142. CCA Study Notes: Dementia Care, Safety, Communication and Dignity

The Big Picture

People living with dementia may have trouble remembering information, communicating, or understanding what is happening around them. As dementia progresses, they may need more help with everyday activities, such as eating, bathing, dressing, and staying safe.

Every person has different needs. Some can still make decisions and complete many tasks independently. Others need help with nearly all their daily care.

As a Continuing Care Assistant (CCA), your job is to provide calm, respectful support while following the client’s care plan. You help keep the client safe, encourage them to do what they can, and protect their dignity and choices.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Understanding Dementia and Individual Care Needs

Dementia is a general term for a group of illnesses that cause a gradual loss of brain functions. These changes can affect memory, learning, behaviour, communication, thinking, and social abilities.

Dementia is not one specific disease. It may be classified as a mild or major neurocognitive disorder, depending on the symptoms.

As dementia progresses, the person’s ability to manage everyday activities may change.

• Early stage: Some clients can make decisions and complete activities with support.
• Moderate stage: Clients may need increasing assistance with hygiene, dressing, toileting, communication, and other daily activities.
• Severe or advanced stage: Clients may depend on others for all their care needs.

These are general care patterns. Each person’s needs depend on the type and stage of dementia and where they receive care.

Follow the Individual Care Plan

The client’s care plan and your supervisor provide specific directions for supporting that person.

Daily care may involve:

• Safety and supervision
• Bathing, grooming, dressing, and skin care
• Toileting and incontinence care
• Food and fluids
• Exercise and activity
• Health, comfort, rest, and therapy

Some clients can remain at home longer when their surroundings are adapted to meet their needs safely.

In community care, support workers often assist clients in the early stage of dementia. These clients may still make some decisions independently. Support with their care needs can help them continue living at home.

Key fact: Dementia care must fit the individual client. One person’s abilities, preferences, and care needs may differ from another’s.

Meeting Nutrition and Fluid Needs

Supporting the Client During Meals

Clients living with dementia may have difficulty concentrating during meals. Some become distracted or cannot sit long enough to finish eating.

As dementia progresses, some clients forget how to use eating utensils. Others may experience difficulty swallowing or need help with feeding.

Disoriented clients may resist assistance or throw or spit out food.

Ways to support eating include:

• Provide a quiet, calm dining environment.
• Offer finger foods when the client has difficulty using utensils.
• Cut food into small pieces as needed.
• Provide eating utensils that are not easily broken.
• Offer smaller amounts of food more frequently when helpful.
• Consider special mealtimes that better meet the client’s needs.
• Assist with feeding when the client requires that help.

Some clients manage smaller, more frequent meals better than eating only three times daily.

Key fact: A calm environment and food the client can manage may make mealtimes easier.

Encouraging Adequate Fluids

Clients with moderate or severe dementia may not recognize when they are thirsty. This places them at risk for dehydration.

You can help by:

• Encouraging the client to drink regularly.
• Keeping water and other drinks nearby.
• Offering fluids whenever you are around the client.
• Pouring drinks for the client when needed.

Adequate fluid intake can help reduce the risk of conditions such as urinary tract infections (UTIs) and constipation.

Never restrict a client’s fluids to control urination or incontinence.

Caffeine and Behaviour

Coffee, tea, and cola drinks contain caffeine, a stimulant.

Caffeine can increase:

• Restlessness
• Disorientation
• Agitation ⓘ

Reducing caffeine intake during the day is one way to support the client’s comfort and sleep.

Supporting Toileting and Elimination

Clients with moderate or severe dementia may have difficulty recognizing where or how to use the toilet.

Some clients may:

• Urinate in unexpected places, such as garbage cans, planters, or heating vents.
• Remove incontinence products and leave them on the floor or in the toilet.
• Soil their clothing, furniture, or nearby surfaces.

These behaviours require patient, respectful care.

What the CCA Should Do

• Offer toileting assistance frequently at regular times during the day and night.
• Provide incontinence care when needed.
• Provide perineal care after urination and bowel movements.
• Keep the client’s skin free from urine and stool.
• Ask your supervisor for help if the client resists care.

Safety: Never limit fluid intake as a way to reduce toileting needs.

Supporting Hygiene, Bathing, and Skin Care

Clients with moderate or severe dementia may not understand why personal hygiene and infection prevention are important.

