Unit 15

Communicating with People Living with Memory Loss

Workplace English for Nursing Assistants

Meet Olga

Watch the video about Olga. Watch what happens.

Talk about it

1. Can Olga recover from this disease?
2. What stage of dementia do you think Olga is in? Why?
3. What common symptoms of dementia is Olga showing in this scenario?

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Warning signs include memory loss of recent events, poor decisions, mood swings, personality changes, trouble following directions or conversation, and trouble with everyday tasks like cooking or bathing. A provider diagnoses dementia after ruling out other causes, using signs and symptoms, lab tests, and a physical and mental exam. After diagnosis, clients live about 4–8 years on average (some up to 20).

Dementia is a general term for serious problems with memory and thinking. Alzheimer’s disease is one cause of dementia.

The Three Stages of Alzheimer's

Stages of Alzheimer's disease

Stage	Also called	What you see
Mild	early stage	small decline; trouble with names/words, planning; short-term memory affected first
Moderate	middle stage	needs more care; upset/angry, confused words, wandering, incontinence, forgets family
Severe	late stage	very hard to communicate; may not respond; needs around-the-clock care

Common Behaviors as Dementia Advances

A client may show a few or many of these, and they grow stronger over time:

Common behaviors as dementia advances

Behavior	What it looks like
Memory deficit	short-term memory first; later may not know family or their own reflection
Impaired communication	trouble finding words → cannot converse → may repeat one word or go silent
Loss of ADLs	forgets how to bathe, dress, eat; becomes fully dependent
Mood/behavior changes	a once-kind person may become sullen or mean; sudden crying or screaming
Restlessness / agitation	pacing, rummaging drawers, repeating questions, trying to leave
Aggression	biting, hitting, pinching, scratching, spitting
Sundowning	more agitation late in the day and evening
Sexual inappropriateness	public masturbation, advances, exposing themselves
Hallucinations / delusions	seeing or believing things that are not real; raises anxiety

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Clients may have other conditions with overlapping or unique challenges. Always give holistic (person-centered) care and follow the care plan or ISP for each client's specific instructions.

Other cognitive and mental health disabilities

Condition	What it means
Intellectual disability	trouble with thinking and learning; lower IQ; may affect ADLs. Meet the client at their developmental level.
Mental illness	a concern with mood, behavior, or thinking (depression, anxiety, addictions, etc.). Becomes an illness when frequent and disrupts daily life. Managed with medication and therapy.

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The Unmet-Needs Checklist — Your Most Important Tool

A client who cannot express themselves may act out because of an unmet need (this includes stroke/aphasia, developmental disabilities, severe mental illness, and brain injury — not just dementia). When behavior increases, run through your checklist:

Therapeutic Interventions

Therapy	What it does	When to use it
Reminiscence	recall memories of the past to calm and engage (long-term memory lasts longer)	talk about their past, not breakfast
Activity	gives purpose, boosts self-esteem	match the client's developmental level; involve family
Sensory stimulation	improves social interaction, lowers anxiety	when dementia is too advanced for group activities (hand massage, aromatherapy, music)
Validation	acknowledge the client's reality, then resolve it	for hallucinations and delusions

Maintaining Function — Break Tasks into Small Steps

Always promote independence with ADLs. A client may not remember to brush their teeth, but will do it with prompts. Break the task down: "Put toothpaste on the brush" → "Now brush" → "Now rinse." You can finish the job for them if needed. This protects self-esteem and physical function.

Approaching Specific Behaviors

The best general approach: stay positive, be kind, be creative, and modify your OWN behavior to meet the client's needs. Use a smiling face, slow pace, and quiet voice. Talk at eye level.

Mealtimes are where these behaviors show up most often.

Mealtime behaviors and what to do

If the client…	It may mean	Try this
won't open their mouth / poor appetite	they do not recognize the food, are not hungry yet, or something in the mouth hurts	Name the food and show it. Touch the spoon to the lower lip. Offer a favorite food or a finger food. Check the mouth for sores or loose teeth and tell the nurse.
won't open wide / bites the spoon	the mouth is closing on reflex, or the spoon is coming too fast or from above	Come from below, at eye level, and go slowly. Use a smaller, softer spoon. Never pull against a bite — wait for the jaw to relax, then take the spoon out.
pockets (packs) food in cheeks	they have forgotten how to chew and swallow — this is a choking risk	Stop offering more. Say “chew” and “swallow” as single-word prompts. Check the mouth is empty before the next bite. Keep them sitting up for 30 minutes and report it.
is aggressive at meals	the dining room is too loud, too bright, or too crowded — or something on the checklist is unmet	Run the Unmet-Needs Checklist first. Move them somewhere quieter, cut down the noise, and put one item in front of them at a time. Do not argue or hold them.

