The “small things” of care are particularly important in ensuring that care is genuinely supportive of the individual and enhances that person’s autonomy and well-being. The humanity with which assistance for everyday living is offered, especially help with eating and intimate care, is crucial in helping the person retain their self-esteem and dignity.

Nuffield Council on Bioethics

Activities of daily living (ADLs) are the tasks we do during our daily lives. ADLs can be divided into basic ADLs and instrumental ADLs. Basics ADLs are the skills needed to take care of personal needs such as:

• eating
• bathing and showering
• grooming
• walking
• dressing and undressing
• transfers
• toileting

Instrumental ADLs (IADLs) are the skills we need to function within the community such as:

• financial management
• shopping
• preparing meals
• communicating with the outside world
• medical and medication management

Promoting independence in a person living with dementia requires patience and the ability to understand and accept that dementia changes how a person approaches an activity. Many caregivers assume a person living with dementia is child-like and no longer capable of understanding directions. Many caregivers simply take over the task. This not only robs people of their independence but also affects their self-worth.

ADL “skills training” is recommended for all caregivers—both family and professional. Emphasis is on encouraging independence in all activities while providing appropriate assistance when needed. ADL skills training can minimize caregiver stress and reduce the amount of physical labor required of a caregiver.

4.1 Strategies for Success in Various Stages

When assisting a person living with dementia with their ADLs, encourage them to say what they want. Try to understand why a person might refuse your help. Are they scared? Do they not understand what you asked them to do? Are they embarrassed? Are they cold or in pain?

If the person seems confused, repeat your request. Offer simple choices, such as “Do you want orange juice or apple juice?” Be empathetic. Examples of empathetic responses include “You must be cold” or “Are you uncomfortable in that chair?” “What would help now?”

A skilled caregiver learns to continually assess the abilities of the person they are assisting. More or less assistance may be needed depending on the task, the time of day, a person’s general health, and the level and type of dementia. For example, a person who is capable of independent self-care but has poor balance might need help setting up a place to safely brush her teeth and do other grooming.

Keep these general practices in mind when assisting someone with their ADLs:

• Make eye contact (where culturally appropriate).
• Do not crowd.
• Be aware of your body language and vocal tone.
• Slow the speed of your movements and speech.

Good communication is the basis for success. A calm tone and short, direct sentences build trust and encourage independence. Remember that people living with dementia often need time to complete a task. A caregiver must be patient while assessing the amount of help needed and must resist the urge to jump in to help when no help is needed.

4.1.1 ADL Strategies: Mild Dementia

A person living with mild dementia may not need any help with dressing and grooming. A caregiver can lay out a person’s clothes or make suggestions, but generally a person living with mild dementia can choose what clothing they want to wear and handle grooming without much help. A caregiver may make suggestions such as using an electric razor instead of a handheld razor or provide grooming supplies. At this stage, the caregiver’s role is to help as needed while promoting and encouraging independence.

In the early stage, mood changes, such as depression and anxiety, can affect ADLs. Learning new tasks, especially complex tasks, may be difficult. Faulty judgment and mild changes in personality may become obvious to family members and caregivers.

Dressing

• Encourage choice in the selection of clothes.
• Allow your client to direct the activity.

Grooming

• Encourage independent grooming, provide tools if needed.
• Monitor progress and provide help as needed.

Eating

When dementia is mild, a caregiver may only need to supervise during meals and snacks. If there are no underlying medical issues, a person living with mild dementia may still be able to help with shopping, cooking, and dishwashing. In the mild stage, a person may still be able to prepare their own meals. Caregivers can supervise and provide help at a distance. Mild memory problems can lead to safety issues, such as forgetting to turn off the stove or leaving water running.

Placing food on a colored plate (for food contrast) and altering the meal schedule to suit the needs of the person living with dementia are recommended practices.

• Ask for food preferences.
• Ask for help with meal preparation and meal set-up.
• Provide adaptive utensils if needed.
• Provide help as needed.
• Provide comfortable seating and support for the feet.
• Make sure food is tasty, warm, and attractive.

Bathing

A person living with mild dementia may not need help with bathing. At this stage, the responsibility of the caregiver is to assist as needed and encourage independence. This is best accomplished by making sure the bathing area is safe, warm, and comfortable. Grab bars and non-skid mats should be available. Bathing supplies should be within reach and the water pre-heated to the proper temperature.