They may depend on the health care team for help with cleanliness, skin care, and preventing infection.

Handwashing

Assist clients with handwashing when needed, especially:

• After urinating or having a bowel movement
• After coughing, sneezing, or blowing their nose
• Before or after handling or eating food
• Whenever their hands become soiled

Good skin care helps prevent skin breakdown. Hygiene assistance also helps prevent the spread of infection.

Bathing Without Causing Fear

Bathing can be frightening for someone living with dementia. The client may not understand why another person is touching them or asking them to undress.

A client who feels threatened may become upset or resist bathing.

When helping with bathing:

• Choose a time when the client is calm.
• Follow the care plan and use the client’s preferred bathing method, such as a tub bath, shower, bed bath, or towel bath.
• Explain what you are going to do.
• Provide privacy and keep the client warm.
• Allow enough time without rushing.

Never force a client into a bathtub or shower.

Soft music during bathing or other personal care activities may help create a more relaxing environment.

Watch for Discomfort During Personal Care

A client may resist care because they are frightened or uncomfortable.

Watch for possible sources of pain, including:

• Skin lesions or damaged skin
• Rough or uncomfortable clothing
• Dental problems

Clients may pull away, shout, cry for help, hit, or kick when they do not understand what is happening.

Sudden movements can cause skin tears, so take care not to rush the client.

Provide oral hygiene as part of the client’s personal care needs.

Helping With Grooming and Dressing

Dressing can become difficult when a client cannot understand or remember the steps involved.

Clothing that is comfortable and easy to manage can make dressing less frustrating.

Choose Clothing That Is Easier to Put On

• Front-opening clothing: Often easier to put on than pullover tops.
• Velcro closures: Easier to open and close than many other fasteners.
• Comfortable clothing: Helps support the client’s physical comfort.

Buttons, zippers, snaps, and other difficult fasteners may frustrate the client.

Pullover tops can also cause fear when the clothing covers the client’s head.

Encourage Simple Choices

Offer only a small number of clothing options.

For example, let the client choose between two shirts rather than presenting a wardrobe full of choices.

When helping a client dress:

1. Lay out clothing in the order it will be worn.
2. Give the client one piece of clothing at a time.
3. Explain or show what to do.
4. Allow the client enough time to respond and participate.

Encourage the client to complete any part of dressing they can safely manage.

Remember: Supporting independence does not mean expecting the client to complete every task alone.

Keeping the Client Safe

Clients living with dementia may not recognize dangerous situations or understand why something is unsafe.

They are at risk for falls and other injuries. A quiet, predictable environment can help reduce fear and confusion.

Remove Hazards From the Environment

Safety measures include:

• Sharp and breakable objects: Keep knives, scissors, razors, glass, dishes, and tools out of reach.
• Eating utensils: Provide dishes and utensils that are not easily broken to help prevent cuts.
• Electrical hazards: Use safety plugs in outlets and keep cords and electrical equipment out of reach.
• Bathroom hazards: Remove electrical appliances such as hair dryers, curling irons, makeup mirrors, and electric shavers.
• Medications and chemicals: Keep medications and household cleaning products in locked storage. Use safety locks on cabinets containing these items.
• Personal care products: Store shampoo, lotion, deodorant, and similar products safely.
• Restricted areas: Keep doors to kitchens, utility rooms, and housekeeping closets locked.

Store other dangerous tools and equipment safely.

Safety measures should also help prevent falls, burns, choking, poisoning, and fires.

Smoking Safety

Clients who smoke require supervision.

Keep cigarettes, cigars, pipes, matches, and other smoking materials in a safe location when they are not being used.

Preventing Falls and Responding After a Fall

Clients living with dementia may not recognize hazards that increase their risk of falling.

If a client falls, they may not understand why moving afterward could be unsafe.

Never use force or hold the client down.

You may need to allow the client to move while you:

• Speak in a quiet, soothing voice.
• Remain calm.
• Continue providing reassurance until someone can assist you.

Supervision and Calm Surroundings

Other safety measures include:

• Stay within sight of the client as much as possible.
• Do not leave the client unsupervised.
• Keep hallways and rooms free from congestion.
• Prevent loud noises and avoid hurried movements.
• Keep the environment peaceful and familiar.
• Explain what you are doing, even when the surroundings appear safe.

