Nursing Guide to Dementia: Nursing Diagnosis, Interventions, & Care Plans

Dementia general overview 

Dementia is a chronic, usually progressive syndrome that arises from various brain disorders and leads to disturbance of multiple higher cortical functions. These include memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment. Consciousness isn’t typically impaired. The cognitive decline is accompanied, and sometimes preceded, by a decline in emotional control, social behavior, or motivation. 

Dementia significantly interferes with a person's ability to complete everyday activities and maintain independence. It differs from normal aging. While older adults may occasionally forget names or misplace items, dementia involves consistent and progressive impairment that disrupts work, social relationships, and self-care. 

Nurses encounter people with dementia in almost every clinical setting: 

• Primary care and outpatient clinics
• Emergency departments
• Acute care and intensive care units (ICUs)
• Inpatient rehabilitation units
• Long-term care facilities
• Assisted living communities
• Home health and hospice
• Community and public health programs 

Nursing responsibilities include early recognition of cognitive changes, ongoing assessment, planning and implementing interventions, medication management, environmental safety, emotional support, caregiver education, and coordination with the interprofessional team. 

Key features of dementia: 

• Progressive decline in at least one cognitive domain
• Impact on functional status and independence
• Behavioral and psychological symptoms such as agitation, apathy, delusions, or sleep disturbance
• Increased vulnerability to delirium, falls, malnutrition, and polypharmacy
• High burden on caregivers and health systems 

Although most causes of dementia aren’t curable, timely diagnosis and high-quality nursing care can: 

• Slow functional decline
• Reduce complications such as falls and hospitalizations
• Decrease behavioral distress
• Improve quality of life for both individuals and caregivers
• Support person-centered, dignity-preserving care through all stages of the illness 

Dementia Etiology and epidemiology 

Common etiologies 

Dementia is a syndrome, not a single disease. Major etiologic types include: 

• Alzheimer's disease (AD)
  • Most common cause of dementia in older adults
  • Characterized by amyloid beta plaques and neurofibrillary tangles of tau protein
  • Gradual onset and continuous decline, typically with early memory impairment
  • Often associated with apathy, depression, and later language and visuospatial difficulties
• Vascular dementia (VaD)
  • Caused by cerebrovascular disease, including large vessel strokes and small vessel disease
  • May have stepwise decline after strokes or a more gradual course in small vessel disease
  • Often coexists with Alzheimer's pathology (mixed dementia)
  • Risk factors include hypertension, diabetes, hyperlipidemia, smoking, and atrial fibrillation
• Lewy body dementia (LBD)
  • Includes dementia with Lewy bodies and Parkinson's disease dementia
  • Features fluctuating cognition, visual hallucinations, REM sleep behavior disorder, and Parkinsonian motor symptoms
  • Individuals are highly sensitive to antipsychotic medications
• Frontotemporal dementia (FTD)
  • Earlier onset compared with Alzheimer's disease, often between ages 45 and 65
  • Prominent changes in personality, behavior, or language
  • Memory may be relatively preserved early
  • Subtypes include behavioral variant FTD and primary progressive aphasia
• Other causes
  • Normal pressure hydrocephalus
  • Chronic traumatic encephalopathy
  • Dementia associated with HIV infection
  • Dementia in Parkinson’s disease, Huntington's disease, or other neurodegenerative disorders
  • Metabolic or toxic causes, when chronic and severe 

Potentially reversible or partially reversible contributors 

Although classic neurodegenerative dementias aren’t reversible, certain conditions can cause or worsen cognitive impairment and should always be assessed: 

1. Vitamin B12 deficiency
2. Hypothyroidism or hyperthyroidism
3. Chronic intoxication or withdrawal (alcohol, sedative hypnotics)
4. Depression (often called "pseudodementia" when primary)
5. Normal pressure hydrocephalus
6. Chronic subdural hematoma
7. Medication adverse effects, especially anticholinergics, benzodiazepines, and opioids
8. Untreated sleep apnea 

Early identification and treatment of these conditions may stabilize or improve cognition. 

