Correctional Staff
Training: Proper Care of
Offenders with Dementia
Kentucky Public Health
Leadership Institute Group:
Dementia Militia
This training was created to provide the tools and skills
needed to enable Correctional Staff to effectively and
efficiently manage offenders suffering from the
cognitive disorder, dementia.
For more information please contact:
The Kentucky Department of Corrections
502-222-7808
Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Table of Contents
PG. 1
Purpose
PG. 2
PG. 3
PG. 8
PG. 9
PG. 16
PG. 19
Background Information: Dementia
Stages of Dementia and Behavioral Changes
Dementia Behavioral Management
Discharge Paperwork
Appendices
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Purpose: This manual has been developed to expand knowledge and enhance skills of correctional staff
assigned to work with offenders diagnosed dementia. The goals of this manual and training are to equip
staff with skills needed to effectively communicate with offenders diagnosed with dementia, to decrease
challenging behaviors associated with population; and to increase effective interactions with offenders
diagnosed with dementia.
Objectives:



Describe the stages of dementia
Apply relational skills
Demonstrate behavioral management skills for people with dementia
Target Audience: Correctional staff, including those from security, programs, mental health and medical
assigned to work in units that house offenders diagnosed with cognitive related disorders like dementia.
Materials and Equipment Needed:
 Audiovisual Equipment
 PowerPoint
 Markers
 Flip Charts
 White Board
 Snacks
 Drinks
 Music
Length of Training: 1-2 hours
How to Use the Manual: This manual will be used by the trainer to conduct the training class and Trainee
manual will be distributed to participants to not only assist in development of appropriate treatment
plans for institutional and community utilization, but also for the implementation of .
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Background Information: Dementia
I am not here anymore
Somewhere else is where I am
A place so hard to find,
You cannot see me here or visit me there
Or wish me out of this anywhere.
If this is where I am supposed to be,
Why can’t I find me?
Dementia is an umbrella term for a group of cognitive disorders typically characterized by memory
impairment, as well as marked difficulty in the domains of language, motor activity, object recognition,
and disturbance of executive function – the ability to plan, organize, and abstract. Generally speaking,
dementia is an illness of older adults, which suggests that as successive units of our population live
longer, it becomes more important to address the issue of dementia.1
Alzheimer’s Disease
(AD) is perhaps the most common form of dementia, although several others exist. AD is a progressive
disease of the brain. In the early stages, people experience some memory loss which progresses to
marked memory loss, then to a decrease in thinking ability such as decision making. 1
Later, the disease leads to the loss in the ability to perform activities of daily living or recognize loved
ones. The changes in the brain
that often mirror the decline
in thinking are the
development of plaques and
tangles in the brain.1
These changes may begin in
areas of the brain associated
with memory, but later
spread more widely
throughout the brain. The
plaques and tangles can lead
to a gradual loss of
connections between brain
cells and eventually cell
death.1
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Up to 5.3 million Americans currently
have AD. By 2050, the number is
expected to more than double due to
the aging of the population. AD is the
sixth leading cause of death in the
United States and is the fifth leading
cause among persons age 65 and
older.2
Figure 1 Represents data that
indicates in the United States, older
African Americans are probably about
twice as likely to have AD when
compared with the older white
population. Hispanics are about one
and half times as likely to have AD and
other dementias as older whites.
AD usually occurs in individuals who
are 60 years old and older. Starting at
age 65, the risk of developing the
disease doubles every five years. By age 85 years and older, between 25 and 50 percent of people will
exhibit signs of AD.2
Studies suggest increasing physical
activity, having a diet rich in fruits
and vegetables, maintaining social
engagement, and participating in
intellectually stimulating activities
may reduce the risk of developing the
disease. Some studies suggest that the
prevention of diseases that damage
blood vessels such as heart disease,
stroke, and type 2 diabetes may also
lessen the risk of AD. 2
Figure 2 represents lifetime risks of
AD for men and women of specific
ages. These differences in lifetime
risks between women and men are
largely due to the longer life
expectancy for women.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Correctional Facilities and Dementia
Over the past 30 years, according to a new report by the Congressional Research Service (CRS), the
federal prison population has jumped from 25,000 to 219,000 inmates, an increase of nearly 790 percent.
Swollen by such figures, for years the United States has incarcerated far more people than any other
country, today imprisoning some 716 people out of every 100,000.4 With more people are being
incarcerated and serving longer terms, providing care for these offenders is quickly become a concern for
correctional facilities.3
Research to date suggests that older offenders possess a physiological age approximately ten years in
excess of their chronological age, which can be explained by a number of factors. Many offenders
experience chronic health problems prior to or during incarceration as a result of poverty, diet,
inadequate access to healthcare, alcoholism, and
smoking and other substance abuse. 4
The psychological strains of prison life, including
separation from family, fear of victimization and the
prospect of spending a long period behind bars,
further accelerate the aging process and affect older
prisoners disproportionately. Additionally it is
argued that the predominance of young adults in
custody encourages inmates to view themselves as
‘elderly’ at a younger age as they begin to feel
distinct and disconnected from the majority of their
neighbors.4
This month
37,576
Americans will be
diagnosed with
Alzheimer’s
2
The treatment and management of dementia within
