9.2 Cognitive Impairment: Alzheimer's Disease and Dementia Behaviors
Key Takeaways
- Alzheimer's disease progresses through 7 stages on the Reisberg Functional Stages (no decline → severe decline); know the hallmark of each — Stage 4 trouble managing finances, Stage 5 needs help choosing clothing, Stage 6 incontinence and needs help with ADLs, Stage 7 loses speech, swallowing, and walking
- Validation therapy enters the resident's emotional reality rather than correcting facts — use it in mid-to-late dementia when reality orientation only causes distress; reality orientation is reserved for early-stage residents who can still absorb facts
- Wandering, elopement, sundowning, agitation, hallucinations, and repetitive questioning are not 'bad behavior' — they are unmet needs or brain damage expressing themselves; the intervention is to identify and address the need, not to argue
- The single most-tested dementia rule: never argue with or correct a resident's confused belief — redirect, validate the feeling, and move on; arguing increases agitation and is an exam trap
- Music therapy and reminiscence reach long-term memories that survive into mid-stage Alzheimer's and can reduce agitation and repetitive questioning when verbal reasoning fails
Cognitive Impairment: Alzheimer's Disease and Dementia Behaviors
Quick Answer: Alzheimer's disease is a progressive brain disease with 7 stages on the Reisberg Functional Staging scale, from no decline to severe decline. The CNA's job is to match care to the stage, use validation therapy (not reality orientation) in mid-to-late stages, and treat behavioral symptoms as unmet needs — never argue, correct, or reason a confused resident out of a belief.
Dementia is an umbrella term for a loss of cognitive function severe enough to interfere with daily life. Alzheimer's disease is the most common cause, accounting for roughly 60–80% of dementia cases. Indiana CNA exam items treat dementia and Alzheimer's as the primary cognitive-impairment content; vascular dementia, Lewy body, and frontotemporal dementia appear as secondary mentions.
Alzheimer's 7 Stages — Reisberg Functional Staging
The Reisberg scale (Functional Assessment Staging, FAST) is the staging tool Indiana CNA items reference. Learn the hallmark of each stage.
| Stage | Name | Hallmark | Care implication for the CNA |
|---|---|---|---|
| 1 | No decline | No noticeable symptoms; brain changes may be starting | No dementia; resident functions independently |
| 2 | Very mild decline | Forgets names and where objects are; still functions independently | Looks normal; do not assume the resident is just "not paying attention" |
| 3 | Mild decline | Noticeable memory gaps on complex tasks, getting lost, trouble with organization | May still live alone but needs reminders; offer written cues |
| 4 | Moderate decline | Trouble managing finances, traveling alone, recalling recent events | Needs help with bills and appointments; care plan should add reminders and supervision for IADLs |
| 5 | Moderately severe decline | Cannot choose proper clothing without help; disoriented to time and place; needs help with ADLs like dressing and bathing | Person-centered care: lay out clothes in order, give one-step instructions, allow extra time |
| 6 | Severe decline | Incontinence (urine then stool), needs help with most ADLs, may forget spouse's name but recognizes faces | Full ADL assistance; incontinence care; risk of wandering and sundowning peaks |
| 7 | Very severe decline | Loses speech (few words), ability to walk, sit up, swallow, and hold head up | Total care; aspiration and pressure-ulcer risk; hospice often appropriate |
Trap to remember: A classic exam bait is a question that lists a Stage 4 symptom (cannot manage finances) and asks what stage the resident is in. The answer is Stage 4, not Stage 5 — Stage 5 is marked by needing help choosing clothing. Memorize the one hallmark per stage and you will not confuse them.
Dementia Behaviors and Interventions
Behavioral symptoms in dementia are the brain's expression of an unmet need — pain, hunger, thirst, a full bladder, fear, overstimulation, or a memory that feels present. They are not intentional. The CNA response is to identify and address the need, not to punish or correct.
