff. Home-based assessment data included demographic characteristics, gait speed, and cognitive status, as well as nine self-reported physician-diagnosed chronic conditions (hypertension, myocardial infarction, congestive heart failure, stroke, diabetes mellitus, arthritis, hip fracture, chronic lung disease, cancer). Researchers established reliability of the disability assessment for bathing ([kappa] = 0.73), disability in bathing ([kappa] = 0.71), and three other essential ADLs.

Gill and colleagues (2006) calculated the number and duration of bathing disability/disability episodes. Episodes were calculated by age (70-79 vs. [greater than or equal to] 80), sex (men vs. women), and baseline physical frailty (absent vs. present). Incidence rates for bathing disability per 1,000 person-months (sum of follow-up months during which participants were at risk for bathing disability) were calculated, along with length of disability at 1 month, and 2-5 (short-term) and 6 months (long-term). Over 60% of participants had at least one episode of any disability and at least one episode of bathing disability over 6 years. Multiple bathing disability episodes were more common in persons who were age 80 and older, female, and physically frail. Incidence rates for bathing disability per 1,000 person-months were 23.0 (CI = 19.2, 27.0) for participants ages 70-79 and 43.6 (CI = 37.1, 50.5) for persons age 80 and older, 22.3 (CI = 18.4, 26.5) for men, 34.5 (CI = 29.7, 39.6) for women, 6.4 (CI = 13.7, 19.3) for persons not physically frail, and 55.6 (CI = 47.7, 63.8) for the physically frail. Physical frailty (p [less than or equal to] 0.001) had the strongest association for each of the three durations of disability (1 month, 2-5 months, [greater than or equal to] 6 months). Bathing disability often was accompanied by disability in the other essential ADLs (dressing, transferring, or walking).

Gill and colleagues (2006) linked disability in bathing to intrinsic risk factors (muscle strength, balance, transfer skills, vision and environmental impediments including absence or nonuse of adaptive equipment). They proposed bathing disability was a sentinel event in the disabling process. Registered nurses should assess patients admitted to acute care agencies for development of a bathing disability as a result of progressive disease, hospitalization, or outcomes of surgery.

Sangeeta, Ahluwalia, Gill, Baker, and Fried (2010) conducted a grounded theory study on the practices, preferences, and goals of community-dwelling older persons on the bathing experience. Participants (N=23) were sampled purposefully from a longitudinal study across sex, race, mode of bathing, and self-reported bathing ability. Semi-structured, in-depth interviews were audiotaped and used open-ended questions on bathing habits, meaning and purpose of bathing, difficulties and concerns about bathing, and use of and attitudes toward different types of bathing assistance. The following themes were identified: importance and personal significance of bathing; variability in attitudes, preferences, and sources of bathing assistance; and older persons' anticipation of and responses to bathing disability.

Participants preferred to bathe independently and felt secure while doing so (Sangeeta et al., 2010). Some of them needed assistance from a caregiver and used aids such as a handheld shower to perform the task. Participants modified bathing routines, such as showering instead of bathing in a tub, because of fear of slipping, falling, or getting stuck in a tub. Bathing and cleanliness were expected socially, and were pleasurable and relaxing. Investigators suggested bathing fostered social interactions and maintained order and routine. Nurses should ask older persons about bathing preferences on admission to acute care agencies and strategize to support patients' maximal function.

Acute illness and hospitalization are linked with disability for older adults. Bathing, an ADL, is assessed on admission to acute care facilities and on return to home following acute care discharge. Researchers developed a clinical index to predict new-onset disability on hospital discharge for adults age 70 and older from two prospective studies using chart reviews and standardized interviews (Mehta et al., 2011). The clinical index for new-onset disability at hospital discharge included 1,638 patients. Older adults in a community teaching hospital (n=885) and a university teaching hospital (n=753) composed participants. Predictor variables, including sociodemographic and clinical characteristics (reason for admission, comorbid illnesses, acute severity of illness, creatinine, hematocrit, albumin, severe cognitive impairment, depressive symptoms, self-rated general health, ADLs, instrumental ADLs [IADLs]) were elicited. Surrogates provided data if participants' mental status scores or illness limited communication.

