hand hygiene in dementia care - dementiability enterprises inc. · 2020-03-18 · hand hygiene is...

Elliot, G. (2020) www.dementiability.com 1

Hand & Personal Hygiene in Dementia Care Personal hygiene is important for everyone, including those living with dementia. However, there are many barriers to achieving the goal of keeping hands, face and full body clean when a person:

• no longer remembers to engage in daily tasks related to personal care, • can no longer remember why it is important, • can no longer remember how to do these tasks in the right order, • never considered hand washing or personal hygiene a priority in the past, • seriously objects to doing what needs to be done now or • associates personal hygiene with negative experiences.

Facts, Tips and Tools The goal of hand and personal hygiene in dementia care is to establish behaviours that enable abilities and improve hygienic practices in an environment that has been set up for success. A few key points need to be considered when helping a person with dementia to wash their hands regularly – and often – thereby establishing important hygienic routines. Memory loss and apraxia impacts outcomes (e.g. - impacting the ability to find locations such as the wash basin or toilet and the ability to do things in the right order). The prompts and pictures are promoting praxis as well as procedural memory, which is normally spared into the later stages of dementia. Loss of the ability to “understand and appreciate the consequences of behaviours and decisions” also impacts outcomes, such as understanding why it is important to wash hands or why it is important to refrain from kissing and hugging during a time of infectious spread of disease. Conditioned behaviours also impact outcomes (e.g. – a previous battle with washing hands or having a bath may negatively impact present invitations to have a bath or wash hands). DementiAbility aims to enable abilities and independence, enhance function and engage each individual in all aspects of daily living. Enabling abilities related to hygiene is vitally important to achieving this overall objective. This includes hand washing, bathing and overall personal care. To learn more about creating a positive bathing experience visit the DementiAbility website at https://www.dementiability.com/pdf/free-downloads/DementiAbility_Bathing_Guidelines_2019.pdf


Key Points for Hand Hygiene in Dementia Care

• We can teach many people with dementia to wash their hands regularly. If the person is no longer able to learn, we can create our own routines for them to follow, to ensure we achieve high hand hygiene standards with safe outcomes for all.

• We need to create positive associations related to care tasks. When staff support individuals as they wash hands or have a bath the recipient of care needs to feel safe, secure and empowered to do things as independently as possible.

• Memory prompts and supports can be used to set people with dementia up for success. Memory aids help them to:

o Find their way o Find things o Do things in the right order and to o Prompt action

Tips for Hand Washing Hygiene in Dementia Care

• Create a positive experience with each encounter. o Smile brightly when you ask a person with dementia, “Would you like to wash

your hands now?” Do not tell them it is time to wash your hands. Provide choice by asking “Would you . . .” – do not demand. No adult wants to be told what to do. If the person says no, explain why it is important to keep the hands clean. Most people tend to be cooperative if they know the request is important.

o Tell a joke when you invite someone to wash their hands. o Post a picture that is fun to look at (samples are provided with this article). o Sing a song – and make the experience fun. For example, you could sing: “I’m

gonna wash those germs right out of my hands”, Repeat, Repeat and then “and dry that water away” (to the tune of “I’m gonna wash that man right out of my hair”).

• Provide memory cues to support independence – and dignity (examples provided in the pages below).

o When some people see the memory cues, the words and/or images will prompt their action. Use both the prompts (examples provided below) and a schedule to remind people to wash their hands (e.g. – list the times of the day or the situations that require them to wash their hands). For example, post signs or give each person a laminated sheet reminding them to do the following:

Always wash your hands: • After going to the toilet • Before and after eating • When hands and face are dirty (at any time of the day) • After sneezing or coughing or touching your face, nose or mouth • After touching a rash or cut or any open wound (yours or others) • After touching your feet


o Some people will need to be taught to use the hand washing cues. Teach them how to do the task step-by-step, as they may no longer remember how to complete simple tasks in the right order. You can easily teach this by pointing to the words and/or images – one at a time – waiting for them to do the action required – and then move to the next step until the task is complete. Some will eventually do this without your prompting – others need a guided approach. Be sure to provide the image or words required each step/action. Let your observations guide you.

o Create a routine. Create a schedule (example provided below), and encourage all family and staff to encourage the individual with dementia to refer to a schedule. Create the schedule according to needs and abilities.

o Encourage each person to use, and learn how to use, hand sanitizer as needed.

• Wash basins should be in the line of sight. If you cannot put a wash basin in the line of sight for those who forget to wash their hands, be sure to put arrows pointing the way to the wash basin. Teach each person to look at the memory cue that will take them to the sink/basin and then be sure the instructions for washing their hands can be clearly seen and are provided in their line of sight.

