8.1 Dementia, Alzheimer's & Cognitive Impairment Care

Cognitive impairment refers to a decline in mental functioning, including memory, reasoning, and judgment, that goes beyond normal aging. While mild forgetfulness—like temporarily misplacing keys—is a common part of aging, dementia is not. Dementia is an umbrella term for symptoms caused by physical changes in the brain that interfere with daily life and impair an individual's ability to perform Activities of Daily Living (ADLs) independently.

Alzheimer’s disease is the most common form of dementia, accounting for 60 to 80 percent of all cases. It is a progressive, irreversible neurological disorder characterized by the accumulation of amyloid plaques and neurofibrillary tangles in the brain. These abnormal structures disrupt neuron communication and lead to widespread cell death and brain atrophy. Other common forms of dementia include:

• Vascular Dementia: Caused by impaired blood flow to the brain, typically resulting from a series of minor strokes (multi-infarct dementia).
• Lewy Body Dementia: Characterized by abnormal protein deposits (Lewy bodies) in neurons, leading to cognitive decline, visual hallucinations, and motor symptoms similar to Parkinson's disease.
• Frontotemporal Dementia: Primarily affects the frontal and temporal lobes of the brain, causing early and progressive changes in personality, social behavior, and language skills.

The Three Stages of Alzheimer's Disease

The progression of Alzheimer’s disease is generally divided into three stages:

1. Mild (Early Stage): Individuals can still function independently in many areas but experience noticeable memory lapses, such as forgetting familiar words or the locations of everyday objects. They may struggle to organize tasks, plan activities, or remember the names of newly introduced people, which often causes anxiety and frustration.
2. Moderate (Middle Stage): This is typically the longest stage, lasting for years. Cognitive decline becomes pronounced, and residents require assistance with daily tasks (ADLs) such as dressing, bathing, and grooming. Behavioral symptoms—including wandering, sundowning, agitation, and hallucinations—emerge strongly. Urinary and fecal incontinence often develop as the disease damages the areas of the brain that control elimination.
3. Severe (Late Stage): In this final stage, residents lose the ability to respond to their environment, carry on a conversation, or control their physical movements. They require total assistance for all care, including eating and repositioning. Dysphagia (difficulty swallowing) commonly develops, putting the resident at high risk for aspiration and pneumonia. As they become bedbound, they are also at extreme risk for skin breakdown and contractures.

Behavioral Symptoms and CNA Care Interventions

Behavioral challenges in dementia are not deliberate attempts to be difficult; rather, they are a form of communication. When a resident cannot express their needs verbally due to brain damage, they communicate through behaviors like wandering, agitation, or resistance to care.

• Wandering and Elopement: Walking aimlessly can be triggered by boredom, pain, hunger, or a desire to find a familiar person or place. In Oregon, memory care units must comply with strict Department of Human Services (DHS) licensing rules to prevent elopement (exiting a facility unsupervised). Facilities use delayed-egress doors, alarmed exits, or wander-detection systems (such as WanderGuard). When a resident wanders, the CNA should walk with them, ensure they have safe, non-skid footwear, check for physical needs, and gently redirect them to a safe activity.
• Sundowning: This refers to increased confusion, anxiety, and agitation that worsens in the late afternoon and evening. It is often triggered by fatigue, changing shift patterns, and fading light. CNAs can manage sundowning by turning on lights before dusk to eliminate shadows, keeping the environment calm and quiet, and maintaining a consistent daily schedule.
• Agitation and Combativeness: Agitation can escalate to physical combativeness (hitting, kicking, scratching) when a resident feels threatened, confused, or in pain. The CNA must approach the resident slowly from the front, establish eye contact, and speak in a low, calm, reassuring voice. Never argue, scold, or force care. If the resident becomes combative, the CNA should step back to ensure their own safety, verify that the resident is not in immediate danger, and return at a later time when the resident has calmed down.
• Hallucinations and Delusions: Hallucinations are false sensory perceptions (e.g., seeing bugs on the wall), while delusions are false, fixed beliefs (e.g., believing the food is poisoned or that staff are stealing their belongings). The CNA should validate the resident's feelings without reinforcing the false perception. For example, if a resident believes their food is poisoned, the CNA should not argue; instead, validate the fear ('I understand you're worried about the food') and offer an alternative, such as a sealed package of food opened in front of them.

Validation Therapy vs. Reality Orientation

Communication techniques must be tailored to the resident's cognitive abilities and the stage of their disease:

• Reality Orientation: This technique involves reorienting the resident to person, place, time, and date using calendars, clocks, and verbal corrections (e.g., 'Today is Thursday, October 12, and you are in the nursing home'). While reality orientation is effective for residents with temporary confusion (delirium) or mild cognitive impairment, it is contraindicated in moderate-to-severe dementia. Constantly correcting a resident with advanced dementia who asks for their deceased parent will only cause intense distress, anger, and anxiety.
• Validation Therapy: Developed by Naomi Feil, this is the standard of care for moderate-to-severe dementia. It involves accepting the resident’s reality and validating the emotions behind their words rather than correcting them. If a resident is crying and asking for their mother, the CNA should explore the underlying feeling: 'You must be feeling lonely. Tell me about your mother. What did she like to cook?' This approach reduces anxiety, restores self-esteem, and preserves the resident's dignity.

Delirium: An Acute Medical Emergency

Under Oregon State Board of Nursing (OSBN) standards, a CNA must be able to differentiate between the slow, progressive decline of dementia and the sudden, acute onset of confusion known as delirium. Delirium is a rapid change in mental state that occurs over hours or days, characterized by extreme confusion, hallucinations, and fluctuating levels of consciousness.

Delirium is NOT a normal progression of dementia. It is an acute medical emergency that is often a symptom of an underlying physical condition, such as:

• Urinary Tract Infections (UTIs): A very common cause of sudden confusion in elderly residents.
• Dehydration and Electrolyte Imbalances: Leading to cognitive instability.
• Medication Interactions or Side Effects: Particularly from new prescriptions.
• Hypoxia: Low oxygen levels.
• Severe Pain or Constipation.

A CNA who observes a sudden, acute change in a resident's mental status or behavior must report it to the licensed nurse immediately. Prompt intervention is critical to identify and treat the underlying cause before permanent damage occurs.

Oregon Headmaster/TMU Skills Exam Considerations

During the hands-on clinical skills evaluation, D&S Headmaster examiners evaluate a candidate's ability to provide safe, resident-centered care. When performing skills on an actor, the candidate must demonstrate appropriate communication techniques for residents with cognitive deficits:

1. Introduction and Explanation: The candidate must introduce themselves, call the resident by their preferred name, and explain each step of the procedure in simple, clear sentences before performing it.
2. Respect and Choice: The candidate must allow the resident time to process information and respond. If the resident refuses care or becomes agitated, the candidate must stop the skill immediately, prioritize the resident's safety, and verbally report the refusal to the RN Test Observer.
3. Pacing and Safety: The candidate must work at a pace that ensures safety, keeping call lights in reach and locking brakes, while maintaining a calm, reassuring presence.