5 Steps to Following Directions with Dementia

Your statement is simple: “Grandma, it’s late, you have a busy morning tomorrow, and it’s time to change for bed.”

But her response isn’t what you expected. Maybe she ignores you. She starts fighting. Or she heads to the kitchen and pulls food out of the cupboards.

What happened?

Even the simplest request requires several mental actions to process. Most of the time, we jump from one to the next without much thought.

But, unfortunately, dementia and Alzheimer’s can short-circuit any of them.

So where are the possible hurdles?

1. Do You Hear What I Hear?

First, Grandma’s ears need to pick up what you said.

Of course, there are the quick fixes:

• Did you speak loud enough? Deep enough? (As we get older, higher-pitched voices can be harder to catch.)
• Are her hearing aids working? Do they need new batteries?
• Are there other noises in the room competing with you? Loud music, the T.V…

But there are also some less-known issues.

• Could her ears need cleaning? Is she congested? Both can mute sounds.
• Could any of her medications be causing tinnitus (ringing in her ears)?
• How’s her eyesight? If she tends to read lips but can’t see well, she may struggle to hear.

But her ears are only part of her understanding you.

2. Simon Says What Again?

Once her ears take in your words, her brain needs to hold on to the information.

It’s the “in one ear and out the other” problem. We all struggle with it now and again if we’re busy. But Alzheimer’s gets in the way of making any new memories, and that means her recalling your words—even after you just said them—might be difficult.

Keep your directions simple.

• One sentence, one direction at a time.
• Keep the sentence short.
• Don’t give explanations for why she needs to do something (Drop the “We’ll have a busy day tomorrow.”) Just tell her what needs to be done now.
• When you give choices, keep it apples to apples. “Would you like your blue pajamas or your pink ones?” (Not “Would you like your blue pajamas or do you want to brush your teeth first?”)

Can Grandma repeat exactly what you said? Great. Now, does she know what the words mean?

3. Sounds Like Greek to Me

Dementia can wreak havoc on vocabulary.

Does Grandma understand the word “bed” right now? If she went into the kitchen, she may have gotten it confused with “bread.” Or it may mean nothing to her at all.

To make things more complicated, her memory of language can change from day to day. One day she doesn’t know, the next, she does. Nancy L. Mace and Peter V Rabins in their book The 36-Hour Day describe it as a loose lightbulb, flickering on and off.

Using body language can often help in connecting wires.

• Point in the direction you want her to go.
• Gently put your arm under her elbow to guide her.
• If she seems confused by one word, use a word that’s similar to see if she remembers that one better.

Not understanding the words can frustrate her. The calmer you stay, the more likely she can process the word. Reassure her that it will be okay.

Does she understand the words individually? Now she needs to process what they mean together.

 4. “10-4, Good Buddy?”

Words can mean one thing on their own. But combined in a sentence, they need to be defined as a whole.

You’ve told her it’s time to change for bed. She remembers each word enough to know she needs to go into her room to do that.

But does she climb into bed with her regular clothes on? Try to change the sheets? Or hand you money because she thinks she needs to pay “change” for her bed like it’s a hotel?

Maybe she gets that it’s about dressing in her pajamas. But even those simple directions may need to be broken down into smaller steps.

• She needs to take off several pieces of clothing and put on several more. If she gets stuck on the order, (tries to put her pajamas on top of her shirt), give her gentle reminders.
• Let her do as much as she can, but if she gets stuck, break steps down even more. She can’t remember how to remove her sweater? Touch the edge of her sleeve as you remind her to pull her arm through.

And because dementia attacks her memories, she may have forgotten where she is.

Context matters, (that whole “context is king” thing), and it can completely change the meaning of your words.

If she thinks you’re a stranger and you’ve told her to change for bed? She may misunderstand it as an inappropriate suggestion.

• Gently reassure her that she’s safe.
• Again, your calm body language will help her process.
• And hold on to your sense of humor. This isn’t easy. But being willing to laugh about it is a great stress reliever for her and you.

Remember, Grandma isn’t trying to be mean or tasteless. Her brain just may not be able to process everything at once.

One way or another, once she does process it?

5. I Say “Jump,” You Say, …

Okay, you’re not really going to tell Grandma to jump. But I’m guessing you know how to finish that title without even thinking about it.

The thing is, even if Grandma hears your words, recalls them, understands what each one means, and can evaluate what they imply even in context, she might still struggle with the appropriate response.

• She says something that’s close to the correct word—like the same first letter—but not the right word. (“top” for “toe”)
• Or the word might have the same theme. (She asks for her hair but means her brush.)

One help? Often her nonverbal skills will be better than her verbal ones. Just like she can probably read your body language, you can often trust hers to show her meaning.

• Again, give her time.
• Don’t rush.
• Ask her to describe or point to what she wants.

If she can’t express her response, assure her it’s okay and change the subject to something else. Sometimes the very act of trying hard makes it harder.

Keep Calm and Hang On

You do your best to explain yourself well and to have her understand.

Unfortunately, sometimes the scrambled message her brain sends her has nothing to do with the message you gave.

• Redirect her while doing your best to treat her with the respect she deserves.
• Return often to that best of medicines. Laughter. (But make sure it’s with her, not at her.)
• Aim to keep your voice clear and understandable. (But avoid the sing-songy and patronizing.)
• She’s had a sudden change in her understanding? Have her checked for a UTI. Those pesky infections may have no other symptoms, but they really like to mess with brain function and memory.

But, through it all, take it easy on yourself, too. Your job in caring for someone with dementia or Alzheimer’s is not easy. Don’t do it alone. Caregiver burnout is a real thing.

If you are interested in assisted living and memory care for your loved one, turn to Frontida Assisted Living. Our experienced, patient, and caring staff is here to help your loved one be as comfortable as possible during this difficult time. Schedule a tour of one of our assisted living communities today.

Need more information? Check out these other helpful posts to learn more about dementia.

Elizabeth Daghfal is a writer, teacher, speaker, and community volunteer. When she isn't teaching or writing-- Who are we kidding? Her husband and five kids say she's ALWAYS teaching and writing. She has a passion to help people who are struggling and is happy to say her shoulders are drip-dry. Born and raised in the South, she now lives in Wisconsin and loves it--except for the fifteen months of winter. Read more about her at elizabethdaghfal.com.