La "towel bath" può ridurre l'aggressività in pazienti affetti da demenza? Risultati di un trial crossover
10.54103/dn/17511
INTRODUZIONE: Il bagno è una delle attività più intime durante le quali le persone affette da demenza vengono assistite. La letteratura suggerisce che il 20-40% dei pazienti con deterioramento cognitivo, ricoverati in strutture a lungo termine, può reagire con comportamenti aggressivi.
OBIETTIVI: valutare l'efficacia della tecnica del bagno con asciugamano nel ridurre l'agitazione, l'aggressività e il disagio dei pazienti con demenza ricoverati in casa di cura.
MATERIALI E METODI: È stato condotto uno studio crossover intenzionale; è stato arruolato un campione di pazienti con demenza. I comportamenti aggressivi sono stati valutati utilizzando la versione italiana del Care Recipient Behavior Assessment (CAREBA- ita).
RISULTATI: Sono stati arruolati 71 residenti. La tecnica del bagno con l'asciugamano ha mostrato una riduzione degli episodi di aggressività e del tempo di esecuzione della procedura con una differenza statisticamente significativa (p &lt; 0,05).
CONCLUSIONI: La tecnica Towel bath fornisce una valida alternativa al bagno tradizionale per ridurre l'aggressività nei pazienti con demenza.
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Giada Cocciolo
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Dissertation Nursing
aggressività
La "towel bath" può ridurre l'aggressività in pazienti affetti da demenza? Risultati di un trial crossover
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Giada Cocciolo
2022/08/01
10.54103/dn/17511
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LMU Klinikum Grosshadern, Munich, Germania
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77
Lazzari T, Terzoni S, Destrebecq A, Meani L, Bonetti L, Ferrara P. Moral distress in correctional nurses: A national survey. Nurs Ethics. 2020 Feb;27(1):40-52. doi: 10.1177/0969733019834976. Epub 2019 Apr 9.
Could Towel bath reduce aggressiveness in patient with dementia? Results from a crossover trial
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                                                                                                                          DOI: 10.54103/dn/17511




             DISSERTATION NURSING
             Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing
Crossover Trial

   Could towel bath reduce aggressiveness in patient with
                        dementia? Results from a crossover trial
                   1
Giada Cocciolo, Lara Carelli 2, Laura Di Prisco2, Paolo Ferrara2, Mauro Parozzi2, Giancarlo Celeri Bellotti2, Elena Sala2,
                   2                   2                 2
Agostino D’Antuono , Stefano Terzoni , Roberta Lodini
1 Lmu   Klinikum Grosshadren, Munich, Germany
2 ASST   Santi Paolo e Carlo, Milano, Italy




Findings:                                          ABSTRACT
This paper provides evidences concerning the       BACKGROUND: Bathing is one of the most intimate activities during
use of the towel bath technique instead of
traditional bathing to reduce aggression in        which persons with dementia are cared for. The literature suggests that 20-
patients with dementia.                            40% of patients with cognitive impairment, hospitalized in long-term
                                                   facilities, may react with aggressive behaviours.

                                                   AIM: To evaluate the efficacy of the towel bath technique in reducing
                                                   agitation, aggression, and discomfort in nursing home residents with
                                                   dementia.

                                                   MATERIALS AND METHODS: An Interventional crossover study was
                                                   conducted; a convenience sample of patients with dementia, was enrolled.
                                                   Aggressive behaviors were evaluated using the italian version of the Care
                                                   Recipient Behavior Assessment (CAREBA-ita).

                                                   RESULTS: 71 resident were enrolled. Towel Bath technique showed a
                                                   reduction in episodes of aggression and in the execution time of the
                                                   procedure with a statistically significant difference (p < 0.05).

                                                   CONCLUSIONS: The technique Towel bath provides a viable alternative
                                                   to traditional bath to reduce aggression in patients with dementia.



