Caregiving Challenges, Bathing and Toileting Your Loved One

Helpful Highlights

• Bathing, grooming, and hygiene can be a very different experience for older adults, especially those with confusion or memory loss.

• Older adults cannot describe their concerns about bathing and their fears may seem irrational to us, resulting in our frustration.

• Patience and kindness, both with yourself and your loved one, are essential to a positive and productive bathing experience.

• Toileting is what it is, but we have some helpful hints.

Bathing, grooming, and hygiene - is there a difference?

Yes, there is a difference, though they are commonly referred to as just "bathing." Bathing, grooming, and hygiene are considered activities of daily living (ADLs) and are often grouped together.

• Bathing: Wasing the body surfaces, including hands, feet, face, and private areas, and washing hair.

• Grooming: Activities such as shaving, beard and mustache maintenance, hair care and styling, and applying make-up. Grooming is also commonly paired with another ADL - dressing.

• Hygiene: Eye and ear care, brushing teeth and oral care, applying lotions and powders, and nail care. Note that hygiene always includes regular hand washing!

Bathing and hygiene are just as important in older age as they are in any other time of life. Bathing twice a week is sufficient for most older adults, though bathing should be done more often if needed. Oral care should be performed daily.

The aging process

As we age, the powerful protective barriers that are our skin and mucous membranes weaken dramatically.

• Moisture decreases

  • Excessively dry skin can cause itching (and scratching), eczema, and flaking that can visibly collect on materials and surfaces causing embarrassment, as well as cracking and bleeding that is painful and increases the risk of infection.

  • Dry eyes can cause redness, itching, swelling, and/or pain, increased risk of eye infections, abrasions to the cornea and corneal ulcers, and reduced vision.

  • Dry mouth can cause lip and mouth cracking and sores, thrush (yeast infection of the mouth), increased plaque, tooth decay, gum disease, and poor nutrition from chewing or swallowing problems.

• Sloughing slows down

• Surface pH (acidity) changes

• Layers of the skin become thinner

• Connective tissue breaks down causing skin to "slide"

• Healing time increases

• Teeth and gums deteriorate

The importance of bathing and what we take for granted

As we age, washing everywhere - under folds, in crevices, and in hard-to-reach areas - is more difficult. For those who have confusion or memory loss, washing everywhere can be nearly impossible without assistance.

There does not have to be obvious soiling or an open wound for older adults to be at risk for infections and other problems from not bathing.

The bathing experience - knowledge

• For older adults, bathing can be quite tasking.

• They don't wish to be a burden, so won't ask for help.

• They may worry about their safety while bathing, so they avoid it.

• Those with confusion or memory loss may fear water (see Helpful Guide on Dementia-Related Fear of Water, Refusal to Bathe)

• Shower benches, non-slip mats, and grab bars should be used.

The bathing experience - skills

• It is best practice to start at the center of the body (private areas first, then the torso) and work outward, finishing with hands, feet, and finally face. However, when bathing the older adult, it is better to start with the face, hands, and feet and work toward the center (torso then private areas). But why?

  • Your face remains where your loved one can see it.

  • Washing hands and feet first promotes security (trust) and relaxation.

  • It encourages your loved one to help if they wish.

  • It helps prevent them from getting cold, especially if bathing takes a while because their core and head can be covered.

  • It's physically and mentally stimulating (we have the most nerve endings in our face, hands, and feet).

Intimacy vs. embarrassment - reframing the approach

Rushing through showering or bathing is commonplace for many of us; however, it can provoke anxiety, fright, and even anger in older adults.

• Commit to taking your time.

• Prepare the bathroom and bathing space with everything you need ahead of time.

• Preserve their dignity and modesty by covering the things you can when you can, and letting them choose how they want to position themselves.

  • If your loved one prefers the bath - use bubbles to cover things!

• Use the time to demonstrate your love for them.

  • If you approach them with irritation, they will respond to it.

  • If you approach them with care and affection, they will respond to it.

• When necessary, consider replacing showing/bathing with a basin and washcloths* or prepackaged bathcloths. (*Note that washcloths should only be used once and then set aside. Rinsing and reusing washcloths that have already touched the body contaminate the basin water. Therefore, you will need several.)

• Lean into intimacy rather than trying to avoid embarrassment.

• There's also no need for constant talking. Some people do this to cover awkwardness. It's best to explain what you're about to do, and then be quiet while doing it.

Toileting

Well, let's face it, there's really no way to make toileting an intimate and caring experience, though it is a tremendous act of love. So, we'll just offer some helpful hints:

• Let your loved one do as much as they can to remove garments and get seated on the toilet. Likewise, let them do as much as they can to rise off the toilet and replace garments.

• Do not remain in the bathroom with them while they're on the toilet unless absolutely necessary. Give them privacy.

• Do not make them call for you when they're finished like a child does. Stay by the bathroom and check on them periodically. Over time, you will know when they're finished.

• The only toileting smells we tolerate are our own and our children's, so when you enter the bathroom, remember to remain pleasant. Don't wrinkle your face, gasp or grunt, or comment on the odor.

• Glove up. (DO NOT flush gloves.)

• Use wipes instead of toilet paper. (DO NOT flush wipes, even if they say "flushable"!)

  • They clean better, don't stick, and you'll probably save yourself repeated wiping.

• Flush immediately after they rise (but do not flush while they're still seated, the cool vacuum feeling is uncomfortable).

• Both of you wash your hands afterward.