Addressing Hygiene Concerns in Old Age: A Focus on Seniors in Home and Care Settings

In the guise of short listing a care facility for our ‘non existing’ uncle, both of us visited few old age homes (care facilities) to know the hygiene standards, and those trips were the genesis of this article. Unfortunately, in some places, the conditions were distressing, as if proper hygiene is an unheard-of concept. The prevalence of poor hygiene in care settings nationwide poses a significant threat to residents’ health. When nursing homes neglect sanitation, it can lead to severe consequences for the older adults residing there. The spread of germs and bacteria, coupled with existing medical conditions, compromised immunity, and inadequate hygiene can wreak havoc on their well-being.

In a care setting, whether labeled as an old age home or assisted living, substandard hygiene can manifest in various ways, impacting not only resident cleanliness but also the overall integrity of the facility. The primary indicator of a well-run care facility lies in its general hygiene standards. If it maintains high standards, it reflects the facility’s competence. Conversely, inadequate cleaning and sanitization of toilets, shower facilities, and kitchens can create a breeding ground for infections. It’s crucial not only to ensure the cleanliness of toilets and shower areas but also to pay attention to other spaces like tabletops, chairs, kitchen, and dining rooms. Neglecting these areas can pose infection risks for residents.

Various factors contribute to the inferior sanitary conditions. Primarily, a negligent management approach involves cutting corners, either through staff reduction or the appointment of less-trained personnel. Unfortunately, many care settings lack a bathing protocol, reflecting management’s diminished priority on this crucial aspect. This often results from inadequate staffing and an insufficient caregiver-to-resident ratio. Under situations like these, residents are often times left unbathed and fail to change soiled clothing on time. The older adults who wear diapers and other continence aids are mostly left for longer periods of time without being changed.

Numerous long-term care facilities face chronic understaffing, exacerbating the situation as overworked nursing assistants are compelled to leave residents in unclean and unsafe conditions for extended periods. This lack of attention and care often reaches a level of negligence, causing distress for the residents. Additionally, a strikingly high turnover rate among nursing assistants, the frontline staff directly involved in care, further complicates matters. With few employees staying beyond a year, nursing homes struggle to promptly recruit new staff, significantly impacting the overall hygiene thus impacting the resident health. Improper hygiene tends to evolve into a facility-wide problem rather than remaining isolated to one or two residents.

A great many care facilities overlook the cleanliness and basic personal hygiene needs of their patients, and the facility itself may also fall short in maintaining proper cleanliness. Essential areas such as toilets, showers, bathtubs, bathroom floors, and rooms may lack regular fumigation and disinfection, promoting the spread of germs and posing a risk of diseases and infections. The kitchen, where food is prepared and served, demands meticulous cleanliness, with kitchen staff appropriately attired and taking necessary precautions for safe food handling. The dining area, including tables, chairs, buffet tables, and floors, requires regular sanitisation to minimise resident contact with potential contaminants. A nursing home’s physical environment should also be presentable, incorporating proper ventilation and lighting. Neglecting regular sanitation in bathrooms and showers can foster germ proliferation. Maintaining sanitary conditions necessitates the liberal use of disinfectants, detergents, and soap liquids, and any cost-cutting measures that compromise cleanliness should be avoided for the sake of residents’ well-being.

Inadequate hygiene can significantly and negatively affect the lives of older adults in various ways. The potential stigma of associating elders with being unclean due to foul odours, unkempt clothing, stained teeth, messy hair, and dirty fingernails is a concern. Yet, the consequences of poor hygiene go beyond mere perceptions. Turning our attention to the personal hygiene of residents, let’s listen to Jina Abraham, a nurse manager in a skilled nursing home. As highlighted by Jina Abraham, there are significant medical implications that older adults and their families must carefully consider. Mrs. Abraham explains, “Compromised personal hygiene can result in skin infections involving bacteria, fungi, and parasitic infestations of the skin and hair. Even worse, it can be transmitted to others in close contact with the affected person. These consequences extend beyond the external body, as unclean hands, utensils, and crockery can heighten the risk of diseases such as gastroenteritis and food poisoning.”

Jina goes on to explain that one’s poor hygiene can have potentially fatal consequences for seniors. The spread of infection can lead those with weakened immune systems to develop conditions like septicemia, which is blood poisoning. Needless to say, it’s vital that seniors to have bath at least alternate days and if incontinent daily bath is recommended. But the reality is older adults are hesitant to take regular bath and we may have to insist. Diminished strength and balance, which is commonplace in our advanced years, and the fear of slipping or falling can be the reason for resistance.

