The bath environment, the bathing task, and the older adult: A review and future directions for bathing disability research

Availability of family care resources, bathing assistance and toileting assistance among older adults with functional limitations: an evidence-based study from China

BACKGROUND

An aging population has contributed to an increasing prevalence of functional limitations among older adults. Family support plays a crucial role in toileting and bathing assistance. Yet, the relationship between availability of family care resources and such actual assistance remains insufficiently explored. Our study aims to describe availability of family care resources and identify the association between availability of family care resources and toileting assistance or bathing assistance.

METHODS

This study employed a cross-sectional analysis of data from the 2018 National Survey of the China Health and Retirement Longitudinal Study (CHARLS). The availability of family care resources was assessed using measurements of spouse availability, adult child availability, and living arrangement. Bathing assistance and toileting assistance were measured based on self-reported receipt of such assistance. Descriptive statistics were used to depict the overall and subgroup situation of availability of family care resources. Multivariable logistic models were employed to investigate the relationship between availability of family care resources and the receipt of toileting assistance or bathing assistance.

RESULTS

Among the sample of older adults with functional limitations, 69% had a spouse, 63% had at least one adult child, and 80% resided with family members. Among those with bathing disability, 13% reported lacking bathing assistance, and among those with toileting disability, 54% reported lacking toileting assistance. Participants with 1-2 adult children had lower odds of receiving toileting assistance (OR: 0.28, 95% CI: 0.09, 0.91, p= 0.034) compared to those with three or more adult children. Spouse availability and living arrangement did not exhibit statistically significant associations with toileting assistance. Participants without a spouse had lower odds of receiving bathing assistance (OR: 0.27, 95% CI: 0.09-0.78, p= 0.016) in comparison to those with a spouse; however, adult child availability and living arrangement did not display statistically significant associations with bathing assistance.

CONCLUSION

The present findings suggest a gap in family commitment when it comes to assisting older adults with functional limitations in bathing/toileting. To address this, policymakers are encouraged to prioritize the implementation of proactive mechanisms for identifying family caregivers, alongside incentives to enhance their engagement in practical caregiving activities. Furthermore, it is crucial to emphasize the prioritization of affordable and easily accessible formal toileting/bathing assistance options for older adults who lack sufficient family care resources.

Bathing and toileting difficulties of older adults in rural China: the role of environment

BACKGROUND

For older adults, difficulties in bathing and toileting are often the most prevalent in the index of Activities of daily living (ADL). This study aims to examine how environmental factors are associated with difficulty of bathing and toileting among older adults in rural China.

METHOD

The data are from the 2014 Thousand-Village Survey (TVS), a national survey of Chinese rural residents of old age. The sample consists of 10,689 subjects, 55 years or older, from 536 villages across all provinces of China. Logistic regressions were applied to examine how difficulty of bathing and toileting was related to environmental factors such as geographic location, neighbourhood amenity, and related facilities of bathing and toileting.

RESULTS

Older adults living in the Southern regions of China had lesser difficulty in bathing and toileting than those living in Northern China, controlling for other confounders. Better neighbourhood conditions also reduced the likelihood of having such disabilities. Persons who bathed indoors without showering facilities, in public facilities, and outdoors were significantly more likely to have bathing disability than those who showered indoors with facility. Rural older adults who used pedestal pans and indoor buckets for toileting were more likely to have toileting disability than those who used indoor squatting facilities.

CONCLUSION

Environmental barriers were associated with functional disability among older adults in rural China, but the disabled individuals may change their environments to adapt to their functional capabilities. Our findings suggest that it is imperative to promote the use of showering facilities and pedestal pans for toileting in rural China.

Exploring the use of assistive products to promote functional independence in self-care activities in the bathroom

In homes, problems in daily functioning of older people often occur in the bathroom, especially in the transfers to the toilet and/or shower/bath. Assistive products have the potential to maximise functional independence (i.e. performance without assistance from another person) in everyday activities; however, more research is needed to better understand the impact of this technology on independence in the transfers in the bathroom. Additionally, little is known about the role of the environmental factors in the process of implementing bathroom adaptations. Therefore, this cross-sectional study aimed to examine the relationship between the use of assistive products and independence in the transfers in the bathroom. The secondary objective was to determine the role of the environmental factors in predicting the implementation of bathroom adaptations. 193 community-dwelling older adults with disabilities in the basic activities of daily life, who requested public long-term care services in Spain, were included. Data was collected in the participant´s homes using a standardised assessment procedure. There was no significant association between the number of categories of assistive products used in the toilet transfer and the independent performance of this task. In a multivariate model, the number of categories of assistive products used in the transfer to shower/bath was positively associated with the independent performance of this transfer (OR = 2.59, 95%CI = 1.48–4.53; p = 0.001). A multivariate analysis revealed that social functioning was significantly associated with the implementation of a bathroom adaptation; social risk was lower in participants who made an adaptation (OR = 0.76, 95%CI = 0.63–0.93; p = 0.006). Assistive products may play an important role in promoting independence in the bathroom. Assistive product needs should be addressed when planning community-based interventions aimed at improving daily life. Moreover, social functioning had a strong influence on the installation of bathroom adaptations, suggesting the importance of paying special attention to social factors in the home adaptations planning process.

