APPLICATION OF THE NURSING
This section focuses on caring for clients with progressive
dementia, which is the most common type. The nurse can use these guidelines as
indicated for clients with dementia that is not progressive.
The assessment process may seem confusing and compli-cated to
clients with dementia. They may not know or may forget the purpose of the
interview. The nurse provides simple explanations as often as clients need
them, such as “I’m asking these questions so the staff can see how your health
is.” Clients may become confused or tire easily, so frequent breaks in the
interview may be needed. It helps to ask simple rather than compound questions
and to allow clients ample time to answer.
A mental status examination can provide information about the
client’s cognitive abilities such as memory, con-centration, and abstract
information processing. Typically, the client is asked to interpret the meaning
of a proverb, perform subtraction of figures without paper and pencil, recall
the names of objects, make a complete sentence, and copy two intersecting
pentagons. Although this does not replace a thorough assessment, it gives a
cursory evalua-tion of the client’s cognitive abilities. It is important to
remember that people with severe depression or psychosis may also be unable to
perform some of these cognitive tasks correctly.
Considering the impairment of recent memory, clients may be unable
to provide an accurate and thorough his-tory of the onset of problems.
Interviews with family, friends, or caregivers may be necessary to obtain data.
Dementia progressively impairs the ability to carry on meaningful
conversation. Clients display aphasia when they cannot name familiar objects or
people. Conversation becomes repetitive because they often perseverate on one
idea. Eventually, speech may become slurred, followed by a total loss of
The initial finding with regard to motor behavior is the loss of
ability to perform familiar tasks (apraxia)
such as dressing or combing one’s hair, although actual motor abil-ities are
intact. Clients cannot imitate the task when others demonstrate it for them. In
the severe stage, clients may experience a gait disturbance that makes
unassisted ambu-lation unsafe, if not impossible.
Some clients with dementia show uninhibited behavior, including
making inappropriate jokes, neglecting personal hygiene, showing undue
familiarity with strangers, or dis-regarding social conventions for acceptable
behavior. This can include the use of profanity or making disparaging remarks
about others when clients have never displayed these behaviors before.
Initially, clients with dementia experience anxiety and fear over
the beginning losses of memory and cognitive func-tions. Nevertheless, they may
not express these feelings to anyone. Mood becomes more labile over time and
may shift rapidly and drastically for no apparent reason. Emo-tional outbursts
are common and usually pass quickly. Cli-ents may display anger and hostility,
sometimes toward other people. They begin to demonstrate catastrophic emotional
reactions in response to environmental changes that clients may not perceive or
understand accurately or when they cannot respond adaptively. These
catastrophic reactions may include verbal or physical aggression, wan-dering at
night, agitation, or other behaviors that seem to indicate a loss of personal
Clients may display a pattern of withdrawal from the world they no
longer understand. They are lethargic, look apathetic, and pay little attention
to the environment or the people in it. They appear to lose all emotional
affect and seem dazed and listless.
Initially, the ability to think abstractly is impaired, resulting
in loss of the ability to plan, sequence, monitor, initiate, or stop complex
behavior (APA, 2000). The client loses the ability to solve problems or to take
action in new situations because he or she cannot think about what to do. The
abil-ity to generalize knowledge from one situation to another is lost because
the client cannot recognize similarities or differences in situations. These
problems with cognition make it impossible for the employed client to continue
working. The client’s ability to perform tasks such as plan-ning activities,
budgeting, or planning meals is lost.
As the dementia progresses, delusions of persecution are common.
The client may accuse others of stealing objects he or she has lost or may
believe he or she is being cheated or pursued.
Clients lose intellectual function, which eventually involves the
complete loss of their abilities. Memory defi-cits are the initial and
essential feature of dementia. Dementia first affects recent and immediate
memory and then eventually impairs the ability to recognize close fam-ily
members and even oneself. In mild and moderate dementia, clients may make up
answers to fill in memory gaps (confabulation).
Agnosia is another hallmark of dementia. Clients lose visual spatial relations,
which is often evidenced by deterioration of the ability to write or draw
Attention span and ability to concentrate are increas-ingly
impaired until clients lose the ability to do either.
Hallucinations are a frequent problem. Visual halluci-nations are
most common and generally unpleasant. Cli-ents are likely to believe the
hallucination is reality.
