25: Late Stages: Personal Care

This program will discuss:

  • Bathing, dressing, grooming, tooth brushing, and incontinence care for the late and end stage individual with dementia
  • The changes in functionality that occur during the late stages of Alzheimer’s
  • Present principles and strategies for providing quality personal care
  • There are no easy answer when its comes to the care of another
  • Our hope is to offer you useful information and guidelines for caring for someone with dementia
  • These guidelines will need to be adjusted to suit your own individual needs
  • Late and end stages of Alzheimer’s disease require significant hands-on care
  • Severe cognitive and functional decline occur
  • Require assistance with personal care
  • Urinary and fecal incontinence increase
  • Severe disruption of the sleep cycle
  • Personality changes and behavioral symptoms
  • Wandering and getting lost can still be concerns
  • Problems arise in bathing, grooming, dressing, toileting, self feeding, and mobility, which can lead to frustration and difficult behaviors
  • Individuals will require assistance with bathing, dressing, mouth care and toileting
  • They will need a wheel chair if they are able to get out of bed
  • Eventually end up bed bound and require complete bed care
  • Physical health declines rapidly
  • Lose their ability to respond to the environment and to speak
  • Muscle rigidity and abnormal reflexes develop
  • Difficulty swallowing
  • Hospice care may be set up to make the person comfortable during the last days
  • Apraxia: loss of ability to perform routine skills
  • Stored skills
  • Motor execution of skills
  • Loss of organizational skills
  • Agnosia: ability to recognize people, objects and places
  • Aphasia: inability to understand words

Physical:

  • Cold, fatigue, weakness
  • Arthritis
  • Pain from medical condition
  • Reduced mobility

Environment

  • Unfamiliar people, objects, sounds and smells
  • Too much noise and clutter
  • Uncomfortable environment
  • Harsh water sprays
  • Fear of falling

Psychological

  • Fear and confusion
  • Anxiety and apprehension
  • Misunderstanding
  • Previous negative experiences
  • Agitation and combativeness
  • See the person beyond the diagnosis
  • Tune into the person’s needs, personal preferences and life history
  • Acknowledge frustrations
  • Respect dignity
  • Never force a person to do something
  • Consider comfort and preferences
  • Focus on the person rather than the task
  • What could be done to improve this situation?
    • A. Mary could reduce the frequency of Robert’s baths.
    • B. Mary could cover Robert with a blanket or towel and raise the room temperature before undressing him.
    • C. Mary could give Robert his pain medication for his arthritis at least a half hour before the bath.
    • D. Mary could schedule Robert’s bath for after his breakfast.
    • E. All of the above.

Choice A: Mary could reduce the frequency of Robert’s baths, is a very good choice. Bathing or showering once or twice a week with spot cleansing when soiled is usually adequate

  • Choice B: Mary could cover Robert with a blanket or towel and raise the room temperature before undressing him, is another good choice.
  • Older people are very sensitive to cold
  • Set a comfortable room temperature
  • Covering Robert with a towel or blanket as he is being undressed would prevent chill and respect his privacy

Choice C: Mary could give Robert his pain medication for his arthritis at least a half hour before the bath, is another good choice.

  • Proper pain management is very important for quality of life

Choice D: Mary could schedule Robert’s bath for after his breakfast, is also a good answer.

  • Resistance to bathing could be because of unmet needs or wants

Choice E: All of the above, is the best answer.

  • 1-2 times/wk unless soiled
  • Make it pleasant and relaxing
  • Practice person-focused care
  • Timing and method based on preference
  • Allow plenty of time
  • Respect privacy
  • Allow the person to do as much as possible
  • Large bathing or showering area accessible from at least 2 sides
  • Non-slip surface and dry floors
  • Nonskid floor mats/bathmats on tile floors
  • Safety strips or nonskid bathmats in bathtubs and showers
  • Avoid bath products that will make the bathtub slippery
  • Rubberized or unglazed ceramic tile floors in showers
  • Carpet of a single color on floors

