Sundowning, a Refused Shower, and a Daughter Who Says Make Her
Mrs. Kim, 88, has mid-stage Alzheimer's disease and lives on the memory care unit. She is usually calm and cooperative with morning care. For two days she has refused showers, saying 'I already washed,' and she pushes your hand away. This evening at 7:00 p.m. she is pacing the hallway, calling for her mother, and will not sit down. She has a faint urine odor and a reddened area between her labia. Her daughter, who is visiting, says, 'Just make her take the shower - she's always been stubborn. She doesn't know what she wants anyway.'
1. It is 7:00 p.m. and she is pacing and calling for her mother. What do you do right now about the shower?
Read the worked answer
Do not attempt the shower now, and do not physically force her.
- 7:00 p.m. with pacing and calling for a long-dead parent is classic late-day agitation. A shower adds noise, water, undressing, and a strange room to an already overwhelmed brain. The odds of a fight, a fall, or a scratch are high, and the payoff is low.
- Meet the immediate need instead: walk with her at her pace, offer a quiet area with softer light, a blanket, a favorite snack or music, and use short, calm, one-idea sentences.
- Do not correct her about her mother. 'You miss her. Let's walk together' works; 'Your mother died 30 years ago' does not.
- Do a brief check for the urine odor when she is calm and let the nurse know.
Plan for tomorrow: shower at her best time of day - her mornings are historically good - with the same aide, the same sequence, and a simple choice ('washcloth today or shower?'). If full showers keep failing, a warm towel bath at the sink accomplishes the hygiene goal. Check whether pain, constipation, or a wet brief is driving the refusal.
2. How do you answer the daughter without arguing with her and without agreeing to force care?
Read the worked answer
Side with her concern, not her method.
- 'You're worried about her being clean, and I understand that. I'm not going to force her tonight - when we push, she gets frightened and can fall or get hurt.'
- Explain that refusal in dementia is usually a symptom, not stubbornness: fatigue, fear of the water, not recognizing the bathroom, or pain she cannot name.
- Tell her concretely what you will do: try in the morning when her mother is at her best, use familiar staff, keep it short, offer a choice.
- Point her to the nurse and social worker for questions about the care plan and her mother's decision-making.
Reasoning: a person with dementia still has the right to decline care, and 'she doesn't know what she wants' is not a basis for forcing a shower. Force also has a cost: agitation, injury, and a resident who fights every future attempt. Your job is to find a workable route to the same goal, not to win the argument with the daughter in the hallway.
3. You notice the urine odor and a reddened area between her labia. What do you do with that, given she is pushing your hand away?
Read the worked answer
Report it now and treat it as a comfort problem, not a compliance problem.
- Tell the nurse: reddened skin between the labia, faint urine odor, two days without bathing, and that she resists perineal contact. Redness plus moisture plus a resident who cannot report burning is a reasonable trigger for the nurse to assess for a urinary tract infection or a skin injury.
- Meanwhile, do what she will tolerate while she is calm: change the wet brief promptly, clean front to back with warm water and pat dry, and keep the area open to air for a few minutes.
- Split care into short pieces. 'Let's just get you dry' lands better than 'we're doing peri-care now.'
- Watch for signs to report: she grabs at her crotch, winces when sitting, urine smells stronger, or she runs a temperature.
What not to do: do not label her 'noncompliant' in the chart, and do not decide the redness is 'just from the diaper' and let it sit for days. A resident who cannot describe pain depends on you noticing it.