                                           KEYWORDS: dementia, towel bath, aggression, nursing




         Corresponding author:                                           64                                    Submission received: 22/03/2022
         Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
         Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
         Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                      This work is licensed under a Creative Commons
          Dissertation Nursing 1 (29/07/2022)                                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                           DOI: 10.54103/dn/17511




              DISSERTATION NURSING
               Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

Crossover Trial

     La "towel bath" può ridurre l'aggressività in pazienti
      affetti da demenza? Risultati di un trial crossover
                    1
Giada Cocciolo  , Lara Carelli 2, Laura Di Prisco2, Paolo Ferrara2 , Mauro Parozzi2, Giancarlo Celeri Bellotti2, Elena
    2                      2                   2                 2
Sala , Agostino D’Antuono , Stefano Terzoni , Roberta Lodini
1 LMU    KLINKUM, Munich, Germany
2 ASST   Santi Paolo e Carlo, Milano, Italy



Riscontri:                                          ABSTRACT
Questo articolo fornisce evidenze nell’utilizzo     INTRODUZIONE: Il bagno rappresenta una delle più delicate attività assistenziali
della tecnica della towel bath al posto del
                                                    durante le quali ci si prende cura delle persone con demenza. La letteratura suggerisce
bagno tradizionale per ridurre l’aggressività
dei pazienti affetti da demenza.                    che il 20-40% dei pazienti con compromissione cognitiva, ricoverati in strutture a
                                                    lungo termine, possono reagire con comportamenti aggressivi.

                                                    OBIETTIVO: Valutare l’efficacia della tecnica di Towel Bath nella riduzione
                                                    dell’agitazione, dell’aggressività e del disagio nelle persone affette da demenza
                                                    ricoverate in residenze assistenziali

                                                    MATERIALI E METODI: E’ stato condotto uno studio crossover interventistico;
                                                    è stato arruolato un campione di convenienza rappresentato da pazienti affetti da
                                                    demenza. I comportamenti aggressivi sono stati valutati utilizzando la versione
                                                    italiana della Care Recipient Behavior Assessment (CAREBA-ita)

                                                    RISULTATI: Sono stati arruolati 71 pazienti. La tecnica della Towel Bath ha
                                                    mostrato una riduzione degli episodi di aggressività e del tempo di esecuzione della
                                                    procedura con una differenza statisticamente significativa (p<0.05)

                                                    CONCLUSIONI: La tecnica della Towel Bath rappresenta una valida alternativa al
                                                    bagno tradizionale per ridurre l’aggressività nei pazienti affetti da demenza




                                 KEYWORDS: demenza, towel bath, aggressione, assistenza infermieristica




          Corresponding author:                                           65                                    Submission received: 22/03/2022
          Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
          Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
          Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                       This work is licensed under a Creative Commons
           Dissertation Nursing 1 (29/07/2022)                                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                       DOI: 10.54103/dn/17511




          DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



BACKGROUND                                                                   cerebrovascular accidents, reduced quality of life and
                                                                             increased mortality (27–30).
                                                                             For these reasons, the guidelines of the American
The presence of aggressive behaviors in person with
                                                                             Psychiatric Association from 2007 onwards have been
dementia is a reality that needs to be addressed and
                                                                             recommending            (31)       non-pharmacological
prevented.
                                                                             interventions as the first choice (32–34). However
It is known in literature that 20% of patients with
                                                                             studies on this subject are few and sometimes
dementia develop psycho-behavioral symptoms
                                                                             discordant, and produce scant evidence (35,36).
within two years from being diagnosed. This
                                                                             Specifically, interventions such as touch therapy (37),
percentage raises to 80% during the course of the
                                                                             aromatherapy (38,39), music therapy (40,41) and
disease (1–3). In patients with dementia, agitation and
                                                                             sensory stimulation (15,42) have shown promising
aggression represent a challenge for both caregivers
                                                                             results in reducing agitation and deterioration in
and healthcare personnel, with direct consequences
                                                                             elderly patients with dementia (15,43,44). The Towel
such as (4) poor job satisfaction, distress and high
                                                                             bath (45,46) is a technique that starts in the early 1990
staff turnover (5,6). In the absence of disease,
                                                                             's, when two research groups, of North Carolina, were
hygienic care including bath or shower, are self care
                                                                             funded by the National Institutes of Health to
activities important for most people, not only because
                                                                             develop interventions to improve the techniques used
they allow adequate prevention against infection but
                                                                             during bathing. This technique is a variant of the bed
also because they provide comfort (7–9). Despite
                                                                             bath, it can be a good choice for people who are frail,
bath being considered by most people a pleasant and
                                                                             non-ambulatory, severely overweight or fearful of
relaxing experience, for patients with dementia and
                                                                             lifts, also representing an useful and viable alternative
their caregivers it can turn into a stressful and
                                                                             to the complete bath in bedridden patients. In 2004,
traumatic moment, triggering aggression (10,11).
                                                                             within a broader educational program, this technique
Bath time can become a real struggle between
                                                                             was used on a group of persons with dementia,
caregivers and patients (10): the literature indicates
                                                                             achieving good results in terms of reduction in
that 20-40% of patients with cognitive impairment,
                                                                             aggressive behaviors against caregivers, reduction in
hospitalized in long-term facilities, can react with
                                                                             care recipient agitation, reduction in care recipient
aggressive manifestations such as screaming, threats,
                                                                             distress and decrease in the time used for the
kicks, punches, and scratches, as well as to remain
                                                                             execution of the bath (10). The technique of Towel
agitated for many hours after the bath (12–14).
                                                                             bath in fact as well as reducing patient discomfort and
Currently, the treatment options for psycho-
                                                                             aggressive behavior helps to promote a therapeutic
behavioral symptoms include pharmacological and
                                                                             relationship between patient and caregiver (10,11,47).
non-pharmacological therapies (15–17). Some studies
                                                                             It is possible to wash these persons adequately in the
show that antipsychotics are used between 21% and
                                                                             bed, which is often less stressful. The technique
46% of cases to manage agitation and aggression (18–
                                                                             consists in gently covering the body of the person
20). Atypical antipsychotics are the most commonly
                                                                             with a large warm towel containing a no-rinse soap
used to reduce the frequency and severity of episodes
                                                                             solution, and washing and massaging through the
of agitation and aggression (21,22) which, however, in
                                                                             towel (47). The technique was performed in all cases
most patients, are poorly controlled by the drug (23),
                                                                             by two operators.
thus leading to consequences (24,25) increased risk of
                                                                             Aggression in people with dementia is a complex
falls and fractures (26), development of
                                                                             phenomenon, with several possible causative factors

      Corresponding author:                                           66                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
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          DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



that requires a multidimensional and multidisciplinary                       or "severe" cognitive impairment, with a Mini Mental
response; nursing assessment in this field is aimed at                       State Examination scores (MMSE) ≤ 19, Pain
researching specific risk factors. The use of valid                          Assessment in Advanced Dementia scores
screening tools assessment helps nurses to identify                          (PAINAD) <4 (that is, absence of pain before the
those at high risk, and to implement interventions                           procedure) and history of physically or verbally
aimed at reducing the risk of aggressive behaviour.                          aggressive behaviours. Patients with a primary
                                                                             diagnosis of delirium, unconscious or comatose
The level of aggressiveness of the person with                               patients, patients with a alcohol-related dementia or
dementia can be assessed through the Care Recipient                          with psychotic disorders as their primary diagnosis,
Behavior Assessment Scale (CAREBA), created in                               patients with a MMSE > 19 with a cognitive "mild"
2004 and used to evaluates signs of behavioral                               impairment and PAINAD patients ≥ 4 were
distress in the person receiving Person-centered                             excluded.
showering and the towel bath in different nursing                            Sample size was calculated considering a probability
homes. In Italy, to date towel bath is not commonly                          of type I error of 5%, and a probability of type II
used, and no Italian versions of the CAREBA scale                            error of 20% (power=80%). Considering an expected
currently exist.                                                             effect size between 30% and 40% a sample size of 71
                                                                             patients was needed to compare the two groups.