The Occupation-Based Intervention of Bathing: Cases in Home Health Care

Although bathing skills can be an indicator of long term placement, documentation of occupational therapists doing bathing as an occupation-based intervention is limited. Five clients were referred to a hospital-based home health agency with various diagnoses and at different levels of functioning. Each client was assessed at admission and discharge using the Outcomes and Assessment Information Set and the occupational therapists used the Activities of daily living (ADL) of bathing as the intervention based on client centered expressed needs. Findings reveal a statistically significant change in individuals pre- and post-assessment of bathing (Z = -2.032, p = .042) supporting occupation-based interventions, specifically bathing, should be further researched as a means of significantly improving the functional status of clients.

Algo Used by Homecare Nonoccupational Therapists Selecting Bathing Assistive Technology: Enhancing Standardization by Exploring Clinical Reasoning

Algo is a clinical decision algorithm developed to support nonoccupational therapists in establishing assistive technology recommendations to enable physically disabled adults to perform their hygiene at home. This study aimed to explore the in-depth clinical reasoning of nonoccupational therapists using Algo to pinpoint the items leading to disagreements regarding recommendations. A multiple-case study was conducted with eight nonoccupational therapists trained to use Algo and filmed while using it with six standardized clients. Explicitation interviews were conducted for the conflicting recommendations. Identifying the key reasoning skills to develop in Algo users has led to three recommendations to enhance standardization with seniors.

Bathing in residential care: understanding the experiences of residents and their care providers

Purpose

– The purpose of this paper is to understand how changes in an older adult’s physical capacity alter their bathing preferences, how the care environment incorporates residents’ values and beliefs around bathing to fulfil these changing care needs, and how institutional factors, such as staff scheduling and communication processes, influence Resident Care Aides’ (RCAs) bathing practices.

Design/methodology/approach

– A multiple methods approach involving surveys and interviews with residents and RCAs in a Canadian residential care facility. This paper draws mostly from the semi-structured, qualitative interviews with older adult residents (n=9; Mini Mental Status Exam (MMSE) scores > 15) and RCAs (n=10) on two nursing units offering different bathing options.

Findings

– Decreasing energy levels and physical decline were commonly cited reasons for residents’ changing bathing preferences. Residents were overall very appreciative of the bathing care they received in residential care, and identified the weekly tub bath as an anticipated encounter where they experienced a valued social interaction with their assigned RCA. While identifying bathing as an occasionally stressful aspect of their work, RCAs also described the bathing experience as an intimate bonding activity. The study identified bathing as an important activity in residential care.

Originality/value

– Previous studies have focused on moderate to severely cognitively impaired older adults’ and their demonstration of agitated behaviours during bathing. Most participants in this study had only minor cognitive impairment, as measured by MMSE scores (average score=20.6); therefore, this study provides insight into the experiences and needs of older adults whose perspective is not generally reflected in the literature.

Understanding challenges in the front lines of home health care: a human-systems approach

A human-systems perspective is a fruitful approach to understanding home health care because it emphasizes major individual components of the system - persons, equipment/technology, tasks, and environments - as well as the interaction between these components. The goal of this research was to apply a human-system perspective to consider the capabilities and limitations of the persons, in relation to the demands of the tasks and equipment/technology in home health care. Identification of challenges and mismatches between the person(s) capabilities and the demands of providing care provide guidance for human factors interventions. A qualitative study was conducted with 8 home health Certified Nursing Assistants and 8 home health Registered Nurses interviewed about challenges they encounter in their jobs. A systematic categorization of the challenges the care providers reported was conducted and human factors recommendations were proposed in response, to improve home health. The challenges inform a human-systems model of home health care.

