Assisted bathing of older people with dementia: a mixed... : JBI Evidence Synthesis (2024)

Introduction

Managing behavioral and psychological symptoms of dementia (BPSD) in people with dementia is now a major challenge for health care professionals and caregivers. These symptoms include various psycho-behavioral symptoms¹ such as agitation, aggression, anxiety, irritability, depression, apathy, sleep, or appetite changes, among others. It has been reported that up to 90% of all cases of dementia have BPSD at some point of their illness trajectory.² Agitation is a common, challenging symptom that constitutes a major source of caregivers’ burdens.³ The term “agitation” is defined as behaviors consistent with emotional distress and excessive motor activity, verbal aggression (eg, cursing, making unpleasant noise) or physical aggression (eg, biting, grabbing).² Agitation can be also used to describe verbally non-aggressive behaviors (eg, negativism, repetitive sentences) and physically non-aggressive behaviors (eg, pacing or restlessness as a result of distress).⁴ This review will use the terms “agitation” and “aggression” interchangeably when addressing physically and verbally aggressive behaviors. The term “agitation” will also include non-physically and non-verbally aggressive behaviors expressed as a result of distress in people with dementia.

Agitation in people with dementia can be difficult for nurses and caregivers to manage, particularly during assisting activities of daily living (ADL).⁵ People with dementia who require help with ADL are likely to exhibit physically aggressive behaviors.⁶ A cross-sectional study with 107 residents with dementia from nine nursing homes in the United States compared the process of assisting shower baths, meals, and dressing/undressing and the occurrence of aggression in residents.⁷ Results showed that only the shower bath was significantly related to aggressive behavior. This could be because bathing for people with dementia involves complex physical and psychological activities, which might make bathing/showering a much harder task to complete for this vulnerable population compared to those without dementia.⁸ People with dementia often have various comorbidities such as chronic orthopedic pain, impaired balance, motor planning disabilities, and impaired eyesight. Moreover, due to impaired cognitive function, understanding their experience during assisted bathing/showering can be problematic.⁸ Bathing-related activities, such as being transferred to an unfamiliar shower room by wheelchair, being undressed by another person, sitting on a cold shower chair, exposure to cold shower water, and noise of water are all potential sources of stress for people with dementia. A mixture of these physical, cognitive, and environmental difficulties may result in anxiety and fear⁸ for people with dementia, and, subsequently, this can trigger agitated behavior during assisted bathing.

Various systematic reviews have been published on the issue of managing agitation^9-11 or other challenging BPSD in older people.^12,13 However, these findings tend to be explored in the broad and general context of dementia care. Considering the complex impact of bathing/showering people with dementia on providers such as nurses and caregivers, evidence-based recommendations specific to the context of assisted bathing/showering are needed. Moreover, because bathing is one of the daily activities that requires assistance from the early stages of dementia onward, the need for a solid evidence base for practice will increase given the aging population in many countries and the demand for better care from patients’ families.

Our previous review in 2013¹⁴ examined quantitative, qualitative, and textual evidence concerning the best strategies for assisted bathing for older people with dementia. However, the limited number of rigorous, research-based studies on this topic hindered the strength of the review findings. The quantitative component examined effectiveness of various bathing/showering methods and related educational/supportive activities for caregivers in reducing agitated behaviors. Due to heterogeneity with reported interventions and outcome measures, statistical pooling was not possible; however, results from the quantitative component generally showed that assisted bathing/showering based on the person-centered approach could, to some extent, be effective in reducing agitated behaviors.^15,16 Other interventions, such as the towel bath/thermal bath and playing the preferred music of older adults to put them at ease, were also recommended for reducing agitated behavior during assisted bathing.¹⁷

Similar to the quantitative component of the review, the small number of qualitative studies was a limitation. A meta-aggregation showed several important concepts such as the importance of promoting safety, a sense of dignity, and a feeling of control for people with dementia in assisted bathing. Developing relevant assessment skills for caregivers to detect any sources or signs of stress experienced by people with dementia was also suggested. However, the findings were based on only two qualitative studies.^18,19 Inclusion of eight textual papers was considered to obtain supplemental evidence that would support research-based evidence. The textual synthesis generally supported and supplemented the findings from both quantitative and qualitative components. However, textual evidence cannot be treated as viable research-based evidence and can be considered only in the absence of research-based studies. The previous review suggested more rigorous studies must be conducted to develop a solid evidence base.

