3.2 Cognitive Changes & Mental Health
Key Takeaways
- Delirium is sudden, fluctuating, and reversible (often from infection, dehydration, or medication) and is a medical emergency to report immediately; dementia is gradual and irreversible; depression is a treatable mood disorder, not memory loss
- Alzheimer's disease is the most common dementia (60-80% of cases); short-term memory fails first while long-term and emotional memory persist longer
- Validation therapy acknowledges the resident's feelings and reality ("You miss your mother") rather than correcting them; reality orientation can increase agitation in moderate-to-severe dementia
- Sundowning is increased confusion and agitation in late afternoon/evening; reduce it with daytime activity, evening light, calm routine, and limited caffeine and naps
- Any statement of self-harm or suicide is reported to the nurse immediately, never kept confidential; CNAs observe and report risk, they do not assess it
Why This Matters
Emotional and mental-health care is about 8-13% of the New Jersey CNA exam and is the heart of psychosocial care. The most-tested skill is distinguishing delirium, dementia, and depression — they look alike but require very different responses.
Delirium vs. Dementia vs. Depression
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Sudden (hours-days) | Gradual (months-years) | Weeks |
| Course | Fluctuates through the day | Slow steady decline | Often worse in morning |
| Reversible? | Usually yes | No | Yes, treatable |
| Attention | Severely impaired | Normal early | Mildly reduced |
| Common cause | Infection (UTI), dehydration, medication, pain | Brain disease (Alzheimer's) | Loss, illness, isolation |
| CNA action | Report immediately — emergency | Report; use dementia care plan | Report; encourage activity |
A new, sudden confusion in a resident who was clear yesterday is delirium until proven otherwise — most often a urinary tract infection (UTI) in older adults. Report it right away.
Alzheimer's Disease Stages
Alzheimer's disease is the most common dementia (60-80% of cases). It is progressive and irreversible. Short-term memory fails first; long-term and emotional memory last longer, which is why a resident may forget breakfast but vividly recall childhood.
- Early (mild) — forgetfulness, word-finding trouble, still mostly independent
- Middle (moderate) — needs help with activities of daily living, may wander, sundowning, behavior changes
- Late (severe) — limited speech, total care, swallowing and mobility decline
Validation and Redirection
Validation therapy acknowledges the resident's feelings and their reality instead of correcting them. If a resident asks for a parent who died years ago, do not say "Your mother is dead" — that re-traumatizes them with each telling. Instead: "You miss your mother. Tell me about her."
Redirection gently shifts attention to a calming activity ("Let's fold these towels together"). Reality orientation (using calendars and clocks) helps in mild confusion but often increases agitation in moderate-to-severe dementia.
Agitation, Sundowning, and Wandering
Behavior is communication. Always check for a physical cause first: pain, hunger, thirst, full bladder, infection, too hot or cold, or overstimulation.
- Sundowning — worsening confusion and agitation in the late afternoon and evening. Reduce it with daytime activity and light, a calm evening routine, limited caffeine, and short or no late naps.
- Wandering — keep the environment safe, ensure the resident has an ID, use the facility's monitoring system, provide safe walking paths, and meet the underlying need (boredom, looking for a bathroom, restlessness).
- Catastrophic reaction — overreaction to a small trigger. Stay calm, remove the trigger, do not argue, give space, and reassure with a soft voice.
Anxiety, Depression, and Suicide Risk
Signs of depression in older adults include withdrawal, loss of appetite, sleep changes, slowed movement, and statements of hopelessness or worthlessness. Encourage participation, listen, and report — do not say "cheer up."
If a resident expresses any wish to harm themselves or others, or says life is not worth living, report it to the nurse immediately. This is never kept confidential, and the CNA does not assess severity — that is the nurse's and clinician's role.
A resident with no prior confusion suddenly becomes disoriented overnight at a New Jersey nursing facility, picking at the air and unable to focus. What is the MOST appropriate CNA action?
A resident with Alzheimer's disease at a Newark facility repeatedly asks to "go home to see Mama," though her mother died decades ago. Using validation therapy, the CNA should say: