8.1 Understanding Dementia
Key Takeaways
Dementia is a group of symptoms affecting memory, thinking, and behavior, not a normal part of aging
Alzheimer's disease is the most common type of dementia (60-80% of cases); vascular dementia is second
Short-term memory is affected first; long-term and procedural memory are preserved longer
Sundowning causes increased confusion and agitation in the late afternoon and evening
Always rule out physical causes (pain, infection, hunger, full bladder) before labeling a behavior 'just dementia'
What Dementia Is and Why CNAs Must Know It
Dementia is not a single disease. It is an umbrella term for a decline in memory, thinking, language, judgment, and behavior severe enough to interfere with daily life. Roughly 70-90% of long-term-care residents have some cognitive impairment, so almost every CNA shift involves dementia care. On the NNAAP/Prometric written exam, Care of Cognitively Impaired Residents is its own scored content area, and the skills evaluation triggers automatic-fail points around safety and dignity with these residents.
Dementia is NOT normal aging. Occasionally misplacing keys is aging; getting lost on a familiar street, forgetting a daughter's name, or losing the ability to dress is dementia. Memorize that distinction, because exam stems love to ask whether a behavior is "a normal change of aging."
Reversible vs. Irreversible Causes
A classic trap: not all confusion is dementia. Delirium is a sudden, fluctuating confusion with a reversible cause (urinary tract infection [UTI], dehydration, low oxygen, medication, fever). Dementia comes on slowly over months to years. If a resident who was calm yesterday is suddenly agitated and confused today, suspect delirium and report it immediately, do not assume the dementia "got worse."
| Feature | Delirium | Dementia |
|---|---|---|
| Onset | Sudden (hours-days) | Gradual (months-years) |
| Cause | Often reversible (UTI, drug, dehydration) | Progressive brain damage |
| Course | Fluctuates, worse at night | Steady decline |
| CNA action | Report STAT as a change | Ongoing supportive care |
Types of Dementia
| Type | Cause | Key Features |
|---|---|---|
| Alzheimer's disease (AD) | Amyloid plaques and tau tangles, brain-cell death | Most common (60-80%); gradual; recent-memory loss first |
| Vascular dementia | Reduced blood flow from strokes/TIAs | Second most common; abrupt, step-like decline |
| Lewy body dementia | Abnormal alpha-synuclein protein deposits | Visual hallucinations; tremor/stiffness; alertness swings |
| Frontotemporal dementia | Frontal/temporal lobe damage | Personality and language change, often before age 65 |
| Mixed dementia | More than one type together | Features of two or more; common in the very old |
Stages, Memory Patterns, and Behaviors
The Three Stages of Alzheimer's Disease
| Stage | Typical Duration | What the CNA Sees |
|---|---|---|
| Early (mild) | 2-4 years | Word-finding trouble, repeating questions, misplacing items; still mostly independent |
| Middle (moderate) | 2-10 years | Needs help with most activities of daily living (ADLs); wandering; sundowning; not knowing time or place |
| Late (severe) | 1-3 years | Total care, incontinence, loss of speech, cannot recognize family, bedbound, dysphagia |
How Memory Breaks Down
Dementia attacks memory in a predictable order, the most recent memories disappear first.
- Short-term memory (last few minutes): lost early; the resident forgets they just ate.
- Long-term memory (childhood, a late spouse): preserved much longer; this is why a resident may insist on "going to work" or "picking up the kids."
- Procedural memory (how to walk, hum a song, brush teeth): often intact until the late stage, which is why music and familiar motions still reach a resident who cannot speak.
Four terms appear on exams: aphasia (loss of language), agnosia (cannot recognize objects or faces), apraxia (cannot perform a learned movement despite intact muscles), and disorientation (confusion about time, place, or person).
Common Behaviors and Their Triggers
| Behavior | What It Looks Like | Frequent Triggers |
|---|---|---|
| Wandering | Walking with no clear destination | Boredom, looking for a bathroom, old routine, pain |
| Sundowning | Worse confusion/agitation late afternoon-evening | Fatigue, low light, hunger, overstimulation |
| Repetition | Same question again and again | Memory loss, anxiety, needing reassurance |
| Catastrophic reaction | Sudden screaming, crying, hitting | Overstimulation, being rushed, too many demands |
| Shadowing | Following the CNA everywhere | Fear of being alone |
| Hoarding/rummaging | Hiding food or items | Insecurity, lifelong habit |
The Golden Rule: Look for a Physical Cause First
Before you treat a new behavior as "just the dementia," rule out a fixable cause. Pneumonic clue many programs teach: a sudden behavior change is often pain, infection (UTI), constipation, hunger, thirst, a full bladder, or being too hot or cold. A resident who suddenly becomes combative during care may simply hurt. Report the change; the nurse may find a treatable problem. This habit prevents unnecessary chemical and physical restraints, which are tested heavily.
Worked Scenario
A resident with middle-stage Alzheimer's who normally eats breakfast quietly suddenly hits a CNA's hand, pulls away, and grimaces during morning care. A new CNA might chart "combative due to dementia." The skilled CNA pauses and asks why: Is there a new pressure injury? A full bladder? Constipation for three days? A UTI causing burning? Did the resident sleep? In this case the nurse later finds a UTI; once treated, the combative behavior disappears. The lesson the exam rewards: a new behavior is a symptom to investigate and report, not a personality flaw to manage with force.
Common Exam Traps for This Section
- "It is normal for an 80-year-old to forget their daughter's name", false; that is dementia, not aging.
- "Sudden confusion overnight means the dementia worsened", false; suspect delirium and report.
- "Long-term memory fails before short-term", false; recent memory goes first.
- "Lewy body dementia is best known for early memory loss", false; its hallmarks are visual hallucinations and movement problems.
Quick Reference: Spotting the Dementia Type
- Gradual memory loss, plaques and tangles -> Alzheimer's.
- Step-wise decline after strokes -> vascular.
- Vivid visual hallucinations plus stiffness -> Lewy body.
- Personality and language change before age 65 -> frontotemporal.
Knowing these one-line cues lets you answer type questions in seconds and frees time for the scenario items, which carry the most weight in the cognitive-care portion of the test.
A resident with stable mild dementia suddenly becomes very confused and agitated overnight. What should the CNA suspect FIRST?
The dementia has rapidly worsened and is now severe
A reversible cause such as a urinary tract infection or dehydration (delirium)
The resident is faking the confusion for attention
Normal aging changes
Which type of memory typically remains intact the LONGEST in a person with dementia?
Short-term memory for recent events
Memory of what they ate at the last meal
Procedural and long-term memory, such as humming a familiar song
All memory is lost at the same rate
Which type of dementia is the second most common after Alzheimer's disease?
Vascular dementia, caused by reduced blood flow from strokes
Lewy body dementia
Frontotemporal dementia
Mixed dementia
Sections you finish are checked off in the contents.