Clients may still feel frightened in a quiet, safe environment because they do not understand what is happening.

Repeated, calm explanations can help.

Supporting Exercise, Activity, and Sleep

Why Daytime Activity Matters

Inactivity and immobility, or lack of movement, increase the risk of pneumonia and pressure injuries.

Daytime exercise and activity are important for clients living with dementia.

Activity can also help reduce wandering and sundowning.

Sundowning means that dementia-related symptoms and behaviours become more noticeable at bedtime or during darkness.

Daytime activity may also help clients sleep better.

When a Client Resists Exercise

A client may refuse activity because they do not understand what is happening.

They may feel frightened, become agitated, act aggressively, or cry for help.

Do not force a client to exercise or participate in activities.

Remain calm, follow the care plan, and ask your supervisor for assistance when needed.

Supporting Better Sleep

Dementia can affect memory and decision-making. Fatigue and changes in vision, which occur with some dementias such as Alzheimer’s disease, may also cause stress.

Ways to help the client fall asleep include:

• Follow familiar bedtime routines.
• Use night lights to help prevent accidents and confusion.
• Limit caffeine during the day.
• Discourage daytime naps.
• Encourage exercise during the day.
• Reduce noise in the client’s surroundings.

Maintain a Regular Day and Night Routine

Help the client recognize the difference between daytime and nighttime.

During the day:

• Open curtains, shades, and drapes.
• Encourage regular daytime clothing instead of sleepwear.
• Follow the client’s usual schedule for meals, bathing, exercise, and activities.

At night:

• Close curtains, shades, and drapes.
• Use a night light.
• Keep the surroundings quiet.

A familiar schedule helps the client know what to expect.

Supporting Socialization and Meaningful Activities

Clients living with dementia continue to need social contact, meaningful activities, and opportunities to feel useful.

Activities should match the client’s interests and abilities.

For example:

• Someone who enjoyed dancing may like a dancing activity.
• A client who enjoys drawing may participate in an art or painting group.
• Familiar music or movies from the client’s past may be enjoyable.

The opportunity to spend time with other people can be as important as the activity itself.

Therapy and Activity Programs

Adult day programs and long-term care facilities may offer:

• Music programs
• Art programs
• Fitness activities
• Support groups

These programs are designed around clients’ needs and cognitive abilities, meaning their abilities related to thinking and understanding.

Therapists may work with individual clients or with small or large groups.

CCA action: Encourage clients to participate in activities they enjoy and can manage. Do not force participation.

Communicating With Clients Living With Dementia

Communication often becomes more difficult as dementia progresses.

In the early stages, the client may struggle to find the correct word.

Later, the client may speak in short sentences or use only a few words. Their speech may become difficult to understand.

Good communication requires patience, simple language, and repetition.

Approach the Client Calmly

When approaching a client:

• Come toward them from the front, not from the side or behind.
• Move calmly and quietly to avoid startling them.
• Smile and use a gentle voice.
• Address the client by name.
• Introduce yourself every time you see them.
• State your name and show your name tag.

A client may not remember you even when they knew you well in the past.

Key fact: Introduce yourself at every visit rather than expecting the client to recognize you.

Use Simple Words and Instructions

When speaking with the client:

• Speak slowly and clearly.
• Use familiar, simple words.
• Give one idea, question, or instruction at a time.
• Ask questions that need simple answers.
• Allow enough time for the client to respond.
• Do not interrupt or rush the client.
• Give consistent answers and explanations.

Explain what you are going to do and why before beginning a care activity.

Break tasks into small steps when assisting the client.

Be prepared to repeat information because the client may be unable to remember new information.

Avoid presenting too many choices at once.

Use Familiar Language

Use words and expressions the client understands.

If the client usually speaks another language, try to communicate using language familiar to them. Family members can often assist with this.

Identify other people by their names instead of relying on words such as he, she, or they.

This makes it clearer who you are discussing.

Use Gestures and Other Communication Aids

Cueing means giving prompts to help a client complete a task.

Cues may include:

• Hand gestures
• Facial expressions
• Short verbal prompts

Pointing to an object may also help a client understand what you mean.

Other ways to support communication include using touch, familiar pictures, and familiar objects.

Have the client wear their glasses or hearing aid if they normally use them.