Epidemiology 

• Dementia is one of the leading causes of disability and dependency among older adults worldwide.
• Prevalence increases sharply with age. Rough estimates:
• Around five to eight percent of people over age 65 years old
• Around 15 to 20 percent of people over age 75 years old
• Over 30 percent of people over age 85 years old
• Women are diagnosed more often than men, partly because women live longer on average.
• The majority of people living with dementia reside in low- and middle-income countries, where services and diagnosis are often limited.
• Risk factors include:
  • Advanced age
  • Family history of dementia
  • Cardiovascular risk factors such as hypertension, diabetes, obesity, and dyslipidemia
  • Smoking
  • Physical inactivity
  • Traumatic brain injury (TBI) history
  • Lower educational level and limited cognitive stimulation 

Protective lifestyle factors include regular physical activity, social engagement, cognitive stimulation, and healthy diet patterns such as the Mediterranean style diet. 

ICD-10 code 

Dementia is coded in ICD-10 according to its cause and the presence of behavioral disturbances. Common examples relevant to nursing documentation and interdisciplinary communication include: 

Unspecified dementia 

• F03.90 Unspecified dementia without behavioral disturbance
• F03.91 Unspecified dementia with behavioral disturbance 

Used when the etiology isn’t specified or not clearly documented, such as in very advanced disease or when evaluation is incomplete. 

Alzheimer's disease with dementia 

Alzheimer’s disease codes are in the G30 category. Dementia associated with Alzheimer's disease is coded with additional F02 codes. 

Examples: 

• G30.0 Alzheimer's disease with early onset
• G30.1 Alzheimer's disease with late onset
• G30.8 Other Alzheimer's disease
• G30.9 Alzheimer's disease, unspecified 

Accompanying dementia codes: 

• F02.80 Dementia in other diseases classified elsewhere, without behavioral disturbance
• F02.81 Dementia in other diseases classified elsewhere, with behavioral disturbance 

In practice, coders often assign both the G30 code (for Alzheimer's disease) and the appropriate F02 code (for the dementia status and presence or absence of behavioral disturbance) according to coding guidelines. 

Vascular dementia 

• F01.50 Vascular dementia without behavioral disturbance
• F01.51 Vascular dementia with behavioral disturbance 

Other specified dementias 

Dementia associated with other neurologic diseases or conditions may also be coded with F02 categories, along with the primary disease code. Examples include dementia in Parkinson's disease, Huntington's disease, or HIV infection. 

Note: Actual coding should follow facility policy and current coding manuals. Nurses do not typically assign ICD-10 codes, but should document diagnoses, symptoms, and behavioral disturbances clearly to support accurate coding and reimbursement. 

Dementia Diagnosis 

Clinical criteria 

Diagnosis of dementia requires: 

• Evidence of significant cognitive decline from a previous level of performance in one or more areas:
• Complex attention
• Executive function
• Learning and memory
• Language
• Perceptual motor function
• Social cognition
• Cognitive deficits that hinder independence in everyday activities (at least requiring assistance with instrumental activities of daily living).
• Deficits that aren’t occurring exclusively during delirium.
• Deficits that aren’t better explained by another mental disorder, such as major depressive disorder. 

Components of a comprehensive evaluation 

History 

1. Onset: gradual vs sudden, early symptom type (memory, behavior, language).
2. Course: steady progression, stepwise decline, or fluctuating course.
3. Impact on daily activities: managing finances, medications, driving, cooking, housekeeping.
4. Behavioral and psychological symptoms: agitation, aggression, hallucinations, delusions, apathy, depression, anxiety, sleep disruption, wandering.
5. Medical history: cardiovascular disease, stroke, diabetes, thyroid disorders, falls, and head trauma.
6. Medication history: sedatives, anticholinergics, antipsychotics, opioids, polypharmacy.
7. Substance use: alcohol, illicit drugs.
8. Family history of dementia or neurodegenerative diseases.
9. Social history: living situation, support system, occupation, educational level. 