Organization

  • Simplify the environment
  • Remove clutter or obstacles on the floor
  • Label and lock away cleaning products and other harmful substances
  • Make sure door locks can be opened from the outside
  • Or remove, disable door locks
  • Shower and bathtub chairs and benches should have padded seats and backs
  • Non-fixed chairs should have non-slip grippers on the feet
  • Sling seats
  • Fold-down chairs
  • Handheld shower head
  • Hand rails and grab bars
  • Sturdy, stable furniture and doors
  • Provide bright overhead and task lighting
  • Reduce glare
  • Wall and floor colors should contrast
  • Use grab bars
  • Step over with assistance
  • Have person sit on edge and swing legs over
  • Consider using a transfer bench
  • Consider overhead trapeze
  • Drain tub first and avoid oily products
  • Consider a sling seat
  • Consider commercial tubs with side doors
  • Provide non-slip floor covering
  • Water temperatures greater than 120 oF can cause burns
  • Comfortable bathwater is usually around 100F
  • If using water heated above 114 oF, consider installing some form of anti-scalding device
  • Anti-scald devices reduce water flow to a trickle when the output water temperature exceeds a set limit
  • Install single lever faucets
  • Clearly label hot and cold taps
  • Start running the cold water first, and then add the hot water
  • Place soft (childproof) covers on faucet taps
  • Have the bathroom prepared prior to bringing in the person
  • Fill the tub before the person enters the room
  • Drain the tub before the person steps out
  • Consider comfort on the way to the bathing area
  • Set a comfortable room temperature
  • Cover exposed areas
  • Warm towels and robe
  • Familiar caregiver with a pleasant, calm manner
  • Familiar and pleasant objects
  • Calming, favorite music
  • Relaxing fragrances
  • Good lighting, without glare or shadows
  • Cover or remove mirrors if necessary
  • Planned and organized the activity before hand
  • Best time of day
  • Familiar bath accessories
  • Used effective communication
  • Smiled, made eye contact, oriented him to the activity
  • Used short, simple directions
  • Said the important word last
  • Used gentle, appropriate touch
  • Used cues when necessary
  • Engaged him in the activity
  • For ambulatory persons
  • Sponge baths can be done in a plumbed lavatory or at a free standing basin of water
  • A shower chair can be placed in front of the basin or in a lavatory
  • Allow them to wash their own private parts if able
  • If not, they can be seated on a shower chair and given assistance
  • Wear gloves
  • Use a separate washcloth or sponge to wash the genital area
  • Pour clean water over the area

Recommended Supplies

  • 1 or 2 bath blankets or large towels
  • 2 or more bath towels
  • 3 or more washcloths
  • No-rinse or tear-free soap for body and hair
  • 2 to 3-quart basin of water, approximately 105°F (In a professional care facility, fill water in a plastic bag within a basin or pitcher)
  • Second basin of water for rinsing if needed
  • Separate basin for hair-rinsing if needed
  • Start with the person’s face, keeping the rest of the body completely covered
  • Fold a warm washcloth into a “mitt” to gently cleanse the face
  • Continue rinsing the washcloth in the basin
  • Blot dry the face and apply moisturizing lotion
  • Expose one arm and shoulder and cleanse and dry
  • If you prefer, place the basin on the bed and place the person’s hand in the water while you wash the rest of the arm, then wash the hand
  • Repeat with other arm
  • Refresh the water in the basins if necessary
  • Next cleanse the upper torso
  • Keep the person covered except for the area being washed
  • Wash the armpits and under any folds of skin
  • Blot dry and then cover the upper torso
  • Proceed to cleanse the abdomen and then cover it
  • Next expose one entire leg and wash the thigh and lower leg
  • Blot dry the leg and cover it
  • Massage the foot in the basin as you cleanse it
  • Dry the foot and between the toes
  • Repeat the procedure on the other side
  • Pressure from lying in bed or sitting for long periods, perspiration and incontinence may cause irritation, pressure, ulcers, “bed sores”, and infection