Reporting a Behavior — Say What You Saw

Everything above ends the same way: you tell the nurse. How you say it decides whether the nurse can act on it. Report the behavior you saw, not the reason you think is behind it and not a word that judges the client.

Judgments vs. what you saw

✘ Judging / guessing	✔ What you saw
“She was being difficult at lunch.”	“She pushed the tray away twice and ate about a quarter.”
“He’s aggressive.”	“He hit my arm when I reached for his shirt at 7:10.”
“She’s confused today.”	“She asked me three times where her mother was, between two and three o’clock.”
“He was attention-seeking.”	“He called out for me six times in an hour, and settled when I sat with him.”

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Dialogue Practice

Read these dialogues out loud with a partner.

Late afternoon. Mrs. Alvarez has moderate dementia and is sundowning. She points at the corner, frightened.

Mrs. Alvarez: There are spiders! All over the wall! Get them off!

You: Oh, no! That sounds frightening. I'm listening — show me where.

The healthcare worker uses validation — does not argue, enters her reality.

You: I see them. I'll get rid of them right now.

The healthcare worker "removes" the spiders with a towel, then returns.

You: There. They're all gone. You're safe now.

Mrs. Alvarez: ...They're gone?

You: Yes. All gone. Hey, let's try this — come sit with me and look at these flowers.

Mrs. Alvarez: The flowers are pretty.

You: Go on — tell me which one you like best.

Mr. Bianchi is incontinent and needs changing, but he refuses. The healthcare worker avoids hot-button words like "toilet."

You: Mr. Bianchi, how about letting me help you freshen up?

Mr. Bianchi: No. Go away. Leave me alone.

You: Uh-huh. That's all right. No rush.

The healthcare worker waits, then re-approaches with different words and a choice.

You: Mr. Bianchi, would you like to wash up now, or after we take a little walk?

Mr. Bianchi: ...A walk. Then I'll wash.

You: That would work. Let's walk first. Let me give you a hand up.

Mr. Bianchi: All right, all right.

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Roleplays

Work with a partner.

Situation

Mr. Tran, 80, has moderate dementia. It is early evening (sundowning). He is frightened and shouting that there is a dog under his bed, trying to bite him. You must validate his reality, resolve it, and redirect him to something calming.

Your Goals:

1. Use verbal cues to show you are listening ("Oh, no!" / "I'm listening." / "Go on.")
2. Validate — do NOT argue that the dog is not real
3. "Remove" the dog, then return and say it is gone
4. Distract / redirect into a calm activity ("Hey, let's try this..." / "Look at me.")

Situation

Mrs. Kovač needs her incontinence garment changed, but she says "No!" and swats your hand. You must offer help kindly, avoid hot-button words, wait, and re-approach with different words and a choice.

Your Goals:

1. Offer help without pushing ("How about letting me help you?" / "Let me give you a hand.")
2. Acknowledge the refusal calmly with a verbal cue ("Uh-huh." / "That's all right.")
3. Re-approach with DIFFERENT words (avoid "toilet"/"diaper")
4. Offer a two-part choice ("Would you like ___ or ___?")

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Cumulative Review

Matching Definitions

Write the letter of the correct definition on the line next to each term.

Match the Behavior to the Best Response

For each client behavior, write the letter of the best nursing-assistant response.

Fill in the Blanks

Use a term from the word bank. Each term is used once.

1. Dementia is a general term for the loss of and brain function.
2. Sundowning is the increase in and agitation later in the day and into the evening.
3. Alzheimer's can be divided into three stages.
4. Certain , such as wandering and impaired communication, are common in people with dementia.
5. A(n) means the client has problems with thinking and learning.
6. Clients may show difficult behaviors because of a(n) need.
7. Clients with dementia may become with leaving a facility to get home.
8. inappropriateness may occur in the later stages of dementia.
9. Reminiscence therapy helps the client recall distant of their life.
10. Difficult behaviors can often be by using a checklist of triggers and unmet needs.
11. occurs when there is a concern with mood, behavior, and/or thinking.

