This document provides information on working with individuals with cognitive impairments and dementia. It discusses common symptoms and causes of cognitive impairment, types of dementia and their progression, domains of cognitive function associated with different brain areas, common behaviors seen in dementia, and tips for managing individuals with cognitive impairments or dementias. The document aims to increase understanding of cognitive impairments and dementia in order to better support affected individuals.

1. Working with Individuals with Cognitive
Impairments and Dementia
Dr. Jeanne E. Knight, Ph.D.
New Mexico Behavioral Health Institute
© 2021

2. Learning
objectives
• common symptoms and signs of cognitive
impairments and dementia
• types and progression of dementing processes and
cognitive impairments
• common behaviors (BPSD) associated with
cognitive impairments and dementia
• autonomic nervous systems related to behaviors
• communication / activity tools to work with
behaviors / needs

3. Functional
Brain Areas
• What are some functions
of the following:
• Frontal Lobes:
• Temporal Lobes:
• Occipital L0bes:
• Parietal Lobes:
• Cerebellum:
• Brain Stem:

4. What are the domains of cognitive impairment?
Executive / Frontal Lobe – organization, planning, empathy,
inhibition. Self-regulation, Emotions, Personality
Language / Frontal & Temporal Lobe – speech, (Broca)
comprehension (Wernicke)
Memory, Emotion / Temporal & Limbic – episodic,
autobiographical, remote, immediate, declarative knowledge
Visual-Spatial / Occipital, Parietal - vision, navigation,
localization
Attention / Frontal & Parietal – sustained, divided, selective
Balance, Timing, Sequencing / Cerebellum – coordinated
movement
Sensation / Frontal – sensory input, body representation
Motor / Frontal – motor output, movement
Arousal, Life Support / Brainstem – breathing, body regulation

5. What are the
causes of
cognitive
impairment?
• Brain Injury – Trauma, Stroke, Toxins, Anoxia
(Drowning, Carbon Monoxide)
• Dementias (Neurocognitive Disorders) – Alzheimer’s,
Vascular, Lewy-Body, Traumatic, Alcohol-Induced
Persisting, Fronto-Temporal
• Developmental – Teratogens, Learning Disabilities,
ADHD, Autism, Asperger’s, Rett’s, Childhood
Disintegrative Disorder, Mental Retardation
• Neurological / Metabolic / Immunological – MS, AIDS,
Epilepsy, Encephalopathy (Hepatic, Mumps, etc.)
• Psychiatric – Schizophrenia, PTSD, Bipolar Disorder,
Borderline Personality Disorder

6. Dementia Types
• Alzheimer’s – insidious onset, can have genetic markers, decline in memory and learning and one other
cognitive domain such as executive functioning based on history or serial testing, has a gradual decline without
extended plateaus, no evidence of mixed etiology (i.e., without neurodegenerative, cerebrovascular, substance
abuse, TBI, etc.)
• Frontotemporal – insidious onset, gradual progression with either Behavioral Variant (disinhibition, apathy, loss
of sympathy or empathy, perseverative, stereotyped or compulsive.ritualistic, hyperorality and dietary changes)
or Language Variant (decline in language ability such as speech production, word-finding, object naming,
grammar, or word comprehension)
• Lewy Body – insidious onset, gradual progression, fluctuating cognition with variation in alertness / attention,
visual hallucinations that are well formed and detailed, parkinsonism with onset subsequent to cognitive decline,
may have REM sleep behavior disorder, or neuroleptic sensitivity
• Vascular – cognitive decline related to vascular events, decline is prominent in complex attention, processing
speed and executive functions, evidence of cerebrovascular disease, not better explained by other brain disease
or systemic disorder
• TBI – evidence of TBI with LOC, Amnesia, Disorientation, Confusion, Neurological signs / deficits, presentation
following TBI and persists
• Substance Induced – impaired not just with delirium, substance is known to produce impairment with type of
use, temporal course fits with use, deficit is stable or lessens after abstinence, not better explained by other
disorders