the prison system is imperative due to the different
stages of dementia. Within the mild stages of
dementia, offenders start to experience moodiness,
and personality changes. Offenders with moderate
dementia have difficulty following instructions and
performing tasks they once did with ease. Even simple tasks like eating or going to the bathroom
becomes increasingly difficult as the disease progresses.5
Being that dementia is so difficult to diagnose along with the lack of training and information given to
correctional officers, an offender exhibiting these changes may be subjected to disciplinary action due to
the lack of knowledge on the officers part. A highly structured regime with an emphasis on maintaining
order can easily mask issues of cognition among an ‘old and quiet’ population that pose little risk to
security. Despite the increase in older offenders, the majority of prison healthcare departments are
largely unfamiliar with the risks and needs associated with this age group, ensuring that many mental
health issues, including dementia, are likely to go unnoticed unless accompanied by extrovert behavior.4
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Mental health problems, particularly forgetfulness and disinterest, are often viewed merely as an
inevitable result of the aging process. With the exception of a tiny minority of costly specialist units,
establishments lack the resources to meet these challenges alone. While the number of older offenders
continues to rise, prisons around the globe are bearing the brunt of government cuts in the wake of the
financial crisis. 4
The offender population is aging rapid and correctional staff need to be trained to handle this booming
population. By equipping staff with skills needed to not only effectively communicate with offenders,
decrease challenging behaviors and to effectively interact with offenders diagnosed with dementia, not
only aides correctional facilities financially, but it also provides a healthier environment for the offender
and correctional officer. The provided training also supports the delivery of appropriate treatment
strategies and the smooth transition of offenders into the community. These efforts will improve public
health and judicial system both on an institutional and community level.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Symptoms of AD
AD affects people in different ways, but the most common symptom pattern begins with a gradually
worsening ability to remember new information. This occurs because disruption of the brain cell function
usually begins in brain regions, which is the area where new memories are formed. As damage spreads,
individuals experience other difficulties.
The following are warning signs of AD:
Memory loss that disrupts daily life
New problems with words in speaking or writing
Challenges in planning or solving problems
Misplacing things and losing the ability to retrace
steps
Decreased or poor judgment
Difficulty completing familiar tasks at home, at
work, or at leisure
Confusion with time or place
Withdrawal from work or social activities
Trouble understanding visual images and spatial
relationships
Changes in mood and personality
Diagnosis of AD
A patient’s primary care physician most commonly makes the diagnosis of AD. The physician obtains a
medical and family history, including psychiatric history and history of cognitive and behavioral changes.
Ideally, a family member or other individual close to the patient is available to provide input.
The patient undergoes conducts cognitive tests and physical and neurologic examinations. In addition,
the patient may undergo magnetic resonance imaging (MRI) scans to identify other causes of brain
changes, that would cause cogitative decline such as the presence of a tumor or evidence of a stroke,
which could cause cognitive decline.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Stages of Dementia
The three stages of AD typically identified are most often described as (1) mild/early stage, (2)
moderate/mid stage, or (3) severe/late stage. It is important to remember that it is often difficult to place
a person with AD in a specific stage, as stages may overlap.
Each stage may be as brief as one year or as long as ten years, as there are wide variations from
individual to individual. The intensity of change-sometimes subtle sometimes profound-varies widely
from case to case. The best refrain for those caring for a patient with AD is “The most predictable part of
AD is the unpredictability.”
Stage I: Mild/Early Stage
Alzheimer's-related changes can
begin in the brain as much as 10 to
20 years before the first symptoms
appear. As tangles and plaques form
in the brain, the areas of brain tissue
that are affected become damaged
and work less effectively.
The first sign of early or mild AD is
usually memory loss. A person with
mild AD may forget where he or she
put the car keys, or be unable to
remember the names of people and
objects. Sometimes people with mild
AD will substitute a real or made-up
word for the one they have forgotten,
such as saying "tiger" instead of "cat."
The difference between AD disease
and normal forgetfulness is that the
memory loss occurs with regularity.
Early
Middle
Early
Late Early
•Behavioral change
•Not remembering appointments
•Not recognizing once familiar faces
•Not storing recent information or events
•Getting lost
•Having difficulty finding words
•Misplacing needed items
•Being unable to make decisions or choices
•Finding it hard to concentrate
•Acting accusatory or paranoid
•Being unable to separate fact from fiction
•Being unable to translate thoughts into actions
•Misunderstanding what is being said
•Making mistakes in judgment
•Withdrawing, being frustrated and/or angry
•Losing ability to sequence tasks
•Speaking in rambling sentences
•Misusing familiar words
•Having difficulty writing
•Requiring supervision for activities of daily living
•Reacting less quickly
As the disease progresses, the
symptoms may become more
noticeable to family, friends, and coworkers. People with mild AD may
repeat questions, get lost in oncefamiliar areas, and have trouble remembering what they have just read or heard. It may be difficult, if not
impossible, for them to learn new things. As they become more forgetful, they will often get quieter or
withdraw from social situations out of embarrassment.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Organizational difficulties and poor judgment are two other hallmarks of mild Alzheimer's. Some people
