Success Story: Increasing Showering Frequency for a Client with Dementia

Flo is a 79 year old woman who was diagnosed with Alzeimer’s disease 4 years before our involvement. She lives at home with her husband Rick who is now her primary carer, with additional input from her close knit family and friends. 

Flo was referred to us due to her lack of showering and at the point of referral it had been multiple months since her last shower. At intake, her behaviour analyst Zoe looked at, amongst many other things, the strategies that were being used to attempt to encourage her to shower. 

Her husband had tried directly asking or telling Flo to shower, reminding her on the way to the bathroom, leaving the shower on for her and sticking notes in the shower that said “shower today please”. None of these techniques had been successful despite the fact that Flo would verbally agree that she would shower. Other times, she would get visibly irritated by being told to shower, or would refuse and say that she was going to have a good wash instead. She would spend a very long time in the bathroom, often 20-30 minutes or more, but there was concern that she wasn’t actually washing when she said she was as the flannel used was often still dry afterwards. 

Personal care is one of the most common challenges when supporting people with dementia and is one of the most frequent reasons we get referrals. However it can come with its own challenges. As behaviour analysts, we do our best work when we can directly observe behaviour. In this case. Zoe was not able to directly observe Flo’s behaviour in the bathroom because Flo would have understandably refused to allow her in, and certainly would not engage in the typical behaviour while in there. 

Instead, Zoe listened outside of the bathroom when Flo went in, to see if she could hear what behaviours Flo was engaging for the duration of her time in the bathroom. This was so that Zoe could try to piece together the chain or chains of behaviours Flo was engaging in and start to determine where in those chains Flo skipped showering, or what other behaviours she was engaging in instead of showering. 

Interestingly, Zoe could hear that Flo was frequently ripping pieces of toilet roll, opening and closing the pedal bin, and was doing what sounded like wiping surfaces down and cleaning. From this, Zoe’s first recommendation to try was simply removing everything from the bathroom that was not needed to be there to have a shower as she suspected that Flo was getting distracted by cleaning and other “pottering” tasks while in the bathroom which meant she unintentionally skipped showering and went straight to getting dressed. 

Zoe and Rick went through the bathroom removing all knick knacks, cleaning products, spare toilet rolls and any toiletries not needed for showering from the room. In addition to this, Zoe also suggested that they try gradually adding in prompts every few minutes if they could not hear Flo getting in the shower from the time that she went into the bathroom. This started by asking her if she needed a towel for the shower once they could hear that she was undressed (this served to remind her that she was about to get into the shower without directly telling her), then Rick asking if he could check the water was working first (they’d had issues with the water flow in the past so this made sense to Flo) and then leaving it on for her to get in, and finally by asking if he could help her in because the floor was slippery and he was worried she’d fall. In this way it gave Flo a additional cues (in behavioural terms we call this discriminative stimuli) to shower, but importantly, it preserved her dignity by blaming the additional “help” in the bathroom on the lack of a towel or fixing the water flow or the slippery floor. This bypassed the idea that it was something that Flo was failing to do and placed the focus elsewhere. 

Zoe supported Rick to implement this strategy and it was successful the first time they tried it, with Flo having her first shower in months! With a few tweaks to get it just right, Rick was able to get Flo to shower on a regular basis with no nagging or reminders. On mornings where Flo got up unexpectedly early and was dressed before Rick realised, or they had somewhere to go so needed to get ready quickly, Rick would not prompt Flo and she would get dressed as usual without showering first. But on the mornings where time was on their side, Flo was able to complete the rest of the shower routine almost entirely independently.

Rick did express concern that Flo wasn’t washing her hair while in the shower, so Zoe suggested adding one extra cue, which was for Rick to have “forgotten” to replace the empty shampoo bottle and so bring her the shampoo once she was already in the shower and playfully squeeze some onto her hand and head. Rick had a great sense of humour and comedy timing so this worked really well and Flo washed her hair with each shower going forward. 

Although the full process has been condensed for brevity here, this work was done over a period of months, working closely with Rick and Flo and their family and ensuring that the most important aspect was that Flo retained her sense of self and was independent as possible throughout. It would have been “easy” to recommend simply staying with Flo in the bathroom and insisting she shower- but this would have likely caused her to become irritated and result in negative interactions between her and Rick. Instead, the method devised worked well to maintain her independence to the maximum degree possible while also not making her feel like she needed help from anyone, the additional cues were well “hidden” as part of the normal course of life. 

This intervention was successful because of Rick’s willingness to give Zoe’s recommendations a go. At first, he was somewhat sceptical and did not think that we would be able to get her showering again because her short term memory was very damaged. Despite this, he still followed the suggestions and was pleased when they turned out to be successful. He was definitely an excellent person to have on board! 

We are extremely grateful to Flo, Rick and their family for allowing Zoe to support them, for being so welcoming and open to a behavioural approach and for allowing us to share details of this work with you here. Having finished our input, we are sad to say goodbye to such a wonderful couple and feel very privileged to have been able to work with them. Thank you Flo and Rick!