10. Module 9 · Personal hygiene & nutrition in dementia

Care

Making basic care dementia-sensitive

Everyday basic and nutritional care (Courses 06/07) places particular demands on care for people with dementia – this is where the principles of this course (understanding, communication, relationship, no coercion) merge with practical care. With personal hygiene (Course 06, Module 9): people with dementia often experience personal hygiene as threatening (they do not understand why strangers are undressing and washing them; fear of water/touch; shame). Helpful are: calm and time (no rush!), a familiar key carer, simple communication that announces each step, using habits/life history (when/how did the person wash in the past?), distraction and pleasant stimuli (music, a warm towel), basic sensory stimulation (Course 06), proceeding in small steps, and – very importantly – no coercion (if the person resists, stop, calm them, try again later/differently).

With nutrition (Course 07, Module 9): people with dementia forget to eat/drink, do not recognise food (contrasts!), can no longer remain seated at the table (finger food/eat by walking!), lose the ability to use cutlery, refuse. Helpful: a calm environment, finger food, contrasts, favourite dishes, patience, guidance, no coercion. The common denominator: knowledge about dementia (understanding, communication, relationship, life history, no coercion) makes basic care dementia-sensitive.

What this module is about. How washing, dressing and eating can go from a daily struggle to a calm, familiar moment, using relationship, small steps, privacy and the person’s own history.

What you will be able to do afterwards. You can plan a morning wash for one person, set up a meal so that it is easy to recognise, read resistance as a message and respond without force.

Think about it first. Mr Kowalski (fictitious), 79, a retired bus mechanic, lives in a care home. Each morning two carers come at 7 a.m., say “time to wash”, and begin to remove his pyjamas. He shouts, grabs the carer’s wrist and tries to leave the bathroom. At lunch he pushes the plate away and says he is not hungry. What might be behind this? Write down two possible reasons and one change you would try. You will compare your ideas with Figure 9.1 and with the worked example on page 3.

Learning objectives of this module

  • You make personal hygiene and nutrition dementia-sensitive.
  • You use relationship, familiarity and life history.
  • You avoid coercion and respond to resistance appropriately.
  • You link the principles of dementia care with basic care.
  • You can plan a washing routine for one person that uses announcing, small steps, privacy and a pause (apply).
  • You can set up a meal so that the person recognises it, and judge whether a problem is a need, a habit or a possible swallowing difficulty (apply, analyse).

Relationship beats technique

The most important principle for basic care in dementia: relationship beats technique. Whether personal hygiene or a meal succeeds depends, for people with dementia, less on the ‘right technique’ than on the relationship, the atmosphere and the attitude. A familiar, calm, respectful carer who knows the person (life history!), takes time, communicates empathetically, conveys safety and exerts no pressure can make personal hygiene/a meal succeed where a hurried, unfamiliar, pushy member of staff fails. Conversely, the most common cause of ‘resistance’ to care is not ‘malice’ or ‘uncooperativeness’ but fear, being overwhelmed, shame, pain or disrespectful/hurried handling (Module 4). Those who understand this approach basic care differently: with relationship, calm, familiarity, empathy – and by understanding resistance as communication. In concrete terms: when the person resists, do not ‘push through’ or even use force (this increases fear/resistance, violates dignity and is legally impermissible – Courses 04/06), but stop, calm the person, understand the cause (pain? fear? wrong time? being overwhelmed?), and try later or differently (different time, different person, different order, more calm, distraction, in line with life history). Care often succeeds then. For care staff this is an important, relieving insight: you do not have to impose care ‘against’ the person but can shape it ‘with’ the person – through relationship, understanding and patience. This sometimes requires more time and creativity, but it is far more effective and dignified (and more pleasant for both sides) than a struggle. Dementia-sensitive basic care is thus a prime example of how the principles of dementia care (understanding, relationship, communication, life history, no coercion) improve everyday care practice.

This insight links the dementia course with basic care (Courses 06/07): the best care technique is of no use without the right attitude and relationship – and this applies especially to people with dementia.

Why basic care is so intimate

Washing, dressing and toileting involve closeness and exposure. A person who no longer understands why a stranger is undressing them can experience it as an attack. Many adults also carry a lifelong sense of modesty and a habit of washing in a certain way, at a certain time. In dementia these habits and feelings remain strong even when explanations are lost, so the manner of care matters at least as much as the task. This is why the guiding idea of this module is the one in the original text: relationship beats technique.

The same holds for eating. A meal is not only nutrition. It is a social and sensory event with smells, shapes, colours and customs, and each of these can be missed when perception and memory change. When a person pushes a plate away, the question is not “Does she want to eat?” but “What is making eating difficult now?” Figure 9.1 shows a frame for such questions. It lists six common forms of resistance, a possible reason and a first response.

Resistance read as a messageResistance as a message: possible reasons and first responsesWhat you seePossible reasonFirst responsePushes your hand awayFear, unannounced touchSay what you will do first→→Covers the body, turns awayShame, no privacyDoor closed, cover, same-sex carer if possible→→Cries out when movedPainReport; ask for pain relief to be reviewed→→Gets agitated in the bathroomToo much at onceOne step at a time, quiet→→Shivers, clenches upCold, discomfortWarm room, towel and water→→Says “I do it myself”Loss of controlHand over the flannel, let them join in→→One behaviour can have several reasons. Try one change, watch, and try another if needed.
Figure 9.1: Reading resistance as a message (examples from general professional knowledge; not a complete list). Source: own illustration.

Read Figure 9.1 from left to right. The table does not tell you which reason is true. It gives you a hypothesis to try. If you cover the person and the shouting stops, shame was part of it. If the person calms after you say what you are about to do, fear was part of it. If the person flinches whenever a limb is moved, you have found a reason to report pain.