Personal Hygiene for Cognitive Impairment

Definition

Personal hygiene refers to maintaining cleanliness of one's body and clothing to preserve overall health and well-being. It includes a number of different activities related to the following general areas of self-care: washing or bathing, oral hygiene, grooming and dressing, keeping one's clothes clean, and toileting. These are sometimes described (along with such other daily tasks as preparing meals or managing finances) as activities of daily living or ADLs. Cognitive impairment may affect a person's ability to maintain personal hygiene in all these areas.

Cognitive impairments refer to limitations on a person's ability to think, pay attention, perceive, and remember. They may be associated with a variety of diseases and disorders, including:

• developmental disorders of childhood including autism, Asperger's syndrome, pervasive developmental disorder (PDD), and others that are sometimes grouped together as autistic spectrum disorders
• mental retardation
• psychotic disorders, including schizophrenia, which is a mental disorder characterized by delusions, hallucinations, and other deficits in reality testing
• mood disorders, particularly depression and bipolar disorder
• substance abuse disorders
• multiple sclerosis (MS), which often affects the patient's visual perception as well as memory and abstract reasoning
• stroke
• dementing illnesses, including Alzheimer's disease and AIDS -related dementia
• mild cognitive impairment (MCI). MCI is a condition found in older adults in which the person has some memory loss but is able to carry out ordinary activities of daily life with the help of notes, calendars, or other written reminders

Purpose

Personal hygiene is a preventive health measure that serves emotional and social as well as physical well-being. Personal hygiene:

• protects against the spread of disease from external parasites (such as body or head lice) or from contact with contaminated feces or other body fluids
• protects the skin against rashes and sores from contact with urine
• protects against malnutrition or swallowing difficulties caused by lack of oral care
• minimizes the chances of social embarrassment, job loss or educational failure, and eventual isolation from others
• keeps up morale and helps avoid depression

Precautions

Inattention to personal cleanliness or grooming in adults or adolescents may be one of the earliest signs of depression, dementing illnesses, substance abuse disorders, and psychotic disorders. Therefore, accurate diagnosis of the cause or causes of the person's cognitive impairment is critical. It is also important to remember that depression may coexist with other disorders, and may require separate treatment. In the case of children with mental retardation or developmental disorders, an evaluation of the child's capacity to learn self-care is necessary. Children with mild cognitive impairments can often learn to perform ADLs related to personal hygiene with appropriate instruction, repetition, and coaching.

Description

Inability or unwillingness to carry out bathing, grooming, or other activities related to personal hygiene is often an early sign of cognitive impairment, particularly in older adults or in adolescents diagnosed with schizophrenia. For this reason, geriatric and other medical assessment checklists include personal hygiene as one of the items to be evaluated in determining whether the impaired person is still capable of living independently.

The onset of a patient's difficulties with personal cleanliness may be either gradual or sudden. In patients with schizophrenia, neglect of self-care often indicates that the patient is relapsing.

Complications

Some types of cognitive impairment present specific difficulties with regard to maintaining the patient's personal cleanliness and grooming.

• dementia. Patients with a dementing illness often lose their ability to control their emotions as well as their thought processes. It is not unusual for these patients to have what is called a catastrophic reaction when they are asked to take a bath or shower. A catastrophic reaction is an emotional outburst or over-reaction to a situation or event. Patients with dementia may become upset about bathing because they are embarrassed by having to disrobe in front of someone else, they are disoriented, they feel rushed, panicked or cold, or because they cannot remember all the steps involved in taking a bath. Many caregivers recommend coaching the patient through one step at a time and allowing him or her to have as much control as possible over the time of day for bathing and the choice of a bath or shower.
• schizophrenia. Smoking is a common behavior in schizophrenic patients that complicates personal hygiene, particularly oral care and keeping clothes clean. About 80% of patients with schizophrenia—three times the rate in the general population—are addicted to nicotine. Stopping smoking is particularly difficult for these patients because nicotine withdrawal often causes their psychotic symptoms to worsen. It is not yet known whether there is a biological basis for the high level of nicotine craving in many persons with schizophrenia.
• children and adolescents with learning or developmental disorders living in troubled homes. Some young people with these disorders react to abuse or other problems in their families by neglecting personal hygiene or refusing to bathe and otherwise care for themselves. A social worker's evaluation of the home situation is usually necessary.

Results

Results depend on the reason(s) for and degree of the patient's cognitive impairment, and whether or not he or she is also physically impaired. A physically healthy young person with mild mental retardation may be able to live independently and maintain a reasonable level of personal hygiene and grooming with occasional instruction or reminders from others, whereas an elderly patient with late-stage Alzheimer's disease will be completely bedridden, incontinent and unable to think clearly or even speak.

KEY TERMS

Activities of daily living (ADLs)— A shorthand term for the everyday tasks that must be carried out to maintain basic cleanliness, nutrition, contact with others, etc.

Catastrophic reaction— An emotional outburst or overreaction to a situation or event. Catastrophic reactions are common in patients with dementing illnesses.

Cognitive— Pertaining to such mental activities as perceiving, thinking, and remembering.

