Plan care for various stages of dementia

The patient’s abilities keep reducing as dementia gets worse. Care has to be continually adjusted accordingly.

What caregivers can do:  Understand the stages of dementia and how they will impact the help the patient needs. Plan for the changes in the patient’s ability and the support required. Consider suitable home adjustments. Learn the required caregiving skills. The caregiving workload will increase over time, so consider available support systems. Make required adjustments in other responsibilities.

Care approaches as dementia progresses

Dementia typically goes on for many years. The initial symptoms are mild and difficult to see, but the damage keeps increasing with time. The type and amount of help have to be adjusted accordingly. Families must understand how care will change over the years, so that they can plan for it.

The progress of dementia is usually discussed under three broad stages. These are: early stage dementia, mid stage dementia, and late or advanced stage dementia. These stages give an overall understanding that can be used to plan care. Dr. Jane Tolman (University of Tasmania) suggests the care goals for these stages as under:

  • First stage: Work to ensure dignity and autonomy. The care goal is to maintain the independence and enjoyment of the person with dementia.
  • Second stage: Work to ensure safety. This is because the patient is more at risk because of decline in function and insight, and more changed and risky behavior.
  • Third stage: Work to ensure comfort, dignity, and quality of life. This includes reassessing medications and treatment approaches.

Different families have different views on what they consider dignity, autonomy, safety, care, quality of life, and so on. Also, the “stages” of dementia are just a simple way to understand how dementia gets worse. These are not fixed and rigid divisions. Though stages help get an overall understanding, every patient’s symptoms are different and they progress differently. Families have to use their own observations and judgment when deciding what they need to do.

(You can read a discussion on the stages at Stages of dementia.)

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Care for early stage dementia

Planning for early stage dementia can be done both by the patient and the family supporting the patient. At this stage, patients are able to think about their situation, understand dementia, tell others what they want, and plan for their future. Family members can help the patients live meaningful, dignified, and independent lives. They can also plan for later stages when they will have to give more support.

early dementia patients can plan finances for later stages

Patients can adjust to dementia. They can find ways to continue living in safe and meaningful ways. Early stage symptoms are mild. Persons with dementia can still function independently and do most of their activities with little or no help. But they may become more forgetful and begin to lose their ability to plan and to make decisions. The may have problems with language or have mood and personality changes. Fortunately, medicines can help some patients by reducing the impact of the memory loss.

Once patients understand that dementia is causing them their problems, they can learn more about dementia. They can adjust emotionally to their dementia and how it will affect their future. They can think how to do what they want to do while remaining safe. This requires some adjustments in their activities and what they expect from themselves. They may need to ask for some help.

Patients may decide to change how they spend their time and energy. Some may pick up activities they had wanted to do later in life. Some slow down and spend more time on their hobbies or with their families. Some continue their life like they were doing before. Some even get involved in spreading dementia awareness. What is important is, they can choose their direction based on an understanding of dementia and how it may impact them.

Patients can make changes for a better future. Dementia will lead to reduced abilities and increased dependence. This affects what patients can do in future. In this early stage, patients can decide what changes they want in their future. For example, if they are working, they may phase out work or business and reduce commitments. If living alone, they can think of how they will move with or near their children. Or they can check out assisted living facilities for themselves. They can create legal documents that will be useful later. Examples are power of attorney and living wills. They can discuss with their families what they want in terms of medical treatment and other arrangements for the later years.

Caregivers can help patients remain independent and do their tasks. The support required is low in this early stage. Caregivers can find ways to help patients live meaningful, dignified, and independent lives.

early dementia patients can use clocks for reality orientation

One activity to plan for this is home adaptations. Caregivers can adjust the surroundings so that patients don’t get confused and can continue to do their tasks independently. Reality orientation techniques are very useful. In early-stage dementia, most patients are able to use aids like reminder notes. They can read large clocks and calendars. Adjust the house to add such aids. Label containers and drawers using words and pictures. Place signs on doors. Put up charts to help the patient with the steps of an activity (like making tea). Give patients medicine boxes so that they can handle their medication. Make choices simple. Choices can be simplified. Reduce clutter to reduce patient confusion. If patients make mistakes such as mixing up shoes, leave only one or two pairs outside. Place lists of contact numbers at convenient spots so that patients can call when they need help.