Although it’s important to be flexible, try to set a regular time for bathing. Be gentle with fragile skin (avoid scrubbing). Practice these techniques (Alzheimer’s Association, 2026a):

• Simplify the bathing process.
• Cue the person through each step, if needed.
• Use a bench or shower chair for comfort and safety.
• Assist with cleansing hard-to-reach areas, if needed.
• Offer a sponge bath in between baths or as an alternative to bathing.
• Give choice as to when, where, and what type of bathing.
• Assist in the decision to bathe.
• Assist with bathing or shower as needed.
• Monitor for safety and comfort.

Toileting and Incontinence*

A person living with mild dementia may be reluctant to ask for help. They will likely be able to get to the bathroom without assistance but might have trouble managing their clothing. The Alzheimer’s Society has partnered with The Able Label, an English company that offers stylish clothing for men and women designed to make dressing and “assisted dressing” easier. Clothing that is easier to manage along with assistive devices such as grab bars and safety poles improve safety and support independence.

A person living with mild dementia may try to address incontinence by cutting back on liquids to decrease the frequency of urination. This can lead to constipation and urinary tract infections, creating a difficult and vicious cycle of dehydration, infection, and incontinence. If balance is an issue, encourage men to sit to urinate rather than stand.

• Monitor and assist as needed.
• Encourage fluids even though more bathroom visits may be necessary.

*Be aware that some medications cause constipation while others increase or decrease the urge to urinate.

4.1.2 ADL Strategies: Moderate Dementia

In the moderate stage, depending on a person’s strength, balance, and flexibility, a caregiver will likely need to assist with at least some aspects of a person’s ADLs. For example, Lula, mentioned above, has severe macular degeneration and moderate dementia. But she is very flexible and still fairly strong at the age of 95. When she’s sitting in a chair with proper back support, she can easily bring her knee up to her chest. However, she can’t see where her clothes are placed. It’s tempting to do everything for her, but this increases caregiver burden and fails to promote Lula’s independence. In this case, the caregiver can help Lula by laying out her clothes and providing verbal cues to direct the activity.

There is often a clear delineation between mild and moderate dementia. While progression varies, middle stage dementia is characterized by measurable executive dysfunction, impaired sequencing, and an increased need for direct supervision and support for safety, planning, and task initiation.

For some, walking, transferring, bed mobility, and basic ADLs remain relatively independent. For others, especially those with physical limitations, more help may be required.

In the moderate stage, caregiver responsibilities increase. Cooking, housework, and shopping may require direct assistance. Typically, in the middle stage, setup, close or direct supervision, and initial guidance or assistance are required for planning and safety due to decline of executive function.

Dressing

• Provide comfortable clothes with elastic waistbands and Velcro closures.
• Encourage participation in the choice of clothing but limit choices.
• Assist closely but encourage independence.
• Lay out clothes in order.
• Provide multiple pairs of favorite outfits.
• Provide adaptive equipment such as grab bars as needed.
• Provide step-by-step cues.
• Demonstrate the task.
• Provide guided touch as support to initiate the task.

Grooming

For mouth care and other grooming tasks, provide a safe and comfortable place, assist as needed, and offer clear instructions. For men, especially in the moderate to severe stage of dementia, an electric razor provides a safe way to shave. For both men and women, regular visits to the beauty parlor or barber shop provides social interaction and reduces caregiver burden.

Step-by step cues can be helpful, in addition to demonstrating the task. Aid with setup and offer guided touch for support or to initiate the task.

• Limit choices (“Would you like lipstick today?” “Would you like to brush your hair?”).
• Encourage as much independence as possible.
• Provide an electric razor for safety and independence.
• Help with the application of makeup and skincare products, if needed.
• Assist men with the trimming and cleansing of facial hair.
• Keep nails clean and trimmed (use a file if preferred by client).
• Assist with brushing teeth, use an electric toothbrush if needed.
• Use floss holders, oral irrigators, or interdental brushes if the client has difficulty with mouth care.
• Be aware of dry mouth, provide artificial saliva if needed.
• Visit the dentist on a regular basis.

Eating

As a person’s dementia progresses to the moderate stage, the need for caregiver assistance increases. Swallowing difficulties may arise in the moderate stage, increasing the risk of aspiration* and choking. Preparing softer foods, cutting food into smaller pieces, and avoiding food that is hard to chew or swallow can help address this issue.

*Aspiration: inhaling food of liquid into the lungs.