at the mild AD stage start to experience moodiness and their personality changes. At this stage, dementia
can be diagnosed with a mental status exam and testing the person's knowledge of current events as well
as their ability to recount their own personal history and perform complex tasks (such as doing math
problems or paying bills).
Stage II: Moderate/Mid Stage
People with moderate AD may begin to have trouble recognizing their family members and friends. At
this stage, for example, a woman with AD may mistakenly believe that her niece is her daughter or her
husband is her father. She may not be able to remember her home address or telephone number, and
may forget what day of the week it is or simple details about her past, such as where she went to high
school.
Early Middle
Middle Middle
•Losing fine motor skills
•Having more serious difficulties with ADL
•Not recognizing objects for what they are
•Being unable to understand written words
•Possibly displaying more sexual interests
•Engaging in repetitious speech and action
•Having hallucinations and delusions
•Having problems with social appropriateness
•Experiencing altered visual perception
•Showing frequent changes of emotion
•Having minimal attention span
•Reacting castastrophically (overacting, having
outbursts)
•Needing assistance with all ADLs
•Walking with a shuffling gait
Those with moderate AD
may have difficulty following
instructions and performing
tasks they once did with
ease, such as getting dressed
(people with moderate AD
may put their underwear on
over their pants or try to
look for their lipstick in the
freezer) or adding numbers
in a checkbook. Even simple
tasks like eating or going to
the bathroom will become
increasingly difficult as the
disease progresses.
People with moderate AD
may have trouble sleeping
through the night, they will
take naps during the day. As
the disease worsens, they
may eventually spend much
of their day asleep.
Personality changes become
more pronounced by the
moderate stage of
Alzheimer's. People at this stage may experience hallucinations (seeing and hearing things that aren't
there), delusions (mistaken beliefs), paranoia (accusing others of lying, cheating, or stealing from them),
and compulsive behaviors (rubbing their hands together over and over or tearing tissues into tiny
pieces). They may become angry and even violent, (hitting, kicking, or screaming) out of frustration.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Stage III: Severe/Late Stage
People with severe AD are virtually unable to respond to the people around them. They lose the ability to
walk, talk, and care for themselves. They must rely on caregivers to handle even their most basic needs,
including eating, washing, and going to the bathroom. Instead of communicating, they may repeatedly
cry out, groan, or scream.
People at the end of this AD
stage can no longer sit
unsupported or hold up their
head. They have trouble
eating or refuse to eat because
swallowing is difficult. They
are unable to control their
urination or bowel
movements.
Late Middle
Late Final
•
•
•
•
Being incontinent
Being mostly unintelligible
Exhibiting a downward gaze
Being unable to separate or recognize sounds
• Losing all language
• Losing gross motor skills (sitting, walking)
• Needing total care
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Behavioral Management of Dementia
Physical Environment
 Reduce Noise
 The reduction of noise is important in the behavioral management of dementia. Individuals
with this diagnosis may be vulnerable to excessive noise in their living area.
 For example, the following noises may tend to overstimulate and/or agitate an inmate with
dementia:
Televisions
Radios
Washing Machines
Car Backfiring
Running Water
Flushing Toilets
Dangling/ Jingling Keys
High Heels
 It is important to monitor for the type of noise that impacts the inmate. When trying to sort out
simple information, remember (background noises e.g. birds singing or a washing machine
operating) may totally interfere with the inmate’s ability to understand what is trying to be
communicated. If a person becomes frightened by a noise, try to explain the source of the
noise.
 Adequate Lighting
 Appropriate individualized lighting strategies are important to the behavioral management of
offenders with dementia. Some individuals may need increased lighting to manage the sun
downing syndrome while others may be better managed by keeping to a strict night and day
schedule with lighting.
 For example, nighttime incontinence might be the result of someone not being able to find the
restroom at night. Reflector tape can be used to run from bedroom to bathroom to assist in
providing light.
 Acceptable Temperature
 Temperature is another area that needs to be monitored and may need to be individualized for
the inmate. As the inmate’s disease progresses it may become impossible for him or her to tell
you that he or she is uncomfortable, but you may notice subtle facial changes and can gauge a
persons’ temperature by touching their hands.
 For example, Making a blanket or sweater available and easily accessible will be helpful.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
 Increase Personal Space
 People with dementia may be sensitive to how close in proximity you are in relation to them. It
is best to approach people with this disorder from a further distance away and then gradually
come closer to them, explaining in short simple sentences what you intend to do.
Caregiver Strategies
 Redirect and Distract
 The person with dementia may begin to talk about events that are distressing or that are
irrelevant to the situation. Instead of arguing with the person, it may be best to try to find a
topic that is positive and familiar to the person.
 Trigger Modification
 When caring for a person with dementia, there may be triggers in the environment that result
in positive or negative memories. When this happens it may be best to calm the patient by
making reassuring statements and then change the stimulus that created distress.
 Positive Reinforcement
 If the person with dementia does something appropriate, it is recommended that those
behaviors be rewarded by verbal praise.
 Differential Reinforcement
 If a person with dementia presents with something negative, then replace the behavior, i.e.
help the person do something positive and then reinforce the positive. It is neither necessary
nor helpful to punish the negative behavior what is most important is the rewarding of the