It is essential to obtain collateral information from family or caregivers because insight and recall are often impaired in individuals with dementia. 

Physical and neurologic examination 

• Vital signs and general appearance.
• Neurologic exam, including cranial nerves, motor function, sensation, reflexes, coordination, and gait.
• Signs of Parkinsonism, focal deficits, or other neurologic conditions.
• Assessment of vision and hearing. 

Cognitive assessment tools
Common standardized tools include: 

• Mini Mental State Examination (MMSE)
• Montreal Cognitive Assessment (MoCA)
• Mini Cognitive Assessment (Mini-Cog)
• Saint Louis University Mental Status (SLUMS) Examination 

These are screening tools and should not be used as the sole basis for diagnosis. They assist in establishing baseline function and monitoring changes over time. 

Functional assessment 

• Basic activities of daily living: bathing, dressing, toileting, transferring, continence, and feeding.
• Instrumental activities of daily living: using the telephone, shopping, food preparation, housekeeping, laundry, transportation, medication management, and handling finances. 

Laboratory evaluation 
Typical baseline tests may include: 

• Complete blood count
• Comprehensive metabolic panel
• Thyroid stimulating hormone
• Vitamin B12 level
• Folate level
• Liver and kidney function tests
• Consider HIV testing, syphilis testing, and others based on clinical context 

Neuroimaging 

• CT or MRI of the brain to exclude structural pathology such as tumors, chronic subdural hematoma, significant strokes, or normal pressure hydrocephalus.
• MRI is more sensitive to small vessel ischemic changes and hippocampal atrophy. 

Differentiating dementia from delirium and depression 

• Delirium has an acute onset, fluctuating course, impaired attention, and altered level of consciousness. It is usually caused by underlying acute illness, medications, or substance effects. People with dementia are at high risk for superimposed delirium.
• Depression can mimic dementia with poor concentration, low motivation, and slowed thinking. In depression, cognitive problems often improve with antidepressant treatment, and the person may be more aware of their deficits. 

Nurses play an important role in detecting sudden changes in cognition that suggest delirium, as well as monitoring mood symptoms that may indicate depression. 

Management 

Management of dementia is comprehensive and multidisciplinary. It includes medical, psychological, environmental, and social components. 

Pharmacologic management 

• Cognitive symptom management (primarily in Alzheimer's disease and some other dementias)
  • Cholinesterase inhibitors: donepezil, rivastigmine, galantamine
    • Aim to slow the decline in cognition and function in mild to moderate dementia.
    • Common side effects include nausea, vomiting, diarrhea, decreased appetite, bradycardia, and syncope.
  • NMDA receptor antagonist: memantine
    • Used in moderate to severe Alzheimer's disease, alone or with a cholinesterase inhibitor.
    • Side effects may include dizziness, headache, confusion, and constipation.
• Behavioral and psychological symptoms of dementia (BPSD)
  • First line: nonpharmacologic strategies such as environmental adjustments, routine structuring, addressing unmet needs, and caregiver training.
  • Medications may be considered when behaviors cause severe distress or safety risk and nonpharmacologic measures are insufficient. Possible options:
    • SSRIs for depression, anxiety, or some forms of agitation
    • Antipsychotics for severe psychosis, aggression, or agitation that threatens safety, used with extreme caution due to increased risk of stroke and mortality in older adults with dementia.
    • Mood stabilizers or other agents in selected cases. 

Nurses are crucial in: 

1. Monitoring therapeutic effects and side effects
2. Ensuring adherence
3. Reporting changes in cognition, mood, or behavior
4. Advocating for the lowest effective doses and regular attempts to taper medications when clinically possible 

Management of comorbid conditions 

• Aggressive control of blood pressure, diabetes, and lipid levels in vascular dementia
• Treatment of pain, constipation, infections, and other medical issues that may worsen confusion or behavior 

Nonpharmacologic management 

Nonpharmacologic strategies are central to dementia care. They’re often safer and can be highly effective when tailored to the individual. 