If signs of dysphagia (swallowing difficulties) are present, a speech‑language pathology evaluation needs to be ordered. Any recommendations for softer food textures and thickened liquids should be guided by a speech‑language pathologist, as these modifications are based on clinical assessment rather than general practice.

• Ask for food preferences.
• Set up the meal before serving.
• Open packages and uncover trays.
• Provide adaptive utensils as needed.
• Monitor closely.
• Place food on a colored plate (for food contrast).
• Alter the meal schedule to suit the needs of the person living with dementia. 

Bathing

In the moderate stage, additional safety equipment will likely be needed. This might include a shower chair, replacement of a shower door with a curtain, and a long shower hose. Depending upon a person’s physical capabilities, tub bathing may no longer be safe.

Although it’s important to be flexible, try to set a regular time for bathing. Avoid scrubbing fragile skin. Practice these techniques (Alzheimer’s Association, 2026a):

• Simplify the bathing process.
• Cue the person through each step, if needed.
• Use a bench or shower chair for comfort and safety.
• Assist with cleansing hard-to-reach areas, if needed.
• Offer a sponge bath in between baths or as an alternative to bathing.
• Provide setup assistance.
• Provide guided touch to support or help initiate a task.
• Ask about bathing preferences.
• Initiate and monitor the activity.
• Provide direct assistance, as needed, particularly for showering.
• Provide adaptive equipment such as shower chairs and grab bars, as needed.

Toileting and Incontinence

A person living with moderate dementia may have decreased mobility, have difficulty getting to the bathroom, and may be unable to undo clothing once in the bathroom. Men may experience problems directing their penis—especially if balance is compromised and there is nothing to hold onto. If this is the case, encourage men to sit on the toilet to urinate. Grab bars or transfer poles allow more independence with toileting.

• Ask regularly if the bathroom is needed.
• Provide close assist, particularly with transfers.
• Label bathroom door for easy identification.
• Provide toileting on a regular schedule.
• Provide adaptive equipment such as grab bars, transfer poles, and toilet chairs as needed.

4.1.3 ADL Strategies: Severe Dementia

As dementia progresses to a more severe stage, caregivers must provide more help with ADLs. Many caregivers help too much, partly because a person living with dementia takes a long time to complete what used to be  simple and automatic.

Caregivers often get impatient (even bored) with the slow pace, especially for a person with severe dementia. Slowing down, encouraging independence, and maintaining an attitude of watchful patience are critical skills for a caregiver to develop and practice.

In the severe stage, a great deal of independence is lost, and caregivers will likely need to oversee and directly assist with eating, bathing, walking, dressing, and other daily living activities.

Difficulty swallowing (dysphagia) can develop in the later stage of dementia, leading to aspiration* of food, fluids, or saliva into the lungs. To prevent this from happening, a speech-language pathologist can help caregivers develop a plan to modify foods by softening the texture of food and thickening liquids.

*Aspiration: the accidental inhalation of food or liquid into the lungs.

To prevent or reduce the risk aspiration, tuck the chin, massage the throat, or rotate the head. These practices should only be implemented under the guidance of a licensed speech-language pathologist. Other practices include:

• Sitting in a supported, upright position.
• Reducing the size of bites.
• Avoiding the use of sedatives and narcotics.
• Providing good oral care.

During this stage, basic ADLs require a lot of setup and assistance, depending on the person’s physical capabilities. Complex, instrumental ADLs will be completely taken over by a family member or caregiver.

In the severe stage, individuals typically require extensive assistance with ADLs, even total care. Executive function is profoundly affected, mobility is often significantly limited, and bowel and bladder function is commonly lost.

A person with severe dementia may still be able to walk somewhat independently and may be independent. or nearly so. with bed mobility and transfers. But anything that requires planning, sequencing, or judgment is severely impaired at this stage. Extensive, close assistance will be needed for dressing, bathing, meal preparation, grooming, and toileting. If mobility is compromised, close assistance will be needed for all ADLs.

Control of bodily functions can be inconsistent, requiring direct help with bathing and toileting. Encourage family members to learn about and use assistive equipment and devices that help them and encourage independence.

Safety awareness may decline in a person with severe dementia, requiring significant direct help with transfers, gait, and mobility. To prevent injuries and falls, it may be necessary to use bed and chair alarms or provide a one-on-one caregiver, which increases the cost of care.