Another thing to do is to look at ways so that patients can do their tasks independently or with very little help. Patients may be able to explain what their problems are. Caregivers can observe how the patients do tasks. See when the patients are slower or more awkward. Make changes that will make the task easier. Or know when to offer help. Give help only to the extent needed, so that the patients feel capable and independent.

Caregivers can prepare for later care.Care in early stage may not need the caregivers to be present with the patient at all times. Effort required is also not as high as it is later. So caregivers can use this time to understand dementia and its impact better, learn the skills they will need, plan for later care, and start making the life changes that will be needed later.

Understand dementia, gather information, and learn care-related skills. This could include:

  • Understand about dementia, its various symptoms, how it progresses, and how it may impact the person now and later.
  • Understand about medicines, when they can help, and what the limitations of medicines are.
  • Understand enough about the patient’s medical state (dementia and other health conditions).
  • Learn more about the patient’s past, and the likes and dislikes. Even if you have known the patient for years (as in the case of a parent or spouse), you may not know many details or may not remember them.
  • Understand which are the areas of the patient’s life where you may need to support later. Examples are bill payments, financial and tax decisions.
  • Learn how to interact with and help someone with dementia. Learn how to adjust your way of talking to the patient to make it easier for them to understand you. Learn how to help them. Read up more on changed behaviors, why they happen, how to adjust to them, and how to handle behaviors that can harm the patient or others.

Special tip:
As dementia worsens, most patients find it difficult to sign documents. They may not be able to sign cheques. They may not understand finances, investments, and tax returns. If the patient agrees, simplify and rearrange finances and taxes so that you can manage them. Discuss with with the patient when it is still early-stage dementia. You and the patient can talk to tax consultants, lawyers, and well-wishers. Possible actions include creating joint accounts, placing jewelry in jointly-operated lockers, keeping some extra cheques signed by the patient, etc.

Plan for later care, and start making required changes. This could include:

  • Think about how you will adjust home and work responsibilities to handle care for mid-stage dementia.
  • Start making changes to adjust your various roles and responsibilities. This could include looking for a more flexible job or selling off your business, or moving house.
  • Set up systems for handling investments and tax and finances. Examples are switching over to joint accounts, getting power of attorney, etc.
  • Find a doctor who can advise all through the following years, when the patient will not be able to explain the problems. Look for doctors whom the patients are comfortable with, and who may do home visits.
  • Collect material that could be used later for jogging the patient’s memories. Examples are old photographs, old valued prizes, posters and songs of old movies, and other objects the patient may have memories of.
  • Start getting more involved in the patient’s life so that the patient gets used to the fact that you will now be more actively connected. You will also be able to get more correct information.
  • Tell relatives, friends, and colleagues about the situation. Explain things so that they do not make fun of the patient when a mistake is made. Uninformed relatives and friends often give unsolicited advice to the patients. They tell patients to show more “will power” or be more “active.” They do not understand the nature of problems the patient is facing. Explain the situation to avoid these types of incidents.
  • Plan for self-care. (This is discussed more in another section of this page)
  • Be ready for emergencies.

Caregivers need to be alert about risks, and about the dementia getting worse. Early stage patients can do many things alone or with some help. So they don’t need full-time help. But their ability changes as the dementia gets worse, which could happen slowly or rapidly. Caregivers have to remain alert about reducing abilities, mistakes, and risks. They have to remain alert on how the patient is handling activities that may be unsafe. They also need to make sure that neighbors and relatives know about the problem and are alert, so that if they see something suspicious, they can call the caregiver immediately.

Some examples of areas to remain alert about are given below:

If the patient drives, check regularly to make sure the patient still drives safely. Confusion about location is common in dementia. Patients may keep driving in circles. Or they may reach some very distant place and not know where they are. They may also cause accidents. Accidents can happen because of missed traffic signals, confusion, poor responses, and so on. If the patient was very used to driving around independently, it can be very difficult to stop them from driving. Patients may not believe or remember that they are no longer safe drivers. In early dementia, when the person can appreciate logic, one technique that works is saying the car insurance has lapsed or the driving license has expired. These do not work if the person forgets that these documents needed for driving. Other techniques used are removing the keys, disconnecting the car battery or parking the car at a different place or even selling it. Many families in India use chauffeurs so that the car can be used for many family members through the day. Getting a driver may be a useful way to stop the person from driving. It also ensures that the person can be taken for outings safely when needed.