AIM                                                                          Crossover trial
The aim of the study was to evaluate the effectiveness                       The study design is outlined in Fig 1. The 71 persons
of the Towel bath technique in reducing                                      were invited to receive the usual-care - traditional
aggressiveness when nursing care for residents with                          bathing, with water, soap, and full-body cleansing
bathing.                                                                     with sponges - with prior permission of the patient's
                                                                             guardians or next of kin.

MATERIALS AND METHODS                                                        The following bath, after an average of 4 days, was
A monocentric, non-randomized, two-arms crossover                            given to the same persons with the towel bath
trial, aimed at comparing the method of Towel bath                           technique, described in the Background section.
(intervention group) with complete bath (control                             During the remaining days of the week, all patients
group) was conducted in a long term care facility                            received daily hygiene but not a full bath. This
dedicated to patients with dementia; aggressiveness                          schedule was compliant with the usual care provided
shown by patients and time required to complete the                          in the hospital, in which full bath was only given
procedure were evaluated.                                                    every four days even before the beginning of this
Setting, sample size and sample characteristics                              study.
The study was conducted in two units of the “Istituti
Milanesi Martinitt e Stelline e Pio Albergo Trivulzio”
in Milan, Northern Italy, both dedicated to patients
suffering from dementia, from June to October
2018.
We enrolled persons with diagnosis of dementia
(Alzheimer's and non-Alzheimer's) with "moderate"

      Corresponding author:                                           67                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                       DOI: 10.54103/dn/17511




          DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



                                                                             English teacher). The final version was approved by
                          T0
                                                                             the original author. Face and content validity of the
                55 inpatients enrolled                                       italian version oft he CAREBA scale were
                                                                             investigated by calculating the content validity index,
                        T1                                                   with the help of six nurses experiences 5 or more
        Day 1: Traditional bathing (n=55)                                    years in this area. Cronbach‘s alpha was used to assess
                                                                             internal consistency.
                      T2
                                                                             Statistical analysis
    Day 4: Cross-over: "towel bath" (n=55)                                   Continuous variables have been described with mean
                                                                             and standard deviation if normally distributed, with
        Figure 1: Flow chart outlining study design                          median and interquartile range otherwise. Wilcoxon
                                                                             matched-pair test was used to compare the
                                                                             CAREBA-ita scores in the two groups (traditional
In order to avoid a bias represented by the possible                         and towel bath) after failure of data normalization,
presence of pain, which could influence aggressive                           attempted with Blom‘s transformation and checked
behaviours, the PAINAD scale was administered                                with Shapiro-Wilk normality test (p<0.05). The
prior to all baths. Patients with positive PAINAD                            threshold of significance of the tests was set at 5%.
scores were treated for pain according to the                                All calculations were checked by a statistician and
physician‘s presriptions, and not enroled for the study                      perfermed wih SAS® 9 (SAS Inc., Cary NY).
until pain came under control again.                                         Post-hoc power analysis on our sample revealed an
Assessment of aggressiveness was performed through                           actual power of all statistical tests between 80% and
repeated administration of the italian version of the                        82%, which can be considered satisfactory.
CAREBA scale to all patients, 15 minutes before the
bath, during the bath and 15 minutes after the end of                        Ethical issues
the procedure.                                                               The hospital does not have an ethical committee, and
Data collection was performed by one nurse only;                             is not affiliated with any external committee. Ethical
assessment and baths was always performed during                             issues are discussed by representatives of the hospital
the morning shift by two experienced nursed with                             management, includind nurses, doctors, and
advanced education and training about towel bath                             managers, according to the ethical principles of the
technique.                                                                   Declaration of Helsinki. We complied with the ethical
                                                                             rules of the hospital, and obtained all required
                                                                             authorizations to conduct the study.
Validation Of The Careba Scale
The scale, reported in table 1 (appendices section),
has 9 items, each corrisponding to a patient‘s                               RESULTS
behaviour, which can be present or not. According to                         Validation of the Italian version of CAREBA
the original author patients are considered at risk of                       scale (CAREBA-ita)
violence even with a single "attempt" of aggressive                          Face validity was satisfactory: the scale had a content
behaviour against the caregiver. The scale was back-                         validity index (S-CVI) of .94. Internal consistency was
translated from English into Italian by two nurses                           good (Cronbach’s alpha = .79). Average time for
independently and then back to English (by an
      Corresponding author:                                           68                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                       DOI: 10.54103/dn/17511




          DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



completing the CAREBA scale was less than 1                                  bathing with the traditional technique and Towel
minute.                                                                      bath, as shown in Table 2. All patients received 6
                                                                             evaluation, 3 in the control group and 3 in the
Sample characteristics                                                       intervention group. Before and after bathing, no
71 eligible patients were enrolled, median age 86                            patient were at risk (CAREBA score=0); one patient
years,    IQR      [83-89]   (skewed     distribution,                       was evaluated at risk of aggressive behaviours during
Kolmogorov-Smirnov test p < 0.05), 61 were women,                            bathing with traditional technique.
10 men, among them 56 patients (79.0%) taking
antipsychotics, 22 patients (31.0%) had Alzheimer's                          Towel bath led to statistically significant reduction in
disease, 27 (38.0%) mixed dementia, 22 (31.0%)                               the number of patients that showed aggressive
vascular dementia. The Mini Mental State                                     behaviours (p=0.037) during the bath. The CAREBA
Examination had a median value Me = 5 [2-8] with a                           scores ranged between [0-3] in the control group and
range between 1 and 19, thus largely compatible with                         [0-1] in the Towel bath.
the diagnosis of dementia. Before bathing, no patients
needed pharmacological treatment for pain, according                         Table 3 shows the comparison of every single item in
to the PAINAD score (always <4).                                             the two groups.

Traditional bath vs Towel bath
The CAREBA scores were calculated in both groups
before (15 minutes), during and after (15 minutes)




              Group                  Before(n, Me[IQR])              During (n, Me[IQR])                   After (n, Me[IQR])

              Traditional bath                0,0[0-0]                        43, 1[0-3]                              1,0[0-0]


              Towel bath           0, 0[0-0]           22, 0[0-1]          0, 0[0-0]
              n= patients with CAREBA >0; Me=median score CAREBA; IQR=InterQuartile Range


                                       Table 2: Comparison CAREBA-ita scores in the two arms




      Corresponding author:                                           69                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
       Dissertation Nursing 1 (29/07/2022)                                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                       DOI: 10.54103/dn/17511




          DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing




                                                                 Traditional bath Towel bath                             p-
                                             Item
                                                                  (n, Me[IQR]) (n, Me[IQR])                             value


                                       Hitting, pushing,
                                                                       24,0[0-2]                 11,0[0-0]                0.02
                                          scratching

                                           Kicking                     10,0[0-0]                  3,0[0-0]               0.001
                                            Biting                     2,0[0-0]                   0,0[0-0]               0.01
                        CAREBA-ita




                                      Grabbing caregiver               11,0[0-1]                  3,0[0-0]               0.001
                                       Throwing things                  6,0[0-0]                  0,0[0-0]              <.001
                                           Spitting                     1,0[0-0]                  0,0[0-0]              >0.05
                                        Calling for Help
                                                                        9,0[0-1]                  2,0[0-0]                0.03
                                     /Protesting/Objecting
                                      Hostile/Aggressive
                                                                        3,0[0-0]                  1,0[0-0]                0.03
                                          language
                                      Screaming/yelling                 9,0[0-1]                  2,0[0-0]                0.01


