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

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