Another area that requires alertness is smoking. If the patient is a smoker, there is a risk that the patient may set something on fire by mistake. Patients may not remember to extinguish cigarettes. Telling the person does to smoke will not work. Smoking is an addiction and the patient will find some way to smoke, often by borrowing or stealing cigarettes. De-addiction techniques can be tried, but they may be difficult for someone with dementia. The family may decide to put smoke detectors and fire alarms, depending on their assessment of the risk.

Remain alert on personal hygiene, medications, food and water. Patients may stop their medicines and an existing health problem may worsen. They may not be eating enough food or drinking enough fluids. They may not be regular in their bath and cleaning up. Problems in these may be more difficult to note if the patient lives independently, which is less likely in India. But even when in the same house, patients may be neglecting some such areas and family members have to remain alert about them.

Remain alert on the mistakes patients are making in activities that can be dangerous. Cooking is one such example. Patients going for walks and then getting confused about the way back home is another. There may be others. See how the patient spends the day, and what to remain observant about. While caregivers may not need to be present all the time, they definitely need to have enough checks and safeguards for activities where mistakes could be dangerous.

Early stage care can be planned and done effectively if the diagnosis is available. Without a diagnosis, the family may not realize that the problems are because of a medical problem and that they need more information and planning to support the person. Unfortunately, in India, diagnosis in early stage is not common. Symptoms are mistaken to be old age problems, stubbornness, personality changes, etc, and doctors are not approached. Or doctors may not give a correct diagnosis. Hopefully as awareness increases, more patients will get diagnosed early and care can also be planned better.

Persons with dementia can play a very active role in decisions around their dementia at the early stage, if they and the society around them understand and accept dementia. Even if patients do not understand all the possible problems of dementia, they can participate and take decisions if they accept that they have symptoms like memory loss and that these may get worse.

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Care for mid stage dementia

Mid-stage dementia is often most stressful for caregivers. Patients, too, are often distressed because they forget they have dementia, but they do not understand many things happening around them. They keep facing more problems and put themselves at risk because of changed behavior.

Understand that changed and risky behaviors are more common in mid-stage. Safety is a very important part of care. Patients who are still able to understand their diagnosis and problems can try to explain their problems to the family members. They can try to trust and cooperate with the caregivers when they can. They can try to enjoy whatever activities they can still enjoy. This may not always be possible for them, because dementia creates too many problems for them.

Caregivers need to appreciate how difficult patients find things. Some patients may be able to cooperate and may be aware of their situation and risks. But many patients will not be able to do so. They forget that they have dementia and so they do not understand why they are having problems, or they get very upset about their lack of control. Risky behavior is much higher. Patients may wander. They get disoriented and confused and agitated. Changed behaviors are common, and some are harmful to the patient and others. Patients are still mobile and more difficult to handle. Confusion and delusion cause several problems. They accuse people of stealing things that they have misplaced. Or they may remember an old watch they owned as a student, and on not finding it, accuse everyone of theft. They may hit people. They no longer recognize many people around them, and this is very frightening for them. Also, patients may have medical problems, but these may not be recognized as medical problems and may remain untreated. All these are things caregivers have to consider while seeing how to plan and give care for patients in this stage.

Caregivers have to set up for mid-stage care and manage daily care. This includes making suitable changes at home and helping patients with their daily activities and also keeping them safe.

Major changes may be needed in the home. Reality orientation tools may no longer work. Patients are mobile and can harm themselves. You must see which things in the home setting can cause problems. Use creative solutions to keep the home safe and friendly for the patient. Changes can be considered to reduce the chance of wandering. The patient may need clothes that are easier to wear. Choices in the house may need to be reduced, and clutter removed. Observe what patients find difficult or where they seem to be more at risk. Make adjustments accordingly. If an attendant is being hired, adjust the home to give the attendant enough space, while also taking care of safety.

