Joy A. Glenner
Page 8
• Simplify meals, as needed.
• Make food colorful and well flavored.
• If your partner seems confused about what is on the plate, tell the person what he or she is eating and then remind him or her throughout the meal. Also remind the person to chew slowly.
• If the person is confused by too many items, present them one at a time.
• If the person eats poorly, try bigger breakfasts. Patients are usually hungrier in the morning.
• Provide beverages in a mug because it is easier to handle than a glass.
• Make sure food and beverages are not too hot because the person may be unable to determine temperature.
• For moderately impaired patients try soft, thick foods, which are less likely to cause choking. Combining liquids and solids, such as ready-to-eat cereal and cold milk, makes it difficult for the person to know whether to chew or swallow. Offer a drink after every few bites to aid swallowing, but not after every bite because it is difficult to switch between the two activities.
• Break down eating into simple steps. Wait for the person to respond to an instruction before going on to the next one. For example, say, “Pick up the spoon,” and then wait until he or she does so before proceeding with the next step: “Open your mouth.” Keep telling the person to chew and when to swallow. If he or she cannot follow verbal cues, use touch and guide the person’s hand (this is called “patterning”).
• If your partner refuses to eat and you have tried everything you can think of, try the liquid nutritional supplements. They taste good and provide a person with all the needed daily nutrients.
Bathing
Bathing and shampooing the hair can be real challenges as dementia progresses. Your partner may have trouble processing all the stimuli. There are many things happening at once: the change in room temperature, the sound of water, getting undressed, feeling uncomfortable undressed, getting wet.
Try to imagine how doing these tasks feels to your partner. Put yourself in the other person’s shoes. The key is simplifying the tasks, instructing one step at a time, and demonstrating as needed. Also, do the tasks really need to be done? If it is a really difficult task, pick your battles!
Remember how important a sense of security and self-esteem are for your partner (see chap. 3). Even if your partner is severely impaired, he or she needs to feel secure and valued as a person. Try to keep a consistent schedule for bathing. Do not expect the person to bathe when tired or anxious. The person’s traditional bathing time is usually best. Give the person as much control as you can over the bathing process. It is very important that he or she maintain a sense of dignity and as much privacy as possible.
Mrs. Ayers now needs assistance with bathing and is embarrassed and depressed about needing the help. She has always been a somewhat private person. Now she feels as if she is fine one day and can do nothing right the next. She is embarrassed that her husband has to help her get undressed and take a bath.
Think about it. How would you feel? Mr. Ayers helped his wife by saying: “I know this is very uncomfortable for you. But I also know you would do the same for me. There are just times in our lives that we need help from each other.”
Goals
Note: Mildly impaired patients may provide most of their own care.
• Cleanse the face, hands, underarms, and perineum (genital area) daily. If the patient is incontinent, cleanse the perineum every time the underwear is changed.
• Provide a bath about twice a week. Older skin is dryer and more fragile, and bathing often can be drying. If the person enjoys bathing more frequently, however, don’t change the routine. (Don’t “rock the boat”!)
• Provide as much independence in bathing as possible. Remember: Avoid creating excess disability!
• Provide a familiar routine, one similar to the person’s previous habits. For example, if he or she always showered every night at 8:00 P.M., keep to that routine if at all possible.
• Ensure that the bathroom is safe.
• Use bath time to assess skin for any problems: bruising, cuts, infection, rashes, or swelling. Watch for pressure sores. Check fingernails and toenails. Remember: Your partner may not be able to tell you if he or she is hurt or uncomfortable.
Problems Meeting Goals
Your partner may:
• feel that bathing is scary and confusing or feel unsafe
• feel you are intruding into his or her personal space and privacy
• have poor self-esteem due to increased dependence
• not be aware that he or she needs bathing
• have physical discomfort
• refuse to bathe
Approaches to Try
• Reduce extraneous distractions: noise (run water slowly to reduce noise), glare (use lightbulbs that mimic true daylight), change in room temperature (warm up the room ahead of time), steam (use a ceiling fan).
• Speak in soothing, soft tones. Try soft music. Stay positive and cheerful.
• For safety avoid the use of oils because they can make a floor or tub slippery. Do not use floor-height space heaters, because they can burn a person and cause fires if towels or clothing are too close. Heaters should be in the ceiling or high on the wall, out of reach. Avoid loose bathroom rugs, which could cause tripping. Also, use your fan to reduce steam because clouded vision can cause accidents.
• Use a hand-held shower nozzle for bathing and shampooing. Water hitting your partner’s head will run into his or her eyes and can be confusing and uncomfortable.
• If the person resists your help, try going to a beautician or barber for shampoos.
• Keep the bathing process as private as possible. Help the person wrap up in a towel while you assist him or her in undressing. You can even let the person stay wrapped in a towel or let him or her bathe in underwear if that will help. Remember to pick your battles.
