By: Margaret P. Calkins, Ph.D.

Many caregivers find giving baths or showers one of the most difficult aspects of caregiving. It's a time when the person with dementia is often most combative. But it doesn't have to be that way. While both caregiver approach and the design of the bath room are important, this article focuses on the latter. Bathing does not occur in a void. It typically happens in a room, which provides a visual, auditory, olfactory, thermal and textural context. There are also spatial qualities of the room that need to be considered, as they can either cause problems, support independence, or support caregivers providing assistance. In general, the issues are the same regardless of the setting (home, assisted living, residential care, or nursing home), although some of the details may vary from setting to setting. Because the environment is experienced primarily through our senses, this article is organized by the different sensory modalities. The greatest emphasis is always given to how the person being bathed is experiencing the setting, with a secondary focus on the ways the environment can support the caregiver.

VISUAL ENVIRONMENT
Bath rooms in most long-term care settings are sterile, institutional and frightening spaces filled with unfamiliar equipment-tubs with mechanical lifts or sides that open up and look like they might swallow you, chairs on wheels or gurneys with arms that look like construction cranes. There may also be soiled utility carts, lifts, scales, extra wheelchairs, and boxes of supplies through which the person must navigate. In homes, while there is likely to be less large equipment, the counters and ledges and other surfaces are often jammed with personal care products-three or four kinds of shampoo, several brushes and combs, a hair dryer, shoe polishing kits, hair color kits---the list can go on and on. It's not surprising that the person who needs some assistance with bathing resists going in.

The first solution is to keep it simple. Find another location to store the extra equipment and supplies. If there is absolutely no other room available for the carts and lifts-or if they are necessary for bathing purposes, find a way to hide all that visually distracting stuff behind a partition or curtain. It can still be physically accessible, just not visually accessible. Add an extra cupboard-in the bath room if there is room, or outside the door if the bath room is small. You want to simplify how the room looks, but not make everyone else miserable because they cannot get to the things they want to use. If there is not sufficient room for any type of cabinet, give other bath room users their own basket or carrying case to hold all their personal toiletries which they can keep in their room and easily bring with them to the bath room.

Once you've eliminated the visual clutter from extra equipment and supplies, the next step is to make the room more visually pleasing. Think about where the person's eyes focus throughout the bathing process. What do you see when you first enter the room, as you get into the tub or shower, as you are being bathed, and when you are getting out and being dried? What is there to look at during each of these stages of the bathing process? Do signs and notices about how to use different pieces of equipment constitute the only "art" in the room? If so, try to make them less conspicuous to the person being bathed.

Laminate posters or prints to keep them dry in the moist atmosphere of the room, and hang them where the person is likely to see them during different stages of the bathing process (undressing, bathing, and dressing again). Add small decorative shelves with knick knacks such as shells, decorative bottles, pretty hand towels, or boxes for tissues. Pay particular attention to where the person is looking during the bath or shower. If they are reclined, could you put a print on the ceiling? In the shower, laminated photos may provide something more interesting to look at. Some facilities even put up photos or drawings of the different steps in the bathing process, to cue the person to what will happen next.

Another strategy that can help-both in downplaying institutional features and highlighting residential looking features-relates to using visual contrast. Many older people, and particularly people with dementia, have decreased contrast perception. Therefore, when there are necessary institutional features (such as signs or equipment) the more you can make them the same color as the background, the less they will be perceived. For residential features-such as art or knickknacks-you are adding to the environment; so make sure they stand out visually in the environment, by giving them a brighter color that contrasts with the background color of the walls.

Finally, lighting is very important in bath rooms. It needs to be sufficient-particularly near the tub and shower-so you can see that the person is getting clean. If the person being bathed is looking up (in a reclined position or on lying prone on a bath gurney), be sure no lights shine directly into the bather's eyes. Get into the tub or lie on the bath gurney and see what they are looking at. If you need to add lights, consider cove lighting which bounces light off the ceiling (this is called indirect lighting), or wall sconces.

While it needs to be adequate, lighting should not be so bright that it feels overly clinical. Some people may actually be more comfortable in a room with softer lighting. Therefore, the best solution is to get the lights on a rheostat so they can be individually adjusted for each person's preference.

AUDITORY ENVIRONMENT
With tile or solid surface floors and walls, noise reverberates in bath rooms. These hard surfaces can also cause echoes, which may make it even more overwhelming. There are two basic techniques to minimize noise in the bathrooms. The first is to stop the noise at its source. Do not let others walk into the bath room when someone is being bathed. This is why is it so important to try to get extra carts and stored equipment out of the bath room when possible. Even if they can not see them, just the sound of someone opening the door and coming in is enough to set some people off, fearing even more for their already compromised privacy.

The other basic technique to minimize noise is to add materials that will absorb noises. More fabric in window and shower curtains, and lined window or shower curtains will absorb more noise. As a general rule of thumb, the fabric should be three to four times the width of the opening to have sufficient folds to make a difference. Another approach is to add water resistant acoustic panels. These can be plain or made into decorative panels. The more walls (including the ceiling) these are placed on, the more noise they will help absorb.
Once negative noises and echoes are under control, you can consider the therapeutic benefits of adding positive sounds, such as music. A small collection of CDs that includes classical, new age, some oldies and possibly country will suit almost anyone. Better yet, try to find a few tunes you can both sing along to ("I'm gonna wash that man right out of my hair" from South Pacific comes to mind as especially appropriate).