positive behavior.
Social Environment
 Individualize Social Activities
 People with dementia enjoy activities just like everyone else, but their physical and mental
health may prevent them from engaging in these behaviors to the extent that others do.
 For example, if someone enjoys walking, a short walk is recommended.
 Structured Environment
 Having a daily routine can be reassuring to someone who is struggling to make sense of his or
her environment.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
 For examples, activities like meal times, medication times, recreational events, bathing times,
and bed times occurring on a regular schedule can provide a sense of security which helps
diminish feelings of helplessness in the offender.
 Increased Staff Presence
 This population can be challenging for even the most seasoned caregivers. Sometimes the
memory problems on the part of the offender with dementia can frustrate staff. When
frustrations build then it can be helpful to have additional support or staff available to help
share the responsibilities.
 Regulate Interactions
 Managing interactions between offenders is important since as the disease progresses they
may have trouble understanding or reading social cues. It will be easier for offenders with
dementia to misinterpret the intentions of others.
 It will also be important for you to manage your own reactions to the behavior of the offender
as they may readily misread your facial expressions or body language. Try to make sure that
your body language and verbal communications match.
 Keep Group Size Small and Manageable
 If group sizes are small, it will not be as overwhelming for the offenders in the group or for the
caregiver. There are fewer variables to manage within a small group size.
 Limit Choices (Keep It Simple)
 Due to the number of problems in understanding and limited verbal communication skills, it is
important to give a small number of choices.
 Create Environmental Cues
 Placing visual cues in the physical environment can help the person anticipate his or her
schedule for the day and prepare them for engagement in these activities.
 For example, a daily schedule posted in the same location, a towel in the cell on the day for
bathing, reflective tape to the toilet, or using bright paper to show where the cup on the table
should be placed may help the offender prepare for daily activities.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
 Separate Hostile Parties
 Since there is a likelihood that social cues can be misinterpreted, the chances for
disagreements increases. When this happens, it is best to separate the two parties.
Cognitive Interventions
 Reality Orientation (within reason)
 People with dementia have a difficult time with the “who, what, when, where and why.”
Therefore it is okay to reorient people to their surroundings, e.g. this is your room, this is the
bathroom. It is less helpful to remind people with dementia of losses that they have
experienced throughout their life, i.e. deaths.
 For example, if an offender is talking about a visit from his or her mother and you know that
that person has died, it is not recommended that you share this information. In order to avoid
distress, use redirection or distraction.
 Validation
 Within reason agree, with the statements made by offenders with dementia. Instead of arguing
with the offender try to find something that you can agree on and lead the conversation that
way.
 Reminiscence
 It may be helpful for the offender with dementia to revisit experiences and memories from his
or her past. This can provide a sense of comfort or reassurance to the offender. However, If he
or she, start reminiscing about the crime, distraction may be the best bet.
 Life Review
 The offender with dementia will remember his or her past more readily than recent events. We
all love telling a good story from our past and people with dementia will as well. Sometimes
therapists will help the offender with dementia create a scrapbook of memories that they may
use to help aid in telling this story. These stories and pictures may be a comfort to the offender
 Visual and Spatial Exercises
 Just like your body needs exercise to perform at its best, so does your brain. This is especially
important for people with dementia who will not remember that they need to exercise this
muscle. That is why it is important for us to assist in these activities by engaging the offender
with dementia in activities like matching their socks, matching laundered scrubs or completing
simple puzzles.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Sensory Interventions
 Sounds
 Music, (theirs, not yours) can change the mood of the offender who has a diagnosis of
dementia. Musical rhythm can resynchronize or reset the timing process of the brain.
 For example, watching music videos, listening to music from his or her past, playing a musical
instrument may be helpful.
 Television can sometimes be the background noise that interferes with the offender’s
understanding. Television noise or other background noise can contribute to agitation or
overstimulation. Soothing sounds and white noise may be helpful in this area.
 Light therapy
 Exposure to limited daylight in this population can interfere with the body clock. Use of a Light
lamp can help diminish agitation especially in the later stages of dementia. Light exposure can
also have an impact on Sundowners Syndrome, (insert description).
 Food Preferences
 Find out about the offender’s preferences, e.g. what the favorite foods are, whether they like
hot or cold tea. Routine and familiarity are the cornerstones of care in this population.
Individualize where possible and change as needed. Not all changes that you make will work permanently. Just like
you or I change our opinions on what we want, the person with dementia may also change his or her wishes.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Treatment Team Discharge Summary for Families
Date:_____________________________________________ Patient Name:__________________________________________
Date of Birth:____________________________________________________________
Medications: ____________________________________________________________
Follow-up Appointments Needed: ___________________________________________
During the patient’s stay with DOC the following strategies were found to be helpful
Physical Environmental Needs: Patient responds best to
 Noise levels