Click here for additional information about bed sores

  • Avoid harsh soaps
  • Blot dry
  • Use moisturizing lotion
  • Observe skin for rashes, burns, sores, and other breakdown
  • Use simple, short directions with the important word last
  • Cue and guide as needed
  • If reluctant, assess for unmet needs
  • Distract and then start by assisting
  • Leave and return a few minutes later
  • Respect privacy and preserve dignity
  • Use effective communication skills
  • Plan and organize
  • Consider comfort and preferences
  • Consider safety issues
  • Use the time to give exclusively to that person
  • Appearance is important for self-esteem
  • Encourage self-care
  • Promote autonomy
  • Offer some choices
  • Dressing requires
  • Fine and large motor skills
  • Where the clothes are
  • Knowing occasion and weather
  • Don’t force or rush–be patient
  • Clothes without many buttons or fasteners
  • Velcro fasteners or elastic waistbands
  • Stretchable and open on the front
  • Dresses easier than slacks
  • Easy to launder
  • Lay clothes out in order they should be put on
  • Layer clothing
  • Have several of the preferred garment or style
  • If insistent about clothing, leave it alone
  • Short nightgowns and pajama bottoms
  • Warm, comfortable clothes
  • Shoes not slippers

Click here to links to websites that offer special clothing

  • Disrobing inappropriately
  • Wrong choice for season
  • Layering of clothes
  • Refusal to remove clothes
  • Be reassuring and respectful
  • Ensure privacy
  • Be flexible
  • Hair care
  • Shaving
  • Nail care
  • Foot care
  • In the shower or bathtub
  • Seated in a chair
  • Use a handheld showerhead/nozzle
  • Place a towel over the eyes or forehead
  • Tilt head back
  • Use as little shampoo as possible
  • Angle water away from the face
  • Use a tear-free baby shampoo
  • Postpone shampooing if the person is fatigued
  • At the sink
  • Lean the person’s head backward over the sink
  • Use a rolled up towel to support the neck and shoulders
  • Use a tear-free shampoo
  • No-rinse shampoo
  • Dry shampoo
  • Offer cueing and guiding to brush and rinse if needed
  • Find a toothbrush that is easy to handle
  • If confined to bed, assist to brush and rinse
  • Use a kidney-shaped basin to catch water running out of the mouth
  • Gently help the individual turn the head to one side, hold the basin against her or his cheek
  • Rinse out the mouth
  • Drink water
  • Moist swabs
  • Mouth moisturizer
  • Consult a dentist about dental issues
  • Incontinence is part of Alzheimer’s disease
  • Initially due to confusion
  • Loss of functionality
  • Declining mobility
  • Beware of skin breakdown and infections
  • Treat matter-of-factly
  • With reassurance
  • Without blame or teasing
  • Assess when, where, and how
  • Watch for signs of restlessness
  • Keep a consistent, frequent toileting schedule
  • Provide clothes easy to manage
  • Avoid caffeine and liquids late at night
  • Dressing is a part of self-identity
  • Offer some choices and encourage self-care
  • Provide clothes that are easy to manage
  • Organize the clothes
  • Respect modesty and privacy
  • Determine the reason for inappropriate behaviors and address any needs
  • Hair care, shaving, nail care, and foot care are important
  • Shampooing can be done in the shower or bathtub, at a sink, or in bed
  • No-rinse and dry shampoos are alternatives
  • Oral care can involve tooth brushing, rinsing the mouth, wiping with wet swabs, and drinking water
  • Incontinence
  • Can contribute to skin breakdown and infections
  • Watch for signs that may precede episodes
  • Keep a frequent toileting schedule
  • Avoid caffeine and liquids late in the evening
  • When changing the bedding for individuals who are bedbound, keep in mind ther safety and comfort when positioning them

Written by:
Catherine M. Harris, PhD, RNCS.
Mindy J. Kim-Miller, MD, PhD

Edited by:
Sasha Asdourian

www.LightBridgeHealthcare.com

24: Late Stages: Hospice & Bereavement

Select the best answers from the list of choices following each question.