Key approaches: 

• Environmental modification
  • Simplify surroundings to reduce overstimulation and confusion.
  • Use clear signage, labels, and contrasting colors for orientation.
  • Ensure good lighting and reduce glare and shadows.
  • Maintain safe, uncluttered walking areas.
• Routine and structure
  • Establish predictable daily schedules for meals, personal care, activities, and sleep.
  • Maintain consistent caregivers when possible.
  • Avoid frequent or abrupt changes in environment or routine.
• Cognitive and social stimulation
  • Reminiscence therapy using photos, music, or familiar objects.
  • Conversation, reading aloud, or simple games.
  • Group activities appropriate to the person's abilities.
• Sensory-based interventions
  • Music therapy for agitation and mood.
  • Aromatherapy or massage to promote relaxation.
  • Pet therapy or robotic companion animals in some settings.
• Physical activity
  • Walking programs, gentle exercise classes, or range of motion activities.
  • Programmed activities help preserve mobility and reduce agitation.
• Sleep hygiene
  • Regular sleep and wake times.
  • Exposure to natural light during the day.
  • Limiting caffeine and daytime napping. 

Caregiver support and psychosocial care 

Caregivers often experience high levels of burden, stress, depression, and financial strain. Support strategies include: 

• Education about disease progression and realistic expectations.
• Training in communication skills and behavior management.
• Emotional support, counseling, and support groups.
• Respite care options and community resources.
• Assistance with future planning, including legal and financial issues. 

Nurses can advocate for caregiver assessments to be included in care plans and for community resources to be provided early in the disease course. 

Dementia nursing care plan 

A nursing care plan for a person with dementia should be individualized and updated regularly. Below is an example framework: 

Priority problems 

• Chronic confusion
• Risk for injury and falls
• Self-care deficits
• Disturbed thought processes
• Impaired verbal communication
• Imbalanced nutrition, less than body requirements
• Disturbed sleep pattern
• Caregiver role strain 

Example overall goals 

• The person will maintain the highest possible level of independence and cognitive function consistent with disease stage.
• The person will be free from preventable injury.
• Behavioral symptoms will be reduced to a level that does not cause significant distress or danger.
• The caregiver will verbalize understanding of the disease and demonstrate coping strategies.
• Quality of life will be optimized for the person and family. 

Planning considerations 

• Stage of dementia (mild, moderate, severe)
• Living situation and supports
• Cultural values and preferences
• Advance directives and goals of care
• Comorbid medical conditions 

Nursing considerations 

Nurses provide person centered care that preserves dignity and identity. 

Key considerations: 

• Communication strategies
  • Approach from the front and establish eye contact.
  • Use calm tone and simple words.
  • Ask one question at a time and avoid long explanations.
  • Allow time for responses.
  • Avoid arguing or trying to force the person to accept reality in cases of fixed delusions; instead, validate feelings and gently redirect when possible.
• Person-centered perspective
  • Learn the person's history, preferences, cultural background, and usual routines.
  • Use preferred names or nicknames.
  • Incorporate favorite activities, foods, and music into care.
• Behavior as communication
  • Recognize that agitation, aggression, or withdrawal often indicate unmet needs such as pain, fear, boredom, hunger, thirst, or the need to toilet.
  • Assess for triggers such as noise, crowding, invasive procedures, or rushed care.
• Pain assessment
  • Use appropriate tools for people with impaired communication, such as pain observation scales.
  • Monitor nonverbal cues: facial expressions, body movements, changes in behavior or function.
• Delirium prevention and recognition
  • Promote orientation using clocks, calendars, and familiar objects.
  • Maintain sleep-wake cycles and minimize nighttime disruptions.
  • Encourage mobility and hydration.
  • Monitor closely for acute changes in attention or consciousness that suggest delirium.
• Ethical and legal issues
  • Respect autonomy while protecting safety.
  • Support shared decision making involving the person, family, and healthcare proxy as appropriate.
  • Be familiar with local regulations about capacity, guardianship, driving, and restraint use. 

