Home Health Care From “Grazers” to “Continual Bathers”—Practical Approaches to Meet Hygiene Needs of People With Late Stage Dementia

From “Grazers” to “Continual Bathers”—Practical Approaches to Meet Hygiene Needs of People With Late Stage Dementia

by Robert Maxwell
written by
older woman getting her hair washed

In a previous post, I outlined the concept behind my Grazers Program for clients with dementia. Grazers sets the framework for a collaborative facility approach to managing deficits in attention and wandering behavior common for people with late-stage dementia. These behaviors can lead to unintentional weight loss and compromised nutritional status, so I came up with Grazers to meet those patients where they are with healthy snacks.

If speech-language pathologists can teach caregivers ways to successfully engage people with late-stage dementia and increase their nutritional opportunities throughout the day, why can’t we apply this concept to other areas, such as bathing? Luckily for us, we can!

As a complementary program to Grazers, I introduced the concept of “Continual Bathers.” My goal with this program is to help caregivers view the act of bathing as a process that can also be segmented and completed over a longer period, possibly reducing stress and refusal of care.

Just like the Grazers program, the Continual Bathers program uses an initial episode of skilled intervention by an SLP, with an occupational or physical therapist, as needed, to determine functional barriers to bathing. Then, we apply a continual bather approach for clients who experience adverse reactions to assisted bathing. In this approach, I view the act of bathing as a large task with multiple sub-components that patients can complete in isolation.

So what would a typical Continual Bather day look like?

First, envision a traditional approach: The resident is told they have to take a shower now and is then escorted to the facility shower area. Care extenders begin undressing the client and start the assisted bathing process only to get resistance and verbal protests. Sound familiar?

What if we instead relied on increased environmental context and pre-existing opportunities to promote multiple opportunities for hygiene throughout the day, and still achieve the same result as a traditional shower?

Take, for example, Mrs. Smith. She continually refuses to bathe by routinely insisting she doesn’t need a shower or she already took one, even though we know she didn’t. Instead of the traditional approach, we examine the available facility environments and resources and proactively plan interactions to offer the maximum amount of contextual cues to normalize the desired interaction. So, as Mrs. Smith wanders the unit, a facility staff member prompts her to see the facility salon and gestures for her to enter. Before anyone speaks a word, the surroundings set the stage and begin the process.

Mrs. Smith sees the salon chair and other residents getting hair and nails done, and immediately has context for the activities taking place in this setting. This helps normalize the contact and what’s about to occur. Depending on her cognitive-linguistic status, use verbal cues, such as, “Let’s get you in for your appointment,” or “It’s time to fix your hair/make up/nails like you wanted,” to further set the stage. In this scenario, words simply reinforce the message already generated by the environment.

You and I experience this same phenomenon daily. If you walk into a large room with a table and see paper plates, plastic silverware, snacks and drinks sitting on a table with flowers, then you immediately understand a party is about to occur. Take that same room, stage the table with a conference-style phone, note pads, pens and water glasses and we anticipate a meeting. Our perception of the environment sends powerful signals as to what is about to occur and gives us all context.

Now that Mrs. Smith has context, let’s see what portions of the overall bathing process we can tackle in this environment. We can use this opportunity to wash her hair and ask her to or help her wash her face and neck in preparation for make-up. Or we can suggest simply taking care of her beautiful skin and thoroughly cleaning her hands and arms as we prepare her for new nail polish. Staff can accomplish this with a washcloth and warm water or by using no-rinse bathing products.

Later in the day, activities staff can jump in with a pedicure party using the same salon environment. This activity provides a chance to wash feet and legs thoroughly in preparation for nail polish. Again, the presence of other residents engaging in the same activity, and visual feedback from the salon setting create context for patients. Pair the salon setting with other hygiene maintenance, such as podiatry rounding, if available in your facility.

In addition to these strategic attempts to complete elements of bathing throughout the day, nursing assistants can also be trained to take advantage of naturally occurring episodes. Use the bathroom-assistance process, for example, as an opportunity to clean all areas of exposed skin rather than just the required hygiene.

When you add up all these continual bather components, we’ve washed hair, face, neck, hands, arms, feet, legs and areas exposed during bathroom breaks. Isn’t that what we attempt to achieve during traditional assisted bathing?

Robert Maxwell, MA, CCC-SLP, is a regional clinical director for Genesis Rehab Services. He chairs the dementia special interest group for Genesis Rehab Services and has presented on the company, local, state and national levels on cognitive-linguistic and swallowing deficits related to people with dementia. He is an affiliate of ASHA Special Interest Group 15, Gerontology. Robert.Maxwell1@genesishcc.com



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Sujata Martin March 9, 2018 - 7:33 am

Activity Analysis (breaking down a task into its component steps and adapting each step to meet client needs) is the heart of Occupational Therapy intervention. What is described in the blog is the essence of what an OT would recommend with the hypothetical client mentioned.
I’m curious as to what skilled intervention an SLP can provide for improving the situation described in your blog that can’t be addressed directly by an OT; and instead necessitates a SLP’s skill base with “an occupational or physical therapist, as needed, to determine functional barriers to bathing”.

Julie Pelzel March 10, 2018 - 10:23 pm

I think SLPs have a unique role in understanding the communication barriers that undermine successful execution of many ADLs. I agree that the task anaylsis utilized by OTs for determining physical and cognitive barriers is absolutely essential when crafting a plan of care that addresses ADLs, and an OT should always conferred with when a patient is demonstrating decreased independence in these areas. However, SLPs also use task analysis to determine how caregivers can modify their spoken language and body language to create successful environments for these patients. Therefore, it is absolutely a skilled service. Our facility OT often refers to me, the SLP, and vice versa. I think at the end of the day, a strong collaboration between the two disciplines is what we should strive for to practice at the top of our license.

Robert Maxwell March 12, 2018 - 2:31 pm

Remember that in both the Grazer and Continual Bather examples given the assumption is that skilled intervention has already been provided by the skilled IDT. ST/OT/PT have already assessed, identified and provided intervention in their respected areas. Task segmentation and staff training has been completed, physical barriers have been addressed and necessary modifications to functional communication have been implemented. Both of these programs offer a means for facility staff to continue/maintain recommended strategies post DC. It is our responsibility to assist staff in developing a framework to maintain functional gains and strategies even when we are no longer involved in cases directly. In addition, despite attempted skilled intervention there are many clients with dementia that we will encounter who will need on-going direct cueing. These formats can help give a more structured approach when needed. In all cases STs should act as part of a larger IDT and utilize the resources available in the client’s environment. In all scenarios, however, we should take the lead in the area of functional communication which is vital to all assisted ADLs and interactions.

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