Caring for Dementia

Disrobing, commonly misconstrued as a sexually expressive behaviour or a “sexualized act,” can stem from various reasons. This blog aims to offer alternative perspectives on potential triggers for disrobing in individuals with dementia. By exploring different possibilities, our goal is to offer insights that encourage a more thoughtful approach to this behaviour. We analyze aspects such as temperature and thermoregulation (the ability to cool and heat oneself), communication challenges, sensory discomfort, pain management, as well as memory loss and confusion. Examining these factors contributes to a more comprehensive understanding of potential connections with undressing behaviour.

1. Temperature:

Our ability to thermoregulate, and the temperature of the external environment can contribute to responsive behaviours related to disrobing. Below we’ve expanded on the main risk factors.

Temperature Regulation:

As individuals age, the ability to regulate body temperature diminishes. In dementia, this challenge is amplified, often leading to a misinterpretation of environmental conditions and behaviours such as disrobing.

When we sweat, sweat glands release a mixture of salt/water and other substances into the skin’s surface. As the sweat evaporates, it absorbs heat from the body, providing a cooling effect. However, as we age, the decline in number and responsiveness of sweat glands, along with thinning of the skin, can affect the sweating process. Reduced sweating hinders the body’s ability to dissipate heat through evaporation, impacting the ability to regulate body temperature. Understanding physiological changes of natural aging can assist us in making appropriate care decisions for our loved one or resident.

Creating an Optimal Environment:

To mitigate temperature-related challenges, caregivers and facility staff can focus on creating a suitable environment. This involves maintaining a comfortable room temperature, considering factors like humidity, and ensuring adequate ventilation. A well-regulated environment can significantly reduce sensory discomfort, minimizing the potential for disrobing behaviours.

Providing Clothing Options:

Provide the option for a couple of different garments suitable for various temperatures, allowing individuals to make choices that align with their comfort preferences at the time. This can contribute to personal autonomy but also reduces the likelihood of disrobing as a response to discomfort. Be prepared to adapt clothing throughout the day to ensure suitability of temperature changes.

Layering clothing for Dignity:

Encouraging the use of layered clothing can offer adaptability while still preserving their dignity. This approach allows individuals to engage in the disrobing behaviour if needed, while still maintaining a certain level of modesty. If a person is in a persistent state of confusion and engaged in disrobing often, you can attempt to preserve dignity by tucking an undershirt into their pants and layering shirts on top.

You can utilize a bodysuit so the suit has to be taken off under the pants – we don’t like to recommend this solution, and would only in certain situations. The reason for this is because often there is another meaning behind the disrobing behaviour we aren’t understanding, a bodysuit may only agitate the person if the unmet need is not being addressed.

Weather-Appropriate Clothing:

Selecting weather-appropriate and comfortable clothing is important in minimizing temperature-related discomfort. Caregivers should consider the season, ensuring individuals are appropriately dressed for the weather.

2. Communication Challenges:

Individuals facing limitations in spoken communication may resort to non-verbal strategies like disrobing to express distress. Understanding non-verbal communication is essential for caregivers to provide effective support.

Understanding Needs through Cues and body language:

Improving comprehension involves using simple and clear language, recognizing that individuals with dementia may struggle with complex verbal communication. Caregivers should utilize non-verbal cues, such as gestures and visual aids, to decipher the meaning behind the behaviour. If we can enhance our communication, we can learn more about what the person is trying to express.

Reciprocal Non-Verbal Communication:

Communication is a two-way street. Both caregivers and individuals with dementia benefit from leveraging gestures and expressions. Caregivers can use non-verbal cues to aid the person in comprehending information while paying attention to the gestures and expressions of the individual. Mirroring their gestures back to them can solidify the meaning behind what they are trying to express. If you notice they are getting frustrated while you’re attempting to comprehend their gestures, it might be an indication that there is a gap in understanding.

Tools for Improved Mutual Understanding:

By observing body language, gestures and cues we can get a glimpse into what the person is trying to express. When coupled with communication tools we can offer an opportunity for better understanding. Below are some examples of visual and non-verbal communication tools we can use with to help us understand unmet needs.

1. Communication Board: A visual board with images or words representing common needs and emotions.
2. Whiteboard or note paper: Using writing or drawing as a means of expression. Or draw on the paper and encourage the person to point to what they would like.
3. Facial Expressions and Emotion Cards: Utilizing visuals representing various emotions to help express feelings.
4. Smartphone or Tablet Apps: Interactive apps designed to facilitate communication through images, symbols, or text.
5. Mirroring Activities: Encouraging imitation or mirroring of facial expressions and gestures.