Use of Lights


Room Temperature

 Personal Space

Caregiver Support: Patient responds best to this type of
 Redirection

 Distraction

 Reinforcement

Sensory Interventions: Patient enjoys the following
 Music

 Food

 Lighting

Patient’s Daily Schedule has been:
8:00A
4:00P
10:00A
6:00P
12:00P
8:00P
2:00P
10:00 P
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Patient Review
Inmate Name:_______________________________________ Inmate Number: _____________________________________________
Patient Review (circle appropriate)
3 Month
6 Months
Other
Diagnosis:
Axis I
Axis II
Axis III
Axis IV
Axis V
GAF
Medications:
1.
4.
7.
10.
2.
3.
5.
6.
8.
9.
11.
12.
Compliance Issues________________________________________________________
Treatment Goals:

Long Term
1.
2.
3.
Treatment Goals:

Short Term
1.
2.
3.
Please provide additional information as to how the offender is responding to the physical environment,
including noise levels, lighting, routines, nonverbal communications, redirections, distractions,
reinforcements. This information will be forwarded in summary form to the family of the inmate at
discharge.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
EVALUATION FORM
Training: Proper Care of Offenders with Dementia
Presenter:
Date:
Please indicate your agreement/disagreement with the following statements by circling the appropriate number
for each statement.
1. INSTRUCTOR(S):
a. well prepared
………………………………..
b. concepts clearly explained……………………
c. responsive to questions……………………….
d. free from bias or stereotyping…………………
Strongly
Agree
Agree
Neutral
Disagree
Strongly
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2. CONTENT/FORMAT/LEARNING
a. workshop description accurate………………..
b. new skill or knowledge acquired…….……….
c. teaching format/length suitable to content……
d. teaching level appropriate to audience……….
e. participant/instructor interaction sufficient….
f. audiovisual aids legible and helpful (if given)..
g. reflective of respect for diversity…………….
h. handouts: current and useful (if given)………
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3. OVERALL RATING
a. workshop met or exceeded expectations……..
b. workshop should be offered again……………
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4. LOGISTICS/staff
a. enrollment smooth and efficient………………
b. staff responsive and helpful…………………..
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5. Please note below any comments and recommendations for change if workshop is presented again, i.e., length,
handouts, format, etc. Also, please make suggestions for future workshop topics or other general comments.
Your Name (Optional):
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Role-play Handout
Role-play #1
Inmate with dementia
You are waiting for your mother to come visit. You do not remember that she passed away 10 years ago.
You insist that she is coming to visit you today and you want to wait on a chair in the hallway so that you
will see her when she arrives.
Correctional staff person
You know that this inmate’s mother is deceased. It is necessary that the hallway be cleared, so you need
to get the inmate to move from his chair. You are fairly certain that the inmate will not want to leave the
hallway.
Discussion points:
 Do you inform him that his mother is no longer alive?
 Is there a way to improve the likelihood that he will move from the hallway without becoming
agitated?
 How can you use what you know about dementia to work with this inmate?
Suggestions:
If he believes his mother is alive, it is likely that he will grieve her death all over again if you inform him
that she has passed away. He does not remember that she has passed away.
One approach is to engage him in conversation about his mother. Ask him to tell you about her. What are
some special things about her? If he mentions something such as his mother’s delicious homemade fruit
pies, listen to him and have a conversation about that.
Then you might suggest that a snack is available and ask him to walk with you to the cafeteria. If he still
wants to wait in the hallway, you could reassure him that staff will let him know when his mother arrives.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Role-play #2
Inmate with dementia
You become agitated whenever a particular staff person approaches you. You feel confused and
somewhat threatened, which causes you to start to become combative.
Correctional staff person
You are a friendly person who whistles a lot at work because often it seems to brighten the day for you
and others around you. You also like to jangle your keys as you walk around. You have been told all of
your life that you have a nice loud voice that carries well. You also are someone who believes that to
truly communicate with someone, a close, face-to-face approach is best.
Discussion points:
 Is there a pattern of the inmate becoming agitated on a regular basis when this staff person is
around?
 If there is a pattern, can you identify particular characteristics of the staff-inmate interaction that
could be contributing to the agitation?
 What changes could be made in this situation to decrease the feelings of confusion and threat that
lead to the inmate becoming agitated?
 How can you use what you know about dementia to work with this inmate?
Suggestions:
Remember that people with dementia can be very sensitive to excessive noise and can become
overstimulated or agitated by different types of noises that someone else might not even notice. The
effects of noise on an inmate with dementia will vary, depending upon the person.
What bothers one person might not affect somebody else, so it is important to monitor for the type of
noise that seems to have a negative effect on that particular inmate. In this scenario, the staff person
might want to take a break from whistling around this inmate, make an effort to stop jangling keys and
talk more quietly.
Also remember that a person with dementia might need more personal space or he will begin to feel
threatened. Approach him from a distance, then gradually come closer. As you approach him, explain in
short, simple sentences what you intend to do. Example: “Mr. Doe, it’s time for lunch now. Let’s walk to
the cafeteria. We’ll walk straight down this hallway. Come with me.”
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Role-play #3
Inmate with dementia
It is 6:00 pm. You ate dinner a while ago and now you are looking out your window. You begin to feel
agitated, fearful and depressed. You begin to feel pretty certain that people are saying things and doing
things to hurt you. You become restless and pace back and forth.
Correctional staff person
You work on the second shift and according to the notes in the log from other shifts, this particular
inmate seems to have a much harder time during your shift. You try to engage the inmate in
conversation, but have a difficult time doing so because of his behavior.
Discussion points:
 Why might the inmate be doing worse during second shift? Is this a consistent pattern?
 What things would you consider when trying to figure out what is causing the change in behavior
on second shift?
 How can you use what you know about dementia to work with this inmate?
Suggestions:
It is possible that the inmate is experiencing “sundowner’s syndrome” or the “sundowning effect”.
Symptoms of this syndrome occur in late afternoon or evening. Symptoms can include rapid mood
changes, anger, crying, agitation, pacing, fear, depression, stubbornness, restlessness, rocking, paranoia,
hallucinations and wandering. If there is a consistent change in behavior each evening, the sundowning
effect should be considered.
Although there is not a particular treatment that will help everyone who suffers from the sundowning
effect, there are a few techniques that might help. Soothing music or recordings of other sounds, such as
ocean waves, might help calm the agitation. Light therapy can also be helpful for some individuals.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Caregivers Action Sheets
Caring for a loved one with dementia poses many challenges for families and caregivers. Below are some actions
sheets that provide some practical strategies for dealing with the troubling behavior problems and communication
difficulties often encountered when caring for a person with dementia.
Some of the greatest challenges of caring for a loved one with dementia are the personality and behavior changes
that often occur. You can best meet these challenges by using creativity, flexibility, patience and compassion. It also
helps to not take things personally and maintain your sense of humor.
Handling Troubling Behavior

