Dementia Roadmap: Strength-Based, Person-Centered Dementia Care

Dementia (and Alzheimer’s) is one of the most prevalent issues we face in the coming years. The DAWN Method^® is a kind, strength-based, person-centered approach to caring for those with dementia and Alzheimer’s. In this article, your dementia roadmap, we will cover what dementia is and who it affects, the stages of dementia, and then we will introduce the DAWN Method of strength-based, person-centered dementia care. Our goal is to help you understand dementia as well as give you dementia care tips that will decrease stress for caregivers as well as for those experiencing dementia.

The dementia epidemic

7.8 million Americans…

Dementia is not only one of the most expensive health issues American families face today, but also the most prevalent. As the baby boomer generation ages, the incidence of dementia and Alzheimer’s is skyrocketing. The expense of providing long-term care in facilities is bankrupting families and putting a huge strain on both Medicare and federal and state Medicaid budgets. A cure is still in the future, yet dementia is already at epidemic proportions in the United States.

According to the Alzheimer’s Association, it is estimated that 7.8 million Americans have dementia in 2020 (5.5 of those have Alzheimer’s). In the United States, the number of people who will need dementia care is expected to increase by 35 percent by 2030 and 110 percent by 2050.

The high cost of Alzheimer’s & dementia care

The Alzheimer’s Association estimates that dementia will cost the United States about $305 billion dollars in 2020. They project that an additional 16 million people will provide approximately 18.6 billion hours of unpaid care, worth about $244 billion.

In order to preserve Medicare and Medicaid, and avoid impoverishing a generation of families, we need a way to help families postpone the high cost of institutional care for as long as possible. The DAWN Method does that. Using the DAWN Method, families can keep their loved ones at home longer, and avoid the behaviors that make looking after them so stressful.

What is dementia and what causes dementia?

Dementia is a condition, not a disease. Dementia means memory loss and progressive cognitive impairment (including the inability to remember steps in a task and the inability to understand why something has happened). It is not a disease, although it can be the result of a number of diseases such as Parkinson’s, Alzheimer’s, alcoholism, and heart disease. People experiencing dementia are often unaware that they are impaired, and do not understand that they need help.

Meeting the emotional needs caused by dementia

Cognitive impairment causes distress, not only confusion. We shouldn’t be surprised that people with dementia have difficult behaviors. The DAWN Method gives families and caregivers a way to respond to behaviors and provide care that meets their loved ones’ emotional needs.

Using the DAWN Method, we can keep our loved ones at home longer. Staying at home longer means not only a higher quality of life, but also less expense—to families, to Medicare, and to Medicaid.

The dementia roadmap: The stages of dementia

People who are experiencing dementia/Alzheimer’s will progress through identifiable stages of dementia, regardless of the type of dementia they are experiencing—if you look at dementia from the perspective of changes in functioning rather than as disease. When we change our perspective, the dementia path becomes clearer. And when we provide just enough care rather than force too many changes too quickly, care is more readily accepted and the person is safer.

Stage 1: Independence

At first, people who have dementia want as little interference from their family and friends as possible. They are still able to read a clock, perceive the passage of time fairly accurately, and look at a calendar to determine what day it is so that they can attend appointments and activities. They wake up in the morning and know that the events of the dream they may recall were dreamed events. They can navigate the kitchen and take care of their homes more or less as well as was their practice earlier in life.

Those who do not have anosognosia (the condition of being unable to perceive our own impairments) prefer to do things for themselves but will be grateful and appreciative. When they do accept help, they’re likely to say something like, “Thanks so much, but really, I’m managing just fine on my own.”

Those with anosognosia will be less grateful for assistance. They may respond to offers of help with indignation, seeing them as inferences that they are needy or incapable. They believe that any mistakes or confusion are caused by other people and so may become paranoid or suspicious. However, in the earlier years of dementia, whether people have anosognosia or not, they will attempt to mask the true extent of their confusion and memory loss so that they can preserve their independence for as long as possible.

Stage 2: Uncertainty

At some point, uncertainty will set in. The person with complete anosognosia will stubbornly persist in believing that their confusion and frustration are due only to other people’s mistakes, but even those with partial anosognosia will begin to doubt themselves. Now that they have so often found themselves unable to complete a simple task, or at a loss about what they were doing or should be doing, they know they need some assistance.

At this stage, when we prepare to leave, rather than thanking us and telling us they are fine, they might ask, “Will I see you tomorrow?” or “Would you like to come in?” This tells us that the person now needs more assistance and will more easily accept it.

Stage 3: Follow the leader

We know someone has moved into this next stage when they start saying to us, “Oh, I’ll just have whatever you’re having” or “It doesn’t matter to me—you decide.” It’s not that they’ve become more easygoing: they simply are no longer able to make decisions without assistance. They cannot track time, read clocks, or interpret calendars consistently. Their desire for independence has melted away unless anosognosia is still fully present.

At this point, we again know it’s time to increase our support. We watch to see whether they are losing weight due to failure to recognize food and packaging, whether they are bathing or have forgotten the purpose of soap, whether they still retain some idea of cleanliness in the home, and whether they have begun to perceive dreamed events as real. Now we expect their judgment to be consistently impaired, and watch for misinterpreted realities that could become dangerous. Their daily activities with us are gradually lengthened to include meals, cleaning, and household chores—and maybe visits to our local wellness center for a supervised shower and soak in the hot tub.

