Self-inflicted abuse caused by poor hygiene and is causing severe skin issues. Any advice? - AgingCare.com

Self-inflicted abuse caused by poor hygiene and is causing severe skin issues. Any advice?

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My mother in-law was diagnosed with MCI. She had been stable for about 5 years, then some changes were noted. She is now diagnosed with mild dementia. She developed a severe fungal infection under bilateral breasts, inner butocks, buttocks, bilateral groin and abdominal folds. She insist sponge baths are adequate, and it is apparent that it is no longer adequate personal hygiene. The condition was noted by one of her MD's in September 2016. She was ordered an antifungal cream. She also had an outbreak of psoriasis which a steroidal cream was ordered. My sister-in-law is the primary caretaker and my mother-in-law resents her hovering and will not allow her to apply the ointments or check her skin. She went to her Geriatric MD on 12/1/16. The fungal excoriation was severe as well as the psoriasis. Once again the discovery was made by the MD and not the caretaker. I have been a geriatric nurse for 24 years and in this capacity I have been the Wound and Skin Care Nurse for entire facility, ADON, Unit Supervisor and I also was a Charge Med/Tx nurse and often would help the CNA's with showering. After seeing the severity of the rash, the Geriatric MD ordered Shower or Bath with Hair Wash 2x a week by family or outside Home Care Agency. My sister- in -law told MD family would do the bathing, no outside help. She also had a dermatology consult which I attended. Nana's sons have been concerned about her personal hygiene for a while,but she is at that stage of dementia where she still wants control but obviously poor decisions are being made. Family members have approached her about assisting with bathing and shower but she refused. There is alot of family dysfunction between my sister-in-law and her brothers. They want an outside Nursing Agency to come in to take the burden of bathing off their sister. I assisted and gave her a shower with her daughter who is the caretaker and my sister-in-law was very negative, had none of the supplies necessary, made inappropriate comments about the shower etc. I knew it would not be easy and I knew it might take 2-3 weeks to get her acclamated, maybe even a couple months. It was a struggle at first. She didnt believe skin was that bad and forgot the MD ordered showers. Finally we got her to take the shower and it really didn't go that bad at all. in my experience I know this can be difficult. I wanted to sit down with my sister-in-law and Care Plan the process, evaluating what was positive and what was negative so that with second shower it could go smoother by adhering to the postive approaches. I asked my sister-in-law what time I should come to assist with second shower. She said 1p.m. When I got to Nana's house I had a basket of supplies and did I said Hi and went to put the basket down. My sister-in-law said to me while I was taking my coat off, that Nana was refusing to take shower. I said okay, let's talk about it, and see what we could negotiate. Nana was aggitated, angry, mean and I have never seen her that way, and had allowed me to do an initial complete bath with hair washing prior to first shower attempt. That was the first time I saw her skin, and I was very concerned as I was not informed by the famiily of severity. I let Nana vent and express her anger, and told her we would take a shower holiday and reattempt it later.I went into the kitchen and my sister-in-law followed me in, and I said to her, that I didn't realize that she was so aggitated prior to even discussing the shower. AfterI had been there an hour, my sister-in-law said to me that she had arrived at the house an hour before me. She had gotten Nana aggitated but never said a word before Nana had the upsetting episode. I could tell she was very annoyed at her daughter, so I told her to go to the store and I would stay and talk to Nana. By the time Ieft, Nana was okay so I went home. I then got a text from my sister-in-law that said Nana was going to dismiss the services of her Geriatric MD if she made her shower and bath.I have been gently trying to explain to my sister-in-law the regulations because I worked in this field and had similar experiences. I told her that according to Office of Aging and Federal/State regulations that inadequate bathing by an elderly person whether in the Home or Long Term Care setting is not acceptable as it is considered self-inflicted abuse and is a reportable incident by her MD, if the problem can't be dealt with, especially since it is the cause of her skin problems which can lead to serious health concerns. She insist it is not a hygiene issue. The dermatologist verbally ordered to continue shower and bathing. My sister-in-law told me she will not allow Nana to be bathed by outsiders and as long as she can apply the creams to her skin, it will be whatever it will be. I know caretaking is a difficult job,but she is also a nurse. Is the information regarding self-inflicted abuse correct. Due to family dysfunction, I went to see the Social Worker to explain the situation.