We cannot change the person
Try to accommodate the behavior, not control the behavior.
For example, if the person insists on sleeping on the floor,
place a mattress on the floor to make him more comfortable.



Check with the doctor first
Remember that we can change our behavior or the physical
environment. Changing our own behavior will often result in a
change in our loved one’s behavior.
Behavioral problems may have an underlying medical reason:
perhaps the person is in pain or experiencing an adverse side
effect from medications.
Behavior has a purpose
In some cases, like incontinence or hallucinations, there may
be some medication or treatment that can assist in managing
the problem.
People with dementia typically cannot tell us what they want
or need. They might do something, like take all the clothes out
of the closet on a daily basis, and we wonder why. It is very
likely that the person is fulfilling a need to be busy and
productive.
Behavior is triggered
Always consider what need the person might be trying to meet
with their behavior—and, when possible, try to accommodate
them.
It is important to understand that all behavior is triggered—it
doesn’t occur out of the blue. It might be something a person
did or said that triggered a behavior or it could be a change in
the physical environment.
The root to changing behavior is disrupting the patterns that
we create. Try a different approach, or try a different
consequence.
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Correctional Staff Training: Proper Care of Offenders with Dementia 2013

What works today, may not tomorrow
The multiple factors that influence troubling behaviors and the
natural progression of the disease process means that
solutions that are effective today may need to be modified
tomorrow—or may no longer work at all.
The key to managing difficult behaviors is being creative and
flexible in your strategies to address a given issue.

Get support from others
You are not alone—there are many others caring for someone
with dementia.
Call your local Area Agency on Aging, the local chapter of the
AD Association. You can request more information at 1800 272
3900 or at alz.org
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Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Wandering
People with dementia walk, seemingly aimlessly, for a variety of reasons such as boredom, medication side effects
or to look for “something” or someone. They also may be trying to fulfill a physical need—thirst, hunger, a need to
use the toilet or exercise. Discovering the triggers for wandering are not always easy, but they can provide insights
to dealing with the behavior.

Make time for regular exercise to minimize restlessness.

Consider installing new locks that require a key. Position locks high or low on the door; many people with
dementia will not think to look beyond eye level. Keep in mind fire and safety concerns for all family
members; the lock(s) must be accessible to others and not take more than a few seconds to open.

Try a barrier like a curtain or colored streamer to mask the door. A “stop” sign or “do not enter” sign also
may help.

Place a black mat or paint a black space on your front porch; this may appear to be an impassable hole to
the person with dementia.

Add “child-safe” plastic covers to doorknobs.

Consider installing a home security system or monitoring system designed to keep watch over someone
with dementia. Also available are new digital devices that can be worn like a watch or clipped on a belt that
use global positioning systems (GPS) or other technology to track a person’s whereabouts or locate him if
he wanders off.

Put away essential items such as the confused person’s coat, purse or glasses. Some individuals will not go
out without certain articles.

