Interventions to reduce dependency in bathing in community dwelling older adults: a systematic review
Golding-Day et al. Systematic Reviews
Interventions to reduce dependency in bathing in community dwelling older adults: a systematic review
Miriam Golding-Day 0
Phillip Whitehead 0
Kathryn Radford 0
Marion Walker 0
0 School of Medicine, The University of Nottingham, Queens Medical Centre , Nottingham NG2 7UH , UK
Background: The onset of bathing disability for older adults has been found to be an indicator and potential precursor of further disability. Thus interventions targeting bathing may prevent or delay further disability and the use of health and social care services. The aim of this systematic review was to identify interventions targeted at reducing dependency in bathing for community dwelling older adults, and determine their content and effectiveness in maintaining or improving function and quality of life. Methods: We conducted a systematic search of electronic databases including: The Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; CINAHL; PsycINFO and OTSeeker. The search took place on 18 October 2016. We included randomised controlled trials, nonrandomised controlled trials, and controlled before and after studies that evaluated an intervention designed to reduce dependency in bathing. Articles were screened for inclusion by two independent reviewers; risk of bias was assessed using quality assessment tools; and data extracted using pre-prepared forms. Disagreements were resolved by discussion and inclusion of a third reviewer. Results: The search process identified one study for inclusion in the review. This study evaluated a bathing intervention delivered by an occupational therapist following discharge from hospital. Overall, the findings suggest modest improvements in functional ability in favour of the intervention group although the results should be interpreted with caution. Conclusion: Despite evidence suggesting the importance of addressing bathing difficulties as a means of possible prevention of disability in the ageing process, there is a dearth of evaluative or interventional research studies. Further robust research is warranted, including studies of randomised and controlled design.
Older adults; Bathing disability; Activities of daily living; Quality of life
The relationship between ageing and limitations in
functional ability is becoming ever more recognised [
an increasing awareness of the impact of factors
affecting an individual’s ability to ‘age well’ [
increased prevalence of aged people, the international
community is placing increasing aegis on identifying and
evidencing interventions which might reduce functional
and societal disability for older adults. Furthermore, the
Care Act 2014 has placed a responsibility on local
authorities in England to provide services which prevent or
delay the need for care and support . The onset of
bathing disability has been shown to be a seminal point
in the disabling process for older adults [
]; it may,
therefore, be a judicious time point for intervention to
prevent the onset of further disability, and reduce the
need for health and social care services.
A cohort study conducted in the USA followed 754
non-disabled adults, aged over 70 years, every month for
6 years with regard to their difficulties in performing
activities of daily living (ADL) [
]. Over the course of the
study, those who developed a disability in bathing were
five times more likely to develop a disability in another
activity of daily living the following month. This suggests
that developing a bathing disability may be an indicator
and potential precursor of further disability. Gill et al.,
] concluded that programmes designed to restore and
maintain independent bathing for older adults have the
capacity to prevent further deterioration in functional
ability. It is possible that such programmes may have a
preventative effect on the disabling process.
The purpose of this systematic review was to determine
whether interventions targeted at bathing could reduce
dependency in other activities of daily living (ADL). The focus
was to identify studies that compared an intervention
designed to reduce dependency in bathing for older persons
living in the community, with provision of routine care where
there was no explicit intention to actively address bathing
disability. In focussing on studies of evaluative design, our
aim was to determine whether there was evidence that
bathing interventions could prevent the onset of further disability
and, consistent with the principles of the Care Act 2014 [
the need for additional health and social care support.
There were three objectives for this review:
1. To determine what interventions targeting the
reduction of dependency in bathing for older adults
have been provided and evaluated in the literature.
2. To determine the efficacy and effectiveness of these
interventions on older adults’ dependency in
bathing, functional (ADL) ability and quality of life.
3. To determine whether bathing interventions prevent
the need for, and use of, other health and social care
The review was registered in the PROSPERO database
] and conforms to the PRISMA
]. Randomised controlled trials (RCTs),
nonrandomised controlled trials, controlled before and after
studies and interrupted time series were all eligible for
inclusion. Participants included individuals aged 60 years
and older, living at home in the community (i.e. not in a
residential or nursing care home) and who had been
assessed as having a bathing disability. For this review,
we did not restrict by diagnosis but required participants
to have had a professional assessment which identified
difficulty in bathing/a bathing disability. We defined
bathing disability as being unable to use, or having
difficulties in using, existing bathing facilities in the home
environment. Studies where otherwise healthy
participants acquired a perceived disability through artificial
environmental changes were excluded.