7. Dementia types (cont.)
• HIV – documented HIV infection, not better explained by other
disorders or medical conditions
• Prion Disease – insidious onset, rapid progression of impairment,
motor features such as myoclonus, ataxia, or biomarker evidence,
not better explained by other disorders
• Parkinson’s – decline in the setting of Parkinson’s disease, insidious
onset, gradual progression, not better explained by other disorder
• Huntington’s – insidious onset, gradual progression, diagnosed
Huntington’s disease, risk, or genetic indicators, not better
explained by other disorder
• Multiple Etiologies – evidence of two or more etiological
contributors, not better explained by other disorders
• Unspecified – criteria of specific types not met but clinically
significant distress or impairment insocial, occupational, or other
important areas of functioning

8. Psychotic SYMPTOMS that
may accompany dementia
Example Psychotic Symptoms of Delirium, Neurocognitive Disorders (Dementias), Medical Conditions,
TBI, Others:
1. Hallucinations (Auditory, Visual, Tactile, Odor, Taste): A sensory experience without provoking
external stimuli (e.g., hearing voices, seeing shadowy figures, feeling insects under the skin, foul
smelling or tasting sensations)
2. Delusions – false beliefs or ideas (e.g., grandiose - “son of god,” “Queen of England,” paranoid -
“being poisoned,” “rotten or contaminated food,” “being threatened or abused”)
3. Illusions – misinterpretation of actual stimuli (often colored with paranoia, grandiosity, etc.)
4. Nonlinear cognitive processes (e.g., loose associations, flight of ideas, derailment, tangential or
circumstantial)
5. Abnormal speech patterns (pressured speech, slowed or blocked, mutism
6. Abnormal movements (hyperactivity, psychomotor slowing, waxy, catatonia)
7. Changes in eating, sleeping, activity levels, etc.
8. Changes in Affect (blunting, flattened, mania, incongruence with mood)

9. Mood / Affective Symptoms of dementia
Example Mood Symptoms of Delirium, Neurocognitive Disorders
(Dementias), Medical Conditions, TBI, and Dementia related Personality
Changes:
1. Irritability, Agitation – commonly seen in many disorders can be related
to numerous factors including physiological needs such as thirst, hunger,
discomfort / pain, infection, lack of autonomy, disorientation
2. Dysthymia, Sadness, Despair, Depression, Blues – overly negative mood
symptoms are commonly associated with a number of disorders
3. Euphoria, Mania – overly positive mood symptoms are more associated
with Schizoaffective Disorder and Bipolar Disorder
4. Apathy, Amotivational – flat affect, reduced ability to initiate, often seen
with long-term use of antipsychotic medications, with Parkinson’s, brain
injury

10. Personality Changes
• Changes in Style of Thinking, Reacting, Interacting:
1. Cluster A – Paranoid (suspicious), Schizoid (prefers to
isolate), Schizotypal (unusual perceptual experiences,
eccentric, peculiar)
2. Cluster B – Antisocial (lies, lacks remorse / empathy,
criminality), Borderline (intense, impulsive, recurrent
suicidality, affective instability), Histrionic (dramatization,
exaggerated emotions, on stage), Narcissistic (grandiose,
entitled, exploitative, lacks empathy, deflects
responsibility)
3. Cluster C – Avoidant (social inhibition, inadequacy),
Dependent (submissive, clinging), Obsessive-Compulsive
(perfectionistic, controlling, overly orderly)
4. Personality Change Due to Medical Condition (e.g.,
Neurocognitive Disorders, TBI, HIV, MS, etc.) often due to
frontal lobe dysfunction

11. Common Behaviors of dementia (BPSD)
Behavioral and Psychological Symptoms of Dementia
• Behavioral – aggression, yelling, agitation, wandering
• Psychological – anxiety, depression, hallucinations, delusions
• Other Examples::
• Whining, Screaming, Yelling, Cursing, Abusive Language
• Hitting, Throwing, Shoving
• Refusal of Care
• Refusal of Medications
• Sexually Inappropriate Behaviors
• Stealing, Hoarding
• Compulsions, Obsessiveness
• Intrusiveness, Rummaging
• Akathisia, Hyperactivity, Wandering
• Depression, Dysphoria, Apathy
• Boredom
• Sleep Disturbances

