Ending the battle of bathing for people with dementia

The world's population is aging and there is a challenge to create a caring environment in which older adults with dementia can live and maintain their dignity.1 Unfortunately, assistance with daily care triggers agitated behaviors in older adults with dementia.2 Of all the daily care activities, bathing is the one most likely to lead to agitation. Receiving assistance in bathing involves complex physical, cognitive, and social challenges for older adults with dementia, which often lead to agitated behaviors. Agitation is defined as behaviors consistent with emotional distress, excessive motor activity, and verbal and physical aggression.3 Agitated behaviors result in an inability to undertake daily activities.3 Following the emphasis on person-centered care in aged care worldwide, agitation is now interpreted as responsive behaviors that older adults with dementia exhibit as a response to stress and unmet needs. These behaviors can be a significant source of caregivers' stress and challenges. Over a decade ago, a systematic review4 was conducted to guide evidence-based assisted bathing for older adults with dementia. It was one of the first attempts to inform evidence-based practice for this hands-on care topic of assisted bathing. Considering the impact of bathing/showering on older adults with dementia and on their caregivers, it is crucial to regularly update evidence-based recommendations. This issue of JBI Evidence Synthesis presents our update to our previous review and provides the best available evidence regarding assisted bathing/showering for older adults with dementia living in aged care facilities and community settings.5 In this update, we decided to integrate quantitative and qualitative evidence by utilizing the mixed methods systematic review methodology with a segregated approach.6 Unlike the previously used comprehensive systematic review approach, the mixed methods approach provides an opportunity to integrate the evidence by comparing and contrasting the evidence generated for 2 different elements of the same phenomena of interest. The segregated approach is a relatively new method of conducting systematic reviews using multiple study designs. This was chosen over the integrated approach because the review questions focused on different dimensions of the phenomena of bathing, which required the inclusion of studies following different ontological and methodological perspectives. Moreover, the 2 components addressed the perspectives of 2 distinct stakeholders: quantitative evidence revealed an outcome for people with dementia, whereas qualitative evidence was based predominantly on the experience of caregivers. The 2 perspectives were then merged in the final stage of synthesis to develop the overall evidence-based recommendations. The quantitative component of the review included and examined intervention studies reporting on bathing/showering methods, environmental modifications, or education/support for caregivers, intending to reduce agitation that can emerge during assisted bathing. The qualitative component explored the findings of studies reporting the experiences of older adults with dementia and their caregivers, such as nurses, care staff, and family members, during assisted bathing. In total, 14 studies were included in the review update:4 10 quantitative and 4 qualitative studies. The quantitative component comprised 5 randomized controlled trials and 5 pre-post studies of poor to moderate methodological quality. The qualitative component incorporated 4 studies ranging from moderate to high methodological quality. They were descriptive analyses with a critical incident technique, a focus group interview, individual in-depth interviews, and non-participatory observation. Despite there being no statistical pooling, evidence from included quantitative studies indicated consistent findings supporting person-centered bathing training for caregivers to reduce agitation in older adults with dementia.4 For instance, Gozalo et al.7 reported a significant decline in agitated behaviors, including verbally agitated behaviors, and the frequency of calling for help. An additional pre-post study by Hoeffer et al.8 also favored training formal caregivers using the person-centered bathing approach. Other tested interventions (eg, music, alternative bathing methods, sensory simulation device, multi-sensory interventions) did not reveal conclusive evidence of their effectiveness in any outcomes of interest. In the qualitative component of the review, 2 synthesized findings were generated.4 The first synthesis demonstrated the importance of working within the reality of each individual living with dementia by having the skills and knowledge required to deliver person-centered assistance. The second synthesis revealed that caregivers needed assistance with training, as well as sufficient and flexible time allocation when delivering bathing assistance. Organizational involvement was required for caregivers to deliver flexible and safe bathing. Finally, the evidence from the quantitative and qualitative components complemented each other, leading to the promotion of caregiver training to deliver person-centered bathing.4 Providing caregivers with person-centered bathing training is recommended before bathing older adults with dementia. To provide comfortable, safe, and effective assisted bathing for these older people, caregivers should have the requisite knowledge and skills, such as relevant assessment and communication expertise. Without commitment from aged care providers to offer training opportunities for caregivers and flexible time allocation, improved assistance in bathing is not possible. Caregivers need to learn the necessary skills of person-centered bathing and allocate flexible time for bathing residents with dementia. This updated systematic review recommends training caregivers in person-centered bathing to reduce agitated behaviors and enable a satisfactory bathing experience for older people with dementia.4 Developing a respectful and trusting interpersonal relationship with these adults during assisted bathing is essential for successful bathing. Caregivers are encouraged to understand the importance of following the perceived reality of each person with dementia, rather than trying to correct it. Knowing each person and being able to detect the behavioral patterns of that person, using appropriate interaction skills, and having the flexibility to wait for the best time for bathing are also required for successful bathing. Furthermore, organizational support is required to provide sufficient resources, routines, and procedures, such as ensuring staff have training opportunities and introducing flexible schedules so that caregivers can complete bathing duties in a reasonable time.