To be included in the review, interventions had to be
bathing specific and targeted at reducing dependency in
bathing for older adults. Interventions could take the form
of home modification/adaptations to aid the bathing
process or be in the form of input from a health or social
care professional to modify the task or activity, or to enable
participants to better use equipment and bathing devices in
order to bathe independently. Studies with a control group
were eligible for inclusion where standard care was used as
the control, or where persons would receive normal
packages of care or intervention in line with local practice.
The main outcome of interest was performance in
personal ADL with specific focus on washing, bathing/
showering but to also include dressing, feeding and
toileting, management of continence, transfers and basic
mobility. An outcome could take the form of an activity
of daily living score such as the Barthel Index or
selfreported difficulties in ADL. Other outcomes included:
dependence in bathing; perceived difficulty in bathing;
health-related quality of life (QoL); social care-related
QoL; service use outcomes; death; performance in
extended ADL (for example shopping, outdoor mobility);
admission/number of admissions to hospital, residential
or nursing care homes; participant mood/morale; falls;
health economic outcomes; caregiver strain/burden;
participant and carer satisfaction with services and
healthcare provider satisfaction with services.
The following databases were searched for studies
prior to October 2016: the Cochrane Central Register of
Controlled Trials (CENTRAL), MEDLINE (1948 to
present), EMBASE (1980 to present), AMED (1985 to
present), CINAHL (1982 to present), PsycINFO (1967
to present) and Occupational Therapy database for
systematic reviews and randomised controlled trials
(OTSeeker; 1980 to present). The search was
conducted in English and the strategy consisted of a
combination of subject headings and free text terms.
The search strategy for MEDLINE is shown in Table 1,
this was adapted for use in the other databases.
Reviewers followed a three-stage screening process
where, firstly, two reviewers (MG-D, PW) examined the
titles and excluded studies not pertinent to the review.
Secondly, the abstracts of all remaining records were
screened independently by both reviewers. Finally,
fulltext copies of those deemed potentially relevant were
screened independently by both reviewers for inclusion.
Data was then extracted using pre-prepared and piloted
data extraction forms, independently and in duplicate,
by two reviewers (MG-D, PW). The extracted
information included study methodology, study setting, study
population and participant demographics and baseline
characteristics, details of the intervention and control,
recruitments and drop-out rates and outcome
measurements and timing. The results of this data extraction
were compared and discussed; any disagreements
resolved in consultation with a third reviewer (KR).
Two reviewers (MG-D, PW) also used the quality
assessment criteria developed by the Cochrane Effective
Practice and Organisation of Care (EPOC) review group
], to independently assess the methodological quality of
the included studies and to identify any risk of bias. This
covered sequence generation and allocation concealment,
9. (bath$ adj3 (independ$ or depend$ or disab$)).tw.
12. randomized controlled trial.pt.
13. controlled clinical trial.pt.
14. (control$ adj2 trial).tw.
15. intervention study/
17. (time adj1 series).tw.
18. (pre test or pretest or posttest or post test).tw.
19. random allocation/
21. evaluation studies/
22. comparative study.pt.
24. 11 and 23
25. nursing home/
26. 24 not 25
28. 26 not 27
29. limit to adults
23. 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22
baseline characteristics and measurements, completeness
of outcome data, blinding of outcome assessment and
selective outcome reporting, as well as other potential
sources of bias. Each of these characteristics were
explicitly rated and categorised as being of low, high or
uncertain risk of bias, and any disagreement about which rating
was most suitable was resolved by discussion with a third
The search process is summarised in Fig. 1. The
reviewers identified 693 records through electronic
database searches, with 566 original works once duplicates
were removed. One hundred forty-one records were
included following a title screen, with nine remaining once
abstracts were assessed for suitability. Out of those nine,
one was deemed suitable for inclusion after the full text
had been obtained and read by both reviewers. A
summary of study characteristics is given in Table 2, and
the findings of the risk of bias assessment [
] are shown
in Table 3. The final study for inclusion in this review
was found to be of high risk in five domains, indicating
an overall high risk of bias.