Assessment 

Nursing assessment for a person with dementia is ongoing and multidimensional. 

Cognitive and functional assessment 

1. Orientation to person, place, time, and situation
2. Ability to follow instructions
3. Short-term and long-term memory observations
4. Capacity to perform ADLs and IADLs
5. Need for supervision during mobility, toileting, and eating 

Behavioral and psychological symptoms 

• Presence of agitation, aggression, irritability, wandering, repetitive questioning, disinhibition, apathy, or withdrawal
• Timing, frequency, and severity of symptoms
• Triggers or antecedents and effective responses 

Using an antecedent behavior consequence (ABC) chart can help identify patterns and guide interventions. 

Physical health and risk assessment 

• Vital signs and pain level
• Nutritional status and weight trends
• Hydration, bowel, and bladder function
• Skin integrity and risk for pressure injury
• Fall risk assessment and history of falls
• Mobility level and use of assistive devices 

Social and caregiver assessment 

• Support network and primary caregiver
• Caregiver physical and mental health
• Caregiver understanding of dementia and coping strategies
• Financial and transportation limitations 

Nursing diagnosis or risk for 

Common nursing diagnoses include: 

• Chronic confusion related to progressive neurodegenerative changes, evidenced by disorientation, impaired memory, and difficulty with problem solving.
• Risk for injury related to impaired judgment, wandering, and decreased safety awareness.
• Self-care deficit (Specify: bathing, dressing, feeding, toileting) related to cognitive impairment and decreased motor planning.
• Impaired verbal communication related to cognitive decline and word-finding difficulty.
• Imbalanced nutrition: less than body requirements related to decreased appetite, forgetfulness, or dysphagia.
• Disturbed sleep patterns related to altered sleep-wake cycles and nocturnal confusion.
• Caregiver role strain related to increasing care demands, emotional burden, and lack of respite. 

These diagnoses guide targeted interventions and measurable outcomes. 

Interventions 

Nursing interventions are tailored to the stage of dementia and individual needs. 

Cognitive support and orientation 

• Provide clocks, calendars, and signage in the environment.
• Use consistent routines and caregivers.
• Offer simple explanations before care activities.
• Use reality orientation when it is comforting and not distressing. 

Safety interventions 

• Implement fall prevention strategies: nonslip footwear, bed in low position, call light within reach, frequent rounding.
• Use bed and chair alarms when appropriate and consistent with policy.
• Remove environmental hazards such as loose rugs and clutter.
• For wanderers, secure exits and use identification bracelets or other forms of safe tracking where available and ethically accepted. 

Support with ADLs 

• Encourage the person to do as much as possible independently, providing step-by-step guidance.
• Use adaptive equipment such as plate guards, large, handled utensils, or shower chairs.
• Provide clothing that is easy to put on and remove.
• Allow extra time for tasks without rushing. 

Behavioral symptom management 

• Identify and address any unmet physical needs such as hunger, thirst, need to toilet, pain, or fatigue.
• Reduce environmental triggers such as noise, crowds, or complex stimuli.
• Use calm, reassuring approaches during care.
• Redirect to structured activities that match the person's abilities.
• Offer meaningful occupation, such as folding towels, sorting objects, or simple crafts.
• Involve family to suggest activities that the person previously enjoyed. 

When medications are used for behavior, nurses monitor for effectiveness and adverse effects and advocate for ongoing review. 

Nutrition and hydration 

• Provide favorite foods and high calorie, nutrient dense options if intake is low.
• Offer small, frequent meals and snacks.
• Monitor swallowing and refer for speech language pathology evaluation if aspiration risk is suspected.
• Assist with feeding as needed while encouraging independence.
• Ensure adequate fluid intake and monitor for signs of dehydration. 