Clients with dementia have poor judgment in light of the cognitive
impairment. They underestimate risks and unre-alistically appraise their
abilities, which result in a high risk for injury. Clients cannot evaluate
situations for risks or danger. For example, they may wander outside in the
winter wearing only thin nightclothes and not consider this to be a risk.
Insight is limited. Initially, the client may be aware of problems
with memory and cognition and may worry that he or she is “losing my mind.”
Quite quickly, these con-cerns about the ability to function diminish, and
clients have little or no awareness of the more serious deficits that have
developed. In this context, clients may accuse others of stealing possessions
that the clients themselves have actually lost or forgotten.
Initially, clients may be angry or frustrated with them-selves for
losing objects or forgetting important things. Some clients express sadness at
their bodies for getting old and at the loss of functioning. Soon, though,
clients lose that awareness of self, which gradually deteriorates until they
can look in a mirror and fail to recognize their own reflections.
Dementia profoundly affects the client’s roles and relation-ships.
If the client is still employed, work performance suf-fers, even in the mild
stage of dementia, to the point that work is no longer possible given the
memory and cogni-tive deficits. Roles as spouse, partner, or parent deteriorate
as clients lose the ability to perform even routine tasks or recognize familiar
people. Eventually, clients cannot meet even the most basic needs.
Inability to participate in meaningful conversation or social
events severely limits relationships. Clients quickly become confined to the
house or apartment because they are unable to venture outside unassisted. Close
family members often begin to assume caregiver roles; this can change
previously established relationships. Grown chil-dren of clients with dementia
experience role reversal; that is, they care for parents who once cared for
them. Spouses or partners may feel as if they have lost the previous
rela-tionship and now are in the role of custodian.
Clients with dementia often experience disturbed sleep– wake cycles; they nap during the day and wander at night. Some clients ignore internal cues such as hunger or thirst; others have little difficulty with eating and drinking until dementia is severe. Clients may experience bladder and even bowel incontinence or have difficulty cleaning them-selves after elimination. They frequently neglect bathing and grooming. Eventually, clients are likely to require complete care from someone else to meet these basic physiologic needs.
Many nursing diagnoses can be appropriate because the effects of
dementia on clients are profound; the disease touches virtually every part of
their lives. Commonly used nursing diagnoses include the following:
Risk for Injury
Disturbed Sleep Pattern
Risk for Deficient Fluid Volume
Risk for Imbalanced Nutrition: Less Than Body Requirements
Impaired Environmental Interpretation Syndrome
Impaired Social Interaction
Impaired Verbal Communication
Ineffective Role Performance
In addition, the nursing diagnoses of Disturbed Thought Processes
and Disturbed Sensory Perception would be appropriate for a client with
psychotic symptoms. Multi-ple nursing diagnoses related to physiologic status
also may be indicated based on the nurse’s assessment, such as alterations in
nutrition, hydration, elimination, physical mobility, and activity tolerance.
Treatment outcomes for clients with progressive demen-tia do not
involve regaining or maintaining abilities to function. In fact, the nurse must
reassess overall health status and revise treatment outcomes periodically as
the client’s condition changes. Outcomes and nursing care that focus on the
client’s medical condition or deficits are common. Current literature proposes
a focus on psychosocial care that maximizes the client’s strengths and
abilities for as long as possible. Psychosocial care involves maintaining the
client’s independence as long as possible, validating the client’s feelings,
keeping the client involved in the environment, and dealing with behavioral disruptions
respectfully (McCabe, 2008; Ouldred & Bryant, 2008; Yuhas et al., 2006).
Treatment outcomes for a client with dementia may include the following:
The client will be free of injury.
The client will maintain an adequate balance of activity and rest,
nutrition, hydration, and elimination.
The client will function as independently as possible given his or
The client will feel respected and supported.
The client will remain involved in his or her surroundings.
The client will interact with others in the environment.
Psychosocial models for care of clients with dementia are based on
the approach that each client is a unique person and remains so, even as the
disease’s progression blocks the client’s ability to demonstrate those unique
character-istics. Interventions are rooted in the belief that clients with
dementia have personal strengths. They focus on demonstrating caring, keeping
clients involved by relating to the environment and other people, and
validating feel-ings and dignity of clients by being responsive to them,
offering choices, and reframing
(offering alternative points of view to explain events). This is in contrast to
medical models of care that focus on progressive loss of function and identity
Nurses can use the following interventions in any set-ting for
clients with dementia. Education for family members caring for clients at home
and for professional caregivers in residential or skilled facilities is an
essen-tial component of providing safe and supportive care. The discussion
provides examples that apply to various settings.