Use suitable ways to talk to the patient, help the patient, and handle changed behavior. Interactions have to be adjusted to the patient’s needs and abilities, dementia care. Care-related skills are very important now. You must know how to talk to and understand patients, how to help them, how to handle changed behavior that seems harmful. If you have not learned these skills yet, you need to do so now. Changed behavior is very common in mid-stage dementia, and some of it may be harmful for the patient and others. Learning how to understand and cope with it is very important.

Plan and maintain a suitable daily routine. A good daily routine gives the patient a predictable way to spend the day, and makes life easier for them. Most patients feel much better if such a routine is used. A good routine has necessary daily tasks and also includes some meaningful and enjoyable tasks the patient can do. It includes sufficient exercise, because exercise improves health and reduces restlessness. It should not be tiring, and it should not be boring.

You need to create a daily routine based on the patient’s abilities and likes and dislikes. As the patient’s abilities will keep changing, this daily routine also needs to keep changing.

The family has to ensure care is available throughout the day if needed. By mid-stage dementia, patients usually cannot be left alone. Even if they don’t need direct help, they may be at risk, and a caregiver needs to be available nearby to prevent harm. This can be a problem because you may not be able to go out even for groceries or withdrawing money from an ATM unless there is someone else who can stay with the patient. Care planning includes ensuring that someone is available for supporting the patient all the time. It could be a family member, a hired attendant, a volunteer or friend. Or you could use some support service like day care or respite care.

Ongoing review is required because dementia keeps getting worse. This review is needed for all aspects.

Review how well patients handle tasks and personal hygiene, etc. Keep adjusting support accordingly. Abilities will reduce as dementia gets worse. This affects the help patients will need, and the support systems that have to be changed or improved. Review the medical aspects.Caregivers need to observe how the patient does tasks. Observe to see which tasks may be more difficult and what additional risks there are now (for example, is the patient finding walking more difficult, so do you need to add grab rails?).

Review the medical situation. Existing medical problems of the patient may have gone worse. Aids for vision and hearing may no longer be working well, and this may add to the patient’s confusion. There may be new medical problems. There may also be side-effects of the medicines. Patients are usually unable to tell about their health problems, so you need to be very careful. The patient should stay under the supervision of a doctor who understands dementia and can also advise on other problems the patient may face. You may need to decide on optional surgeries. For example, you may decide whether the patient’s cataract should be operated now if you and the doctor feel the patient will not be able to handle the surgery later.

They need to check that the patient wears appropriate clothing and footwear.

Review whether major re-planning is needed because of decline. Change may keep happening gradually and you may not realize that the status has declined so much that you need major changes. This could be hiring an attendant, or using two attendants instead of one. Dementia may be getting worse and reaching the advanced stage when dependence is much heavier. Patients sometimes get worse after an infection or other illness or a fall and may end up becoming bedridden. Or you may find that care at home is becoming very difficult and may need to start looking for a suitable respite care. So, as a regular review, you need to see how severe the decline is, and plan. For example, you need to understand what late-stage care will require, so that you are ready for it.

Caregivers should understand the common problems faced in care and get help to reduce them Mid-stage care takes a heavy toll on caregivers, stressing them and tiring them completely. It requires major changes in their lives. By knowing the problems caregivers usually face, you can plan what you can do to reduce them or handle them better.

Caregiving can tire you physically. Patients need at least some help for most tasks. You have to make sure all tasks are done, and may need t guide the patient or help them for many of them. For example, patients may not be able to take a bath alone. They may forget to apply soap or forget to rinse the soap, or to dry off. You need to be ready for doing or supervising/ helping with a lot of physical support. Ask a physio-therapist how they can help the patient without harming their back or getting too tired.

maid may be accused of theft for something that the dementia patient does not possess

Caregiving can be difficult emotionally, too. Patients often show difficult behavior in mid-stage dementia. Outsiders often misunderstand the situation, or believe the patient who complains to them. They are critical of the care, and suspect neglect. Hurtful comments are common. You have to be ready to face and handle difficult behavior. You also have to be emotionally ready to cope with unfair criticism, or reduction in friends.