Multiple Choice

Circle the best answer.

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Back to Olga

Situation

Olga is a 68-year-old client with Alzheimer's disease. Olga's partner Harry can no longer care for Olga at home — Harry cannot rest because Olga is up all night wandering. Olga is moving into the nursing home today. When you enter, Olga seems anxious and is rummaging through the dresser. When you try to talk, Olga does not look at you or answer. When you approach, Olga screams and pushes you away. Harry is upset and wonders if the nursing home was the right decision.

1. Can Olga recover from this disease?

   ______________________________________________________________

2. What stage of dementia do you think Olga is in? Why?

   ______________________________________________________________

3. What common symptoms of dementia is Olga showing in this scenario?

   ______________________________________________________________

4. What unmet needs might be making Olga lash out?

   ______________________________________________________________

5. What therapeutic interventions might help Olga?

   ______________________________________________________________

6. What should your demeanor be when approaching Olga?

   ______________________________________________________________

7. How can you keep Olga safe when they wake up at night?

   ______________________________________________________________

8. What can help keep Olga safe from wandering in the facility?

   ______________________________________________________________

9. Why do you think Harry is so upset and doubts the decision?

   ______________________________________________________________

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Instructor Answer Key

Unit 15 — Communicating with People Living with Memory Loss

This unit develops practical communication strategies for supporting people with dementia and other cognitive conditions. Learners study warning signs and stages of Alzheimer’s disease, behavior as communication, unmet needs, therapeutic interventions, maintaining function, wandering, hallucinations, refusal, and caregiver strain. A case study about Olga connects anxiety, aggression, nighttime wandering, relocation, and family guilt to person-centered care. Through illustrated readings, knowledge checks, dialogues, and role-plays, learners practice approaching calmly, validating feelings without arguing, redirecting attention, offering simple choices, identifying unmet needs, keeping clients safe, supporting family members, and reporting behavior objectively by stating what happened, when it happened, and what they did.

Practice — Say What You Saw, and Language: Reporting a Behavior Objectively

Practice — Say What You Saw (sample): Answers vary. Score three things in each: an observed behavior, a time, and no guess about why. (1) “At about nine he told me twice to get out and turned his back when I came in.” (2) “She ate about a quarter of her breakfast and left lunch untouched — the third day now.” (3) “At two o’clock he was pulling at the exit door and asking for his car keys.” (4) “She sat without speaking for most of the morning and did not go to the activity she usually joins.”

Language Part 1: the judgements are (1) being stubborn → e.g. “She said no to her cardigan three times and pulled her arm back.” (2) manipulative → e.g. “He called out eight times between two and four, mostly during the med round.” (3) gone downhill → name what changed: “This week she has needed help with dressing, and she did not know my name on Tuesday.” Part 2: answers vary — score saw + when + what you did, in the past tense, with no cause given. Part 3: no written answer; the partner’s list should contain no why.

R5 — Case Study — Sample Answers

1. No. Alzheimer's is progressive and has no cure; Olga will not recover.
2. Likely the moderate (middle) stage — Olga wanders at night, does not respond to conversation, and needs full-time care, but is still mobile and reactive.
3. Wandering, agitation/restlessness (rummaging), impaired communication (no eye contact, no answer), and aggression (screaming, pushing).
4. Possible unmet needs: fear/anxiety from a strange new place, needing to toilet, hunger or thirst, pain, or overstimulation.
5. Reminiscence therapy, a calming activity, sensory stimulation (music, hand massage), validation, and a consistent routine.
6. Calm and positive: smiling face, slow pace, quiet voice, at eye level; approach from the side, not suddenly.
7. Use a nightlight, an alarm bracelet or bed alarm, and never leave Olga unattended when awake at night; check for unmet needs.
8. An alarm bracelet, a locked unit with a restricted code, and a gated courtyard; redirect with distraction.
9. Harry is exhausted (caregiver strain) and feels guilt — as if moving Olga means he failed her. Reassure him it was a safe, loving choice and involve him in her care.

Suggested drill — strike the judgement

Read out reports one at a time — “she was being difficult,” “he’s manipulative,” “she’s gone downhill.” The class calls out the judging word, then one learner rebuilds the sentence with what you would have seen and a time. Go round until nobody reaches for a judging word first.

The tell is speed: a learner who has to think for ten seconds is still translating from judgement to observation.