Dementia care training for CNAs: what to rehearse

November is National Alzheimer's Disease Awareness Month in the United States, often shortened to Alzheimer's Awareness Month, which makes it a natural time to ask what a CNA student should rehearse before caring for a resident with dementia. Three situations are worth the class time, because they take the most out of a shift: a question that keeps coming back, a firm no at the bathroom door or the shower, and the restlessness that builds in the late afternoon, known as sundowning. The Alzheimer's Association and the National Institute on Aging both describe a response to each one, and each can be practiced with a partner and a rubric long before a student meets it on the unit.

The month has a paper trail. President Reagan's Proclamation 5110 was written to "proclaim the month of November 1983 as National Alzheimer's Disease Month." Later proclamations carry the longer name, as in the 2007 version: "National Alzheimer's Disease Awareness Month is an opportunity to honor and support those living with Alzheimer's disease."

You've probably covered dementia once already. Our post on long-term care training from daily care to dementia gives the overview. This one goes into the conversation itself: what a student says, in what order, and how an instructor can score it.

Dementia isn't an optional extra in the federal rules. Paragraph (g) of 42 CFR 483.95, on required in-service training, says that training must total "no less than 12 hours per year" and must "Include dementia management training and resident abuse prevention training." Paragraph (c)(3) of the same section lists "Dementia management and resident abuse prevention" among the topics a facility's staff training has to cover at a minimum.

On the training-program side, 42 CFR 483.152(b)(5) lists "Care of cognitively impaired residents" among the content areas, including "Techniques for addressing the unique needs and behaviors of individual with dementia (Alzheimer's and others)."

The regulation says what to cover, and the how is left to you. Your approved curriculum and your state program set the details. A year-round plan for those 12 hours is in CNA in-service training; the sections below are a way to fill the dementia slice with practice.

Picture a resident who asks, for the fourth time in an hour, when her daughter is coming. Run it in the lab with one student in the resident's chair, and listen to what the CNA says on the third and fourth rounds. The tempting answers are "I already told you" or a longer explanation of the visiting schedule.

The Alzheimer's Association suggests something else. Start by looking for a reason: "Does the repetition occur around certain people or surroundings, or at a certain time of day?" and "Is the person trying to communicate something?" Then "Focus on the emotion, not the behavior," and "Stay calm, and be patient." It's explicit about logic, too: "Don't argue or try to use logic; Alzheimer's affects memory, and the person may not remember he/she asked the question already." And finally, "Give the person the answer that he or she is looking for, even if you have to repeat it several times."

Its page on communicating with a person with dementia adds two habits students can drill: "Ask one question at a time" and "Avoid criticizing or correcting."

What the instructor scores is delivery. The fourth answer should sound like the first: same calm voice, same words, no sigh. A student who gets the content right and lets the tone slip has found the actual skill.

Students practice bathing on a manikin or a classmate who cooperates. A resident with dementia may say no, and nothing in the skill checklist covers that moment.

The Alzheimer's Association's bathing page gives students reasons to consider before they take the refusal personally. The person "may be uncomfortable receiving assistance with such an intimate activity," may have "depth perception problems that make it scary to step into water," and may "find it a cold, uncomfortable experience." The tips that follow are practical: "Always protect the person's dignity, privacy and comfort," "Check that the room temperature is pleasant," "Be open to adjusting your bathing standards," coach the person "through each step of the process" with simple phrases such as "Put your feet in the tub," and "Try bathing at the same time of day the person is used to."

That page is written for family caregivers. In a nursing home the care plan and the nurse decide when and how bathing happens, so the student's job in the lab is narrower: stop, stay calm, check the room and the water, offer to try again, and tell the nurse. Refusal is also a rights question, which teaching resident rights scene by scene covers, and the refusal belongs in the chart. For that, see how to teach CNA charting.

The National Institute on Aging describes sundowning as "restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade." The Alzheimer's Association defines it as "increased confusion that people living with Alzheimer's and dementia may experience from dusk through night." The NIA is candid that "the causes of sundowning are not well understood," and lists other possible contributors: being overly tired, unmet needs such as hunger or thirst, depression, pain and boredom.

That list changes what a student should do first. Before any technique, the CNA checks whether the resident is hungry, thirsty, in pain or worn out. The tempting responses are to tell the resident to sit down, to walk her back to her room, or to switch on the TV. The sources point elsewhere:

• Stay calm and find out if there's a need. The Alzheimer's Association's page on sleep issues and sundowning says to "Approach them in a calm manner," "Find out if there is something they need," "Avoid arguing" and "Offer reassurance that everything is all right."
• Don't restrain. The same page says "Don't use physical restraint. Allow the person to pace back and forth, as needed, with supervision."
• Turn down the room. The NIA suggests you "Reduce noise, clutter, or the number of people in the room," offer a drink or "a simple task like folding towels," and close the curtains and turn on lights at dusk to minimize shadows. It advises a familiar TV show, "but not the news or other shows that might be upsetting."
• Report it. The NIA says that if sundowning continues, a medical exam "may identify the cause," such as "pain, a sleep disorder or other illness, or a medication side effect." In a nursing home, that conversation starts with the CNA telling the nurse what they saw and when.

Sundowning is a good case for teaching timing. Ask students what they'd do differently at 2 p.m. than at 5 p.m., when the same resident has been up all day.

The three situations share a shape, so one table can sit on the wall of the lab.

A rubric for any of these needs four or five lines, such as: gave the same answer in the same tone each time, didn't argue or correct, checked for a need or a cause, kept the resident safe, and told the nurse. Observers mark each line while a pair rehearses, and the roles swap so everyone plays the resident at least once.

For next week's class, try this exercise. Split students into groups of three: a CNA, a resident and an observer. The resident asks the same question four times, then, in a second round, says no at the bathroom door. The observer holds the five-line rubric and writes the exact words the CNA used on the fourth repeat. After the round, the group compares the first and fourth answers word for word and decides which one the nurse would want to hear from them.