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.
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
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
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.
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
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).
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.
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
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.
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
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
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