The included study [
] focussed on the provision of
home care services in northern Sweden. Participants
were not randomised, but divided into treatment and
control groups due to locality. One area acted as the
control providing usual care, the second provided an
occupational therapist visit and assessment following
hospital discharge. They then delivered interventions in
accordance with the client’s individual needs in an
attempt to improve their ability to bathe independently.
These interventions took the form of an encouraging
approach as well as a gradual withdrawal of support as
appropriate for each client. Sixty percent of clients also
received assistive devices and/or environmental
adaptions to aid with bathing activity. The authors presented
their findings graphically, with measures based on the
client’s perceived difficulty in performing each task
rather than their actual task completion. The primary
domain in the ADL taxonomy scale associated with
bathing was classified as ‘washing body’, with two others
that can be considered supplementary including
‘washing hair’ and ‘washing hands and face’. Significant
improvements were reported in both groups for ‘Washing
body’, whilst only those in the intervention group
reported significant improvement in ‘Washing hair’.
As well as evidencing an individual’s ability to perform
ADLs, secondary outcomes were also recorded by the
authors. The EQ-5D questionnaire was used to assess
health-related quality of life. This was also presented
graphically with both groups improving significantly in
‘self-care’ and ‘usual activities’, and a further two,
‘mobility’ and ‘pain/discomfort’, demonstrated significant
improvement only in the intervention group. Overall
clients in both groups demonstrated an improved
health-related quality of life in total. The study also
provided additional outcomes in the form of number of
homecare support hours, death of client and number of
admissions to hospital, residential or nursing care. Of
particular interest was the recorded effect on allocation
of home help, with only 30% of those in the intervention
group being allocated home help in comparison to 75%
in the control group. The average weekly time given for
home help with bathing was also significantly decreased,
with those in the intervention group only requiring
31 min, and those in the control group averaging
66 min. These differences suggest the intervention has
an effect of reducing the citizens need for home help,
though we must consider the discrepancy may also be
due to local differences in service delivery or availability
of support between the two municipalities.
The search, though comprehensive, only returned one
study, which was limited by its small sample size,
nonrandom allocation of intervention and some differences
between groups at baseline. This was compounded by
the use of a non-standardised ADL measure, which
limits the primary outcomes comparability with other
studies. However, the outcomes of this study tentatively
suggest that occupational therapist, specific targeting of
a bathing disability, might decrease the need for
additional social care involvement and increase overall
health-related quality of life.
Despite observational studies indicating that the onset of
bathing disability is an important event in the disabling
process for older adults, we found a dearth of evidence
from interventional studies on bathing using evaluative
study designs. Most noticeable was the distinct lack of
randomised or controlled trial methodologies. The search
did, however, identify one study providing tentative
evidence to support the use of interventions to reduce
bathing disability in older adults living in the community. In
adopting a focussed scope for this review, which included
a specific population group, specific intervention and
specific study designs, the intention was to identify
evaluative studies with strong, replicable results. However, very
few studies were identified as being suitable for analysis.
Due to the return of only one study, a meta-analysis was
not possible. The very limited number of studies which
were eligible for inclusion in the review highlights the
specialist nature of this research field and the restricted
evidence available currently.
We identified two other potentially relevant studies,
which partially met the inclusion criteria, but which
74 adults aged > 65 years, in process
of applying for help with bathing.
Ability to perform ADL
were excluded on the grounds of population age.
Chamberlain et al., [
] conducted an evaluation of
bathing aids and equipment by accelerating provision
following discharge from hospital compared to usual care.
However, they did not limit the age of the population to
those over 60 and thus were excluded from the analysis.
Chiu and Man [
] evaluated whether additional training
in the use of assistive bathing devices led to a higher level
of functioning and independence for older adults
following a stroke. Participants for this study were aged between
55 and 92 years old, and thus this study was also excluded
as being outside our pre-determined age range. The
results of both studies suggested that the intervention
groups had better outcomes in terms of independence in
] and better functional independence [
However, both were based on small sample sizes.
It is possible that other studies may have been
identified for inclusion if we had included a wider age range
than the specified ≥ 60 years. However, the rationale for
this review was based on evidence gathered from
observational cohort studies specifically with older adults [
indicating the particular importance of bathing for this
population. This highlights the need for further robust
research in this area, with the older adult population
We believe the search strategy used in this review was
extensive and comprehensive; however, there is a
possibility some studies were not identified during the search
process. In particular, the need to adapt key words and
terms for the different electronic databases meant that
some studies may have been missed, and it is possible
that all relevant studies were not identified. Additionally,
all the searches were conducted in English and so
studies without an English abstract were not included.