Because it has been seven years since the previous systematic review was published, it is reasonable and timely to update the review. A preliminary search revealed that several new published studies make the review update legitimate.^5,20-22

The review team has decided to focus only on research-based studies in this review update. The original review included textual opinion papers because of the lack of research-based papers. Because a sufficient number of recent research-based papers have been identified, the decision to not consider non-research papers will help build a scientifically sound evidence base for assisted bathing/showering of older people with dementia in aged care. Additionally, this update will follow a mixed methods approach to data synthesis, unlike the original review. JBI recently updated their guidance on undertaking mixed methods systematic reviews,²³ and this will allow the review to formally integrate the quantitative and qualitative evidence.

Consequently, the present project aims to update our previously published systematic review.¹⁴ A preliminary search of PROSPERO, MEDLINE (PubMed), the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted. It identified no current or in-progress systematic reviews on this topic. The objective of this review is to update the evidence regarding assisted bathing/showering for older adults with dementia in aged care facilities and community settings.

Definition of agitated behaviors

In this review, the term “agitated behaviors” will be used as an umbrella term encompassing the following four types of behaviors:

• verbally aggressive behaviors (eg, cursing, making unpleasant noises, screaming, verbal sexual advances)
• physical aggressive behaviors (eg, biting, grabbing, hitting, hurting oneself or others, kicking, spitting)
• verbally non-aggressive behaviors (eg, negativism, complaining, repetitive sentences or questions, attention-seeking behaviors)
• physically non-aggressive behaviors (eg, inappropriate dressing and/or disrobing, inappropriate eating or drinking, handling things, hiding things, pacing, restlessness).

Review questions

The quantitative component of this review will aim to answer the following review question:

• What are the most effective bathing/showering methods or other related supportive interventions for older adults with dementia in aged care facilities and community settings?

The qualitative component of this review will aim to answer the following questions:

• What are the experiences of older adults with dementia receiving assisted bathing/showering or supportive interventions in aged care facilities and community settings?
• What are the experiences of nurses, formal caregivers, and family caregivers involved in delivering assisted bathing/showering or supportive interventions to older adults with dementia in aged care facilities and community settings?

Inclusion criteria

Participants

Both the quantitative and qualitative components of the review will consider studies that include older adults (older than 60 years of age) with dementia, their families, nurses, and formal caregivers. Nurses will include any level of formal qualification in nursing. Formal caregivers will be care staff who carry out care work with formal payment.

Any type of dementia will be considered including, but not limited to, Alzheimer disease, Lewy body dementia, and vascular dementia. Studies that include participants who have a formal diagnosis of dementia as well as those with suspected dementia (ie, without a formal diagnosis of dementia but exhibit agitated behaviors) will be considered.

Interventions

The focus of this review will be assisted bathing/showering of older adults with dementia and related interventions to support the delivery of assisted bathing/showering. This may include but is not limited to:

• various methods of bathing/showering (eg, use of bathtub, showering, steam bathing, use of aroma oil in steam bath)
• supportive interventions in the form of environmental modification (eg, changing the room color, room temperature, brightness of light in the shower room, frequency and timing of bathing/showering), altered communication approach, nurse/caregiver education or support, and other modifications (eg, changing communication pattern, education or training on dementia care or bathing/showering for people with dementia).

Interventions can be a combination of these, and there are no limitations with regard to frequency or intensity of interventions.

Comparators

Studies that compare the intervention with different bathing/showering methods, environmental modification, communication approach by nurse/caregiver, or nurse/caregiver education or support, among other modifications, will be considered. Studies that do not use a comparator will also be considered.

Outcomes

This review will consider studies that report outcomes in older adults with dementia, nurses, formal caregivers, or families. These may include but are not limited to:

• frequency and severity of agitated behaviors measured using scales such as the Rating Scale for Aggressive Behavior in the Elderly (RAGE)
• satisfaction of older adults with dementia, family caregivers, nurses, or formal caregivers, as measured by tools such as the Risser patient satisfaction scale,²⁴ self-developed five-point Likert scale, and others
• confidence of family caregivers or nurses/formal caregivers as measured using Dementia Burden Scale-Caregiver²⁵ and other scales.

Phenomena of interest

For the qualitative component, the review will consider the experiences of older adults with dementia as well as nurses, formal caregivers, and families of older adults with dementia involved in assisted bathing/showering, including:

• factors (both positive and negative) impacting on experiences of delivering or receiving assisted bathing/showering
• factors (both positive and negative) impacting on experiences of delivering or receiving supportive interventions for delivering bathing/showering.

Context

The review will consider long-term aged care settings and community care settings. This will include any form of aged care service outside acute care hospitals, such as residential aged care and temporary/short-term care (eg, respite care, day service, home care). There will be no restriction with regard to geographical location or cultural or ethnic contexts.

Types of studies

The review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies.