Tell neighbors about your relative’s wandering behavior and make sure they have your phone number.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Incontinence
The loss of bladder or bowel control often occurs as dementia progresses. Sometimes accidents result from
environmental factors; for example, someone can’t remember where the bathroom is located or can’t get to it in
time. If an accident occurs, your understanding and reassurance will help the person maintain dignity and
minimize embarrassment.
 Establish a routine for using the toilet. Try reminding the person or assisting her to the bathroom
every two hours.
 Schedule fluid intake to ensure the confused person does not become dehydrated. However, avoid
drinks with a diuretic effect like coffee, tea, cola, or beer. Limit fluid intake in the evening before
bedtime.
 Use signs (with illustrations) or reflective tape to indicate which door leads to the bathroom.
 A commode, obtained at any medical supply store, can be left in the bedroom at night for easy
access.
 Incontinence pads and products can be purchased at the pharmacy or supermarket. A urologist
may be able to prescribe a special product or treatment.
 Use easy-to-remove clothing with elastic waistbands or Velcro closures, and provide clothes that
are easily washable.
 Establish a routine for using the toilet. Try reminding the person or assisting her to the bathroom
every two hours.
 Schedule fluid intake to ensure the confused person does not become dehydrated. However, avoid
drinks with a diuretic effect like coffee, tea, cola, or beer. Limit fluid intake in the evening before
bedtime.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Agitation
Agitation refers to a range of behaviors associated with dementia, including irritability, sleeplessness, and verbal
or physical aggression. Often these types of behavior problems progress with the stages of dementia, from mild to
more severe. Agitation may be triggered by a variety of things, including environmental factors, fear and fatigue.
Most often, agitation is triggered when the person experiences “control” being taken from him.
 Reduce caffeine intake, sugar and junk food.
 Reduce noise, clutter or the number of persons in the room.
 Maintain structure by keeping the same routines. Keep household objects and furniture in the same
places. Familiar objects and photographs offer a sense of security and can suggest pleasant
memories.
 Try gentle touch, soothing music, reading or walks to quell agitation. Speak in a reassuring voice.
Do not try to restrain the person during a period of agitation.
 Keep dangerous objects out of reach.
 Allow the person to do as much for himself or herself as possible—support his independence and
ability to care for himself.
 Acknowledge the confused person’s anger over the loss of control in his or her life. Tell him or her
you understand his frustration.
 Distract the person with a snack or an activity. Allow him to forget the troubling incident.
Confronting a confused person may increase anxiety.
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Repetitive speech or actions (perseveration)
People with dementia will often repeat a word, statement, question or activity over and over. While this type of
behavior is usually harmless for the person with dementia, it can be annoying and stressful to caregivers.
Sometimes the behavior is triggered by anxiety, boredom, fear or environmental factors.

Provide plenty of reassurance and comfort, both in words and in touch.

Try distracting with a snack or activity.

Avoid reminding them that they just asked the same question. Try ignoring the behavior or question and
distract the person into an activity.

Don’t discuss plans with a confused person until immediately prior to an event.

You may want to try placing a sign on the kitchen table, such as, “Dinner is at 6:30” or “Lois comes home at
5:00” to remove anxiety and uncertainty about anticipated events.

Learn to recognize certain behaviors. An agitated state or pulling at clothing, for example, could indicate a
need to use the bathroom.
Paranoia
Seeing a loved one suddenly become suspicious, jealous or accusatory is unsettling. Remember, what the person is
experiencing is very real to them. It is best not to argue or disagree. This is part of the dementia—try not to take it
personally.

If the confused person suspects’ money is “missing,” allow her to keep small amounts of money in a pocket
or handbag for easy inspection.

Help them look for the object and then distract them into another activity. Try to learn where the confused
person’s favorite hiding places are for storing objects, which are frequently assumed to be “lost.” Avoid
arguing.

Take time to explain to other family members and home-helpers that suspicious accusations are a part of
the dementing illness.

Try nonverbal reassurances like a gentle touch or hug. Respond to the feeling behind the accusation and
then reassure the person. You might try saying, “I see this frightens you; stay with me, I won’t let anything
happen to you.”
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Kentucky Department of Corrections
Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Sleeplessness/Sundowning
Restlessness, agitation, disorientation and other troubling behavior in people with dementia often get worse at the
end of the day and sometimes continue throughout the night. Experts believe this behavior, commonly called
sundowning, is caused by a combination of factors, such as exhaustion from the day’s events and changes in the
person’s biological clock that confuse day and night.

Increase daytime activities, particularly physical exercise. Discourage inactivity and napping
during the day.

Watch out for dietary culprits, such as sugar, caffeine and some types of junk food. Eliminate or
restrict these types of foods and beverages early in the day. Plan smaller meals throughout the day,
including a light meal, such as half a sandwich, before bedtime.

Plan for the afternoon and evening hours to be quiet and calm; however, structured, quiet activity
is important. Perhaps take a stroll outdoors, play a simple card game or listen to soothing music
together.

Turning on lights well before sunset and closing the curtains at dusk will minimize shadows and
may help diminish confusion. At minimum, keep a nightlight in the person’s room, hallway and
bathroom.

Make sure the house is safe: block off stairs with gates, lock the kitchen door and/or put away
dangerous items.

As a last resort, consider talking to the doctor about medication to help the agitated person relax
and sleep. Be aware that sleeping pills and tranquilizers may solve one problem and create
another, such as sleeping at night but being more confused the next day.

It’s essential that you, the caregiver, get enough sleep. If your loved one’s nighttime activity keeps
you awake, consider asking a friend or relative, or hiring someone, to take a turn so that you can
get a good night’s sleep. Catnaps during the day also might help.
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Eating/Nutrition
Ensuring that your loved one is eating enough nutritious foods and drinking enough fluids is a challenge. People
with dementia literally begin to forget that they need to eat and drink. Complicating the issue may be dental
problems or medications that decrease appetite or make food taste “funny.” The consequences of poor nutrition
are many, including weight loss, irritability, sleeplessness, bladder or bowel problems and disorientation.

Make meal and snack times part of the daily routine and schedule them around the same time
every day. Instead of three big meals, try five or six smaller ones.

Make mealtimes a special time. Try flowers or soft music. Turn off loud radio programs and the TV.

Eating independently should take precedence over eating neatly or with “proper” table manners.
Finger foods support independence. Pre-cut and season the food. Try using a straw or a child’s
“sippy cup” if holding a glass has become difficult. Provide assistance only when necessary and
allow plenty of time for meals.

Sit down and eat with your loved one. Often they will mimic your actions and it makes the meal
more pleasant to share it with someone.

