Course content – PFLEGE-16
10. Module 9 · Personal hygiene & nutrition in dementia
10.1. In depth: eating, drinking, washing and the law
Eating, drinking, washing and the law
Basic care in dementia
| Principle | In concrete terms |
|---|---|
| Relationship/familiarity | Key carer, calm, knowing the person |
| Communication | Simple, announcing, respectful |
| Life history/habits | Familiar routines, preferences |
| No coercion | Understand resistance, stop, try later |
Resistance as communication
When a person with dementia resists during care (hits, scratches, struggles, turns away), this is easily misinterpreted as ‘aggression’ or ‘uncooperativeness’ and is sometimes met with more pressure or even sedatives. But resistance is communication (Module 4) – it always has a reason that the person cannot put into words. Common reasons: fear (the person does not understand what is happening, feels threatened/ambushed – especially with unannounced touch/address), shame (exposure, intimate care by strangers – especially with cross-gender care), pain (the movement/touch hurts – Course 14!), being overwhelmed (too many stimuli/demands at once), cold/discomfort, or a loss of control (the person wants to decide for themselves). Those who read resistance as a message and look for the cause can often resolve it: announce and explain care (relieve fear), preserve privacy (shame), treat pain beforehand, proceed in smaller steps/more slowly (being overwhelmed), ensure warmth/wellbeing, involve the person/let them join in (control), use a familiar person (safety), or try at a better time/differently. The key is not to take the resistance personally (it is not directed at the carer but is an expression of distress) and not to respond with coercion (coercion increases fear, violates dignity, is legally impermissible and dangerous – Course 04). Instead: understand, calm, address the cause, try later/differently. Care often succeeds then without a struggle. This attitude – understanding resistance as communication and responding to it empathetically – is central to dignified, successful basic care in dementia and at the same time protects both the carer (fewer injuries, less stress) and the person (less fear, more dignity). It requires patience, empathy and sometimes creativity, but it is the only humane and effective way.
This insight rounds off dementia-sensitive basic care: understanding instead of fighting, relationship instead of coercion – this is how care succeeds in the person’s interest.
Eating and drinking: what to look at
Difficulty with eating has many causes, and they can be sorted into five groups. The first is perception and recognition: the person does not see the food, or does not know what it is. The second is attention and sequence: the person is distracted, forgets to continue or cannot follow the steps of eating. The third is movement: tremor, weakness or loss of skill with cutlery. The fourth is the body: a dry mouth, dental pain, poorly fitting dentures, constipation, nausea or swallowing problems. The fifth is the setting: noise, hurry, uncomfortable seating or a plate that is full and complicated. Looking at all five groups prevents the common mistake of assuming that the person is “just refusing”.
Figure 9.2 shows two settings. On the left, pale food, a white plate and a pale cloth make it hard to see what is on the table. On the right, the plate contrasts with the cloth, there is one dish at a time and the setting is plain.
Drinking, weight and swallowing
People with dementia often forget to drink or do not feel thirsty. Offering drinks regularly, in a cup the person recognises and likes, and with a visible reminder is better than waiting for a request. Teams usually watch weight and fluid intake over time. The details of this belong in your organisation’s procedures. Take particular care with swallowing. Coughing or choking during meals, a wet or gurgling voice after drinking, food held in the cheeks or repeated chest infections are signs to report to the nurse in charge or doctor, who can arrange an assessment, for example by a speech and language therapist (Logopädin). Until then, sit the person upright, offer small amounts, and follow the instructions of your organisation. Do not feed a person who is drowsy or lying down, and do not rush.
Washing and dressing: small choices
Dignity in washing is made of small choices. Which time of day suits the person? A shower or a wash at the sink, and which parts first? Many people can still do part of the task if you hand over the flannel or lay out clothes in the right order. Protect privacy with a closed door and a towel over the parts not being washed. Wash the face and hands before the intimate areas. Keep the room warm. If a full wash is too much on a given day, a wash of the essential areas is better than a battle, and the rest can wait.
When care stays hard
Some people continue to resist even when you adapt everything. This does not mean that you have failed. First check that you have addressed pain, shame, fear, temperature and timing. Then change who is involved: a different carer, a relative present, or the person who knows them best. Then change the setting, the time and the order. Record what you tried and share it at handover, so that the next carer does not start from the beginning. If distress persists, ask for the doctor’s advice and discuss in the team how much care is necessary today. Safety-critical care, such as treating a wound, sometimes cannot wait, and your organisation has procedures for such situations. Use of force is not among them (Module 11).
Who decides what in your setting?
- Section 2 of the Social Code Book XI (SGB XI), the law on social long-term care insurance, aims at a life that is as independent and self-determined as possible and that respects human dignity. Wishes about the way help is given are to be met as far as is reasonable (Bundesministerium der Justiz, n.d.-a). A person’s own washing habits and food preferences belong here.
- Section 14 SGB XI describes the need for care in six areas. One of them is self-care, which covers washing, dressing, toilet use, eating and drinking. Another covers behaviour and psychological problems, including resisting care (Bundesministerium der Justiz, n.d.-b). Careful records of what you observe also support the assessment of the care level.
- Section 240 of the Criminal Code (StGB) makes it an offence to force a person unlawfully by violence or a threat of serious harm to do, accept or omit something (Bundesministerium der Justiz, n.d.-c). Section 1831 of the Civil Code (BGB) regulates deprivation of liberty in care facilities and requires the approval of the custodianship court (Betreuungsgericht) for longer-term or regular measures (Bundesministerium der Justiz, n.d.-d). Holding a person down for washing or restraining them to make them eat does not fit into basic care.
Medical decisions, such as artificial feeding or medication, belong to doctors, the person and their legal custodian (rechtliche Betreuung) where there is one, and are not covered here. This course does not give legal advice for individual cases.