| Behavior | What it looks like | Likely cause / need | CNA intervention |
|---|---|---|---|
| Wandering | Pacing halls, walking into other rooms | Looking for a bathroom, food, a person, or an old routine; boredom | Walk with the resident; redirect gently; offer a snack or activity; ensure safe walking paths; do not lock doors or block exit |
| Elopement | Leaving the facility or a safe area unsupervised | Same as wandering but with exit risk | Use door alarms and WanderGuard per facility policy; escort back calmly; never chase or grab; report every elopement to the nurse immediately |
| Sundowning | Increased agitation, confusion, or restlessness in late afternoon or evening | Fatigue, low light, disrupted body clock, hunger | Increase lighting before dusk; offer a snack and fluids; reduce noise and stimulation; keep a calm routine |
| Agitation / aggression | Hitting, grabbing, shouting, resisting care | Unmet need (pain, full bladder, fear, being rushed); overstimulation | Stop the task; step back; lower your voice; identify and address the need; return to the task slowly with one-step instructions |
| Hallucinations | Seeing, hearing, or feeling things that are not there | Brain damage (Alzheimer's or Lewy body); sensory deprivation; infection | Do not argue; assess for a real trigger (a shadow, a noise); reassure the resident; report persistent or new hallucinations — they can signal infection or medication effect |
| Repetitive questioning | Asking the same question every few minutes | Short-term memory loss; anxiety; an unmet need the resident cannot name | Answer briefly the first time, then redirect to an activity; use validation ("You are worried about your mother — let's look at her photo"); avoid saying "I already told you" |
| Catastrophic reaction | Sudden extreme distress over a small trigger | Being rushed, overstimulated, or asked too many questions at once | Stop the task; move to a quiet space; return slowly with one step at a time |
Trap to remember: The single most-tested dementia rule on the Indiana CNA exam is this: never argue with, correct, or try to reason a confused resident out of a false belief. If a resident says she is waiting for her mother (who died 30 years ago), do not say "Your mother is dead." That causes distress and agitation. Use validation — acknowledge the feeling, redirect gently, and move on. Arguing is the wrong answer every time.
Communication Strategies and Therapies
Four named therapies appear on the Indiana CNA exam. Know what each is and when to use it.
Validation Therapy (Naomi Feil)
Validation enters the resident's emotional reality and accepts it as real for them. You do not correct the facts; you validate the feeling. Example: a resident asks when her husband is coming home. You do not say "he passed away." You say, "You must miss him very much. Tell me about him." Validation is the right choice in mid-to-late stage dementia, when the resident cannot absorb or retain new facts and reality orientation only causes distress.
Reality Orientation
Reality orientation repeatedly presents accurate facts — the day, the date, the season, the current location, the names of people. It uses clocks, calendars, and boards. It is appropriate only in early-stage dementia, when the resident can still absorb and use the information. Using reality orientation on a mid- or late-stage resident who cannot retain it increases agitation.
Trap to remember: A common exam item pairs reality orientation with a late-stage resident. The answer is to switch to validation. Reality orientation is not wrong — it is wrong for this stage. Match the strategy to the stage.
Reminiscence Therapy
Reminiscence invites the resident to talk about the past using photos, music, familiar objects, or open-ended questions ("Tell me about your first job"). Long-term memory often survives into mid-stage Alzheimer's even as short-term memory is gone, so reminiscence reaches the resident where they still have functioning memory. It reduces anxiety and repetitive questioning and gives the resident a sense of identity.
Music Therapy
Music therapy uses songs from the resident's young adulthood (roughly ages 18–25) to reach preserved emotional memory. It can reduce agitation, improve mood, and ease ADL care — playing a resident's favorite hymn during a bed bath can turn a fight into cooperation. The CNA does not need a music therapist present; using a playlist on a phone or facility speaker is a recognized application.
Behavior Interventions for ADLs
Caring for a resident with dementia through ADLs (bathing, dressing, eating, toileting) requires stage-matched technique:
| ADL | Dementia-friendly technique |
|---|---|
| Bathing | Warm the room; pre-fill the tub or basin; explain each step in one short sentence; offer a towel for the resident to hold for modesty; if the resident refuses, leave and try later — never force |
| Dressing | Lay clothes out in order; hand the resident one item at a time; give one-step instructions ("Put your arm here"); choose easy-on clothing; respect preference even when the choice looks odd |
| Eating | Quiet dining area; one or two foods at a time; offer finger foods if utensils frustrate; watch for swallowing problems in Stage 7; never rush |
| Toileting | Take the resident on a schedule (every 2 hours) before they ask; watch for restlessness or tugging at clothes as a cue; label the bathroom door with a picture, not just the word |
| Oral care | Use a soft brush; let the resident hold it if they can; sing or play music; never force the mouth open — use a bite block only per facility policy |
When to Report and What the CNA Does Not Do
A CNA reports to the licensed nurse when a dementia resident:
- Shows a new or sudden change in behavior, alertness, or cognition — this can signal an infection (urinary tract infection is the classic cause of sudden worsening in dementia)
- Has a new or worsening hallucination
- Becomes physically aggressive toward self or others
- Stops eating or drinking
- Has a fall
- Tries to elope or does elope
A CNA does not diagnose, does not medicate, and does not restrain. If a resident's behavior is unsafe, the CNA stays with the resident, protects others nearby, and calls for the nurse — the nurse and physician decide on any medication or restraint order.
A resident in Stage 6 Alzheimer's repeatedly asks where her late husband is. What is the BEST CNA response?
Which of the following BEST describes the hallmark of Stage 5 on the Reisberg scale?
A resident with dementia becomes agitated every afternoon around 4 p.m. and tries to walk toward the front door. What is the most likely cause and the correct intervention?
A CNA tries to give a Stage 6 resident a bed bath. The resident starts shouting and pushing the washcloth away. What should the CNA do FIRST?