For caregivers, healthcare providers, direct care workers, and family members, this is the stage of dementia that requires all of your patience, skills, and expertise. People still want to use the bathroom without assistance, get out of bed whenever they want, and live in the way they have lived for their entire lives. These needs, desires, and habits are deeply embedded in our psyche, and it requires a great deal of patience and wisdom on the part of caregivers to understand these changes and provide support in a dignified and respectful manner.

In the severe stage of dementia:

Dressing

• Limit choices, select clothes and set them out.
• Choose comfortable clothing that is easy to wash.
• Use simple, one-step commands and gestures.
• Provide as much assistance as needed but encourage independence.
• Provide assistive equipment such as transfer bars and grab bars.

Grooming

Step-by step cues can be helpful, in addition to demonstrating the task.

• Provide as much assistance as needed.
• Move slowly, limit choices.
• Use one-step commands and gestures.
• Provide an electric razor for safety, help if needed.
• Assist as needed with the application of makeup and skincare products.
• Assist men with the trimming and cleansing of facial hair.
• Keep nails clean and trimmed.
• Assist with brushing teeth by providing step-by-step instructions.
• Use an electric toothbrush if needed.
• Use floss holders and oral irrigators if needed.
• Be aware of dry mouth, provide artificial saliva if needed.
• Visit the dentist on a regular basis.

Eating

In the severe stage, managing oral nutrition supplements, modifying food, and considering dysphagia (swallowing difficulties) can become a daily concern for caregivers. Proper ergonomic seating and simple swallowing techniques can be taught at this stage by a speech-language pathologist to reduce the risk of aspiration (food accidentally going into the lungs). Nevertheless, caregivers should continue to encourage independence and choice in food and drink.

Assistance, encouragement, and social support encourage eating and drinking. A person living with severe dementia may still be able to help with some parts of meal preparation—even if they only beat an egg, peel an orange, or pour juice into a cup. Remember that spilled food can always be cleaned up.

Behavioral issues can arise at this stage—refusals to eat and drink, complaints about food taste and quality, throwing food, shouting, knocking over glasses, and refusal to come to the table. Many of these things can be avoided—especially in the home setting—by adjusting to, listening to, and addressing a person’s changing needs.

Assistive or adaptive tableware can be used to make meals more pleasant. Attractive assistive tableware can be used by people of all abilities, and at all stages of dementia. Color contrast helps as a visual cue—for example royal blue plates provide a contrast with a white table covering and food on a plate. A plate with a high lip and slanted bottom helps a person push the food onto the spoon and scoop it up.

The same approach can be used with cups. In the example below, a royal blue bottom and a white cover help a person with low vision or agnosia* locate the cup handle and rim. The sides of the cup are angled to reduce spillage, a large handle assures a good grip, and a wide top allows a person’s nose to fit inside the cup when tipped.

*Agnosia: a sensory disorder in which a person is unable to recognize an object by sight, touch, or hearing.

Because dementia is a progressive disease, a person will gradually lose the desire to eat. This can be extremely distressing for caregivers even though it is a normal part of the disease progress. Caregivers who have worked hard to keep a person eating and drinking may struggle as it becomes harder and harder to convince the person they are caring for to eat and drink. This will be accompanied by weight loss—sometimes severe.

• Ask for food preferences and provide small amounts of food at a time.
• Let the person know what they are eating.
• Sit to the side while helping (sitting in front may be intimidating).
• Offer a bite of the meal and a bite of something sweet.
• Make sure the person has swallowed before introducing more food (food can be pocketed in the cheeks).
• Provide high-calorie, healthy foods to eat or drink (protein drinks, dietary supplements, or foods prepared with healthy fats).
• Consider a multivitamin (tablet, capsule, powder, liquid, or injection).
• Fully set up the meal before serving.
• Provide adaptive equipment as needed.
• Monitor closely and be ready to provide feeding assistance.
• Offer liquids on a regular schedule.
• Allow plenty of time to finish eating.
• Be aware of the potential for aspiration of food or fluids.

Bathing*

In the severe stage, direct help is likely needed with bathing. Shower chairs, grab bars, transfer poles, and even modifications allowing a rolling shower chair may be needed. Caregivers should expect to get wet at this stage as they assist with bathing. Continue to encourage as much independence as is safe and possible.

*Goal is for clients to be clean and comfortable. Shower or tub bath is not necessary—a sponge bath may suffice.