Support Orientation and Memory

Disorientation means confusion or difficulty remembering people, time, or places.

It may result from changes in the brain, disease processes, or substance-related factors.

A disoriented client may need frequent reminders about their surroundings.

Ways to help include:

• Tell the client the date and time each morning.
• Repeat the date and time as needed.
• Remind the client of their location.
• Keep large clocks and calendars where the client can see them.
• Use picture signs to identify places such as bathrooms and dining rooms, following your supervisor’s directions.
• Remind the client about holidays, birthdays, and special events.
• Keep familiar objects, pictures, and personal belongings visible.

Do not rearrange furniture or the client’s personal belongings.

Familiar surroundings can help the client feel more comfortable.

Encourage Conversation and Familiar Interests

Talk with the client about current events and plans for the day.

Keep conversations short and allow time for responses.

Other communication activities may include:

• Reading newspapers or magazines together
• Providing TV or radio programs
• Reading aloud to the client when appropriate
• Discussing familiar events
• Listening to music from the client’s past

What to Avoid During Communication

Do not:

• Criticize the client for forgetting information.
• Correct or argue with the client.
• Give several instructions at once.
• Rush answers or interrupt.
• Approach suddenly from behind.
• Assume the client understands or remembers everything you explained earlier.

Remember: Calm, consistent communication and frequent repetition are important parts of supporting a client living with dementia.

Helping Clients Who Become Frightened or Resist Care

Clients living with dementia may show responsive behaviours.

Responsive behaviours are actions, gestures, words, or other behaviours that usually occur in response to something such as illness, infection, or physical discomfort.

During care, a client may also react because they are frightened or do not understand what is happening.

They may:

• Pull away when touched.
• Shout or cry for help.
• Become restless or agitated.
• Hit or kick.
• Refuse bathing, exercise, meals, or other assistance.

These behaviours do not mean the client is deliberately trying to make care difficult.

Respond With Calm, Respectful Support

When a client becomes frightened or resists care:

• Stay calm.
• Speak in a gentle, reassuring voice.
• Explain what you are going to do.
• Use simple instructions.
• Avoid rushed movements.
• Do not force bathing or exercise.
• Ask your supervisor for help when needed.

Have equipment ready before starting a care procedure. This reduces how long the client needs to be involved in the care activity.

Key fact: The client may be reacting to fear, discomfort, or confusion rather than understanding the purpose of the care.

Recognizing Health Problems and Changes in Behaviour

Clients living with dementia may have other illnesses or injuries.

They may not recognize or communicate that something is wrong.

Possible health concerns include:

• Pain
• Fever
• Constipation
• Incontinence
• Other signs of illness or injury

A client may also show changes in behaviour instead of clearly explaining discomfort.

Changes From the Client’s Usual Behaviour

Watch for changes from what is normal for that particular person.

Examples include:

Usual Behaviour	Possible Change
Frequently moans or groans	Becomes unusually quiet or withdrawn
Friendly and outgoing	Becomes agitated or aggressive
Usually quiet and does not speak	Becomes restless or cries easily

Loss of appetite may also be a sign of pain.

Changes in behaviour can signal pain, discomfort, or delirium.

Delirium is a temporary state of confusion that can begin suddenly.

These possible causes require immediate medical investigation.

Report any change in the client’s usual behaviour to your supervisor.

Do not assume an unexpected behaviour change is simply part of dementia.

Protecting Clients From Abuse and Neglect

Clients living with dementia must be protected from abuse and neglect.

Caring for someone with challenging behaviours can be frustrating. Family caregivers and health care workers may become tired or short-tempered.

The client’s illness does not justify mistreatment.

What the CCA Must Do

• Treat the client with patience and respect.
• Protect the client from abuse and neglect.
• Report any signs of abuse to your supervisor at once.
• Speak with your supervisor if you are becoming frustrated with a client.

A change in care assignment may be needed when a worker is struggling with frustration.

Report: Signs of abuse must be reported to your supervisor immediately.

Comfort and Emotional Well-Being

Comfort is an important part of dementia care.

Ways to help a client feel physically comfortable include:

• Providing a quiet environment
• Speaking in a calm voice
• Offering soothing touch
• Using massage
• Playing gentle music
• Using aromatherapy
• Choosing comfortable clothing

A client’s physical surroundings and personal belongings can also affect their comfort.