Mehta and co-authors (2011) examined the outcome variables of composite outcome disability at hospital discharge and death in the hospital. Catastrophic disability (dependence in three or more ADLs), long-term care placement at discharge, and long-term survival were described. Multivariate logistic regression analyses built a risk index for new-onset disability. A risk score summed points assigned for each risk factor. Seven risk factors were associated independently with new-onset disability using best subsets regression in the logistic model: age (80-89, [greater than or equal to] 90), dependent in three or more IADLs 2 weeks before admission, mobility 2 weeks before admission (able to walk uphill or stairs but unable to run a short distance, unable to walk uphill or stairs), number of dependencies on admission (2-3, 4-5), metastatic cancer or stroke, severe cognitive impairment, and albumin less than 3.0 mg/dL. The risk score was associated with disability severity, indicated by the number of ADL dependencies at discharge. Catastrophic disability predicted discharge to a long-term care setting and long-term survival. The seven independent risk factors in the clinical index, consistent with the disablement model, were present within 24 hours of hospital admission. Many risk factors for disability could be assessed on admission, allowing nurses and other providers to plan post-hospital care for older adults and encourage maximal self-care.

Next, investigators (Berlau, Corrado, & Kawas, 2009; Berlau, Corrada, Pelz, & Kawas, 2011) reported on the functional disability of the oldest old (age 90 and older). The 90+ Study examined the most impaired ADLs that made the best targets for interventions. Incident disability rates for each ADL used person-years analysis (e.g., denominator is sum of individual units of time persons in a study population are at risk and were observed [Gordis, 2009]). Disability in ADLs referred to performance of a function that required help from another person. Annual mailed questionnaires were completed by surrogates for participants on bathing, dressing, feeding, toileting, walking, and transferring in and out of a bed or chair. Most nondisabled participants (N=216) lived alone (56.9%); mean follow-up time was 2.7 years. The incidence of bathing disability was 14.9% per year (95% CI=12.0, 18.2). Females residing in an institution were at risk for ADL dependency (<0.05) (Berlau et al., 2009) at a statistically significant level. Walking had the lowest incidence rate of disability (6.9% per year, CI=5.2, 9.0). Investigators considered assistive bathing devices ineffective for the oldest-old and called for research development in support of functional performance.

The impact of bathing disability is experienced by families, nursing staff, other caregivers, and patients (Hall, Wodchis, & Johnson, 2013). The ability to bathe independently is valued highly, and its gradual decline is lamented across care receivers and caregivers. While nursing staff have responded to individual patient needs for bathing as part of routine nursing care, they may not have confronted the phenomenon of bathing disability and its predictability of decline and long-term care admission in persons with increased frailty. Considering the increased lifespan of older persons, bathing disability is a concern for health care policymakers and providers. They need to develop strategies to increase the number of persons who remain in their homes, aging in place. Nurses should consider assessing the ability to self-bathe in older hospitalized adults. Supporting older adults' self-care performance may contribute to the maintenance of this function.

Assessment of Bathing Disability

The Katz Index of Independence in Activities of Daily Living, frequently identified as the Katz ADL, measures normal changes in the declining functional status of older persons (Shelkey & Wallace, 2012). The Katz ADL documents decline or improvement in health status and provides data for planning nursing interventions; it is considered the most appropriate scale to assess a patient's ability to perform ADL independently. Convergent construct validity and test-retest reliability have been established (Hartigan, 2007). The instrument is useful to many caregivers and ranks six ADL functions: bathing, dressing, toileting, transferring, continence, and feeding. Each item scored "yes" (independence, no supervision, direction, or personal assistance) is ranked as 1, and each item scored "no" (dependence, with supervision, direction, personal assistance, or total care) is scored as 0. Total scores are as follows: 6 indicates full function, 4 moderate impairment, and 2 or less severe functional impairment. Each function describes behaviors for 1 or 0. Nurses in diverse settings can use the Katz ADL instrument to determine baseline and changing functional status; however, measures of small increments of change are limited (Hartigan, 2007).

The Bathing Disability Scale was tested during a longitudinal study conducting three comprehensive assessments on community-living persons age 70 and older who initially were nondisabled (Gill, Gahbauer, & Van Ness, 2009). Participants who indicated they needed help from another person with bathing and had difficulty completing bathing were asked about eight specific bathing subtasks: obtaining and using supplies, getting undressed, turning on the water and adjusting the temperature, getting into bathing position, washing the whole body, leaving the bathing position, drying the whole body, and getting redressed. Items were based on an occupational therapy component of a home-based rehabilitation protocol. Degree of difficulty was assessed: 0 (no difficulty at all), 1 (a little difficulty), 2 (some difficulty), 3 (a lot of difficulty), and 4 (help). Scores on the eight subtasks were summed. Construct validity (convergent, discriminant, and responsiveness) and reliability (test-retest, intraclass coefficient [alpha] = 0.76, and internal consistency, [alpha] = 0.9-10.97) were established. The scale could evaluate the effectiveness of interventions to enhance independent bathing. Nurses in acute care agencies can administer the scale to assess patients' ability to perform the various tasks involved in bathing activities.

