Resistance to care

People living with dementia often need assistance with personal care requirements such as bathing or eating, especially in the later stages of dementia. Care workers and family carers report that assisting with personal care can at times be difficult and distressing for both themselves and the person living with dementia. [1] As these tasks are of a personal and private nature, people may feel self-conscious and uncomfortable having other people perform them. They may also feel that they have lost their dignity and independence. When a person living with dementia shows reluctance to receive care, this is known as ‘resistance to care’ (also referred to as non-compliance, rejection, or refusal of care). These situations can be difficult as the absence of certain care may lead to health or hygiene issues. Therefore, approaches that aim to reduce resistance to care from the person living with dementia have been the focus of many research investigations.

This evidence theme on interventions to reduce resistance to care is a summary of one of the key topics identified by a scoping review of dementia research. If you need more information on this topic, try using the PubMed search below.

We found four systematic reviews that focused on reducing resistance to care, with varying approaches. Environmental interventions had generally positive impacts on resistance to care. Music-based interventions were the most common approach. These interventions usually included playing either relaxing music or music preferred by the person living with dementia during personal care. [2] Other environmental approaches included a simulated natural environment in the bathroom involving pictures, food, sounds of nature, and carer interaction regarding the environment. [1-3]

Another approach was providing care worker education to increase person-centred bath skills. This training emphasised the importance of the person with dementia’s right to privacy and aimed to improve comfort during bathing. Most studies found that a focus on person-centred care during bathing interventions reduced resistance to care [2, 4], although one study reported that bathing time increased significantly. [2]

Another care worker training approach included ability-focused interventions to improve how care workers assessed the person living with dementia’s abilities. Workers used this assessment to improve their care skills and create a supportive environment. The effectiveness of this approach was inconclusive because some studies reported reductions in resistance to care, and other studies did not. [2] 

The use of towel baths (an in-bed bathing method using no-rinse soap, towels/blankets, and warm water) was also associated with reduced resistance to care. [3, 4]

Some studies found that how care workers interacted and communicated with people living with dementia was associated with resistance to care. Clear, concise, feasible, and positively phrased requests that focus on simple tasks that the person can do, rather than negative ‘don’t’ commands, were associated with reduced resistance to care. On the other hand, ambiguous or multi-step requests, requests outside what the person is capable of doing, and distracted communication on the part of the carer were met with greater resistance to care. [1]. The use of elderspeak (i.e., overly endearing terms and tones, or speech that may be overly accommodative, repetitive, and slower with simpler sentence structures and vocabulary) also increased resistance to care. [1]

There was no evidence that massage or aromatherapy reduced resistance to care. [1]

According to qualitative studies, there are several important components when reducing resistance to care during assisted bathing, including:

• Helping the individual living with dementia to feel safe and secure
• Care workers being able to understand the unique needs of individuals with dementia
• Respecting the person with dementia’s right to privacy
• Maintaining the person with dementia’s sense of dignity and control. [3]

The reviews highlighted concerns about the methods used in some of the studies. This reduces the degree of certainty we might have about the benefits of interventions to reduce resistance to care. For example:

• Some studies only had a small number of participants. [1, 4]
• Potentially important approaches were not assessed (e.g., Namaste Care). [1]
• Interventions were mostly conducted in residential care, so there was little to no evidence about how beneficial these interventions may be for people living in the community. [1]

• Be clear, calm, and positive when communicating with a person living with dementia.
• Take a person-centred approach to bath times. Make sure the room and water are at a comfortable temperature, protect the person’s privacy as much as possible, and offer simple options for the person to choose from to allow them to have a sense of control over the experience.
• Ask the person with dementia and/or their family about playing music during personal care and find out the style they would most enjoy. Discuss this approach with colleagues and your line manager.
• Be aware that not all people living with dementia will appreciate changes to their usual routine.

• Provide regular training on person-centred care, communication, and different methods of bathing (e.g., towel baths).
• Encourage conversations between staff about how they may provide person-centred strategies during certain times or the provision of certain types of care.
• Support interdisciplinary collaboration to discuss certain approaches which may be beneficial for certain individuals with dementia.

1. Backhouse T, Dudzinski E, Killett A, Mioshi E. Strategies and interventions to reduce or manage refusals in personal care in dementia: A systematic review. Int J Nurs Stud. 2020;109:103640.
2. Konno R, Kang HS, Makimoto K. A best-evidence review of intervention studies for minimizing resistance-to-care behaviours for older adults with dementia in nursing homes. J Adv Nurs. 2014;70(10):2167-80.
3. Konno R, Stern C, Gibb H. The best evidence for assisted bathing of older people with dementia: A comprehensive systematic review. JBI Database System Rev Implement Rep. 2013;11(1):123-212.
4. Pieper MJC, van Dalen-Kok AH, Francke AL, van der Steen JT, Scherder EJA, Husebø BS, et al. Interventions targeting pain or behaviour in dementia: A systematic review. Ageing Res Rev. 2013;12(4):1042-55.