               Table 3: comparison of different Item both physical and verbal aggression while bathing in the two groups

38 patients (54.0%) had a Mini Mental State                                  well-being (48). It is an important component of job
Examination below 5 points. Having a MMSE above                              satisfaction and job performance. An aggressive event
or below MMSE=5 was not related to any significant                           can adversely affect the healthcare worker's problem-
differences in the scores CAREBA during bathing                              solving        skills      and       and       expose
(always p > 0.05). As regarding the variables
“Diagnosis“, “Gender“ and “Age“ the scores during
the procedure showed no significant differences in                           them to the risk of experiencing other issues as moral
the different domains of the CAREBA (always p >                              distress (49).
0.05).                                                                       Bathing persons with Alzheimer's disease is physically
                                                                             and emotionally demanding for the healthcare
As regards the time required to complete the                                 workers. Hitting, kicking, biting, swearing, and
procedure there was a statistically significant                              shouting at staff by dementia patients while bathing is
difference in favour of Towel bath, requiring a                              an everyday occurrence in long-term care facilities.
median of 7 minutes IQR [6; 8] against 9 minutes                             This study shows that changing the nursing approach
IQR [8; 10] traditional bath (p=0.01).                                       can significantly reduce aggression and agitation
                                                                             without having a negative effect on bathing
CONCLUSIONS                                                                  completeness or hygiene outcomes. The reduction in
The perception of a safe environment is a                                    behavioral symptoms produced by the technique
fundamental characteristic of individual and social                          Towel bath was large except for spitting, but the lack

      Corresponding author:                                           70                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
      Dissertation Nursing 1 (29/07/2022)                                          Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                       DOI: 10.54103/dn/17511




          DISSERTATION NURSING
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



of this occurrence suggests the need for further                             health professionals through education, supportive
investigation. It also seems interesting to investigate                      administrative    practices  and     regulation    is
the perceived any caregiver regards the effecetivenss                        recommended to maintain the level of improvement
of this technique.                                                           achieved in this study. Efforts in this direction are
About the execution time of the procedure, there was                         currently ongoing.
a statistically significant difference in favour of Towel
bath technique against traditional bath. These results                       Declarations of interest: The study was performed
are in line with what it was declared in international                       by part of the editorial board of Dissertation Nursing:
studies that have implemented Towel bath (10,11).                            the appropriate editorial conflict of interest policies
The CAREBA scale (10) was translated into Italian by                         (Publication Ethics - Art. 7.2) and the conflict of interest
the method of back translation. We proceeded to the                          procedure described in the Author Guidelines were
internal consistency evaluation by calculating                               adopted.
Cronbach Alpha which turned out to be 0.79: this
value is satisfactory, indicating that among the items
of the scale there is a good correlation and therefore,
a strong logical connection. The scale is easy to use,                       REFERENCES
requires less than a minute to be completed and thus                         1.     Savva GM, Zaccai J, Matthews FE, Davidson
represents a valid and reliable instrument in assessing                      JE, McKeith I, Brayne C, et al. Prevalence, correlates
the aggressiveness even in personss with dementia in                         and course of behavioural and psychological
long term facilities.                                                        symptoms of dementia in the population. Br J
This study supports the growing belief that a change                         Psychiatry. 2009 Mar 1;194(3):212–9.
in attitudes and practice can and should take place
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In conclusion our results support the idea that the                          Sep;9(5):602–8.
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The towel bath technique can be incorporated into
                                                                             behavioral impairment. Alzheimers Dement. 2016
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      Corresponding author:                                           71                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
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      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
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      Corresponding author:                                           73                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
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          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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      Corresponding author:                                           74                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
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Epub 2019 Apr 9.