12. Recovery and Consequences of Cognitive Impairments
- Fastest improvement usually occurs in first 6 months after onset
- Some forms do not recover and may deteriorate such as some dementias
- Better improvements with stimulation
- Speed of recovery then slows
- Recovery is individualized
- Depression is common
- Changes can occur in:
- Thinking and Cognition
- Attention and Concentration
- Tolerance to alcohol, drugs, medications
- Sensitivity to Environmental Factors
- Emotions, Anger, and Control
- Physiology, Spasticity, Motor Functions, Senses, Sexuality, Seizures, Sleep,
Appetite
- Social Skills and Relationships
- Energy Levels

13. Tips for Managing Brain Injury or Dementias
• The person can’t help that they have impairments
• Not all impairments are obvious
• The person may not be able to recall or learn new things
• Consider that difficult behaviors may be part of the
impairments
• The person is not intentionally being difficult
• The interaction is not personal to you – maintain professional
distance
• Do not react to resistance with pressure – back off and offer
choices or to come back later instead
• Do not directly challenge or correct errors – use softer
strategies to redirect and coach
• Avoid power struggles – reassure that you are here to help
• Step away or get help if you can’t cope, are frustrated / angry

14. Autonomic Nervous System Arousal –
Sympathetic vs. Parasympathetic
• The normal human nervous system has primitive protection mechanisms that are critical
to our survival, so when we are AFRAID, we tend to respond by either running away (FLIGHT)
or by aggressively confronting (FIGHT) or immobility (FREEZING).
•Although useful for survival in more primitive man, with increasing socialization, some of
these primitive responses are less useful so we learned to control (self-regulate) them
through inhibition and the increased development of the frontal cortex (front brain).
• Residents of LTC have cognitive impairments. They have difficulty self-regulating.
• Because of impairments they get disoriented, confused, misunderstand, and respond
emotionally. These are often a result of entering a state of FEAR (which we often call
agitation or anxiety) which triggers sympathetic arousal.

15. Braking System
Parasympathetic – Social Engagement System
• Normally, we can engage the brakes, once we see things are
safe.
• It is harder for people with certain impairments to put on the
brakes, so we need to help them to reach a place of safety, so
they can become calm (parasympathetic engagement).
• Good Communication which is RESPECTFUL and
EMPOWERING is a critical tool.

16. INCREASE Safety CUES
• Individuals with Dementias often feel unsafe
• Unsafe feelings trigger the sympathetic nervous system - a flight or fight response
• We need to engage the parasympathetic - relax and digest
• Increase safety cues – familiarity; comfort; gentle movement; social engagement
(friendly talking); collaboration (working together); adequate temperature, better
lighting; pleasant smells; pleasant sounds; pleasant visual surroundings; safe touch /
massage = PROVIDE SENSATIONS that people LIKE & WANT

17. Creating safety
• Assure physical comfort – temperature, lighting, comfortable but
attractive attire, comfortable positioning, needs met (hunger, thirst,
toileting, etc.)
• Respect Residents’ Autonomy –Ask? – Don’t Tell!! Provide options /
choices … Empower, rather than Demand, Ask if assistance is wished
• Address with Respect – knock and ask to enter, use Residents’ names,
respect their home and their body
• Body Language – relax shoulders, friendly, calm tone, relaxed arms at
sides
• Proximity – respect personal & cultural distance / space
• Identify / Empathize with Residents – How would you want to be
approached?
• Active Listening; Collaborate with Residents for solutions or plan
• Avoid Power Struggles; When Encountering Resistance – Yield; Come
Back Later and Try Again
• Direct attention toward pleasurable or interesting things – Know your
Residents’ likes and dislikes

18. Reassurance
• offer support and try to comfort the
resident and make them feel safe
• For Example:
• “Everything is okay, you are safe, I will help
you,” etc.

19. Distraction
• redirect the resident verbally; change topic of
conversation; point out something interesting or
that you would like to show them; offer physical
guidance if needed
• For Example, “Let’s go ____ and we can do
________.”

20. Predictability
• Maintain Routine – try to establish predictable
routine that can become habits, familiarity creates a
sense of security
• For Example, “This is the time we usually help with
your bath. Would you like to come now or shall I
return in 15minutes.” (vary time depending on
memory capability)

21. Music
• Music – facilitating patients choice of favorite music at a
volume that is appropriate for their hearing level;
encouraging musical participation
• For Example, Providing mp3 players loaded with favorite
music, group singing of highly familiar, “old,” songs
appropriate to residents’ era, rhythm keeping, expressive
dance-like movements, drumming, listening to music during
mealtime, etc.