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I found that an outside caregiver was the best option for my mother-in-law. That eliminated her embarrassment over family members bathing her (not your issue, I understand, but it is for many). It also made her realize that it was "bath time" no matter what so she cooperated.

Since so many community members suggested this, it seems to be a good idea.
Good luck. I know it's hard.
Carol
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By all means, you need a fresh approach. No more lecturing, nor more bossing around, and also, this is a control issue, especially when family members are involved. I'd say an entire outsider should be employed at this point. A super pleasant person. An entire blank slate. Someone who is not "prepped" nor "warned" about Nana. Someone cheerful, fun, upbeat, but also down to business.

Remember how Mary Poppins totally blew the other nannies out of the water upon her arrival? She was like no other. She did not lie about the medicine that was in that spoon. She did not deceive. No, she simply made it fun. She got stuff done, rooms were clean, everything spic and span. And at the same time, she turned those kids' drab lives around, and brightened up the lives of children moviegoers around the world.

A friend of mine dreaded having to hire a personal caregiver to help her with basic housework. But this one, she told me, was "different." An angel. She said she even started looking forward to the caregiver's arrival every other day, and cried the day she no longer needed her.
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So basically, your MIL has several skin conditions related to not bathing regularly and she refuses to have a shower or a bath and neither you (the DIL) or her daughter (your SIL) can get your MIL to bathe.

The fungus infection and other skin conditions won't heal if someone just applies fresh crème on top of old crème. The same goes for powder. The skin must be washed with warm soapy water and dried thoroughly.

Can you just concentrate on the affected areas for now? Don't do a whole bath or shower, just wash and dry the irritated skin and apply whatever was prescribed and leave it at that. For now. Build some trust with your MIL by just doing the infected areas and take the pressure off of having a bath or shower for the time being.

If your MIL will allow this exclaim how great her skin is looking. Ask her if she feels better after having her skin treated. Maybe rub some clean-smelling lotion onto her feet. Ask her how that feels. Make over her and make it a positive experience. A bonding experience. After a while re-introduce the idea of a bath or shower. A bed bath might go over better as it doesn't require as much upset as a shower.

I think this will require baby steps. Does your SIL antagonize your MIL? It sounds like she does. On skin care days you may have to talk your MIL down before you can get to work. Sit with her. Don't require anything from her. Chat with her. Get her into a better frame of mind before you care for her skin. I'm all for care plans and meetings but when the "patient" is a family member the principles of the care plans can go right out the window because there is emotion involved, history, resentments, etc. It might be best to approach this as just a DIL and not a nurse.
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As a nurse also, I see too many nurses applying their training to a person with whom logic does not apply. My first thought was this woman is very overweight to have folds under her breasts as well as thighs, etc. The infection is fueled by too much sugar, not enough good bacteria (i.e. yogurt), not enough exercise and probably no sunshine (Vitamin D). If there is a tub involved and no walk in shower, I can understand her reluctance to showering. If she can shower by walking in, try letting her do it herself. But be firm and wait until her thinking process changes (and it will in 5 - 10 minutes), then try again. When ordering a wheelchair for my husband yesterday, there were also products like waterless cleaning gels (or whatever it is made from). At this point the more control she has, the more compliance there will be, at least for now. With dementia, this illness is ever-changing and can change overnight. Remember, the more you push, she will resist!
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You mention the skin condition is self-inflicted, but are you absolutely sure about that 100%? There's a strong possibility that maybe something else is causing this condition, not ruling out possible abuse by another party. Something just struck me as you were describing how the patient becomes agitated around shower time and won't let no one clean her up. Have you considered putting her in the hospital under strict observation to see what's really going on? See if the hospital rooms have surveillance cameras, some of them do in some circumstances.
You also mentioned dementia, and it may be time to put her in a facility that can handle people like her. Unless you're a trained worker in this area, chances are it's going to become too hard for you at some point, and it sounds like it already is and she's probably going to need more help in the family can give her. It sounds to me like someone really needs to go for guardianship. Demented people have a tendency to self neglect, but not everyone who self neglects has dementia. I don't know for sure what the problem really is, but if she's not showering as the doctor ordered, then someone needs to just put her in the shower and start scrubbing, (much like a G.I. bath when people don't bathe like they're supposed to). I strongly support this method, always have and always will because people must get clean one way or the other or it's a health hazard to them and others around them. If the family can't or won't do it, someone else will, I've seen it happen and again I'm all for it, hook, line, and sinker!
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Your SIL is neglecting your MIL's welfare to the point of abuse. You, as an experienced geriatric nurse, will know better than I do that you have to act on this.