• Take each task step by step. If your partner is still fairly independent, guide the choices. For example, if Tuesday is a bath day, try saying: “Today is Tuesday, your bath day. Would you like to bathe before breakfast?” If the answer is no, then respond with, “Okay, then after breakfast.” It gives the person some choice in the matter. Also, arrange bathing items in the order in which your partner will need them. If your partner is more severely impaired, guide him or her through the steps of bathing. For example, you can say: “Take the washcloth. Wash under your arm.”
• Have the doctor prescribe two therapeutic baths per week, written as a prescription for you to show to your partner.
• Let your partner eat a favorite snack, cookie, or candy while bathing to distract him or her or try giving the person something to hold (washcloth, soap), to keep him or her from grabbing you or resisting as much.
• Comment on how good the person must feel and how good he or she looks when clean.
• If resistance is very strong, try sponge baths. Help the person clean one part of the body each day, and use dry shampoo occasionally instead of a wet shampoo.
• Although routine is important, adapt your approach, method, day, and time for a bath to how the person seems to be feeling. If he or she is having a bad day, it is not a good day for a bath.
• Allow plenty of time. Think how irritated you feel when you’re rushed. If your partner becomes irritated, he or she may actively resist or strike out at you.
Keep in mind that you are doing the best that you can. Don’t feel guilty if your partner is not as clean as you think he or she ought to be. The person’s anger with you or distress is not worth the price, unless the person’s health is at risk. Remember to pick your battles. Try not to feel guilt or regret.
Grooming
Grooming tasks are generally less problematic than bathing. Brushing the hair, applying lotion, and doing nails are all easy for a patient to understand. They are pleasant, tactile (touch) activities.
Oral care (brushing the teeth) and shaving are often difficult because:
> • They are more complex activities, like bathing.
• The patient cannot see what is happening (except in a mirror).
• Lots of sensations, some not pleasant, are happening at once.
Oral Care
Doing oral care is a habitual skill, even more so than bathing. The actions are so based in habit that we do not need to think about them. This works in favor of the person with dementia, but, unfortunately, oral care is complicated, so it becomes more difficult as the disease progresses. The person must try to hold water and toothpaste in his or her mouth while brushing. There is the odd sensation of the brushing action and the odd-tasting toothpaste. Then the person must try not to swallow and must rinse out his or her mouth.
Goals
• A clean, fresh mouth, clean teeth (without decay or chips), and healthy gums
• Bathroom safety
Problems Meeting Goals
Your partner may:
• feel you are invading his or her personal space
• no longer be aware of the need for clean teeth
• state that he or she has brushed when this is not true or refuse to brush (the person may not remember and may be embarrassed)
• drink the mouthwash or use shaving cream for toothpaste (safety issues)
• not be able to recognize oral pain or discomfort
• not cooperate—for example, refuse to open his or her mouth or clamp down on the brush
• have more difficulty with dentures or resist using dentures
Approaches to Try
• Guide rather than take over.
• Brush your teeth with your partner. Show him or her what you are doing face to face or in the mirror.
• Remove dangerous products from the bathroom. Make sure only the things the person needs to use are out. Put child-proof latches on the under-sink cabinet if you must store items there. Keep mouthwash locked away after use; it could make the person ill if he or she drinks it.
• If your partner will not open his or her mouth, demonstrate or start brushing his or her front teeth.
• Check dentures frequently to make sure they are in place and that they still fit properly.
• Check plates, napkins, and wastebaskets in case the person throws dentures away.
• Observe while your partner eats. If he or she winces, chews on one side only, or stops eating sooner than usual, suspect mouth pain. Examine the mouth as much as you can. The person may need to go to the dentist, as difficult as this can be.
Shaving
Again, pick your battles. This is hard if you are used to seeing your partner freshly shaved each day, but you only have so much time and/or energy to do things. Remember that you are doing an extremely difficult job. If your partner hates to shave, it is not worth his anger and your stress to keep him shaven every day. Your relationship and your health are not worth it.
Goals
To help the person:
• maintain dignity and self-esteem
• stay comfortable
• keep his or her skin in good condition
Problems Meeting Goals
Your partner may:
• refuse to shave
• be fearful of shaving (fear the sound of an electric razor or fear cutting himself)
• want to do it himself yet is not able to do it well or safely
• insist on using a straight razor
Approaches to Try
• If your partner refuses to shave, try another time.
• See if the person is comfortable with a beard.
• Try a barber.
• Dispose of any hand razors. (Perhaps it is “lost.”)
Remember: Praise and compliment your partner on how fine he looks when he is done.
Toileting and Continence Care
Incontinence, the inability to control the bladder and/or bowel, happens for various reasons, but it also occurs as dementia progresses. It is usually only an occasional problem at first, but eventually it could become a chronic condition. It begins with urinary incontinence and usually progresses to bowel incontinence as well.
