How to Solve Hygiene Problems Common to People with Dementia

Odd or frustrating behaviors around clean clothes, bathing, oral care, hairstyling, and shaving seldom come “out of nowhere.” Usually there’s a trigger, and ways to work around it.
Dementia Hygiene Problem: Wears Same Dirty Clothes Over and Over
Possible causes
the person:
• Forgets the clothes are dirty after they’re removed (so they never go in the hamper or wash).
• Has impaired ability to make judgments.
• Likes the familiarity.
• Is overwhelmed by too many choices while dressing.
• Prefers solid colors over busy patterns, which can be distracting or annoying.
What to do
• Avoid pointing out that clothes being worn are dirty, which puts the person on the defensive and sets up an argument she doesn’t understand.
• Ask yourself if you’re bothered by the repetition of the outfit or by actual dirt or odor. (A couple of generations ago, people didn’t change clothes every day.)
• Pare down the closet to fewer options. Stock solids in favorite colors instead of patterns.
• Buy an identical replacement for favorite outfits (same color, style) so you can wash one while the other is being worn.
• Remove soiled clothing from the room at night once the person is sound asleep. She’ll forget about it the next morning if there’s something else handy to put on.
Dementia Hygiene Problem: Forgets to Bathe
Possible causes
the person:
• Has memory loss that makes her unable to keep track of or care about bathing.
• Feels confusion about the sequence of steps involved.
• Feels juvenile, anxious, or defensive when asked or reminded about bathing.
What to do
• Stick to a consistent bathing routine. Make it the same time the person previously bathed (first thing in the morning, right before bed).
• Don’t remind or even mention how long it’s been since the last cleanup. Instead of arguing, proceed with bath preparations.
• Don’t ask, “Did you shower?” or “Would you like to shower now?” Get everything ready and invite the person in: “Look, your bath is ready. I know how you love your evening bath.”
• Try leading the person to the bath unexpectedly, on your way to doing something else. Or lead the way to the bathroom but without talking about a bath.
• Have everything ready so you don’t leave the person alone, as she may abandon the idea.
• Don’t worry about a full daily bath or shower. Bathe weekly and “top and tail” (face, genitals) as best you can the other days.
Dementia Hygiene Problem: Refuses to Bathe
Possible causes
the person:
• Has depression.
• Is embarrassed being seen naked.
• Had a previous upsetting experience (slipped, the water was too hot, it took too long, she got chilled).
• Has fears (of falling or drowning).
• Dislikes being told what to do.
• Feels rushed and out of control.
• Can’t remember the complex sequence of activities involved.
What to do
• Build positive associations with bathing: Precede the bath with a pleasant activity (listening to a favorite radio program) and follow up with another one (a dish of ice cream).
• Build pleasant associations with the bathroom, such as hanging favorite pictures there. Keep the door closed for privacy. Buy the person’s favorite brands or scents.
• Stick to a consistent routine for bathing, which becomes soothing. When you find an approach that works, try to replicate it exactly the next time.
• Keep the room and water warm. Feeling chilled may be what upsets the bather. Pour a little water on her open hand to show her it feels nice before she gets in.
• Use as little water as necessary in a bath; a few inches is fine. The tactile sensation of entering water can cause fear or confusion.
• Cover the mirror if the person talks about other people watching; she may perceive your reflections as other individuals, adding to her fright.
• Put water in the tub before the person enters the room; the loud pouring of water can cause distress and your loud voice over it can be interpreted as angry shouting. Showers are also noisy and may be more frightening than a bath.
• Place a brightly colored, nonskid bath mat in the tub or shower to help the person judge depth; put a colored carpet on the floor outside the shower or bath, for focus.
• Use distractions in the room to take the person’s mind off the washing: Play favorite music, install a lava lamp on a shelf opposite the tub or hang favorite pictures, keep up a conversation about a pleasant topic (antics of a dog or child, old family stories). Give the person a washcloth or wash mitt to occupy her hands.
• Act as if you have all the time in the world.
• Simplify the process so there are as few steps as possible:
o To wash, use a combination body wash-shampoo, ideally in a pump-style bottle.
o If washing hair is too difficult, skip it for a separate time out of the bath and/or use dry shampoo.
o To rinse, use a handheld shower head or a pitcher of water.
o To dry, use a terrycloth robe as a towel instead of toweling off first and then putting on a robe. If the person is becoming impatient, don’t worry about a little moisture. Exception: Cornstarch powder is handy to absorb lingering moisture, especially in people with many skin folds or sensitive skin prone to irritations.
• Never force or intimidate (nudge the person into the shower, lift her foot into the tub, threaten “or else!”). You can set off a contest of wills or catastrophic panic.