So look one step ahead: if your MIL's care is taken out of your SIL's hands, forcibly if necessary, what's the alternative care plan?
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It is often easier to get someone to bathe if they have "outside" help.
I think telling MIL that someone will come in on Tuesday and Friday (examples) and will help her get ready. A bath or shower, wash hair and then tend to the skin issues and help her get dressed.
It may be that this will have to be done more often than 2 X a week until the skin issues are cleared up.
Often the fear of falling is greater than the desire to shower or bathe.
Make sure that there is a bench or a shower chair for MIL to sit on. Make sure it is secure. For a long time my husband used a walker that I would purchase at a resale shop. He would stand and hold the walker and he felt safe. Even though we have secure grab bars he felt better with the walker. So a walker might be an option if she does not want to sit.
Get a pair of shower shoes if she is still unsure of her footing. The feet can be dried and checked once she is done with the shower.
My husband also became fearful of the drain. It was silver and may have appeared as a hole or slippery spot. (never did figure out what he was afraid of) I got spray paint the same color as the floor tile and sprayed the drain cover. He never balked at stepping on it again!

The bigger problem here is if this continues the people responsible directly for caring for MIL may be charged with neglect.

And if all else fails if bathing is a real issue and causes a lot of agitation medication might be the answer. It will cause less trauma mentally and will be easier for everyone physically.
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That's a tough situation for you to be in. I do not envy it. I think that I would consider the following:

First of all, by now, you have seen that your MIL isn't likely to listen to arguments, pleading or reasoning. Pleas for vanity aren't likely to get through, due to her cognitive decline. With your experience, you know that it's not stubborn issue, but a brain damage issue. As she progresses, this resistance could change.

You state that the family does have a certain amount of dysfunction. I can relate, as we all have that. I'd consider just how much there is and especially, if they and MIL's primary caretaker will hold grudges for long. If they do, then I might consider one approach. If they aren't then, I'd do another.

One approach is to tell them politely, but bluntly that MIL needs a professional to address the skin/hygiene problem and that it's not really something to mull over, but do immediately. Enough attempts have been made for family to handle it and it's not their health that is suffering, but MIL. And that I wouldn't let it rest. MIL needs an advocate. They may not like it and they defy you and stay upset. But, I would consider it, because that's just the kind of person that I am. Some people may not go that route. I'd let them know that I would not let it rest, until professionals were handling her skin/hygiene issue.

Another approach is to stay out of it and report it to the authorities. I'd likely call adult protective services. You can do it anonymously, right? The family can guess it was you, but, they can't know for sure.

Is there some reason that your husband can't stand up to them? When it's an in-law situation, it's a little more tricky, than it being your own mom or dad.

I hope something works.
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We're in same situation almost, and what helped us was the doctor ordering an Occuational Therapist to help me (the only caregiver) with health situations that were aggravated/caused by her dementia and refusal to bathe any longer, sleep in her bed, etc. (Her current problem is a skin problem caused by lack of bathing and resistance to same - pressure ulcers since August in various stages. We also had home nurse care for wounds, which educated me for my care of these.) The OT so far has really helped me, as he analyzed where her dementia was really at (to help with "cues," approaches, etc.), family dynamics (in our case, just me and a part-time caregiver), her previous habits prior to dementia, daily and weekly outings and social interactions, etc. In just a few weeks, with only one visit per week, he has helped me get her going with better habits: She is now sleeping in her bed, changing her clothing when retiring for bed, getting more hydrated, and being gently coaxed to moved every hour or so for better circulation. The bathing we are now confronting with a tactic designed for her personally, so this might be an option prior to outside home health aides, which would be the next step that I will go to, if we don't get enough compliance eventually to help her wound(s). We also use wipes and the no-rinse perinneal cleaners, but soap and water is the best, which I used when changing out her barrier cream and Depends twice daily.
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Just my opinion, but I have a feeling your sister-in-law is being totally controlled by her mother and cannot stand up to her. She has probably been subservient to mom all her life. Now the ugly part: you are an in-law. In-laws often have nothing to say. Do not call in a report unless the other siblings back you up.
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