Sleep support 

• Encourage daytime activity and exposure to sunlight.
• Limit daytime napping, especially late in the day.
• Promote relaxing bedtime routines.
• Minimize nighttime noise and interruptions as much as possible in the care setting. 

Caregiver focused interventions 

• Provide clear, understandable education about the disease and expected progression.
• Demonstrate communication and behavior management techniques.
• Validate caregiver emotions and refer to support groups or counseling when needed.
• Provide information about respite care, home health, and adult day services. 

Expected outcomes 

Realistic outcomes for dementia care focus on maintaining function, preventing complications, and enhancing comfort and well-being. 

Examples of measurable outcomes: 

• The person remains free from falls and injury during the hospitalization or care period.
• The person maintains a stable weight or experiences minimal unintentional weight loss.
• Behavioral symptoms decrease in intensity or frequency as evidenced by fewer episodes of agitation or aggression per day.
• The person participates in ADLs with assistance appropriate to the disease stage.
• Caregiver verbalizes understanding of disease processes and demonstrates at least two effective coping strategies.
• Caregiver reports decreased stress after education and support interventions. 

Because dementia is progressive, goals often center on slowing decline, maintaining abilities for as long as possible, and optimizing comfort rather than cure. 

Individual or caregiver education 

Education is continuous and should be reinforced at multiple encounters. 

Key topics: 

• Understanding dementia
  • Explanation that dementia is a syndrome caused by disease in the brain, not a normal part of aging.
  • Overview of likely course and progression.
• Communication tips
  • Use short, simple sentences.
  • Avoid arguing about facts; instead, validate feelings.
  • Offer choices with limited options, such as "Would you like tea or juice?"
• Behavior management
  • Recognizing that behaviors are often responses to stress or unmet needs.
  • Strategies for redirecting, simplifying tasks, and creating a calm environment.
  • Avoiding physical confrontation when a person is agitated and focusing on safety.
• Home safety
  • Removing tripping hazards and securing loose rugs.
  • Installing grab bars in bathrooms and railings on stairs.
  • Locking or monitoring access to potentially dangerous items such as medications, cleaning agents, or tools.
  • Strategies for managing wandering, such as door alarms or alert systems.
• Health maintenance
  • Importance of regular medical follow-up.
  • Vaccinations, nutrition, hydration, and physical activity.
  • Monitoring for signs of infection, dehydration, or acute confusion that may signal delirium.
• Driving and safety in the community
  • Discussing when driving may no longer be safe.
  • Exploring alternatives for transportation.
• Legal and financial planning
  • Encouraging early conversations and documentation of wishes through advance directives and powers of attorney while the person retains decision-making capacity.
• Caregiver self-care
  • Recognizing signs of burnout and depression.
  • Seeking support through friends, family, faith communities, counseling, or support groups.
  • Using respite care and accepting help from others. 

Written materials in plain language, along with spoken explanations and demonstrations, are often helpful. 

Resources 

Nurses should be familiar with local and national resources for people with dementia and their caregivers. Examples include: 

1. National organizations dedicated to Alzheimer's disease and other dementias
2. Government or nonprofit agencies for aging services
3. Community-based programs such as adult day centers, memory cafes, and respite programs
4. Caregiver helplines, online education, and support groups
5. Legal aid services experienced in elder law and long-term care planning 

Referrals to occupational therapy, physical therapy, speech language pathology, social work, and case management are also valuable. 

References 

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 
• World Health Organization. (2012). Dementia: A public health priority. https://www.who.int/publications/i/item/dementia-a-public-health-priority 
• World Health Organization. (2016). International statistical classification of diseases and related health problems (10th rev.) (ICD-10). https://icd.who.int/browse10/2016/en  

Nurses can also reference clinical practice guidelines for dementia management from recognized professional organizations, such as geriatric and neurology societies. 

(Note: Specific guideline editions and years may vary by region and practice setting. Clinicians should consult the most current local and national guidelines available.)