Caregiving often affects job and finances of the caregiver. This includes changes needed to remain available to the patient, and may require switching to a more flexible job or giving up work. It is also common for family income to reduce because of the expenses on care and loss of earning when some family members have to stop working to give care.

India does not have schemes for assisting families for care of patients, but you can check if subsidized medicines are available. Some income tax deduction for medical expenses incurred is available under section 80DDB. The income tax site has more information. Tax consultants can give more information. Note that only some types of doctors are authorized to give the required certificate.

Things you can consider for such typical problems include:

  • Learn and apply caregiving tips and techniques. Dementia care can be simpler if you understand dementia and its impact better and learn more effective ways to talk to and help patients. Learn the caregiving skills using books, videos, training classes; it is well worth the effort. For physical work, ask physiotherapists how to help the patient without tiring yourself.
  • Look at all possible sources of support. Share the work and costs with family members. Get help from friends and others for errands or giving you company or emotional support, whatever they can help you with. Join support groups (online or in-person). Use counseling services if you feel stressed. To reduce workload, think of using attendants, and other dementia support and services.
  • Plan for self-care. There are many small things you can plan and do for yourself to reduce your stress and remain in better health. These are discussed in a separate section on this page.
  • Try to get some good, fulfilling moments during caregiving. The care work may seem less tiring if you can get at least some happy moments while doing the work. This is possible if you add some fun activities and relaxed times with the patient in the daily routine and reduce your expectations about what the patient can do.

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Care for late stage dementia

for late stage dementia, plan home nursing for bedridden patientBy this stage, the patient is dependent for all activities. The patient is unable to explain things or understand others well, and has poor body coordination. Incontinence is common. Patients often become bedridden. They fall ill more often and have more health problems. Some of these are because of dementia and some are because of other illnesses which don’t get detected as patients cannot tell when they are unwell. Care for such patients needs very different type of planning and also knowledge of home nursing. It is also more emotionally exhausting for many caregivers because the patients are so clearly getting worse.

In India, families typically take care of patients at home even at this stage. Care for late stage is an extensive topic. It is covered in detail on: Late-stage care.

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Special care aspects for young onset/ early onset dementia

Some dementia patients are less than 65 years of age. This is called young onset dementia, or younger onset dementia, or early onset dementia. A young-onset patient may be in the 40s and 50s, or even younger. Most such patients have Alzheimer’s Disease or fronto-temporal dementia (FTD). The World Health Organization estimates that around 6-9% patients are young onset patients.

Care for young-onset patients is usually handled by the husband or wife, who is also at a busy and active stage of life. Young children, still studying or just starting their careers, may take on part of the work. Elderly parents, facing their own age-related problems, may also become caregivers.

Most dementia care discussions assume that the patients are retired and frail, and not having many responsibilities. But younger patients are leading active lives, doing work, and handling many responsibilities. When they start facing dementia problems, the caregiver has to also see how to take over or reduce the work the patient was doing. Above in this page, the discussion has covered care areas based on the dementia stage. For young onset patients, you also have to pay attention to some more things because the patients are young and active.

If you have to support a young-onset dementia patient, please see the page: Plan care for younger persons with dementia.

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Care for the caregiver (self-care)

Caregivers are so busy helping the dementia patient that they often forget to take care of themselves. They keep working harder and harder and try to do all the work. Then the dementia gets worse and they are doing the work almost full time. They get physically, mentally, and emotionally tired. But they are not able to take breaks. They are confined to home. They get isolated from their friends and social circles. Because they are tired and overwhelmed, they don’t have the energy for the additional effort to take care of themselves. Persons around them may not know they need support. They may not know how to help.

As a caregiver, you must plan for self-care as early as possible, before you start getting tired and overwhelmed. Understand your role and how it will increase when the dementia gets worse. Think of what you have to set up for your self-care later. Planning for your own health and happiness is as important as planning care for the patient. Tips on what you can do for this are discussed in detail in some other pages (links in the See also below).

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See also….

Pages discussing some of the topics mentioned above:

Some relevant interviews on this site:

Some external references and links based on the discussion on the page

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[This page was last updated in July 2015]