      Corresponding author:                                           75                                    Submission received: 22/03/2022
      Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
      Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
      Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                   This work is licensed under a Creative Commons
      Dissertation Nursing 1 (29/07/2022)                                          Attribution-NonCommercial-NoDerivatives 4.0 nternational
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         Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing




APPENDICES:

Table 1 - CARErecipient Behavior Assessment (CAREBA) – first part

                          This coding system is used to rate clear signs of behavioral distress. If
                           two behaviors occur simultaneously, rate BOTH. Attempts do not
                          make contact with the caregiver. If a behavior cannot be clearly seen,
                                                    do NOT rate it.

                        1. PHYSICAL SYMPTOMS


                        BEHAVIOR                    DESCRIPTION

                         Hitting,                   - physically abuses caregiver with hand or
                         pushing,                   handheld object or with other body parts (head,
                         scratching, etc            whole body), includes pushing, shoving,
                                                    scratching, pinching (contact must occur)

                         Hitting,                   - swings out arm and hand with force towards
                         pushing,                   caregiver (check for signs of a wind-up)
                         scratching, etc.
                         ATTEMPT

                         Kicking                    - strikes forcefully with foot or leg (contact occurs)

                         Kick attempt               - swings out leg and foot with force towards
                                                    caregiver

                         Biting                     - bites, chomps, gnaws (on caregiver only)

                         Biting attempt             - moves face and open mouth towards caregiver to
                                                    bite

                         Grabbing                   - grabs onto a caregiver. Do not rate if resident is
                         caregiver                  holding on to the caregiver for safety reasons. If it
                                                    is unclear, do not rate.

                         Throwing things            - forcefully throws object, knocks object off
                                                    surface

                         Spitting                   - spits other than for dental hygiene purposes.



     Corresponding author:                                           76                                    Submission received: 22/03/2022
     Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
     Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
     Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                  This work is licensed under a Creative Commons
     Dissertation Nursing 1 (29/07/2022)                                          Attribution-NonCommercial-NoDerivatives 4.0 nternational
                                                                                                                      DOI: 10.54103/dn/17511




         DISSERTATION NURSING
         Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



Table 1 - CARErecipient Behavior Assessment (CAREBA) – Second part


                         2. VERBAL SYMPTOMS

                         BEHAVIOR                               DESCRIPTION

                         Calling for Help                       -says “You are hurting me”, “Ouch”,
                         /Protesting/Objecting                  “Help”, etc.; these may include
                                                                expressions of pain, discomfort or
                                                                dissatisfaction or calls for help

                         Hostile/Aggressive                     - verbally threatens to physically harm
                         language                               the caregiver, eg, "I'm going to kill you."
                                                                or threatens the caregiver in a
                                                                nonphysical way, eg., “I’m going to tell
                                                                my son about you.” Must be words.

                                                                -uses curse words(profane or obscene
                                                                language)

                         Screaming/yelling                      - Clearly above conversational level:
                                                                howls, shouts out, includes LOUD
                                                                verbal outbursts, e.g., - loud
                                                                exclamations such as "Oh!" or "Help!"
                                                                would be rated as Screaming/yelling and
                                                                Protest/Objecting. Rate "help" said in a
                                                                pleading manner as
                                                                Protesting/Objecting.




     Corresponding author:                                           77                                    Submission received: 22/03/2022
     Giada Cocciolo: giadacocciolo88@hotmail.com                                                    End of Peer Review process: 21/07/2022
     Lmu Klinikum Grosshadern                                                                                        Accepted: 21/07/2022
     Marchioninistrasse 15, Munich, Germany      Via Festa del Perdono 7, 20122 Milan, Italy                      Last Version: 01/08/2022
                                                                                  This work is licensed under a Creative Commons
     Dissertation Nursing 1 (29/07/2022)                                          Attribution-NonCommercial-NoDerivatives 4.0 nternational