Toileting and continence care can be very difficult problems. They are embarrassing and uncomfortable for your partner and can distract him or her from participating in other meaningful activities.
Continence problems are time-consuming, heavy work for you. They are the primary reason for residential care or nursing home placement.
Goals
• maintaining dignity and self-esteem
• preventing urinary tract infection
• preventing constipation and/or impaction
• preventing skin breakdown
• maintaining continence and independent toileting for as long as possible
Problems Meeting Goals
Causes of incontinence may be:
• side effects of medication
• weak pelvic muscles
• infection
• a person’s inability to find the bathroom
• lack of privacy
• intake of diuretics (coffee, tea, colas)
• trouble undressing, needing assistance with clothing
• a poorly lit bathroom
• a person’s fear of making a mistake
• inability to recognize the sensation of needing to void (urinate or defecate)
• inability to get out of a high bed, a chair that is too deep or soft, or a chair without arms
Approaches to Try
• Observe your loved one for specific behavioral cues indicating he or she needs to void.
• Practice behavior modification (yours and your partner’s). A reminder every two hours at home is a good place to start. Then modify the schedule to suit. Stop at a bathroom every two hours when out in public to avoid accidents. Remember to tell the person privately and quietly that “it’s time to use the bathroom.”
• Observe the person’s natural toileting routine and respond to that routine.
• Reduce consumption of caffeinated beverages. Avoid alcohol. Six to eight cups of fluid daily is usually enough. (Jell-O and popsicles count as fluid.)
• Make sure the person’s clothing and underwear are easy to remove. Dementia patients, as well as those with arthritis or those who have minimal muscle strength, will have trouble with buttons, hooks, and zippers. Use sweatpants with an elastic band. Many companies have affordable, attractive clothing suitable for those who are incontinent. Buck and Buck Designs is one such company (see www.buckandbuck.com or 800-458-0600). Sears stores have also started carrying them.
• Put signs with easy-to-read words and/or pictures on bathroom doors to identify them.
• Try a commode by the bed at night. Bruce Medical Supply has useful products (800-225-8446 or www.brucemedical.com); also try the Posey Company (800-44p-osey or www.posey.com).
• Remove physical obstacles to getting to the bathroom in time.
• Try to make sure the person chooses seating that he or she can get up out of easily.
• When your partner is incontinent, treat it in a matter-of-fact manner, quietly, with understanding and empathy. Do not scold the person.
• Use the words your partner uses for going to the bathroom. Do not call it “going potty” or some such term unless the person does. If the person does use a childhood term of some sort, then that is the term to use.
• Do not call disposable underwear “diapers” unless that is the only term the person seems to respond to. Patients are usually embarrassed enough that they are incontinent and do not want to be made to feel more childish.
• Have appropriate supplies and disposable underwear in each bathroom.
• Always use disposable gloves when assisting your partner. Use a slightly larger size than your regular gloves, because you need to be able to get them on and off quickly. Dispose of them and the soiled disposable underwear immediately. Put them in a disposable trash bag without touching the soiled items. Use a container
with a lid. Put it out of the reach of your partner or small children. (A cabinet with a child-proof latch would be a good choice.)
• Make sure your partner is clean and dry to prevent skin irritation, sores, and skin breakdown.
• Patients with dementia can lose the ability to concentrate on pushing and the ability to push when having a bowel movement. This can result in impactions (hard-to-move waste buildup). Fiber products such as Citrucel, Fibercon, and Benefiber make it easier for the person to have a bowel movement. Make sure the person drinks adequate water with fiber products to avoid choking. Water also helps prevent impaction.
• Encourage a male patient to sit to urinate. He may then also have a bowel movement, and it may help avoid messy clean-up.
• Toilet paper, washcloths, and tissues can be confused with one another. If possible, leave an appropriate amount of toilet paper and remove the other items.
• If there is a wastebasket beside the toilet, the person may void into that. Put it elsewhere. Be aware that the sink or tub can be used as a urinal by a male patient too! Pull a shower curtain across the side of the tub if there is confusion.
• Many good spot-removal products are available at home repair and grocery stores. Use white vinegar to remove urine smells. Polyester pants will retain urine smells more than others.
Dressing
Dressing is usually not a huge problem early in the disease process, but it can become one as the dementia becomes more severe. Some points to remember are:
• Always allow plenty of time.
• Simplify clothing.
• Reorganize storage spaces as needed.
• Be prepared for unusual combinations and then determine if these are suitable for the day’s events. Remember to pick your battles.
• Letting the person choose clothing and dress independently is more important than being dressed perfectly in most cases.
• Be sure your partner is dressed appropriately for cold, very warm, or wet weather.
If your partner has early-stage dementia, he or she probably has little trouble dressing except for using more complicated things such as ties, blouses with tiny buttons, pantyhose, and jewelry with clasps. As the disease progresses, the person will probably have more difficulty. Remember to assess carefully and help as little as possible.