3. Sensory Discomfort:

Sensory discomfort encompasses various factors such as the environment, our internal temperature, physiological elements, clothing, loud noises, and bright lights. These elements can play a role in disrobing behaviours, as environmental stimuli may lead to agitation or frustration. Additionally, clothing choices might result in skin irritation and discomfort, contributing to the urge to undress.

Clothing Textures and Preferences:

Individuals with dementia might undress due to discomfort caused by dry and scratchy clothing materials or tags. Caregivers and facility staff can alleviate this by choosing clothing with soft and soothing fabrics, minimizing seams and tags. Some individuals may have specific likes for colou

rs, patterns, textures, or types of clothing. Conversations with individuals or their families about past preferences enable us to select clothing that resonates with the person’s unique taste.

Creating a Supportive Environment:

To further address the disrobing dilemma, we should attempt to establish an environment that minimizes potential triggers. Lighting, Noise, Temperature. Harsh lighting and loud noises can contribute to sensory discomfort, by creating a calm and relaxed environment we can assist in managing anxiety. We can promote relaxation and comfort by ensuring the environment is well-lit but not overly bright, and by minimizing loud or sudden noises in the surroundings. It’s important to pay attention to the environment as well as the person. Introducing a tranquil atmosphere can help in managing responsive behaviours should they manifest in disrobing or not.

4. Memory Loss and Confusion:

The cognitive challenges associated with dementia, such as memory loss and confusion, can lead to a disconnect in recognizing appropriate times and places for undressing.

Gentle Cues and Re-Orientation:

In situations where individuals exhibit disrobing behaviours, providing gentle cues can be helpful. Caregivers and facility staff can offer subtle reminders about the specific time and place, helping individuals better understand their surroundings. To promote socially appropriate responses, we can focus on re-orienting individuals when other people are present. For instance, when entering communal spaces like a dining room, announcing the purpose of being in that room serves as a helpful cue. This verbal reinforcement helps individuals understand the context of the environment, and encourages behaviour that aligns with social norms. This has the potential to minimize the occurrence of disrobing in inappropriate settings, depending on the cognition level of the individual.

5. Physical Discomfort or Pain:

Undiagnosed physical discomfort or pain can serve as a trigger for behaviours like disrobing. Recognizing this link is important for us to provide comprehensive care and support.

Non-Verbal Expression of Pain:

Although we covered gestures, body language and cues, it’s important to emphasize the importance of non-verbal communication, especially when it is pain related. The inability to verbally express pain may manifest as behavioural expressions. We should be attuned to non-verbal cues that could indicate physical discomfort, such as fist clenching, grimacing, restlessness, and increased agitation. Observing changes in body language, behaviours and facial expressions can assist us in identifying potential pain triggers. There are particular tools to help us understand pain in those who have limited ability to communicate it.

Observation and Medical Evaluation:

It’s important to remain vigilant in observing signs of physical pain and discomfort. There are a variety of tools we can use with someone who has dementia that can further assist us in understanding pain levels.

1. Numerical Scale – Asking the person to rate their pain from a 1-10.
2. Communication cards – Including “pain” in our communication cards allows us to capture unmet pain management.
3. Face pictures – Asking the person to choose which “face” represents their current state, using different facial expressions and colours. For example a green happy face would indicate no pain, where as a red angry face may indicate a lot of pain.

Assessments used in dementia

• PAINAD
• Behavioural Pain Scale
• Non-verbal Pain scale

Regular monitoring of the individual’s behaviour and well-being is essential. When indications of pain are present, seeking medical evaluation is imperative. Professional assessments helps uncover undiagnosed issues, allowing for a targeted and timely intervention.

Appropriate Pain Management:

Upon diagnosis of physical discomfort, caregivers and/or facility staff should ensure appropriate pain management strategies are implemented. This may involve medications, physical therapy, or other non-pharmacological interventions. Effectively addressing the underlying physical discomfort can significantly reduces the urge to undress as a response to untreated pain.

Let them disrobe!

If you notice someone consistently removing their clothes, it may take some time to grasp the underlying reasons behind this behaviour. During this period, especially if the individual resides in a facility or with family, consider bringing them to a private area and allowing them to undress independently. Disrobing behaviours are often challenging, mainly because they tend to occur in inappropriate settings with others present. This approach upholds their dignity while embracing emotion-focused care, providing a space where they can disrobe alone ensures a safe and secure place for the individual.

Addressing disrobing in individuals with dementia requires a comprehensive understanding of underlying factors. Exploring aspects such as temperature misinterpretation, communication challenges, sensory discomfort, pain, memory loss, and the desire for autonomy can offer insights for those caring for someone with dementia. While not exhaustive, these considerations, based on collective experience, aim to create a supportive environment.