Safety considerations involve protecting against injury, meeting
physiologic needs, and managing risks posed by the environment, including
internal stimuli such as delu-sions and hallucinations. Clients cannot
accurately appraise the environment and their abilities; therefore, they do not
exercise normal caution in daily life. For example, the client living at home
may forget food cook-ing on the stove; the client living in a residential care
setting may leave for a walk in cold weather without a coat and gloves.
Assistance or supervision that is as unobtru-sive as possible protects clients
from injury while preserv-ing their dignity.
A family member might say,
“I’ll sit in the kitchen and talk to you while you make lunch” (suggesting collaboration) rather than “You can’t cook by yourself because you might set the house on fire.”
In this way, the nurse or caregiver supports the client’s desire
and ability to engage in certain tasks while provid-ing protection from injury.
Clients with dementia may believe that their physical safety is
jeopardized; they may feel threatened or suspi-cious and paranoid. These
feelings can lead to agitated or erratic behavior that compromises safety.
Avoiding direct confrontation of the client’s fears is important. Clients with
dementia may struggle with fears and suspicion through-out their illness.
Triggers of suspicion include strangers, changes in the daily routine, or
impaired memory. The nurse must discover and address these environmental
trig-gers rather than confront the paranoid ideas.
For example, a client reports that his belongings have been stolen.
The nurse might say,
“Let’s go look
in your room and see what’s there.”
and help the client to locate the misplaced or hidden items
(suggesting collaboration). If the client is in a room with other people and
says, “They’re here to take me away!” the nurse might say,
are here visiting with someone else. Let’s go for a walk and let them visit.” (presenting
The nurse then can take the client to a quieter and less
stimulating place, which moves the client away from the environmental trigger.
Clients require assistance to meet basic physiologic needs. The
nurse monitors food and fluid intake to ensure ade-quacy. Clients may eat
poorly because of limited appetite or distraction at mealtimes. The nurse
addresses this problem by providing foods clients like, sitting with cli-ents
at meals to provide cues to continue eating, having nutritious snacks available
whenever clients are hungry, and minimizing noise and undue distraction at
mealtimes. Clients who have difficulty manipulating utensils may be unable to
cut meat or other foods into bite-sized pieces. The food should be cut up when
it is prepared, not in front of clients, to deflect attention from their
inability to do so. Food that can be eaten without utensils, or finger foods
such as sandwiches and fresh fruit, may be best. In contrast, clients may eat
too much, even ingesting inedi-ble items. Providing low-calorie snacks such as
carrot and celery sticks can satisfy the desire to chew and eat without
unnecessary weight gain. Enteral nutrition often becomes necessary when
dementia is most severe, although not all families choose to use tube feedings.
Adequate intake of fluids and food is also necessary for proper
elimination. Clients may fail to respond to cues indicating constipation, so
the nurse or caregiver monitors the client’s bowel elimination patterns and
intervenes with increased fluids and fiber or prompts as needed. Urinary
elimination can become a problem if clients do not respond to the urge to void
or are incontinent. Reminders to uri-nate may be helpful when clients are still
continent but not initiating use of the bathroom. Sanitary pads can address
dribbling or stress incontinence; adult diapers, rather than indwelling catheters,
are indicated for incontinence. The nurse checks disposable pads and diapers
frequently and changes soiled items promptly to avoid infection, skin
irri-tation, and unpleasant odors. It is also important to pro-vide good
hygiene to minimize these risks.
Balance between rest and activity is an essential compo-nent of the
daily routine. Mild physical activity such as walking promotes physical health
but is not a cognitive challenge. Daily physical activity also helps clients to
sleep at night. The nurse provides rest periods so clients can conserve and
regain energy, but extensive daytime napping may interfere with nighttime
sleep. The nurse encourages clients to engage in physical activity because they
may not initiate such activities independently; many clients tend to become
sedentary as cognitive abilities diminish. Clients often are quite willing to
participate in physical activities but cannot initiate, plan, or carry out
those activities with-out assistance.
A structured environment and established routines can reassure
clients with dementia. Familiar surroundings and routines help to eliminate
some confusion and frustration from memory loss. Providing routines and
structure, how-ever, does not mean forcing clients to conform to the struc-ture
of the setting or routines that other people determine. Rather than imposing
new structure, the nurse encourages clients to follow their usual routines and
habits of bathing and dressing (Yuhas et al., 2006). For example, it is
impor-tant to know whether a client prefers a tub bath or shower and washes at
night or in the morning and to include those preferences in the client’s care.
Research has shown that attempting to change the dressing behavior of clients
may result in physical aggression as clients make ineffective attempts to
resist unwanted changes. Monitoring response to daily routines and making
needed adjustments are important aspects of care.
The nurse needs to monitor and manage the client’s tol-erance of
stimulation. Generally, clients can tolerate less stimulation when they are
fatigued, hungry, or stressed.
The therapeutic relationship between client and nurse involves
“empathic caring,” which includes being kind, respectful, calm, and reassuring
and paying attention to the client. Nurses use these same qualities with many
dif-ferent clients in various settings. In most situations, clients give
positive feedback to the nurse or caregiver, but clients with dementia often
seem to ignore the nurse’s efforts and may even respond with negative behavior
such as anger or suspicion. This makes it more difficult for the nurse or
caregiver to sustain caring behavior. Nevertheless, nurses and caregivers must
maintain all the qualities of the thera-peutic relationship even when clients
do not seem to respond.
Because of their disorientation and memory loss, clients with
dementia often become anxious and require much patience and reassurance. The
nurse can convey reassur-ance by approaching the client in a calm, supportive
man-ner, as if nurse and client are a team—a “we can do it together” approach.
The nurse reassures the client that he or she knows what is happening and can
take care of things when the client is confused and cannot do so. For exam-ple,
if the client is confused about getting dressed, the nurse might say,
“I’ll be glad to help you with that shirt. I’ll hold it for you while you put your arms in the sleeves.” (offering self/suggesting collaboration)
Supportive touch is effective with many
clients. Touch can provide
reassurance and convey caring when words may not be understood. Holding the
hand of the client who is tearful and sad and tucking the client into bed at
night are examples of ways to use supportive touch. As with any use of touch,
the nurse must evaluate each cli-ent’s response. Clients who respond positively
will smile or move closer toward the nurse. Those who are threat-ened by
physical touch will look frightened or pull away from the nurse, especially if
the touch is sudden or unex-pected or if the client misperceives the nurse’s
In a psychosocial model of dementia care, the nurse or caregiver
plans activities that reinforce the client’s identity and keep him or her
engaged and involved in the business of living (Yuhas et al., 2006). The nurse
or caregiver tailors these activities to the client’s interests and abilities:
They should not be routine group activities that “everyone is supposed to do.”
For example, a client with an interest in history may enjoy documentary programs
on television; a client who likes music may enjoy singing. Clients often need
the involvement of another person to sustain atten-tion in the activity and to
enjoy it more fully. Those who have long periods without anything to engage
their inter-est are more likely to become restless and agitated. Clients
engaged in activities are more likely to stay calm. A wide variety of
activities have proven beneficial for clients with dementia. Music, dancing,
pet- or animal-assisted therapy, aromatherapy, and multisensory stimulation are
examples of activities that can be explored to maximize the client’s
involvement with the environment and enhance the qual-ity of his or her life
(Milev, 2008; Ouldred & Bryant, 2008; Raglio et al., 2008).
Reminiscence therapy (thinking about or relating
per-sonally significant past experiences) is an effective inter-vention for
clients with dementia. Rather than lamenting that the client is “living in the
past,” this therapy encour-ages family and caregivers also to reminisce with
the cli-ent. Reminiscing uses the client’s remote memory, which is not affected
as severely or quickly as recent or immediate memory (McCabe, 2008). Photo
albums may be useful in stimulating remote memory, and they provide a focus on
the client’s past. Sometimes clients like to reminisce about local or national
events and talk about their roles or what they were doing at the time. In
addition to keeping clients involved in the business of living, reminiscence
also can build self-esteem as clients discuss accomplishments. Engaging in
active listening, asking questions, and provid-ing cues to continue promote
successful use of this tech-nique. Reminiscence therapy can also be effective
with small groups of clients as they collectively remember their early life
activities (Wang, 2007).
