Hot Water and Scald Safety for Older Skin

Why older skin burns more easily

• Thinner skin. The outer layers become thinner and more fragile, so a given temperature causes deeper injury than in a young adult.
• Slower sensation and reaction. Nerves carry signals more slowly. Conditions such as diabetic neuropathy, stroke, spinal problems and some medicines reduce feeling in the feet, legs and hands.
• Slower movement. A person may not be able to jump away quickly from scalding water, particularly if sitting on a shower chair or in a bath, or if they have weak legs.
• Confusion or dementia. A person may not understand the danger, or may turn the wrong tap.
• Poor eyesight. Hot and cold labels may be hard to read.
• Healing is slower, and burns are more likely to become infected, particularly in people with diabetes or poor circulation.
• Being alone or unable to call for help, which delays first aid.

Burn injury depends on temperature and time. At very high water temperatures, adult skin can be seriously burned within seconds; at lower temperatures it takes longer. In older, thinner skin the time is shorter. That is why even a "just hot" shower can hurt an older person, and why it is wise to lower the maximum temperature that can ever reach the tap.

What temperature is safer?

Guidance from health and safety bodies in several countries suggests keeping the temperature of water at the bath or shower tap to a limit of about 44 degrees Celsius for people at risk, with many care guides recommending around 37 to 41 degrees for the actual bath or shower. Water that feels comfortably warm to the inside of the wrist is usually near body temperature, which is about 37 degrees. A bath thermometer is a cheap and reliable way to check, and a digital thermometer with a waterproof probe can do the job too. See digital thermometer guide for general thermometer tips, though a bath thermometer is a separate item.

Water in a storage geyser is often stored much hotter than the temperature at which it is used, to keep the tank free of bacteria and to mix with cold. It is the mixing at the tap that sets the final temperature. If the mix is wrong, the water arriving can be scalding.

Geysers, buckets and Indian bathrooms

Many Indian homes use an electric or gas geyser, either storage or instant, and a bucket and mug for bathing. Each set-up has its own risks:

• Storage geysers. The thermostat can often be set to a range, such as 40 to 75 degrees. Many are set high by default or by the installer. Ask a plumber or electrician to set a lower maximum, as low as practical for your hot water needs, and to check that the thermostat and the safety valve work.
• Instant geysers and gas geysers. The temperature depends on the flow rate: a low flow produces very hot water, and a high flow is cooler. If another tap is opened, the water can suddenly become hotter. Teach everyone to avoid turning on other taps during a bath.
• Bucket bathing. Fill the bucket from the geyser, then add cold water, and test it with your hand or a thermometer before the person is near. Do not pour water directly from a hot tap onto the skin. Place the bucket where it cannot be knocked over. A hot bucket on the floor beside a shower chair is a scald and a trip hazard.
• Water at the tap. Hot water tanks on the roof, heated by the sun, can supply very hot water in summer afternoons. Check before use.
• Winter and cold floors. People may use very hot water to warm up. Offer a warm room, a warm towel and a warm drink instead.
• Heaters. Electric heaters and immersion rods near water are hazards. See safe use of heaters and geysers.
• Gas geyser fumes. A gas geyser in a closed bathroom can produce dangerous fumes; ensure ventilation. See smoke and gas safety for older adults.

Equipment that reduces scald risk

• Thermostatic mixing valve (TMV). A device fitted to a tap, shower or the main hot supply that blends hot and cold water to a set, safe temperature and cuts off the hot if the cold fails. It is the most reliable protection and is widely used in care settings. A plumber can fit one on the shower or the geyser outlet.
• Anti-scald device on a tap. A small fitting that limits the hot water temperature or flow. Quality varies.
• A geyser with an adjustable thermostat and a safety cut-out, set low.
• Single-lever mixer taps with a stop that limits the hot setting.
• Temperature display on some shower mixers. Useful if it works reliably.
• A handheld shower that lets a person test the water on a hand or foot before directing it at the body; see handheld shower guide.
• Colour-coded taps and large, high-contrast hot and cold markings, for people with poor eyesight or dementia.
• Bath thermometer with a clear, large display.
• Insulation of exposed hot pipes and covers beneath basins, to avoid contact burns.
• Smart plugs or timers are not a substitute for safe thermostat settings.

Habits that prevent burns

1. Run the water first, with the person not in the stream. Test with your own wrist or a thermometer. 2. Cold first, then hot. When filling a bath, run cold water first, then add hot, so that the tub surface and the base are not too hot. 3. Mix well. Stir the water so there are no hot pockets. 4. Test again at the start and during bathing, since water temperature can change. 5. Do not leave the person alone in the bath or shower if they have reduced feeling, dementia, balance problems or fainting spells. 6. Do not let a person with reduced feeling control the taps alone. 7. Do not use other taps while someone is in the shower, to avoid temperature surges. Flushing the toilet or running a washing machine can change the pressure. 8. Turn the tap off and then stand up, not the other way round. 9. Use warm, not hot, water for foot soaks, and test it with the elbow or a thermometer. People with diabetic neuropathy have burned their feet in water that felt "just warm" to their numb skin. See diabetic foot care at home and neuropathy foot care. 10. Avoid hot water bottles and heat packs on numb skin, and use covers. See hot pack safety for older skin. 11. Keep children and pets out of the bathroom when a person is bathing.

Other bathroom heat risks

• Hot tap water at the basin can scald when washing hands or the face.
• Hot pipes under the basin or on the wall.
• Hair dryers and heaters, which should be kept away from water.
• Steam, which causes dizziness; ventilate.
• Hot tea or coffee carried to the bathroom.
• Radiators and towel rails in cold climates, which can burn a person sitting against them.

First aid for a scald

If a scald occurs, act quickly. These are general first-aid principles; follow local emergency advice and get medical help.

1. Stop the burning. Remove the person from the hot water. Remove clothing or jewellery near the burn, unless stuck to the skin. 2. Cool the burn with cool running water, not ice, for about 20 minutes. Do not use ice, iced water or creams, butter, toothpaste or turmeric, which can worsen injury or cause infection. 3. Keep the person warm elsewhere on the body, as long cooling can chill an older person. 4. Cover the burn loosely with a clean, non-fluffy material such as cling film or a clean cloth. 5. Do not burst blisters. 6. Get medical help. Call an ambulance or go to hospital for large burns, burns on the face, hands, feet, groin or over a joint, deep burns, burns that look white or charred, and any burn in an older person, a person with diabetes or reduced feeling, or a person who is unwell, confused or in severe pain.

See ambulance and emergency numbers in India and knowing when to call the doctor. Older adults should be checked by a doctor after any significant burn, since infection and shock can develop later, and healing may need dressings.

When to ask a professional

Ask a plumber or electrician to set the geyser thermostat, fit a thermostatic mixing valve and check the pressure and gas safety. An occupational therapist can assess whether your parent can sense water temperature and control the taps, and suggest equipment. A doctor or nurse should be consulted if your parent has reduced feeling in the feet or hands, diabetes, nerve damage or dementia, and about wound care after a burn.