Familiar possessions may provide security and reassurance.

Providing Compassionate and Dignified Care

Respect the Person, Not Just Their Care Needs

Clients living with dementia do not choose to forget information, become incontinent, feel angry, or show other dementia-related behaviours.

These changes are caused by the disease.

Dignity means treating the client as a person who deserves respect and consideration, regardless of their abilities.

Clients living with dementia continue to have rights under human rights codes and long-term care legislation ⓘ.

Even when a client cannot recognize or exercise those rights, they are still entitled to them.

Protect the Client From Embarrassment

A client may forget information, misplace belongings, or need help with personal care.

Do not make the client feel foolish or ashamed.

Even in later stages of dementia, clients may experience embarrassment and shame.

Ways to protect dignity include:

• Remain patient and respectful.
• Explain care activities before starting.
• Avoid criticizing the client’s mistakes.
• Do not assume the client cannot understand you.
• Provide privacy during care.
• Allow only those involved in the client’s care to be present during care procedures.

Encourage Independence

Autonomy means having the ability or right to make choices about oneself.

Clients living with dementia have the right to autonomy.

Encourage clients to remain independent for as long as safely possible.

This may mean allowing the client to:

• Choose between two clothing items.
• Participate in dressing or grooming.
• Complete manageable parts of an activity.
• Make decisions that are still within their abilities.

Do not take over a task simply because the client needs more time to complete it.

Respect Personal Preferences

Individualized care means adapting care to the individual client.

Consider the client’s:

• Personal choices and preferences
• Physical abilities and limitations
• Cognitive abilities and limitations
• Personality
• Care plan

Clients in the early stage of dementia may be able to explain their preferences.

Clients with moderate dementia may still make simple choices, such as selecting between two sweaters or deciding whether to watch television.

When the client can no longer make these decisions, a family member or substitute decision maker usually makes choices about bathing times, clothing, meals, activities, and other care.

Respect Meaningful Personal Belongings

A client may want to keep a particular blanket, pillow, sweater, or other familiar item.

The item may have special meaning or provide a sense of comfort and security.

Later, the client may not remember why the item matters or may no longer recognize it.

Do not remove the item simply because the client cannot explain its importance.

It may still provide comfort.

Recognize the Client’s Emotions

People living with Alzheimer’s disease and most other dementias continue experiencing emotions into the final stages.

A client who can no longer speak may still express feelings through behaviour or emotional reactions.

Recognizing the client’s emotions can help you understand their:

• Wishes and preferences
• Fears
• Likes and dislikes

Loss of spoken language does not mean the client has lost their feelings.

Protect Privacy and Confidentiality

Clients living with dementia have the right to privacy and confidentiality.

Respect these rights by:

• Providing privacy during personal care.
• Allowing private space for visits with others.
• Protecting the client’s personal information.
• Not sharing information about the client with others.
• Not telling other people stories about the client’s behaviour.

Only people involved in the client’s care should be present during care procedures.

Understanding the Rules About Restraints

All clients have the right to be free from restraints ⓘ.

Restraints must not be used for the convenience of health care workers.

Important rules include:

• Restraints require a physician’s order.
• They are used only when they are the best way to protect the client.
• Restraints may worsen agitation and disorientation.
• Your supervisor will tell you when restraints are to be used.

Clients who are combative or aggressive may have an increased risk of injury.

Tired family caregivers or other caregivers may be more likely to restrain or confine a client because they are struggling to manage the person’s behaviour. This does not make restraints appropriate for caregiver convenience.

Role limit: Do not independently decide to use restraints. Follow the directions provided through your supervisor.

Common Mix-Ups

Wrong Idea	Better Idea
All clients with dementia need exactly the same care.	Care depends on the individual, the type and stage of dementia, and the setting.
A client who cannot speak no longer experiences emotions.	Clients may continue experiencing emotions even when they lose spoken language.
A client who resists care is deliberately being difficult.	Resistance may result from fear, confusion, illness, or discomfort.
A sudden behaviour change must be normal dementia progression.	Changes may signal pain, discomfort, or delirium and require reporting.
Helping a client means doing every task for them.	Encourage independence for as long as safely possible.
Restraints can be used when care becomes difficult.	Restraints require a physician’s order and must be used only when best for client protection.