Clients have increasing problems interacting with oth-ers as
dementia progresses. Initially, clients retain verbal language skills, but
other people may find them difficult to understand as words are lost or content
becomes vague. The nurse must listen carefully to the client and try to
determine the meaning behind what is being said. The nurse might say,
“Are you trying to say you want to use the bath-room?” or “Did I get that right, you are hun-gry?” (seeking clarification)
It is also important not to interrupt clients or to finish their
thoughts. If a client becomes frustrated when the nurse cannot understand his
or her meaning, the nurse might say,
“Can you show me what you mean or where you want to go?” (assisting to take action)
When verbal language becomes less coherent, the nurse should remain
alert to the client’s nonverbal behavior.
When nurses or caregivers consistently work with a par-ticular
client, they develop the ability to determine the cli-ent’s meaning through
nonverbal behavior. For example, if the client becomes restless, it may
indicate that he or she is hungry if it is close to mealtime or tired if it is
late in the evening. Sometimes it is impossible to determine exactly what the
client is trying to convey, but the nurse can still be responsive. For example,
a client is pacing and looks upset but cannot indicate what is bothering her.
The nurse says,
“You look worried. I don’t know what’s wrong, but let’s go for a walk.” (making an observation/ offering self)
Interacting with clients with dementia often means deal-ing with
thoughts and feelings that are not based in reality but arise from the clients’
suspicion or chronic confusion. Rather than attempting to explain reality or
allay suspicion or anger, it is often helpful to use the techniques of
distrac-tion, time away, or going along to reassure the client.
Distraction involves shifting the
client’s attention and energy to a
more neutral topic. For example, the client may display a catastrophic reaction
to the current situa-tion, such as jumping up from dinner and saying, “My food
tastes like poison!” The nurse might intervene with distraction by saying,
“Can you come
to the kitchen with me and find something you’d like to eat?” or “You can leave
that food. Can you come and help me find a good
program on television?”
Clients usually calm down when the nurse directs their attention
away from the triggering situation.
Time away involves leaving clients for
a short period and then returning to
them to re-engage in interaction. For example, the client may get angry and
yell at the nurse for no discernible reason. The nurse can leave the client for
about 5 or 10 minutes and then return without referring to the previous outburst.
The client may have little or no memory of the incident and may be pleased to
see the nurse on his or her return.
Going along means providing emotional
reassurance to clients without
correcting their misperception or delusion. The nurse does not engage in
delusional ideas or reinforce them, but he or she does not deny or confront
their exis-tence. For example, a client is fretful, repeatedly saying, “I’m so
worried about the children. I hope they’re okay,” and speaking as though his
adult children were small and needed protection. The nurse could reassure the
client by saying,
need to worry; the children are just fine” (going along),
which is likely to calm the client. The nurse has responded
effectively to the client’s worry without addressing the reality of the
client’s concern. Going along is a specific intervention for clients with
dementia and should not be used with those experiencing delusions whose
conditions are expected to improve.
The nurse can use reframing techniques to offer clients different
points of view or explanations for situations or events. Because of their
perceptual difficulties and confu-sion, clients frequently interpret
environmental stimuli as threatening. Loud noises often frighten and agitate
them. For example, one client may interpret another’s yelling as a direct
personal threat. The nurse can provide an alterna-tive explanation such as
“That lady has
many family problems, and she yells sometimes because she’s frustrated.” (reframing)
Alternative explanations often reassure clients with demen-tia and
help them become less frightened and agitated.
Treatment outcomes change constantly as the disease pro-gresses.
For example, in the early stage of dementia, main-taining independence may mean
that the client dresses with minimal assistance. Later, the same client may
keep some independence by selecting what foods to eat. In the late stage, the
client may maintain independence by wear-ing his or her own clothing rather
than an institutional nightgown or pajamas.
The nurse must assess clients for changes as they occur and revise
outcomes and interventions as needed. When a client is cared for at home, this
includes providing ongo-ing education to family members and caregivers while
supporting them as the client’s condition worsens. See the sections that follow
on the role of the caregiver and com-munity-based care.