22. Movement
• Dance / Exercise / Movement – sitting exercise for
residents at risk for falls
• For Example, Rocking chairs, walking, dancing, tai
chi, wheelchair basketball, etc.

23. Touch
• Touch Therapy – Providing Human Connection
• For Example, Hand massages, back rubs, hand
shaking, human touches that are appropriate,
calming, and safe

24. Key Points for Effective Interactions
• Speak directly, distinctly, and at a natural volume and rate of speed.
• Gain the person's attention.
• Sit in front of and at the same level as him or her and maintain eye contact.
• Orient the person. Explain (or re-explain) who you are and what you will be doing.
• Use familiar surrounding if possible.
• Support and reassure the patient. Acknowledge when responses are correct.
• If the patient gropes for a word, gently provide assistance.
• Clarify that you are seeking information to help the patient.
• Use simple, direct wording. Present one question, instruction, or statement at a time.
• If the patient hears you but does not understand you, rephrase your statement.
• People with cognitive impairments often have difficulty with open-ended questions.
Consider using a yes-or-no or multiple-choice format.
• Remember that many older people have hearing or vision problems, which can add to
• their confusion.
• If the patient can read, provide written instructions and other background information
about the problem and options for solutions. Use pictures or gesture to help convey
information.

25. Do Your Detective Work
• Often people with Cognitive Impairments are not able to communicate
effectively what may be wrong
• You may need to be a detective to try to determine what may be at the
root of a behavior
• Consider the following:
• Pain or Discomfort
• Illness / Infection
• Boredom or Overstimulation
• Constipation, Thirst, Hunger, or other physiological problem
• Need for Socialization
• Need to move or adjust position
• Need to alter temperature – too cold, too hot
• Need for soothing, calming, difficulty self-regulating
• Try to identify issues which may be contributing and address them

26. Focus on the Positive - Effective Approaches
• Establish Collaboration – assist don’t direct
• Establish Respect – ask to enter, ask to help, ask how resident wants to be
addressed
• Listen to Resident’s Concerns – don’t be dismissive, don’t deceive, say you
are uncertain when you don’t know
• Identify with Resident’s Circumstances – imagine what its like for them
• Practice Patience – understand that Resident’s presentation is part of
their brain problem and not about you, you may need to repeat things,
slow down your speech, wait for them to reply, help with word finding but
don’t put words into their mouths or think you know everything they are
trying to communicate
• Simplify how you communicate – use shorter sentences with common
words, point or gesture
• Use a short list (Multiple Choice) they can select from if unable to answer
open-ended questions
• Empower the Resident by encouraging success, self-efficacy, improved
self-esteem

27. Identifying Resistance
• Uncooperative behavior = Resistance
• Resistance manifests as direct or indirect opposing behaviors in a
push and pull of a change or request process. It impedes the
development of authentic, reciprocal nurturing experiences in a
clinical setting. The common source of resistances and defenses is
shame, vulnerability, fear of losing control, or feelings of
inadequacy.
• Examples of psychological resistance may include perfectionism,
criticizing, contemptuous attitude, being self-critical,
preoccupation with appearance, social withdrawal, need to be
viewed as independent and invulnerable, or an inability to accept
compliments or constructive criticism

28. Handling Resistance
• Resistance will increase with push-back – avoid argument, power struggles,
instead pull back
• Roll with Resistance – Approach with Nonjudgmental Professionalism that
affirms Resident’s Autonomy and Choice
• Offer acceptance without judgment
• Use reflective listening – discuss ideas resident has expressed in a different
way and allow for correction
• Use Discrepancy – reflect discrepancy between Resident’s goals / values and
current behavior
• Use techniques of Motivational Interviewing - RULE:
• Resist – Avoid telling them what to do, directing, convincing
• Understand – their motivations, their values, needs, abilities and barriers
• Listen with Empathy – seek to understand, their values, needs, abilities, and barriers
• Empower – work with them to set achievable goals and identify ways to overcome
barriers