The National Institute on Aging's Alzheimer's Disease Cooperative Study generated the ADCS-Activities of Daily Living Inventory (Galasko et al., 1997; Galasko et el., 2006) which is available for review (National Institute on Aging, Alzheimer's Disease Cooperative Study, 1999). The items on the instrument include descriptions of each ADL and elicit observed actions or behaviors from raters. It focuses on behavior observed over the last 4 weeks. Contingency questions also elicit observations on sub-questions. In addition to eating, walking, toileting, bathing, grooming, and dressing, other functions are elicited (e.g., use of the telephone, watching television, paying attention to conversation or small talk). The total score ranges from 0 to 78 and the number of Don't Know responses also is tallied. Test-retest reliability (baseline, 1 and 2 months) indicated moderate to very good agreement ([kappa]s = 0.4-0.75). Although the instrument was created for clinical trials, its use for assessing older persons admitted to acute care agencies may be worthwhile.

While various instruments are available to measure disability in performing ADLs, nurses are in a position to select the tool, such as a functional disability scale (Hayward & Krause, 2013), most suitable to their clinical practice. Family members and other caregivers are very interested in determining the progression of Alzheimer's disease so they might predict increasing disability (Gelb, 2000). Nurses caring for patients admitted to acute care agencies could document baseline and serial evidence of progressive disability, and plan interventions accordingly.

Bathing Persons with Dementia: Linking Bathing Disability with Best Practices

Persons with dementia who require assistance with bathing also might be said to have bathing disability. Because bathing disability predicts decline and long-term care admission, nurses and other caregivers might consider the seriousness of this loss of self-care ability. Persons with dementia often are admitted to long-term care facilities because of this, other disabilities, safety issues at home, and nursing care challenges (Ahluwalia, Gill, Baker, & Fried, 2010; Mehta et al., 2011).

Nurses and caregivers in various settings often are challenged by the responses of persons with dementia during bathing activities (Rader et al., 2006). Affected persons might resist efforts of caregivers, sometimes strenuously and aggressively. Such changes of behavior many be considered defiant, troublesome, or disruptive, and patients may be labeled as difficult.

When caregivers bathe patients with dementia, including persons with Alzheimer's disease, multiple cerebral infarction, or other causes, they use many strategies to overcome any resistance to hygienic care. They find bathing very difficult in this personal care situation. Patients who resist hygienic care may display agitation, yelling, screaming, pinching, slapping, or hitting (Berman et al., 2011; Rasin & Barrick, 2004). Many caregivers want to complete the task rapidly, but this is not the best approach to accomplish a reduction in patient or caregiver discomfort with the bath procedure. Gallagher, Hall, and Butcher (2014) suggested using a person-focused approach with the individual with dementia to reduce agitation during this episode of care. This approach consists of fundamental elements such as the following: preparing the patient and environment for the bath, listening to and observing the person and interviewing family members, determining the preferred bathing method (e.g., tub, shower, or bed bath), using persuasion, insuring privacy, pre-medicating with analgesics and allowing time for action, speaking with a pleasant voice, and describing bathing activities prior to performing them. Other specific interventions include engaging the person in purposeful conversation, playing preferred music during bathing, providing verbal cues and tools that are easy to manipulate, and using praise and feedback (Sidani, LeClerc, & Streiner, 2009).

In a classic work by Barrick, Rader, Hoeffer, Sloane, and Biddle (2002), guidelines for bathing persons with dementia initially described the bathing process as a battle. Engaged communication strategies were recommended to request information about patients' preference during bathing, reassure and comfort them, use diversion tactics, ask them to participate, and use humor and compliments. Experts suggested a person-directed approach changes the provider's inclination from getting the task done to meeting the needs of patients. Persuasion helps patients maintain control and participate to the level of their ability (Barrick et al., 2002; Gaspard & Cox, 2012).

Adaptations in the physical environment can contribute to the pleasantness of the bathing experience (Barrick et al., 2002). Occupational therapy interventions can be effective in improving abilities to bathe. In a randomized controlled trial with older adults experiencing some level of difficulty with ADLs or IADLs, Gitlin and colleagues (2006) found participants who received an occupational therapist treatment that consisted of cognitive training (problem-solving, reframing), behavioral adaptations (pace self, sit instead of stand to perform tasks), and environmental modifications (grab bars) had less difficulty with ADLs and IADLs than controls, with largest benefits occurring in bathing (p=0.02) and toileting (p=0.049).

A longstanding feature of occupational therapy interventions has been modification of activity demands. Evidence suggests these strategies can be effective in enabling persons with dementia to participate in self-care. An intervention focus should be on individualizing activities to the highest level of retained skill, using short cues with clear directions, and using environmental modifications and adaptive equipment on the basis of the unique needs of the person with dementia (Padilla, 2011).