According to Jina, depression can cause seniors to lose interest in how they look or smell. “The elders who are isolated or are depressed over life or health issues, they may not care enough to bother with hygiene,” she continues, “If you feel depression is the problem, the children of the older adult should see a doctor and the doctor can evaluate and prescribe medications. Everyone knows depression is a much larger issue than cleanliness. Once the depression issue solved, then there is a chance for a renewed interest in hygiene.”

Jina also points out that diminished faculties such as hearing and vision loss contribute to seniors avoiding bathing. Additionally, their weakened sense of smell and memory loss can impact their hygiene habits. In the skilled nursing home where she works, management insists on bathing all residents, even those who are bedridden. Jina shares a compliment from a dementia patient’s son, who expressed, “I dropped my father at your care facility, and you made him my younger brother.” The son was amazed by the positive transformation given to his father.

Elderly individuals, particularly those afflicted with dementia or Alzheimer’s, may face challenges in verbal communication, making them less responsive to unhygienic conditions. On the other hand, those with intact faculties who can communicate might hesitate to report such issues due to fears of retaliation from staff. Consequently, it falls upon the families of the residents to prevent blatant neglect and advocate for improved hygiene practices from the management. Recognizing signs that may indicate a lack of bathing or cleaning is essential in addressing these concerns.

Indicators of potential hygiene issues include:
• Wearing soiled and unwashed clothing
• Stains on clothing and bedding
• Offensive odors like feces or urine
• Unwashed and unkempt hair
• Lack of shaving
• Absence of shampoo and soap
• Presence of bed sores and infections
• Behavioral changes such as withdrawal, anger, or depression
• Unchanged diapers

For those with loved ones in nursing homes, consider the following questions during visits:
• Is there a hygiene protocol in place, and is it consistently followed?
• Does it seem like residents have been bathed recently and adequately?
• Are their teeth and gums in good health?
• Are their clothes clean?
• Does their skin appear moisturized and healthy?
• Does their hair seem recently washed?
• Is the bedding clean, and how frequently is it changed?
• How often are diapers changed?
• Is the bathroom maintained in a sanitary condition?
• Is the food prepared with proper hygiene?
• Are vegetables and meat adequately washed before cooking?
• Are plates and vessels properly cleaned and dried?

For those residing relatively close to the care facility, consider making surprise visits at least once a week. Since care facilities often anticipate weekend and holiday visits, opting for unannounced weekday visits can prevent staff from concealing potential neglect of personal care for your loved one. If distance prevents you from unexpected visits, enlist nearby relatives or friends to drop in and assess whether your loved one is receiving adequate care.

While we’ve emphasized the significance of good hygiene practices in care settings and pointed out lapses, as mentioned in the synopsis, let’s now examine the perception of “better hygiene” in homes. There’s a common misconception that elderly individuals living in their own homes experience perfect hygiene. However, we challenge this notion, beginning with a compelling story.

Ramanathan, an 87-year-old retired railway employee, welcomed his only daughter and son-in-law into his home after his wife’s passing, hoping they would care for him in his old age. Despite a strained relationship with his son-in-law, Ramanathan had no expectations, but he anticipated support from his daughter, Malathi. However, when arthritis left him bedridden, Malathi’s attention shifted to her daughter’s delivery, leading to neglect. As a professor at Bangalore University, Malathi faced overwhelming demands, prompting her to hire a caregiver, 55-year-old Cletus, inexperienced in caregiving.

When the unbearable foul odor became evident, Ramanathan’s daughter and granddaughter decided to place him in a care facility, leading him to our skilled nursing home. He developed bed sores extensively, requiring debridement and surgical management by a plastic surgeon. Ramanathan revealed he hadn’t been bathed in nearly 14 days, and Cletus, the caregiver, admitted to struggling alone without assistance and that’s why he couldn’t give bath. Sadly, this incident is not unique, as we’ve encountered many similar “horror” stories.

Ramanathan’s situation underscores how families compromise personal hygiene, revealing a lack of concern for unhygienic conditions at home. While we criticize Ramanathan for his naivety, considering his son-in-law’s grudge and his daughter’s lack of sensitivity to his plight, he could have opted for a care facility much earlier. Fully aware of his daughter’s family dynamics and the challenges she faced, it’s unrealistic to expect her to provide hands-on care, even for her father. It’s essential to note that Uncle was financially independent due to his pensions, and the decision regarding his living situation was within his control.