Functional disability and ability 75-year-olds: a comparison of two Swedish cohorts born 30 years apart

OBJECTIVE

to compare the level of functional disability and involvement in leisure activities between two birth cohorts of Swedish 75-year-olds examined in 1976-77 and 2005-06.

DESIGN

cohort comparison.

SETTING AND PARTICIPANTS

representative data from the general population in Gothenburg, Sweden, examined at the age of 75 in 1976-77 (n = 744), and in 2005-06 (n = 731) with comprehensive somatic and psychiatric examinations.

MEASUREMENTS

activities of daily living (ADL); instrumental activities of daily living (IADL); a battery of self-report measures, including involvement in leisure activities, satisfaction with home-environment, social networks and self-rated health.

RESULTS

functional disability in ADL decreased between the cohorts (13.9 versus 5.6%, P < 0.001). Functional disability in IADL also decreased between the cohorts (33.4 versus 13.0%, P < 0.001). Combining ADL and IADL resulted in an overall decreased dependency, with the largest decrease seen in women (42.3 versus 15.1%, P < 0.001). Involvement in leisure activities increased between the cohorts. For example, the proportion going on international and domestic holiday travels increased (6.3 versus 16.2%, P < 0.001), and the proportion who independently drove their own car also increased (10.0 versus 53.0%, P < 0.001).

CONCLUSION

later born cohorts of 75-year-olds are less dependent in ADL and more engaged in leisure activities compared with earlier cohorts. Later born cohorts of 75-year-olds are thus better equipped to maintain a non-age-related identity compared with earlier cohorts. Our findings might serve as a reason to adopt a more positive view to ageing in a world with an increasing number of older people.

Exponential increases in the prevalence of disability in the oldest old: a Canadian national survey

BACKGROUND

As most studies generally treat all 85+ year-olds as a homogeneous group, little is known about the specific disabilities of the oldest old population, those aged 90 and older.

OBJECTIVE

To estimate age-specific prevalence of disability in activities of daily living for older Canadians, including the oldest old, those aged 90 and older.

METHODS

Cross-sectional national survey with a representative sample of noninstitutionalized Canadians aged between 50 and 104 years old (n = 28,406). Disability was self-reported and defined as needing assistance to perform self-care and domestic life activities.

RESULTS

The prevalence of disability increased with age, and the rise appeared exponential when considering the oldest old. At age 90, the highest estimated rates of disability were reported for housekeeping (50%), shopping (45%) and transportation (44%), and 21% reported requiring assistance for washing themselves. Compared to the 85-89 age group, the estimated proportion of people reporting disability in the 95+ age group approximately triples for self-care activities and doubles for domestic life activities.

CONCLUSION

Even if we knew that disability increases with age, we can now state that it increases at an accelerated rate beyond age 85. Grouping people aged 85+ into one category leads to substantial underestimates of disability in the oldest old. Accurate estimates are necessary for adequate allocation of care and rehabilitation resources for a rapidly expanding age group.

Effects of a home visiting nurse intervention versus care as usual on individual activities of daily living: a secondary analysis of a randomized controlled trial

BACKGROUND

Home visiting nurses (HVNs) have long been part of home and community-based care interventions designed to meet the needs of functionally declining older adults. However, only one of the studies including HVNs that have demonstrated successful impacts on Activities of Daily Living (ADL) has reported how those interventions affected individual ADLs such as bathing, instead reporting the effect on means of various ADL indices and scales. Reporting impacts on means is insufficient since the same mean can consist of many different combinations of individual ADL impairments. The purpose of our study was to identify which individual ADLs were affected by a specific HVN intervention.

METHODS

This is a secondary analysis comparing two arms of a randomized controlled study that enrolled Medicare patients (mean age = 76.8 years; 70% female) with considerable ADL impairment. At baseline difficulty with individual ADLs ranged from a low of 16.0% with eating to a high of 78.0% with walking. Through monthly home visits, the HVN focused on empowering patients and using behavior change approaches to facilitate chronic disease self-management. Three categories of analyses were used to compare difficulty with and dependence in 6 individual ADLs between the HVN (n = 237) and care as usual (n = 262) groups (total N = 499) at 22 months after study entry: (1) unadjusted analyses that strictly depend on random assignment, (2) multinomial logistic regression analyses adjusting for baseline risk factors, and (3) multinomial regression analyses that include variables reporting post-randomization healthcare use as well as the baseline risk factors.

RESULTS

Compared to care as usual, patients receiving the HVN intervention had less difficulty performing bathing at 22 months. However, there were no effects for difficulty performing the other 5 ADLs. While no effects were found for lower levels of dependence for any ADLs, impacts were detected for the most dependent levels of 4 ADLs: patients experienced less dependence in walking and transferring, a substitution effect for toileting, and more dependence in eating.