Prepare foods with your loved one in mind. If they have dentures or trouble chewing or
swallowing, use soft foods or cut food into bite-size pieces.

If chewing and swallowing is an issue, try gently moving the person’s chin in a chewing motion or
lightly stroking their throat to encourage them to swallow.

If loss of weight is a problem, offer nutritious high-calorie snacks between meals. Breakfast foods
high in carbohydrates are often preferred. On the other hand, if the problem is weight gain, keep
high-calorie foods out of sight. Instead, keep handy fresh fruits, veggie trays and other healthy lowcalorie snacks.
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Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Bathing
People with dementia often have difficulty remembering “good” hygiene, such as brushing teeth, toileting, bathing
and regularly changing their clothes. From childhood we are taught these are highly private and personal activities;
to be undressed and cleaned by another can feel frightening, humiliating and embarrassing. As a result, bathing
often causes distress for both caregivers and their loved ones.

Think historically of your loved one’s hygiene routine – did she prefer baths or showers? Mornings
or nights? Did she have her hair washed at the salon or do it herself? Was there a favorite scent,
lotion or talcum powder she always used? Adopting—as much as possible—her past bathing
routine may provide some comfort. Remember that it may not be necessary to bathe every day—
sometimes twice a week is sufficient.

If your loved one has always been modest, enhance that feeling by making sure doors and curtains
are closed. Whether in the shower or the bath, keep a towel over her front, lifting to wash as
needed. Have towels and a robe or her clothes ready when she gets out.

Be mindful of the environment, such as the temperature of the room and water (older adults are
more sensitive to heat and cold) and the adequacy of lighting. It’s a good idea to use safety features
such as non-slip floor bath mats, grab-bars, and bath or shower seats. A hand-held shower might
also be a good feature to install. Remember—people are often afraid of falling. Help them feel
secure in the shower or tub.

Never leave a person with dementia unattended in the bath or shower. Have all the bath things you
need laid out beforehand. If giving a bath, draw the bath water first. Reassure the person that the
water is warm—perhaps pour a cup of water over her hands before she steps in.

If hair washing is a struggle, make it a separate activity. Or, use a dry shampoo.

If bathing in the tub or shower is consistently traumatic, a towel bath provides a soothing alternative. A bed bath has traditionally been done with only the most frail and bed-ridden patients,
soaping up a bit at a time in their beds, rinsing off with a basin of water and drying with towels.

Towel Bath: The towel bath uses a large bath towel and washcloths dampened in a plastic bag of
warm water and no-rinse soap. Large bath-blankets are used to keep the patient covered, dry and
warm while the dampened towel and washcloths are massaged over the body.
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Correctional Staff Training: Proper Care of Offenders with Dementia 2013
Additional Problem Areas
Dressing




Hallucinations



Sexually Inappropriate Behavior



Choose loose-fitting, comfortable clothes with easy zippers or snaps
and minimal buttons.
Reduce the person’s choices by removing seldom-worn clothes
from the closet.
To facilitate dressing and support independence, lay out one article
of clothing at a time, in the order it is to be worn.
Remove soiled clothes from the room. Don’t argue if the person
insists on wearing the same thing again.
State simply and calmly your perception of the situation, but avoid
arguing or trying to convince the person their perceptions are
wrong.
Keep rooms well-lit to decrease shadows, and offer reassurance and
a simple explanation if the curtains move from circulating air or a
loud noise such as a plane or siren is heard.
Distractions may help. Depending on the severity of symptoms, you
might consider medication.
Remember, this behavior is caused by the disease. Talk to the
doctor about possible treatment plans.
Develop an action plan to follow before the behavior occurs, i.e.,
what you will say and do if the behavior happens at home, around
other adults or children.
If you can, identify what triggers the behavior.
Verbal Outbursts

React by staying calm and reassuring. Validate your loved one’s
feelings and then try to distract or redirect his attention to
something else.
Shadowing

“Shadowing” is when a person with dementia imitates and follows
the caregiver, or constantly talks, asks questions and interrupts.
Like sundowning, this behavior often occurs late in the day and can
be irritating for caregivers. Comfort the person with verbal and
physical reassurance.
Distraction or redirection might also help. Giving your loved one a
job such as folding laundry might help to make her feel needed and
useful.


Uncooperative and Resistant Behavior



Often this is a response to feeling out of control, rushed, afraid or
confused by what you are asking of them.
Break each task into steps and, in a reassuring voice, explain each
step before you do it. Allow plenty of time.
Find ways to have them assist to their ability in the process, or
follow with an activity that they can perform.
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Bibliography
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Chronic Disease Prevention and Health Promotion. (2011). Dementia/alzheimer's disease.
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Health Promotion website: http://www.cdc.gov/mentalhealth/basics/mentalillness/dementia.htm
2. Alzheimer Association. 2012 Alzheimer disease facts and figures. Alzheimer Disease and
Dementia: The Journal of the Alzheimer Disease Association. March 2012; 8:131–168.
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http://www.ipsnews.net/2013/02/u-s-prison-population-seeing-unprecedented-increase/
4. Moll, A. (2013, 02). Losing track of time: Dementia and the ageing prison population. Retrieved
from http://www.mentalhealth.org.uk/publications/losing-track-of-time/
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