Take a look at the following statements:
Ramanathan never planned his infirm days
Ramanathan blindly believed his daughter, whose hands were full.
Ramanathan’s son in law had a grudge towards him and still he allowed him to move in.
Ramanathan know that he had a debilitating disease and need round the clock care.
Ramanathan never anticipated and demanded a more congenial environment.
Ramanathan is a pensioner and he is financially independent.
Ramanathan’s care taker has no clue about his condition and management.
Ramanathan’s care taker has no clue about the importance of hygiene. (bathing and cleaning)

Ensuring proper personal hygiene for your aging parent is crucial, yet intervening can be challenging, often perceived as an infringement on their dignity. As discussed earlier, inadequate hygiene may lead to severe infections and skin diseases. To prevent such issues, you or your parent’s caregiver may need to gently encourage them to accept assistance. However, we have reservations about how actively many of you are involved in providing this assistance or overseeing the caregiver’s actions. Malathi in Ramanathan’s story didn’t actively engage or supervise Cletus. Firstly, Cletus’s competence and expertise were never questioned. If you’ve chosen a live-in caregiver for your home, it’s crucial that they possess fundamental caregiving skills and understand the importance of maintaining personal hygiene.

When choosing “care at home,” a comprehensive care plan addressing your parents’ specific needs should be developed. This plan should encompass personal and preventive care, nutritional considerations, and medication management. Both you and the caregiver need a clear understanding of the various conditions involved. Establishing a daily routine is crucial, including regular washing of the face and genital area, with a minimum of three baths or showers per week. Cleaning teeth or dentures should occur in the morning and evening. While initially, it may be awkward for an older person to accept assistance with such private activities, the initial embarrassment is expected to subside as they come to terms with their live-in caregiver providing support with washing and bathing.

George uncle’s story serves as a compelling illustration of how older adults establish and adhere to their personal care routines. Following his retirement from a senior position at L&T, George uncle chose to settle in Bangalore, primarily because of his membership at the prestigious Bangalore Club and the presence of his friends. Despite being in his early eighties and encountering challenges with walking, George remains dedicated to a meticulous hygiene routine. While his faculties remain intact, his wife, Ammini aunty, is experiencing forgetfulness, nearing the onset of dementia. When George uncle’s son visited from the US, a care agency was enlisted to provide a live-in caregiver for Ammini aunty. However, she agreed to this arrangement with the condition that the caregiver would sleep in the outhouse rather than inside the house.

Despite physical challenges, George uncle insisted on continuing his daily bathing and shaving routine. The care agency arranged for a male attendant to assist with daily baths. George uncle, dressed in his white shirt and dhotis, insists on reading Times of India and Hindustan Times (Delhi Edition) before breakfast. This routine, much to Ammini aunty’s irritation, becomes a point of contention as she questions and ridicules him for his daily grooming habits, as if he were still going to the office. Despite objections from his wife, George uncle remains steadfast in his belief and adherence to his morning routine.

Ensuring good personal hygiene significantly influences your daily well-being and demeanour. Follow these 10 hygiene tips to help maintain optimal personal hygiene and feel your best:

1. Prioritise Healthy Eating: Include high-fibre fruits, vegetables, and whole grains in your diet to support digestion and sustain energy levels.
2. Stay Hydrated: Seniors are susceptible to dehydration, so ensure you drink an ample amount of water daily to prevent dehydration.
3. Aim for Sufficient Sleep: Target 6 to 8 hours of sleep each night to enhance mood, lower blood pressure, and fortify your immune system.
4. Daily Shower Routine: Take a daily shower to eliminate bacteria and irritants from your skin, reducing the risk of rashes and skin issues.
5. Regular Nail Maintenance: Trim your nails frequently to eliminate bacteria residing under your nail beds, promoting overall cleanliness and preventing infections
6. Twice-Daily Teeth Brushing: Brush your teeth twice a day to ensure strong gums and prevent gum disease, reducing the risk of oral hygiene-related illnesses.
7. Frequent Hand washing: Wash your hands regularly, especially after touching surfaces that haven’t been recently cleaned, to prevent the spread of viruses and bacteria.
8. Maintain a Clean Home: Enhance personal hygiene by keeping your home clean. Wipe down frequently touched surfaces with disinfectant spray for an easy way to maintain cleanliness.
9. Daily Deodorant Use: Control excessive sweat, eliminate body odour, and stay fresh by wearing deodorant daily.
10. Change into Clean Clothes Daily: Change into fresh clothes daily to prevent skin infections. Regular clothing changes help avoid the spread of germs, as clothes can harbour bacteria.

George uncle’s story serves as a clear example of maintaining a strict routine for bathing and grooming. Even in his advanced age, he is unwavering in his desire to look dapper, a trait he has carried from his younger days. While personal hygiene practices vary from person to person, George stands out as an exception. Nevertheless, regardless of individual differences, maintaining good personal hygiene is crucial for healthy living, whether you are in a care setting or your own home. As people age, their ability to uphold hygiene may diminish, emphasising the importance of following these practices, either independently or with the assistance of caregivers. Prioritising good personal hygiene contributes to overall health and well-being, reducing the risk of infections and diseases associated with poor hygiene.