CONCLUSIONS

Future research is needed to confirm these findings and determine how HVN interventions affect individual ADLs of older adults with multiple ADLs.

Can home health aids using the clinical algorithm Algo choose the right bath seat for clients having a straightforward problem?

Objective:

To determine if Algo, a clinical algorithm to select bathing equipment for ‘straightforward’ cases, guides home health aides in selecting the appropriate bath seat.

Design:

Criterion validity study.

Setting:

Community home care.

Subjects:

Eight home health aides used Algo with community-dwelling older adults having a straightforward problem.

Main measures:

Their bath-seat recommendations were compared with those proposed by an occupational therapist (OT), which were considered as the gold standard. In order to determine a clinically acceptable threshold of agreement between the recommendations, a subgroup of community-dwelling elderly people was assessed a third time by another OT.

Results:

Half of the clients (74/143) for whom bathroom assessments were requested qualified as potentially straightforward cases after triage and were visited at home by a home health aide using Algo. In 84% of cases (95% confidence interval (CI) = [75, 93]), the non-OTs using Algo identified a seat that would enable these older adults to bathe according to their preferences, abilities and environment, as confirmed by the gold standard OT. Moreover, this appropriateness rate did not statistically differ from that obtained when comparing another OT to the gold standard.

Conclusion:

Algo guides non-OTs toward a bath seat that meets the needs of community-dwelling older adults in the majority of cases.

Bathing Area Safety and Lower Extremity Function in Community-Dwelling Older Adults

Occupational therapists and others frequently recommend grab bars and slip-resistant surfaces inside and outside of the bathing area to prevent accidental falls. In addition to observing and describing grab bar safety and floor surface safety, the authors tested the correlations between these safety features and three falls risk factors: lower extremity dysfunction, fear of falling, and self-reported falls history. Sixty community-dwelling participants aged at least 60 years were recruited. Only 13 of 60 (22%) in the total sample had adequate grab bars, and only 7 (12%) had adequate surfaces both inside and outside the bathing area. Of those with less than ideal scores on the Short Physical Performance Battery (SPPB) testing lower extremity function, 39 of 52 (75%) did not have adequate grab bars and 31 of 52 (60%) had inadequate surfaces inside the bathing area. The point-biserial correlation between the SPPB and grab bar adequacy was statistically significant ( r = −.41), indicating a mild tendency for grab bar adequacy in individuals with relatively low SPPB scores. However, there was little relationship between the SPPB and slip-resistant surfaces inside ( r = −.08) or outside ( r = .07) the bathing area. Secondary analyses found no discernible relationships between bathroom safety equipment and participants' self-reported histories of falls or their fear of falling. Of the five participants reporting histories of severe falls, all lacked adequate grab bars and non-slip surfaces. Modifications to improve the safety of bathing areas for community-dwelling older adults at risk for falls are needed.

Criterion validity of a home health aide's algorithm for recommending bathroom equipment

Background

Occupational therapists are experts at adapting bathroom environments. However, to increase access to services, the algorithm “Préalables aux soins d'hygiène” (French for “Prerequisites for bathing care”) has been developed to be used by trained home health aides to recommend bathroom equipment.

Purpose

The purpose of this study was to assess the criterion validity of the algorithm by measuring the level of agreement between an occupational therapist's recommendations (gold standard) and those made by four home health aides using the algorithm.

Methods

Community-living adults with bathing difficulties (n = 96) were visited by both types of evaluators.

Findings

Home health aides correctly identified clinical situations in which they should feel confident about their ability (sensitivity: 96%, specificity: 69%) and, apart from type of bathing seat (Kw = 0.63 [0.52; 0.75]), agreement between recommendations varied from substantial to almost perfect (△≥0.72).

Implications

Results increase confidencein the algorithm, but other studies are needed to ensure population safety and fulfil the occupational therapist's obligations.

Assistive technologies in the home

Assistive technologies are critical to elders maintaining independence in the home. Adequate assessment of the patient's needs, the appropriateness of the device to that need, and the patient's motivation to use of a device is required for successful outcomes. A team approach is needed to ensure that devices are correctly prescribed, and the patient is taught how to use it effectively. A wide range of devices is available to support activities of daily living, mobility, home management, and safety. The use of personal computers is significantly expanding the possibility of independent living through support systems, monitoring systems, and information resources.