OLFACTORY ENVIRONMENT
One doesn't generally think of the olfactory environment in relation to bathing, yet bathrooms are often characterized by lingering (or sometimes powerful) remnants of urine and excrement. Opening the door to a bath room with these odors will certainly not get the bath off to the right start.
The best way to eliminate these odors is to not let soiled clothing, sheets or incontinence products sit in the bath room to begin with. This is an admirable goal, but not always feasible, especially in a home setting where a trip to the trash can out back after every change may not be realistic.

If odors are present, it is important to minimize them. There are two ways to do this. The first is to try to get at the source. Even if soiled products have been removed, they may leave a lingering odor in the hamper. Or if there has been an accident, the odor can linger in the seams and joint of the floor. To prevent lingering odors, clean these areas thoroughly and regularly with a strong disinfectant. If there are cracks in the floor, or between the floor and the base board of the wall, seal them (clear silicone available at hardware stores works well). The other method is to simply mask the odors by spraying with a room freshener or using plug-in fresheners. Long-term care settings may want to install deodorizers that spray a fine mist of air freshener into the bath room at regular intervals.

As with the acoustic environment, it is also important to consider the role of positive aromas in the bathroom. An aroma therapy diffuser can be filled with a variety of calming essential oils (such as sweet marjoram, lavender, ylang ylang and clary sage). If this seems impractical, simply spray a little scented room freshener in the bathroom a minute or so before bringing the person in. Recognize, however, that these sprays seldom last very long.
Scented bath oils can also be pleasing, although they often cannot be used in tubs with whirlpool mechanisms. A variety of scented body soaps may work well. As an alternative, apply a scented body oil or lotion after the bath.

TACTILE ENVIRONMENT
As mentioned above, bath rooms are typically full of hard surfaces. This is important because of the moisture, and the need to clean the area between different people's baths. But it does not make for a very comfortable experience. When you think of being comfortable, you typically think of being surrounded by warm, soft materials.

Few people at home do not have either carpeting or at least a bath rug on the floor to stand on. Tiles are cold and uncomfortable on the feet. Try it at home in your own bathroom. Stand around naked and wet on a tile floor, and see how comfortable (or rather uncomfortable) it is. While carpeting a bath room in a long term care facility may be impractical, having something soft on the floor, like a (washable) rug can make a big difference to the experience.

The other aspect of flooring that is important to consider is how slippery it is when wet. If installing a new floor, select a flooring material with a high coefficient of friction (COF), ideally above 80. There are also a number of coatings that can be used with existing floors, that will substantially increase the COF.
For some people, there is nothing more wonderful than being wrapped in a warm towel or blanket. There are commercial towel warmers available which can make bathing a much more luxuriant experience.

When people are using showers, it is important to have stable grab bars to hold onto for balance. For many years, we have relied on stainless steel grab bars, which are aesthetically unappealing and often cold and hard to the touch. There are a variety of powder coated grab bars that come in decorative colors and have a non-slip grip (which is important), which are much more appealing.

The temperature of the room is critically important to the comfort of the person being bathed. Older people are highly sensitive to drafts and are easily chilled. Anyone taking a shower is likely to have a significant amount of exposed, wet skin which can quickly feel cold. Also, many of the tubs available on the market only cover the bather from the waist down, leaving the upper portion of the body wet and exposed to drafts and chills. Thus, every bath room should be equipped with an extra source of heat. If the caregiver is overly warm, almost to the point of sweating, the temperature is probably about right for the older person being bathed. Common sources of heat include heat lamps or radiant heat panels. Be sure the heat source is not a potential fire hazard. No products that include exposed heating elements should be placed in a bath room. Also, all heating elements should be mounted permanently to the wall or ceiling, to avoid the possibility of coming in contact with water.

Finally, while not necessarily apparent to the person being bathed, it is extremely helpful to have at least one floor drain in all bath rooms. It helps deal efficiently with excess water should the shower or tub overflow. It also makes cleaning the room much easier.

CONCLUSIONS
In long-term care settings, the bath room is one of the strongest remnants of the old institutional model, where the goals of efficiency and utility still reign supreme over the psychological and emotional comfort of the person being bathed. But this can, and indeed must, change to reflect our changing cultural values about long-term care. If the priorities in long-term care are to recognize and support the cognitive, emotional, psychological and spiritual needs of individuals as well and their physical needs, then all spaces need to reflect these goals. This is especially true for spaces where the most personal care-such as bathing-is provided. How a facility manages the minutia of life, such as the bathing process, including how bath rooms and designed and decorated, can speak volumes about the quality of a care setting.

This article is condensed from The physical environment of the bathing room, by Margaret P. Calkins, in Barrick, A.L., Rader, J., Hoeffer, B. & Sloane, P. 2001. Bathing without a battle: Personal care of individuals with dementia. New York: Springer Publishing Co.

Reprinted with permission: Journal of Dementia Care, Vol 10, No. 3. Hawker Publications, 2nd floor, Culvert House, Culvert Road, London, SW11 5DH. 020-7720-2108