Furthermore, search terms for non-randomised studies
are less well developed and there is a possibility that
some studies may not have been identified.
We searched only for controlled trials or interrupted
time series analyses because our aim was to evaluate the
potential preventative effect of bathing interventions.
This strict study design criterion was a limiting factor in
the amount of studies eligible for inclusion. The search
showed that research across all designs is significantly
limited in this topic area, particularly evaluative designs.
Evaluative designs were of particular interest to the
reviewers as with the introduction of the Care Act 2014
], there is an increased emphasis on providing
evidence for prevention interventions that has parity with
other health and social care interventions. Conducting
and collating such controlled trials are, therefore, of
significant importance within current social care provision
and the prevention agenda. However, qualitative studies
have also been conducted into bathing interventions and
we would recommend a further complementary synthesis
of qualitative works to add to the understanding of the
mechanisms of the potential preventative effects of bathing.
To our knowledge, this is the only systematic review
to date which has collated studies related to bathing.
The result of the single study included in the review
suggests that interventions such as providing bathing aids,
adopting an encouraging approach and the installation
of adaptations may potentially reduce dependency in
bathing for this population group. However, the authors
suggest that further research is needed, recommending
randomisation and masked evaluation for future studies.
We believe the results of the review highlight this need,
and also advocate for further research which seeks to
determine the relationship between bathing disability and
its effect on the older populations, so that the
mechanism can be better understood and thus targeted by
timely and effective interventions. The authors believe
this review would be of most interest to those working
both at a personal and policy level within the prevention
agenda for older adults. Principally, the review has
emphasised the need for evaluative study designs to
further investigate the findings from observational studies
on the onset of bathing disability and the subsequent
decline in ability to perform other ADL. Currently, we are
aware of one ongoing study examining the effect of
bathing adaptations as an intervention for older people
living in the community [
]; however, this study is yet
to report its results.
A key consideration for further studies should be the use
of standardised ADL outcome measures and scales to
ensure comparability between studies and facilitate
future evidence synthesis. Further research in this area
should also explore the wider and longer-term effect
bathing specific interventions have for older adults, as
well as the potential impact for population groups of
different ages. For future research, we advocate for study
designs which incorporate randomisation of participants,
adding quantitative authority to the current evidence
The identification of only one relevant study is an
important finding demonstrating the limited evidence in this
area. Given the focus on prevention and delaying the
disabling process in older adults in current national and
international policy, the lack of evidence is surprising. As
bathing has been identified as an important precursor to
the onset of difficulty in other ADL, the limited number of
studies evaluating whether bathing interventions do
prevent, or delay, the onset of further disability is a particular
paradox. Further research is required with specific focus
on interventions designed to reduce dependency in
bathing which are yet to be evaluated.
The authors would like to thank the BATH-OUT trial co-investigators for their
assistance with the ongoing study: Prof Marilyn James, Mr. Tony Dawson and
Mr. Stuart Belshaw. The authors would also like to thank the BATH-OUT
project advisory group for their support and guidance: Sue Adams OBE
(chair), Professor Pip Logan, Mrs. Julie Pert, Mr. Doug Stem and Ms. Claire Ward.
This paper is independent research conducted within the remit of the
BATH-OUT study, (Bathing Adaptations in the Homes of Older Adults: A
feasibility Randomised Controlled Trial and qualitative interview study), which
is funded by the National Institute for Health Research - School for Social
Care Research. ISRCTN Registration 14,876,332. The views expressed in this
publication are those of the authors and not necessarily those of the NHS,
the National Institute for Health Research or the Department of Health.
MG-D developed the search strategy, carried out the database search,
extracted the outcomes of the included study and was the first reviewer for
data analysis. PW conceived the research question and was the second
reviewer for data extraction and analysis, also overseeing the preparation of
the manuscript. KR and MW acted as third reviewers, and assisted in the
interpretation of the results. All authors read and approved the final
The authors declare that the primary author, Miriam Golding-Day, is the
research assistant on the ongoing BATH-OUT trial, Phillip Whitehead is the
Principal investigator and Marion Walker MBE is a co-applicant. This systematic
review has been conducted in part to inform the results of the BATH-OUT trial
analysis. However, at the time of writing, all outcome data is locked and no
analysis has begun which might introduce a bias in the conducting of this
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