The “small things” 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 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 are the personal tasks we do during our daily lives. ADLs are divided into two categories: basic ADLs and instrumental ADLs. Basic ADLs are those skills needed to take care of personal needs. Instrumental ADLs are the more complex skills needed to function within society and within the community.

Basic and Instrumental ADLs
Basic ADLs (skills needed to take care of personal needs)	Eating, bathing, showering, grooming Walking Dressing and undressing Transfers, toileting
Instrumental ADLs (skills needed to function within the community and society)	Housework Financial management Shopping, preparing meals Communicating with the outside world Medical management

3.1 General ADL Strategies

When assisting anyone with their activities of daily living, encourage them to express their wishes. If someone refuses your help, try to understand why. Are they scared? Do they misunderstand what you asked them to do? Are they embarrassed? Are they cold or in pain?

If the person seems confused, repeat your request using the same words or slightly rephrase the question. Rephrasing the request can support understanding and reduce frustration. Offer simple choices, such as “Would you like to shower now or after you eat?” Be calm and empathetic. Examples of empathetic responses include “You must be cold” or “Are you uncomfortable in that chair?” “What would help now?”

Best practices include:

• Make eye contact (where culturally appropriate).
• Be aware of your body language and vocal tone.
• Slow the speed of your movements and speech.
• Approach from the front.

3.2 ADL Strategies: Mild Dementia

A person with mild dementia may need little help, if any, with basic activities of daily living. They can get dressed, bathe, do chores around the house and in the yard, and may still be able to shop and cook. They will likely begin to need help with complex tasks such as balancing a checkbook or paying bills.

At this stage, there may be some loss of interest in hobbies and activities. Mood changes, such as depression and anxiety, can occur. 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 the resident to direct the activity.

Grooming

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

Eating

• Ask for food preferences.
• Ask for help with meal preparation and meal set-up.
• Provide adaptive utensils if needed.
• Provide help as needed.

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.
• Provide adaptive equipment such as transfer poles and grab bars.

Toileting and Incontinence*

• 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.

3.3 ADL Strategies: Moderate Dementia

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.

The amount of help a person needs depends upon a person’s physical capabilities and the type of dementia. But 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 general, during this stage, a moderate level of assistance will be needed.

In the moderate stage, caregiver responsibilities increase. Cooking, housework, and shopping require more direct assistance. Basic ADLs may require assistance for set-up and safety and may be disrupted by behaviors such as anger, frustration, and denial.

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 clothing in order.
• Offer multiple pairs of favorite outfits.
• Provide adaptive equipment such as grab bars as needed.

Grooming

• 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 and provide artificial saliva if needed.
• Enable visits to the dentist on a regular basis.

Eating

• Ask for food preferences.
• Set up the meal before serving.
• Open packages and uncover trays.
• Provide adaptive tableware as needed (see picture at the end of this section).
• Monitor closely.

Bathing

• 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 (see picture at the end of this section).

Toileting and Incontinence

• Provide close assistance, 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.

3.4 ADL Strategies: Severe Dementia

My mom has pretty severe dementia and needs lots of help with everything. I start getting her ready at least an hour-and-a-half ahead of appointments. When she’s dressed and bathed and I think we’re ready to go, she insists on brushing her teeth. Recently, we were running late for a doctor’s appointment, and I tried to get her to go without brushing her teeth. Big mistake! She grabbed the door leading from the kitchen to the garage, sat down on the floor, and refused to move. She actually leaned back and put both of her feet and hands on the door opening and wedged herself in. After she brushed her teeth and was safely in the car, she yelled at me to hurry up because she said we were going to be late!

Family Caregiver, Cottondale, Florida

In the severe stage, a great deal of independence is lost, and around-the-clock supervision may be needed. Caregivers must 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.* To prevent this from happening, food choices need to be modified by softening the texture of food and adding a thickening agent to liquids. Tucking the chin, massaging the throat, sitting in a supported, upright position, and taking smaller bites of food when swallowing can also help. These practices should only be implemented under the guidance of a licensed speech-language pathologist. Avoid the use of sedatives and narcotics, which can affect swallowing.

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

A person with severe dementia may still be able to walk with assistance. But anything that requires planning, sequencing, or judgment is severely impaired at this stage. Close assistance will be needed for dressing, meal preparation, and grooming. Control of bodily functions can be inconsistent, requiring direct help with bathing and toileting. If mobility is compromised, close assistance will be needed for all ADLs.

For caregivers, healthcare providers, direct care workers, and family members, this is the stage of dementia that requires all your patience, skill, and expertise. People still want to participate in social activities, 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 skill 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

• 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

• 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).
• Perhaps 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*

• 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.

*Consider bathing habits (time of day, bath or shower); consider bed bath if more acceptable to resident.

Toileting and Incontinence*

• 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.

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

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.

People living with severe dementia are completely dependent on help from staff. At this stage they have the highest need for assistance and at the same time the highest need for a quiet environment. They tend to become overwhelmed by sensory impressions and can have a hard time interacting with other people due to cognitive and emotional impairment (Lygum et al., 2025).