The qualitative component of the review will consider studies focused on qualitative data including, but not limited to, uncovering trends in thoughts and opinions, which are often found using unstructured or semi-structured techniques. Common methods include focus groups, individual interviews, and participation/observations. Quantitative designs include phenomenology, grounded theory, ethnography, action research, and feminist research.

Mixed methods studies will be also considered for inclusion if the data and analysis from the qualitative and quantitative components can be extracted separately.

Textual opinion papers will not be included in this review update. The original review included textual opinion papers due to the limited amount of research-based papers available.¹⁴ However, a sufficient number of recent research-based papers have been identified. Although they will not be formally included and assessed in the review, textual opinion papers identified in the search will be retained and discussed and compared with the other results of this review.

Methods

The review update will be conducted in accordance with JBI methodology for mixed methods systematic reviews.²³ The review has been registered in PROSPERO (CRD42020166134).

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE via PubMed and CINAHL via EBSCO was undertaken to identify studies on the topic. The text words contained in the titles and abstracts of relevant studies, and the index terms used to describe the articles have been used to develop a full search strategy for the relevant database (see search strategy for MEDLINE in Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected for critical appraisal will be screened for additional studies.

The databases to be searched for published papers will include MEDLINE (PubMed), CINAHL (EBSCO), and Embase (EBSCO). For gray literature, the following databases will be searched: Conference Proceedings Citation Index, Dissertation Abstracts International (ProQuest Dissertations and Theses Global), MedNar (including Google Scholar).

The TRIP database and webpages of professional bodies were also searched in the previous review, but they will not be included in the present review because no relevant research-based studies were identified from such information sources.

The previous review included studies published up to April 2011.¹⁴ In this updated review, studies published from May 2011 onward will be included, and will be limited to those published in the English language.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote V8 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full texts that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final update review report. The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)²⁶ flow diagram. Any conflicts of interest or disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers specializing in methodological quality using the standard JBI critical appraisal tools for randomized controlled trials, quasi-experimental studies and qualitative studies.^27,28 Authors will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of the critical appraisal will be reported in narrative form and in a table.

Following critical appraisal, all studies regardless of the result of their methodological quality will undergo data extraction and synthesis, where possible, because we do not expect a large number of new studies available on this topic. The possible impact of methodological quality in included studies will be addressed in the discussion section.

Data extraction

For the quantitative component, data will be extracted from quantitative and mixed methods (quantitative component only) studies included in the review by two independent reviewers using the standardized JBI data extraction tool in JBI SUMARI. The data extracted will include specific details about the populations, study methods, interventions, and outcomes of significance to the review objective.

For the qualitative component, data will be extracted from qualitative and mixed methods (qualitative component only) studies included in the review by two independent reviewers using the standardized JBI data extraction tool in JBI SUMARI. The data extracted will include specific details about the population, context, culture, geographical location, study methods, and the phenomena of interest relevant to the review objective. Findings and their illustrations will be extracted and assigned a level of credibility.

Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data synthesis and integration

This review will follow a convergent segregated approach to synthesis and integration according to the JBI methodology for mixed methods systematic reviews²³ using JBI SUMARI. This will involve separate quantitative and qualitative syntheses followed by integration of the resultant quantitative evidence and qualitative evidence.

Quantitative synthesis

Data will, where possible, be pooled with statistical meta-analysis using JBI SUMARI. Effect sizes will be expressed as either odds ratios (for dichotomous data) or weighted (or standardized) final post-intervention mean differences (for continuous data), and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard χ² and I² tests. Statistical analyses will be performed using the random effect model because a large degree of heterogeneity across studies is expected.²⁹ Subgroup analyses will be conducted where there are sufficient data to investigate specific types of interventions. Sensitivity analyses will be conducted to test decisions made regarding inclusion criteria for statistical pooling. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation, where appropriate. A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test) will be performed where appropriate.

Qualitative synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.²⁷ This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings based on similarity in meaning. These categories are then subjected to a synthesis to produce a comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Integration of quantitative evidence and qualitative evidence

The findings of each single-method synthesis included in this review will then be configured according to the JBI methodology for mixed methods systematic reviews.²³ This will involve quantitative evidence and qualitative evidence being juxtaposed and organized or linked to a line of argument to produce an overall configured analysis. Where configuration is not possible, the findings will be presented in narrative form.

Acknowledgments

Toshiyuki Suwa, research librarian, for assisting with the database search.

Funding

This work is supported by School of Nursing, Hyogo University of Health Sciences, Japan. This funding source had no role in the design of this study and will not have any role during its execution, analysis, interpretation of the data, or decision to submit results.

Appendix I: Search strategy

MEDLINE (PubMed)

Date searched March 3, 2020

References