5.2 Cognitive Impairment and Dementia Care

The Three Ds: Delirium, Dementia, and Depression

Three conditions cause confusion in older adults and are frequently confused with one another on the CNA exam. Knowing the differences guides what the CNA reports.

Delirium is a medical emergency in the making — a urinary tract infection or dehydration is a common cause in elders — so a sudden change in a resident's confusion, alertness, or behavior must be reported to the nurse immediately. Dementia is a permanent loss of brain function affecting memory, judgment, and language; Alzheimer's disease is the most common cause. Depression can look like dementia (slowed thinking, withdrawal) but the memory is usually intact, and it improves with treatment.

Alzheimer's Stages and Behaviors

Alzheimer's disease progresses through roughly three stages:

• Early (mild): Recent-memory loss, repeating questions, misplacing items, and trouble with complex tasks. The resident is mostly independent but needs reminders.
• Middle (moderate): Greater disorientation to time and place, wandering, sundowning, agitation, and a need for step-by-step help with activities of daily living. This is the longest stage.
• Late (severe): Loss of speech, inability to recognize family, and total dependence for all care, eating, and toileting.

Common behaviors the CNA must manage:

• Sundowning — rising confusion, restlessness, and agitation in the late afternoon/evening. Reduce noise, increase daytime light, keep a calm routine, and limit caffeine.
• Wandering — moving about with no safe destination. Provide a safe walking path, use door alarms, ensure the resident wears identification, and walk with the resident rather than restraining them.
• Catastrophic reaction — an extreme, sudden overreaction (crying, striking out) to a small trigger such as too many directions or noise. Stay calm, lower stimulation, do not argue, and redirect.
• Agitation and aggression — often caused by pain, fear, or unmet needs. The CNA looks for the trigger behind the behavior.

Communication and Therapeutic Approaches

Two named approaches are tested. Reality orientation repeatedly reminds the resident of the correct name, date, time, and place; it helps in the early stage but can frighten or anger a resident with advanced dementia who cannot retain it. Validation therapy instead enters the resident's reality and responds to the feeling behind the words. If a resident insists she must "go pick up the children from school," the CNA does not argue the children are grown; the CNA acknowledges the feeling ("You love your children — tell me about them") and gently redirects.

Effective communication techniques for any cognitively impaired resident:

• Approach from the front, make eye contact, and identify yourself.
• Use short, simple, one-step directions and yes/no questions.
• Speak slowly and calmly; allow extra time to respond.
• Use gestures, demonstration, and a gentle tone.
• Do not argue, correct, or reason with a confused resident.
• Redirect and distract instead of confronting.

Managing ADLs, Safety, and Person-Centered Care

Daily care for a resident with dementia is built on routine and simplicity. Keep the same caregiver and schedule when possible, lay out clothing in the order it is put on, and offer one item or one choice at a time to avoid overwhelming the resident. Break bathing and dressing into small steps and give one cue at a time. Maintain dignity and never rush, scold, or speak about the resident as if they are not present.

Safety is a constant concern: confused residents are at high risk for falls, wandering off, and ingesting unsafe items. Keep the environment uncluttered and well lit, store chemicals and sharp items locked away, monitor wandering residents closely, and use identification and door alarms rather than physical restraints, which increase agitation and injury.

Person-centered care means treating the resident as a unique individual — knowing their history, preferences, routines, and what soothes them. Familiar music, a beloved object, looking at old photographs, or a calm walk can ease anxiety far better than medication. The CNA respects the person behind the disease at every interaction.

Other Dementias and Responding to Behaviors

Alzheimer's disease causes most dementia, but the CNA may also care for residents with vascular dementia (from strokes or reduced blood flow, often with a stepwise decline), Lewy body dementia (with visual hallucinations and movement problems), and frontotemporal dementia (with early personality and behavior changes). The CNA does not need to treat these differently in daily care, but should know that behaviors are part of the disease, not deliberate.

When a resident with dementia shows a difficult behavior, the CNA looks for the unmet need or trigger behind it rather than reacting to the behavior alone:

Restraints — physical or chemical — are a last resort that require a doctor's order and actually increase falls, injuries, and agitation. The CNA prevents the need for restraints through routine, activity, comfort, and supervision.