Click here to open Certificate of Completion
  • Allen RS, Burgio LD, Fisher SE, Hardin JM, & Shuster JL, (2005). Behavioral characteristics of agitated nursing home residents with dementia at the end of life. The Gerontologist 45: 661-666.
  • Bayles, K.A., Tomoeda, C.K., Cruz, R.F. & Mahendra, N. (2000). Communication abilities of individuals with late-stage Alzheimer Disease.Alzheimer Disease and Associated Disorders, 14 (3), 176-181.
  • Bernick L, Nisan C, Higgins M. (2002). Care of the body: maintaining dignity and respect. Perspectives.;26(4):10-4.
  • Boyd CO and Vernon GM. (1998). Primary care of the older adult with end-stage Alzheimer’s disease. The Nurse Practitioner. 23 4:63–83.
  • Broton, M., & Koger, S.M. (2000). The impact of music therapy on language functioning in dementia. Journal of Music Therapy Association,37 (3), 183-195.
  • Dougherty J, Long C. (2003). Techniques for Bathing Without a Battle. Home Health Nurse. 21(1):38-9.
  • Dunn JC, Thiru-Chelvam B, Beck CH. (2002). Bathing. Pleasure or pain? J Gerontol Nurs. 2002 Nov;28(11):6-13.
  • Eisdorfer C, Cohen D, Paveza GJ, et al. (1992). An empirical evaluation of the global deterioration scale for staging Alzheimer’s disease.American Journal of Psychiatry 149(2):190–194.
  • Ekman, S., Norberg, A., Viitanen, M. & Winblad, B. (1991). Care of demented patients with severe communication problems. Scandinavian Journal of Caring Science, 5 (3), 163-170.
  • Ekman, S., Wahlin, T., Biitanen, M., Norberg, A., & Wiknblad, B. (1994). Preconditions for communication in the care of bilingual demented persons. International Psychogeriatrics, 6 (1), 105-120.
  • Epps, C.D. (2001). Recognizing pain in the institutionalized elder with dementia. Geriatric Nursing, 22 (2), 71-77.
  • Gill TM, Naik AD. (2005). Underutilization of environmental adaptations for bathing in community-living older persons. J Am Geriatr Soc.Sep;53(9):1497-503.
  • Gleeson, M. & Timmins, F. (2004). Touch: a fundamental aspect of communication with older people experiencing dementia. Nursing Older People 16 (2), 18-21.
  • Gotell, E., Brown, S., & Ekman, S. (2002). Caregiver singing and background music in dementia care. Western Journal of Nursing Research,24 (2), 195-216.
  • Hoeffer, B; Talerico, KA; Rasin, J; et al. (2006). Assisting cognitively impaired nursing home residents with bathing: Effects of two bathing Interventions on Caregiving. The Gerontologist 46(4) 524-532.
  • Hoffman, SB & Kaplan M. (1996). Special care programs for people with dementia. Health Professions Press.Baltimore.
  • Kim, W.J., & Buschmann, M.T. (1999). The effect of expressive physical touch on patients with dementia. International Journal Nursing Studies, 36 (1999), 235-243.
  • Kovach CR, Meyer-Arnold EA. (1997). Preventing agitated behaviors during bath time. Geriatr Nurs. 18(3):112-4.
  • O’Donovan, S. (1996). A validation approach to severely demented clients. Nursing Standard. 11 (13-15), 48-52.
  • Prigerson, HG (2003). Costs to Society of Family Caregiving for Patients with End-Stage Alzheimer’s Disease. N Engl J Med. 2003 Nov 13;349(20):1891-2.
  • Rader J, Barrick AL. (2000). Bathing without a Battle. Alzheimer Care Quarterly 1(4) 35-49.
  • Rader J, Barrick AL,Hoeffer B, et al. The bathing of older adults with dementia: Easing the unnecessarily unpleasant aspect of assisted bathing. Am J Nurs. 106(4):40-8.
  • Sally Planalp a; Melanie R. Trost (2008). Communication Issues at the End of Life: Reports from Hospice Volunteers Health Communication.23(3):222 – 233.
  • Sloane, PD, Hoeffer B, Mitchell M, McKenzie DA, et al. (2004). Effect of person-centered showering and the towel bath on bathing associated aggression and discomfort in nursing home residents with dementia: A randomized controlled trial. Journal of the American Geriatrics Society 52: 1795-1804.
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