General considerations for bathing:

• Provide complete bathing care.
• Retain as much of a person’s earlier bathing rituals as is reasonable.
• Use the person’s behavior as a guide.
• Provide assistive equipment such as shower chairs, transfer poles, and grab bars.
• Ask about bathing preferences.
• Initiate and monitor the activity.
• Provide direct assistance as needed, particularly for showering.
• Provide adaptive equipment such as shower chairs and grab bars, as needed.
• Consider bathing habits (time of day, bath or shower).
• Consider bed bath if more acceptable to client.
• Provide guided touch to support or to help initiate a task.

There are times when a person may need to be bathed in bed. This is not uncommon at, or near, the end of life. Bed bathing is not as effective as showering and should only be used when there is no alternative. Cleanliness promotes skin health and supports dignity. Even at this stage, caregivers should encourage participation and consider a person’s preferences for bathing.

General principles for bed bathing:

• Keep the person warm.
• Expose only the area being washed.
• Change water when dirty and after washing genital areas.
• Pat skin dry rather than rubbing.
• Talk to the person (even someone who is unconscious).

Toileting and Incontinence*

As dementia becomes more severe—and physical, sensory, and cognitive skills continue to decline—toileting becomes more difficult. A person living with severe dementia may do some things that are extremely frustrating to a caregiver. They may hide soiled underwear, hand feces to the caregiver, or wipe feces off their hands onto clothing or furniture. A person may resist help, fail to remove clothes before voiding, or void in inappropriate places.

A person living with severe dementia may or may not be able to walk without assistance but, due to sensory changes and decreased vision, may have difficulty locating or recognizing the bathroom. This probably won’t stop them from trying, increasing the risk of falls. Caregivers can find this stage extremely frustrating and stressful—partly because more physical help and direct oversight are needed, and partly because more time is spent cleaning up accidents.

• Expect both bowel and bladder incontinence requiring total care.
• Set up timed toileting schedule.
• Provide assistive equipment such as transfer bars and grab bars.
• Check for skin breakdown, skin rash and redness, and infections and treat promptly.
• Review medications that may contribute to incontinence.
• Restrict drinks that contain caffeine.
• Change adult diapers regularly and keep the area clean and dry.

Urgency, urinary frequency, lower abdominal pain or tenderness, blood in the urine, pain or burning sensation with urination, and changed mental status can be signs of a urinary tract infection, which should trigger a urinalysis and urine culture. Catheter-associated urinary tract infections are common and can occur when germs enter the urinary tract by way of the catheter. Caregivers should consistently clean their hands before touching a catheter.

4.1.4 Incontinence

Incontinence is the involuntary leaking of urine or feces, or both. Whatever the stage of a person’s dementia, incontinence is embarrassing and stigmatizing. Incontinence adds to caregiver stress and depression and is often a factor in the decision to admit a family member to a care home. Because many caregivers believe it is normal for older adults to be incontinent, reversible causes of incontinence may not be adequately considered.

Incontinence can be related to a medical problem such as urinary tract infection, constipation, or prostate problems. It can also be associated with diabetes, stroke, Parkinson's disease, and physical disabilities that prevent the person from reaching the bathroom in time. Medications and diuretics (drugs that increase urination) can also cause incontinence. Sleeping pills and anxiety-reducing drugs that relax the bladder muscles, and drinks such as soda, coffee, and tea, can contribute to incontinence (Alzheimer’s Association, 2026b).

Techniques and strategies used by caregivers to manage toileting and incontinence in a person living with dementia typically start with reminders to go to the toilet on a regular basis. As dementia progresses, other techniques may be needed such as adult diapers, bedside commodes, and direct help from the caregiver. At every stage of dementia, assistive equipment promotes independence and decreases the amount of direct caregiver assistance.

To make it easier for a person living with dementia to find and use the toilet, clear the path to the bathroom and keep the bathroom door open so the toilet is visible. Make the toilet safe and easy to use by raising the height of the toilet, installing grab bars, and using night lights to illuminate the bedroom and bath.

Additional recommendations:

• Consider a portable commode or urinal for nighttime use.
• Remove plants, wastebaskets, and other objects that could be mistaken for a toilet.
• Remove slippery throw rugs.
• Use glow-in-the-dark tape to create a clear path to the toilet.

Stress incontinence (involuntary loss of urine), can sometimes be reversed through surgical interventions. Kegel exercise—in which the floor of the pelvis is strengthened by regular contractions—can be of great help in this type of incontinence. Some people require a combination of treatments such as anti-spasmodic medications* with lengthened periods between toileting to increase bladder capacity and reduce wetting episodes.

*Anti-spasmodics: medications that relax smooth muscles and help treat overactive bladders.