Maintaining the privacy of patients during bathing is essential. To meet patients' personal needs, the nurse or other caregiver should focus on comfort and safety (Rader et al., 2006). Padded shower chairs and benches assist patients who are stiff and frail to feel more comfortable (Barrick et al., 2002). Nursing staff need to assemble bathing equipment, prepare the room by running hot water to increase room temperature, and maintain safety in transferring patients (Touhy & Jett, 2014). Music and noise reduction might help to provide a pleasant milieu.

Different strategies for improving the bathing process include keeping parts of the body covered while washing one section at a time; scheduling the bath before patients are dressed for the day, moving slowly and preparing patients for the next movement, starting with the least sensitive area, and patting dry rather than rubbing the skin (Barrick et al., 2002). Some interpersonal strategies consist of calling patients by their preferred names, encouraging self-care, engaging them in conversation, telling patients what is being done at all times, matching language to patients' comprehension, following patients' needs, speaking slowly and calmly, going slowly, and using gentle touch and distractions (Barrick et al., 2002; Sidani et al., 2009). If patients' behavior escalates with crying, screaming, and protests, the nurse or other caregiver should stop the bath, reassess the situation, and postpone bathing (Gaspard & Cox, 2012; Rader et al., 2006; Touhy & Jett, 2014). Nursing staff who tailor care to each person attempt to make sense of patients' behavior, select solutions, and test solutions. Patients might fear being bathed, have lost control of the situation, not trust the provider, find the equipment frightening, are in pain, or be unable to understand they need a bath (Barrick et al., 2002).

Bathing Safety Considerations

Long-term care residents who are bathed with assistance and patients in acute care agencies who bathe themselves may be at risk for scalding and burning from temperatures in shower rooms (Fathers, 2004). Being burned may be due to individual factors, such as cognitive impairment, circulatory problems, and declines in functional ability, including delayed reaction time (Berman et al., 2011; Fathers, 2004). Nursing staff must monitor water temperature during bathing episodes, and validate perceptions of water temperature by patients and dependent residents.

Water in health care agencies may be maintained at high temperatures to kill bacteria. While this alone can be monitored and controlled by nursing assistants and other nursing staff, long-term care residents and acute care patients may be unable to respond rapidly to changes in temperature that may burn their skin (Fathers, 2004). Some individuals may not be able to verify a suitable temperature (Berman et al., 2011). Nursing staff need to check patients who are independent bathers frequently and never leave residents alone in shower rooms. Staff in physical facilities departments can regulate water temperature, but nursing staff must ensure safety at the point of care.

Agitation and subsequent physical aggression during the bath may signal a self-protective response of the individual with dementia to a physical demand or pain during the assistive bathing process. Because these aggressive actions may lead to serious injury for patients or caregivers, training in the use of calming communication strategies is essential in minimizing potential injuries (Hoeffer et al., 2006) as well as discontinuing or adjusting the timing of the bath when indicated (Gaspard & Cox, 2012).


Functional disability and long-term care admission following discharge from an acute care facility (Gill, Gahbauer, Han, & Allore, 2009) are serious concerns for nurses, other health care providers, patients, and families. Moreover, the inability to perform ADLs during acute care hospital stays calls for nursing staff to be alert to the functional trajectory of patients concerning this ADL ability. Using an assessment instrument such as the Bathing Disability Scale (Gill, Gahbauer, & Van Ness, 2009) can alert the staff of the presence and severity of the bathing disability. They then may consider nursing interventions that support maintenance of self-care performance. However, when older persons enter long-term care facilities following acute care admissions, continuous disability is a likely and serious outcome (Gill, Gahbauer, Han et al., 2009).

A referral for rehabilitative services may be appropriate, especially when the patient exhibits a new onset disability (Mehta et al., 2011). For example, occupational therapy interventions can improve the person's ability to self-bathe with environmental modifications and adaptive equipment related to the bathing process (Zingmark & Bernspang, 2011). Early interventions may prevent further decline and disability. Bathing disability may signal nurses caring for patients in acute care settings that persons who entered the hospital able to perform this ADL independently now have evidence of functional decline. Because of the seriousness of this loss of ability, nurses must implement interventions to assist patients to accomplish self-bathing tasks to the highest level of their ability.


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Zane Robinson Wolf, PhD, RN, FAAN, is Dean Emerita and Professor of Nursing, School of Nursing and Health Sciences, La Salle University, Philadelphia, PA.

Kathleen E. Czekanski, PhD, RN, CNE, is Associate Dean of Nursing Programs and Associate Professor, School of Nursing and Health Sciences, La Salle University, Philadelphia, PA.
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Title Annotation:CNE SERIES
Author:Wolf, Zane Robinson; Czekanski, Kathleen E.
Publication:MedSurg Nursing
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2015
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