• In LTC environments, consider distributing a wet, warm cloth before and after meals. This initiative will help to remove the germs before they eat – and after. It improves hygiene for both the person with dementia and the staff. A dry, small napkin is not sufficient if the goal is to “clean” and prevent the spread of bacteria.

• For those in late stage dementia, consider putting a rolled warm cloth in a

person’s closed hand and ask him/her to pull it through his/her closed hand, using one of the corners of the cloth (see photo on the left). Do this with each hand – a number of times throughout the day. This will remove the bacteria from the hands and prevent staff from carrying the bacteria to other residents – as this person may hold a health care worker’s arm or shoulder when being moved – and then the next resident picks up the bacteria from the arm or shoulder – not the hands – which have often been so carefully cleaned.

A number of memory aids are provided below. Please feel free to print and re-produce widely. Let’s help to stop the spread of infection – and keep fellow staff and those in our care safe! Note: Many of the images are from our Memory Aids book, available on our website at www.dementiability.com. I’d like to thank Karen and Brian Romeril for their contribution to the artwork in our Memory Aids book, as some of the images are included in this article, with their permission.


Note: Insert a message tailored to your environment.

Please wash your hands.



Morning Routine

Check When

Complete Go to the toilet Wash face and hands Brush teeth Comb my hair

After Lunch Routine Check When

Complete Go to the toilet Wash face and hands Brush teeth Wash and dry hands

Bedtime Routine Check When

Complete Go to the toilet Wash face and hands Brush teeth Comb my hair



Don’t forget to dry your hands!


Wash hands with soap and water. Dry hands when done.


Please wash and dry your hands each time you go to the toilet. Please wash and dry your hands after touching your nose or face. Please wash your hands after touching your cut/wound.


Note: This graphic of cues would work for those who are able to follow the instructions. Some people, with limited ability, would likely benefit from just the hand washing graphic above. Let your observations guide you. Use the memory cues according each individual’s abilities – aiming for success – and independence.

a

1. Wet hands with water 2. Use soap 3. Palm to palm

4. Palm to palmƓQJHUV�LQWHUODFHG�

��%DFN�RI�KDQGV ��%DVH�RI�KDQGV ��)LQJHUQDLOV

8. Rotationally rub wrists

9. Rinse hands with water

10. Dry hands WKRURXJKO\�ZLWK�WRZHO�


Hand Hygiene References & Resources Summary of Research:

• Hand washing is important. People with dementia need our help. o Some people with dementia do not remember to wash their hands – they need

memory prompts. o Some people need to be reminded how to wash their hands thoroughly. They

may need to be taught. Memory prompts are recommended to support “remembering” to wash their hand and the steps to do it.

o Triggers that are in the line of sight help to prompt action. A sink that can be seen when individuals enter a dining area will serve as a trigger, which helps to encourage hand washing if staff invite each person to use the sink before and after meals. The more they go to the sink - the more likely they will go without prompts. Be sure to use memory aids to direct them to the wash basin if it is not in the line of sight. Research states that most homes do not have a hand washing basin in the dining area. In these situations, it is important to find the toilet (where they will find the sink to wash their hands).

o Fecal matter is of great concern, contributing to the spread of bacteria. The hands hold onto fecal matter and spread bacteria.

o Hands carry many germs – from the body, kitchen, handrails, door knobs and bathrooms. When a person with dementia touches staff on the arm, when being assisted with ADL’s, the spread may come from the next person touching the arm of the person providing care. Hand hygiene is therefore important all day long. Encourage staff to place a warm cloth in the hands of those in late stage dementia – asking the individual to pull it through the hand (as noted in the guidelines above). This cleans the hands – and provides sensory stimulation.

o Some people have never washed their hands. Hand washing, and perhaps overall hygiene, will be a new routine for these people when they have dementia. We need to create new routines – that are associated with positive experiences.

o The whole organization needs to be on board to create a sustainable change in practice. Be sure to read the Public Health Ontario Best Practices in All Health Settings, 4th Edition : https://www.publichealthontario.ca/-/media/documents/bp-hand-hygiene.pdf?la=en

o Education is needed for staff and families. Be sure to check out Ontario’s “Just Clean Your Hands” power point document at https://www.publichealthontario.ca/-/media/documents/4-moments-ltc.pdf?la=en

o When we improve hand hygiene, we not only impact patient/resident safety, we also improve health care worker safety (Landers, et al 2012).


