Daily routines are sacred for most people. When caring for individuals with dementia, sticking to a routine is not only sacred, but a necessity. Since change is difficult for individuals with Alzheimer’s disease and related illnesses, a structured schedule can meet two objectives: relieving caregiver stress and helping individuals maintain their abilities.
Involve the individual in daily tasks. Disrupting his usual habits may result in an inability to perform that activity. For example, if you begin dressing him, he might soon forget how to dress himself. Participation also helps to maintain the person’s self-esteem. Be realistic about what the individual can do given his degree of impairment. This will result in less frustration on both your parts. Bathing should follow the individual’s routine prior to onset of the disease unless specific hygiene needs arise. If they previously showered in the evening, they should continue that pattern. However, keep in mind that changes may be necessary due to the progression of the disease.For example, someone who normally bathes at night might have to switch to the morning if they wake up soiled or if they are experiencing “sundowning,” or behavioral problems toward evening. Repeating the same act may be meaningful for the individual and provide relief of tension. For example, he may spend 20 minutes tearing a tissue or wiping the kitchen counter. If the activity does not seem to be upsetting him, let him continue. If it upsets you, try to gently redirect his activity by giving him something else to do. Be consistent. If you say that you are going to do something, follow through with it.
Bathing is a complex activity of daily living composed of several phases: undressing, introduction into the shower or tub, washing, drying and re-dressing. Recognizing a person’s abilities and preparing ahead of time can help simplify the process.
- Most older individuals retain a sense of modesty and resist undressing; this is a normal response.
- Frightened, disoriented individuals may not recognize the family or professional caregiver.
- They may have forgotten how to undress, wash or dry themselves, or redress.
- Individuals, especially those who are visually or hearing impaired, recovering from recent medical problems or on certain medications, are at risk of falling.
- Shower and bathtub surfaces can be dangerous’”cold, hot or slippery.
- An individual, especially in the middle to late stages, may forget how to pick up their legs or sit in a bathtub.
- Someone can become alarmed during any part of the process and attempt to flee.
- Give one-step instructions in short, simple terms, and go slowly.
- Communicate with non-verbal cues to help the individual understand.
- Remember to provide privacy, and ensure dignity.
- Be reassuring since concern over modesty also may increase agitation.
- Approach the individual from the front whenever possible.
- Make sure the room temperature is appropriate for disrobing.
- Smile, speak calmly and do not express any frustration.
- Remove the bathroom door lock for safety.
- Do not leave the individual unattended in the bath area.
- Minimize safety risks by installing a no-skid surface and grab bars.
- Try the shower instead of the tub, or vice versa, if someone becomes afraid of either.
- Keep the individual in a bathrobe until they are in the bathing area.
- Make sure the individual uses the toilet prior to bathing to prevent accidents during or after the bathing process.
- Secure soap, towels and other bathing items in advance.
- Ensure appropriate water temperature, especially to prevent scalding.
- Keep the individual in a warm room until they are completely dry and clothed.
- Lay out clothing in advance to proceed quickly from drying to dressing.
Be flexible. Bathing does not have to occur daily. If the regular routine stops working, try sponge baths, switch to every other day or change the time of day.
- Loss of communication skills and motor coordination makes the process difficult.
- Too many choices of clothing can be confusing and frustrating.
- Clothing may be difficult to put on or remove due to zippers, buttons, etc.
- Encourage the individual to dress himself to whatever extent possible.
- Intervene when attempts at self-dressing are not working.
- Recognize the need for a sense of dignity.
- Set a daily routine; try to have the individual get dressed at the same time each day.
- Do not rush the process.
- Give one-step instructions if the person needs prompting.
- Limit the choice of outfits to two.
- Clear closets and drawers of excess clothing to reduce confusion.
- Provide loose-fitting, comfortable clothes with elastic waistbands.
- Lay out the articles of clothing in the order they are to be put on.
- Use a consistent method of helping the individual dress each day. For example, first dress their upper body and then the lower body. If the individual can still dress himself, hand him one article of clothing at a time in the same order each day.
- Use gestures to show the individual what to do.
- Do not argue if they want to repeat the same outfit.
- Has the individual forgotten how to feed himself?
- Do they have trouble chewing or swallowing?
- Are they having problems with dentures or gums?
- Have they lost the ability to taste?
- Is the individual having coordination problems, such as difficulty in using the silverware?
- Are there co-existing medical or psychiatric problems, such as ulcers, depression or delusions, that are causing loss of appetite?
- Do they seem disinterested in eating?
- Is the person fearful at meal times? For example, do they say or think that the food is poisoned?
- Are they unable to ask for food?
- Do they dislike the food?
- Is there too much noise or other environmental stimuli?
- Do they eat only sweets, or like to eat them first?
- Are they filling up on fluids?
- Are other residents in a group setting eating the individual’s food?
- Consult a physician to detect any medical causes.
- Seek a swallowing assessment from a speech therapist if the person is regularly having trouble chewing and swallowing.
- Have the individual sit in an upright, comfortable position.
- Try to have them eat with others to increase socialization and make mealtimes more pleasant.
- Check that their mouth is empty, especially if they hoard food or cigarette butts.
- Make sure they have their glasses, dentures, hearing aids or any other appliances they need.
- Prompt or feed those who can’t feed themselves (apraxia).
- Give the individual food they like and adequate snacks.
- Provide nutritional supplements if there is significant weight loss.
- Present one item at a time if the person seems confused by too much food in front of them.
- Consider moving food to a different location on the tray or table.
- Serve the drink last if the individual drinks too much and will not eat.
- Serve pre cut or finger food, if using utensils becomes difficult.
- Keep stressing that the food is safe if the individual believes it is poisoned.
- Reassure the person that you will make sure they are well fed.
If someone loses five pounds within a month or 2.5 pounds in two consecutive weeks, aggressive intervention should be undertaken to prevent further weight loss and to help them gain the weight back.
- Medical problems, such as enlarged prostate glands and urinary tract infection, or medication side effects.
- An individual cannot remember where or what the bathroom is.
- Loss of verbal skills makes them unable to express their needs.
- Clothing is hard to remove in time.
- Individuals are not able to perceive internal signals for urination.
- Treat the individual with respect and dignity.
- Be understanding and reassuring when accidents occur.
- Establish a routine; for example, take the person to the bathroom every two hours while they are awake.
- Try to respond quickly to an individual’s request for the bathroom.
- Watch for non-verbal cues, such as facial expressions or tugging on clothing.
- Put up signs (with illustrations) to indicate the bathroom door.
- Use easy-to-remove clothing, such as those with elastic waistbands.
- Avoid caffeine and other stimulants in the evening.
- Continue to let ambulatory individuals use the bathroom, even if they are managed with adult continence products, until such efforts are counter-productive, e.g., the individual fights during attempts to place them on the toilet.
- Do not give liquids a few hours before bedtime.
- Place a commode in the bedroom at night for easy access.