Stage 4: Clinginess, or clingy dementia

When someone slips into this stage—becoming clingy—they are experiencing confusion on such a level that they are commonly unable to do simple tasks when alone, or cannot understand whether it’s morning or afternoon, Tuesday or Saturday, October or May. They might say, “I’d feel better if I could hold your arm.” They may not be able to verbalize this need and just reach out and take their companion’s arm. In a crowd, even in a small group, these people sidle closer or lean into their companions. They look for eye contact and want to make eye contact often. For them, at this point most people have become strangers—even family members and dear friends—although they will still do their best to mask it. Memories can be recalled and faces placed, but it requires careful leading through a series of related memories to get there, if at all.

Routine and familiarity are now essential. The smallest change can bring on a crisis of fear and confusion. When someone reaches this stage, we need to vigilantly watch for the moment they move to the next level of need, which will be a transition we dare not ignore. The change may be sudden or gradual, the result of a crisis or merely a response to an accumulation of daily failures or irritations. They will now need someone with them at night.

Stage 5: Overnight care

At this point, people who have been living alone but with daytime caregiving who do not have anosognosia will begin turning to caregivers, friends, and family members and say, “Would you like to move in with me or stay over?” Wanting to have someone with them overnight does not imply that they need full-time care. People at this level still enjoy the autonomy of being able to spend a few hours alone, but not much longer than that.

At DAWN, we’ve found that if resources allow, it works well to immediately provide a caregiver who is present from dinnertime through breakfast, full-time on weekends, and off-duty during business hours. We have found this works very well as a part-time job for students studying nursing or social work. During the day, we arrange midday activities that provide the client with sensory and social stimulation but allow our clients an hour or two each morning and afternoon to be spent alone. This helps them preserve a sense of autonomy and privacy within their own homes for a little longer.

Stage 6: Fulltime care

Eventually people who are experiencing dementia become so unable to choose their own activities or make sense of the world around them that they need to have someone present at all times in order to feel comfortable. To me, this is the greatest heartbreak of memory care facilities, because their residents are left alone for hours at a time. Even people who have anosognosia will eventually welcome the full-time presence of other people.

At DAWN, we know it is time for full-time care when we arrive and find someone who’s only been alone for minutes wandering from room to room, unable to relax; they have lost the ability to know what they want to do. These people will say, “I just don’t know what I’m supposed to be doing” when you arrive, and “Do you have to go?” when you get ready to leave. This will happen long before they become bedridden or unable to communicate.

At this last stage of dementia, we make sure that someone is always present. We are careful to continue the same schedule of daily activities so they continue to receive enough sensory and social stimulation to avoid sundowning or wandering. We maintain the same evening and bedtime routines so the sleeping habits we’ve helped them develop can be maintained for as long as possible.

These are the stages of dementia I have watched my clients go through here at DAWN. They reflect changes in functioning—that are not determined by medical diagnoses. When we watch for and respond to our loved ones’ and clients’ changing ability to function and their emotional needs, tailoring the level of care accordingly, they more readily accept care and are less likely to put themselves at risk. At DAWN, we believe that people who feel secure are less anxious. And how someone feels dictates how they will function and act—whether they are experiencing dementia or not.

What is strength-based, person-centered dementia care?

Here at the Dementia & Alzheimer’s Wellbeing Network (DAWN^®), we’ve discovered something really special. We’ve found that although our clients lose their rational functions, they are able to live intuitively—enjoying emotions, beauty, and everything their senses bring to them—in the present. By recognizing this pattern, we’ve developed an approach to dementia care that makes living and working with people who have dementia less stressful because when their emotional needs are met, they are happier. This means that people with dementia can stay home longer, with fewer behavior problems, and their families have less stress and expense.

The seven tools of the DAWN Method^® of dementia care

The first three DAWN tools help people who have dementia develop a sense of security. The last four tools enhance a sense of happiness or wellbeing. When caregivers use the first three tools, their loved ones and clients begin to develop a sense of security and become more emotionally stable. The last four tools can be used to enhance wellbeing in minutes and have lasting results.

Here in northern Idaho, where I and my caregivers have used the DAWN Method for over ten years, the change in our clients’ moods and behavior is remarkable. Instead of descending further into an inner world marked by fear and frustration, they become increasingly relaxed and remain engaged with the outer world in an intuitive way. The following diagram is how we picture the tools of the DAWN Method:

The first tool, mood management, is central. It is the beginning—the constant and renewable energy source that supports the other tools. Without a positive mood, our efforts in the other six areas would be short-lived. Once we, as caregivers, know how to establish and maintain a positive mood, we can begin creating an enduring sense of security in the two areas most vital to someone undergoing cognitive impairment: living with confusion and being cared for by others. Then, while we’re seeing our loved ones and clients’ sense of security growing, we enhance their lives with the four components of wellbeing. Once all seven of the DAWN tools are in use, the relationship between us—the caregivers—and our loved ones and clients becomes a thing of beauty.

What we believe

At the DAWN Method, we believe in preserving dignity and autonomy through aging in place. We do this by training families and caregivers to meet the emotional needs and rational thought losses caused by dementia.

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