Cognitive therapy— An approach to psychotherapy that focuses on interrupting and correcting the patient's present faulty thinking patterns rather than on exploring emotions or childhood memories. It appears to be particularly helpful in treating depression.

Dementia— A decline in a person's level of intellectual functioning. Dementia includes memory loss as well as difficulties with language, simple calculations, planning or decision-making, and motor (muscular movement) skills.

Incontinence— Inability to control one's bowel or bladder functions.

Mild cognitive impairment (MCI)— A transitional phase of memory loss in older people that may eventually progress to dementia or Alzheimer's disease.

Psychosis— A type of mental disorder in which the patient's contact with reality is severely impaired. It is characterized by delusions, hallucinations, incoherent speech, and disorganized behavior. Schizophrenia is one type of psychosis.

Health care team roles

Depending on the age of a patient with cognitive impairment and the cause(s) of it, most or all of the following health professionals will be involved:

• primary care physician.
• dentist and dental hygienist. These professionals may be able to give instruction in care of the mouth and gums as well as perform examinations and routine cleaning of the teeth.
• psychiatrist, neurologist, gerontologist, or clinical psychologist. These specialists may help to diagnose the cause or causes of the cognitive impairments. A psychiatrist usually prescribes and monitors medications for psychotic and mood disorders. A neurologist may be needed to evaluate the patient for evidence of a stroke or other organic brain damage, while a clinical psychologist may administer tests to determine the type and severity of learning or developmental disorders. Gerontologists specialize in the care of the elderly.
• psychotherapist. Patients recovering from depression or substance abuse disorders are often helped by individual or group psychotherapy. Cognitive therapy appears to be useful in treating depressed patients by interrupting and correcting the distorted thought patterns that underlie and maintain depression.
• case manager, social worker, occupational therapist, and/or personal support worker or "coach." Many patients with schizophrenia or mental retardation are capable of living in the community and holding jobs with the help of these professionals.
• physical therapist. May design physical exercises for stroke patients to speed recovery, minimize loss of cognitive function, and minimize the risk of depression.
• home care aide. May be needed to help moderately cognitively impaired patients with ADLs related to personal care.
• twelve-step or similar support group. Important in helping persons recovering from substance abuse to maintain self-care as well as other aspects of recovery.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: American Psychiatric Association, 2000.

Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery. Cognitive Therapy of Depression. New York: The Guilford Press, 1987.

Crissey, Pat. Personal Hygiene? What's That Got to Do with Me? Philadelphia: Jessica Kingsley, 2005.

Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day, revised and updated edition. New York: Warner Books, Inc., 2001; by arrangement with The Johns Hopkins University Press.

Marcantonio, Edward, MD. "Dementia." The Merck Manual of Geriatrics, Mark H. Beers, and Robert Berkow, eds. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Morris, Virginia. How to Care for Aging Parents, revised edition. New York: Workman Publishing, 2004.

"Schizophrenia and Related Disorders." Section 15, Chapter 193 in The Merck Manual of Diagnosis and Therapy, Mark H. Beers, and Robert Berkow, eds. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Ziefert, Penelope, Mark Leary, and Alicia A. Boccellari. AIDS and the Impact of Cognitive Impairment. San Francisco: University of California at San Francisco AIDS Health Project, 1995.

PERIODICALS

Dunn, Joshua C., Brenda Thiru-Chelvam, and Charles H. M. Beck. "Bathing: Pleasure or Pain?" Journal of Gerontological Nursing 28 (November 2002): 6-13.

Rao, Stephen M. "Cognitive Function in Patients with Multiple Sclerosis: Impairment and Treatment." International Journal of MS Care 1 (2004): 9-22.

Shankle, William R., A. Kimball Romney, Junko Hara, et al. "Methods to Improve the Detection of Mild Cognitive Impairment." Proceedings of the National Academy of Sciences 102 (March 29, 2005): 4919-4924.

ORGANIZATIONS

Alzheimer's Association. 225 North Michigan Avenue, Floor 17, Chicago, IL 60601. (800) 272-3900. http://www.alz.org.

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. www.aacap.org.

American Association on Mental Retardation (AAMR). 444 North Capitol Street, Washington, DC 20001-1512. (202) 387-1968. Fax: (202) 387-2193. http://www.aamr.org.

American Physical Therapy Association (APTA). 1111 North Fairfax Street, Alexandria, VA 22314-1488. (703) 684-APTA. Fax: (703) 684-7343. http://www.apta.org.

National Alliance on Mental Illness (NAMI). Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201-3042. (800) 950-NAMI or (703) 524-7600. Fax: (703) 524-9094. www.nami.org.

National Institute of Mental Health (NIMH). 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513 or (866) 615-NIMH. Fax: (301) 443-4279. www.nimh.nih.gov.

OTHER

Alzheimer's Association. Caregivers: Hygiene and Personal Care. http://www.alz.org/Care/DaytoDay/Hygiene.asp.

American Association on Mental Retardation (AAMR). Fact Sheet: Frequently Asked Questions About Mental Retardation. http://www.aamr.org/Policies/faq_mental_retardation.shtml.

National Institute of Mental Health (NIMH). Schizophrenia, revised edition. Bethesda, MD: NIMH, 2005.