• Be respectful but matter-of-fact about cleaning genitalia. If you’re squeamish, offer a warm washcloth and prompt the person to do it during bathing. But if she can’t, you should do so yourself at least every few days, to keep the area clean and watch for lesions or rashes.
• Know when to quit trying to persuade. If you’re heading to a stand-off after five minutes of negotiations, drop the subject of bathing. Distract the person with another activity and then try again 15 or 20 minutes later. Make it sound like a fresh new idea.
• Try alternatives. A gentle, handheld shower while seated on a shower chair helps some people feel more secure and therefore willing. A spouse might follow his or her mate into a shower. Suggest a warm sponge bath “just to wipe off the day” before dressing into pajamas. Use warm, damp washcloths (store several in a plastic bag before you begin) and no-rinse soap. Keep the person covered and warm with an oversized towel.
Dementia Hygiene Problem: Dislikes Being Helped While Bathing (But Needs It)
Possible causes
the person:
• Is modest.
• Feels diminished by loss of independence.
• Had an unpleasant experience with someone helping.
What to do
• See if a substitute helper works better. A father may refuse a daughter’s help, for example, but accept that of a son or an aide.
• Avoid a situation where the person has to walk from changing room to bathroom naked or wrapped in a small towel. This can build embarrassment or resentment. Use an ample robe or let the person disrobe in the bathroom.
• Use distraction while helping the person undress, such as singing or a telling a happy story unrelated to bathing.
• Consider providing a light robe to wear in the tub. It’s more cumbersome to wash around but can provide a sense of privacy. Have a thicker, dry robe at the ready to change into when the bath is done. Alternative: Cover genitals and breasts with washcloths.
• Someone who doesn’t mind a full tub of water may feel more modest if it’s full of bubbles.
• If she can handle it, don’t actually bathe the person, but hand her the washcloth and let her do it. Issue repeated gentle prompts: “Now wipe your neck. Next the arms. Now the other arm.”
• Don’t towel the person off yourself, but let her do it. While helping her dress, try to make a quick check for missed areas. Have a small towel handy to dry those areas surreptitiously. Apply cornstarch if necessary.
• Try a warm sponge bath out of the tub, given while a robe is worn. But take care to clean the genitals and under breasts or folds of skin.
Dementia Hygiene Problem: Doesn’t Take Care of Teeth
Possible causes
the person:
• Suffers memory loss (a common hygiene problem).
• May dislike help because she feels she’s being treated like an infant or out of control.
• May have dexterity problems.
What to do
• Have professional backup: Visit a dentist twice a year to check for cavities, gum infections, dangerously cracked teeth, ill-fitting dentures, and the like. Make sure the office knows the person has dementia, to book adequate time. For tough cases, ask for a referral to a geriatric dentist who has experience working with Alzheimer’s patients.
• Incorporate tooth brushing into the daily routine, such as when getting dressed or ready for bed (ideally both). If it becomes a battle, pick the person’s most cooperative time of day. Try brushing your teeth at the same time.
• Use the same brand of toothpaste the person has always used, if you can. Apply it to the brush for him.
• Provide a thick-handled, easy-to-grip toothbrush. The noise of an electric toothbrush may cause distress.
• If the person doesn’t recognize a toothbrush, slowly insert your own toothbrush in your mouth to model how it’s done.
• If the person clenches her teeth and won’t open them, brush what you can see.
• Dentists recommend flossing, but unless the person is cooperative about oral care, it’s not worth the battle or risk of being bitten.
• Clean dentures daily. Don’t leave it up to her. Ask her dentist the correct way if you’re unsure.
• Minimize the number of products in the bathroom. People with dementia may use shaving cream for toothpaste, for example. Avoid mouthwash, which may be swallowed.
Dementia Hygiene Problem: Trouble Grooming (Hairstyling and Shaving)
Possible causes
the person:
• Forgets the task entirely.
• Forgets the complicated steps involved.
• Can no longer identify tools involved (comb, razor).
• May be embarrassed.
What to do
• Let the stylist or barber know the person has dementia when you book the appointment, to allow for extra time.
• Don’t try to maintain an elaborate women’s hairstyle. Ask the stylist to “accidentally” cut it extra-short, so you can go longer between trimmings. Exception: If a woman has a long tradition of a weekly salon visit, she may get pleasure in continuing. But don’t keep it up for her out of loyalty once she no longer seems interested.
• Ask the stylist to shampoo hair first. A professional cleaning and conditioning will feel good and reinforce your efforts.
• Skip hair products (spray, gel, pomade, dye). Fewer steps make it easier.
• For shaving, get the razor and lotion ready and give prompts at each step. Some men avoid shaving because they can’t remember how.
• Use an electric razor — it’s less likely to nick.
• Quit shaving and let a man grow a beard.
• Acknowledge efforts: “Your hair looks so nice today.”