Alzheimer’s Society United Against Dementia. (2015). When someone with dementia is reluctant to wash. Retrieved from: https://www.alzheimers.org.uk/get-support/daily-living/when-someone-dementia-reluctant-wash Borreli, Lizette. (2019). Why wash your hands? Fecal matter bacteria are the most common type found on your fingers. Retrieved from: https://www.medicaldaily.com/why-wash-your-hands-fecal-matter-bacteria-are-most-common-type-found-your-399815 Centers for Disease Control & Prevention. . (2016). Hand Hygiene in Health Care Settings Retrieved from: https://www.cdc.gov/handhygiene/patients/index.html CDC indicates handwashing before EVERY meal. https://www.cdc.gov/handhygiene/patients/index.html Hattula, J. L., & Camp; Stevens, P. E. (1997). A Descriptive Study of the Handwashing Environment in a Long-Term Care Facility. Clinical Nursing Research, 6(4), 363–374. https://doi.org/10.1177/105477389700600406 Help for Alzheimer’s Families. (2020). Bathing & Hygiene. Retrieved from: https://www.helpforalzheimersfamilies.com/learn/quick-tips/bathing-and-hygiene/ Landers, T., Abusalem, S., Coty, M. B., & Bingham, J. (2012). Patient-centered hand hygiene: the next step in infection prevention. American journal of infection control, 40(4), S11-S17. “Despite epidemiologic evidence to suggest that hand hygiene is an important part of preventing health care-associated infection, patients are not provided the opportunity to do so. Human behavior is extremely complex and is the consequence of multiple interdependent influences from biology, environment, education, and culture. Major beliefs and barriers that alter nurses' pre-existing behavior toward patient hand hygiene must be acknowledged.” Lasseter, G, Charlett, A, Lewis, D & Donald, I. (2010). Staphylococcus Aureus carriage in care homes: identification of risk factors, including the role of dementia. Cambridge University Press. 138 (5). 686-696. https://www.cambridge.org/core/journals/epidemiology-and-infection/article/staphylococcus-aureus-carriage-in-care-homes-identification-of-risk-factors-including-the-role-of-dementia/BF82485D857CBC6C9AC4056C475612FF (Conclusion: “We concluded that cross-infection through staff caring for more dependent residents may spread MRSA within care homes and from the recently hospitalized. Control of MSSA and MRSA in care homes requires focused infection control interventions.”


Mathei C, Niclaes L, Suetens C, Jans B, Buntinx F. (2007). Infections in Residents of Nursing Homes. Infectious Disease Clinics of North America. 21 (3). 761-772. https://www.sciencedirect.com/science/article/abs/pii/S0891552007000657 Newsmax Health. 80% of infections spread by hands. (2014) Retrieved from: https://www.newsmax.com/t/health/article/546258?section=Health-News&keywords=infections-hand-fist-bump&year=2014&month=01&date=09&id=546258&oref=r.search.yahoo.com Public Health Ontario (2014). Best Practices for Hand Hygiene in All Health Care Settings, 4th edition. Retrieved from: https://www.publichealthontario.ca/-/media/documents/bp-hand-hygiene.pdf?la=en Public Health Ontario. (Version 1.3). Your 4 Moments for Hand Hygiene for Long Term Care Homes. Retrieved from: https://www.publichealthontario.ca/-/media/documents/4-moments-ltc.pdf?la=en Rummukainen M, Jackobsson A, Karppi P, Kautiainen M & Lyytikainen O. (2009). Promoting hand hygiene and prudent use of antimicrobials in long-term care facilities. American Journal of Infection Control. 37 (2), 16-171. https://www.sciencedirect.com/science/article/abs/pii/S0196655308008055 One year after the visits, a significant increase in the mean amount of alcohol-based hand rubs used was detected while usage of antimicrobials for the prevention of urinary tract reinfections had decreased. Landers T, Abusalem S, Coty MB, Bingham J. (2012). Patient-centered hand hygiene: The next step in infection prevention. American Journal of Infection Control. 11-17. http://www.chpso.org/sites/main/files/file-attachments/landers_2012.pdf “In the health care setting, current best practices to promote hand hygiene behavior include the use of multimodal strategies. As with HCWs, successful patient hand hygiene programs will likely require a multimodal approach that emphasizes important features, including the formulation, design, and availability of hand hygiene resources; timing and technique for hand hygiene behavior; education and training of patients and caregivers; monitoring adherence and providing feedback and reminders; and creating a culture of hand hygiene and patient safety among patients, HCWs, and senior hospital personnel 69 (Table 2). For a review of the components of a multimodal strategy, see the article by Pincock et al.

Links: Global Handwashing Resources https://globalhandwashing.org/wp-content/uploads/2018/02/AdvocacyToolkit_v8-int.pdf

hand hygiene in dementia care - dementiability enterprises inc. · 2020-03-18 · hand hygiene is...

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