6.2 Caring for Residents with Dementia
Key Takeaways
- Sundowning is increased confusion and agitation in the late afternoon and evening; reduce stimulation, increase light, and limit caffeine after noon.
- Validation therapy (Naomi Feil) accepts the resident's emotional reality; reality orientation is used selectively in early dementia and may cause distress in severe dementia.
- Restraints, including locked-door units, are governed by 42 CFR 483.10 and 10A NCAC 13F — they require a physician's order, a documented medical reason, and the least restrictive option.
- Approach a resident with dementia from the front at eye level, speak slowly, use short sentences, and give one instruction at a time.
- Wandering is managed with distraction, secured units, ID bracelets, and wander-guard systems — not with physical restraint of the resident.
More than half of NC nursing home residents have some form of dementia, and special-care dementia units are a significant share of NC's licensed long-term care beds. Most CNA work in dementia care is non-pharmacological: the way you approach, speak, and structure the environment is the intervention.
Behavioral and Psychological Symptoms of Dementia (BPSD)
BPSD is the umbrella term for the non-cognitive symptoms of dementia. These are what families and staff find hardest, and they are the focus of most NNAAP dementia questions.
| Symptom | What it looks like | Typical trigger | CNA response |
|---|---|---|---|
| Wandering | Walking without obvious purpose, trying to leave the unit | Boredom, pain, need to toilet, looking for a familiar person or place | Walk with resident, redirect, offer purposeful activity, ensure ID bracelet and wander-guard are in place |
| Sundowning | Confusion, agitation, pacing in late afternoon/evening | Fatigue, low light, shift change, hunger | Increase light, calm routine, limit caffeine after noon, reduce noise |
| Agitation / Catastrophic reactions | Sudden anger, yelling, hitting, out of proportion to trigger | Overstimulation, pain, being rushed, too many choices, being corrected | Stop, step back, lower voice, simplify, try again later |
| Hoarding / rummaging | Collecting items, going through drawers | Need for control, anxiety | Provide a labeled rummage drawer with safe items; do not scold |
| Repetitive behaviors | Asking the same question, rubbing the same spot, pacing | Anxiety, unmet need, memory loss | Brief calm answer each time; check for pain or toileting need |
| Hallucinations and delusions | Seeing people who are not there; believing staff are stealing | Lewy body dementia, infection, medication, sensory loss | Do not argue, do not reinforce; acknowledge the feeling and redirect; report new hallucinations |
The Communication Approach
NNAAP questions almost always reward a specific approach pattern. Memorize this list:
- Approach from the front, never from behind. Make eye contact before touching.
- Get to eye level, especially if the resident is seated.
- Identify yourself by name and role every time — do not assume the resident remembers you.
- Speak slowly, in a low tone, short simple sentences, one idea per sentence.
- Give one instruction at a time. Wait. Then give the next.
- Avoid open-ended questions and choices in late dementia. "Would you like to wear the blue or the red shirt?" is easier than "What do you want to wear?" but in severe dementia even two choices may overwhelm.
- Use the resident's name and the preferred form of address (Mr. Garcia, Miss Ruby) — never "honey," "sweetie," or "grandma." These are forms of elderspeak that violate dignity and are tested as wrong answers.
- Match nonverbal cues to words. A calm voice and a tense body confuse the resident.
Validation, Reality Orientation, Redirection, Reminiscence
| Technique | What it is | When to use |
|---|---|---|
| Validation therapy (Naomi Feil) | Accept the resident's emotional reality without correcting facts. "Tell me about your mother." | Moderate to severe dementia. First-line for distressing beliefs ("I have to pick up my children"). |
| Reality orientation | Gently provide today's date, location, names. Calendars and clocks visible. | Early or mild dementia, or delirium. Do not force on severe dementia — it can cause distress and catastrophic reactions. |
| Redirection | Shift attention to a different topic or activity. | Any stage, especially when an unmet need or trigger is unclear. |
| Reminiscence | Use photos, music, familiar objects to evoke long-term memory. | Any stage. Long-term memory is preserved longer than short-term. |
Rule of thumb: Never argue with a resident who has dementia. You will not win, and you will damage the relationship. If grandmother is "waiting for the school bus," do not say "You are 88 and your children are grown." Say, "Tell me about your children. What grade are they in?"
Sundowning Management
Sundowning peaks between approximately 3 p.m. and 8 p.m. Care-plan interventions tested on the NNAAP:
- Increase light in late afternoon — open blinds, turn on overhead lights before dusk.
- Reduce stimulation — lower TV volume, limit visitors at peak time, avoid the shower at 4 p.m.
- Limit caffeine after noon and screen for late-day napping.
- Maintain a predictable routine — same staff, same order of ADLs.
- Toilet, hydrate, and check for pain before agitation builds.
Wandering and Restraint Rules
Wandering is dangerous (elopement, falls, exposure) but the resident still has the right to move. The hierarchy of interventions, in order:
- Identify and meet the unmet need — toileting, hunger, pain, boredom.
- Walk with the resident and redirect to a destination.
- Provide a safe wandering path — circular hallways, secured courtyard.
- Use environmental safeguards — wander-guard ankle bracelet alarms, secured-unit doors with delayed-egress (federally required exit signage still applies), photo ID bracelet with no facility address visible.
- Restraints are a last resort. Under 42 CFR 483.10 / 483.12 (federal) and 10A NCAC 13F (NC), physical and chemical restraints require a physician's order, a documented medical reason, the least restrictive option, time limits, and ongoing monitoring. Restraints can never be used for staff convenience or discipline. Locked-door dementia units are permitted but must be reviewed against current NC restraint rules at the facility level.
NNAAP wrong answers around wandering almost always involve restraint or scolding. The right answer is environmental safety plus engagement.
A resident with moderate Alzheimer's disease tearfully tells the CNA, "I need to go home. My mother is waiting for me." The resident's mother died 30 years ago. Using validation therapy, the BEST response is:
A resident with dementia becomes increasingly confused, paces, and yells starting around 4 p.m. each afternoon. This pattern is BEST described as sundowning. Which intervention is MOST appropriate?