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. These skills tend to decline as a person’s dementia progresses. Even at the end of a person’s life, encouraging independence allows people to actively manage their condition, reduce symptoms, and stay independent and socially active (WHO, 2023).

ADLs are often divided into two categories: basic ADLs and instrumental ADLs. Basic ADLs are those skills needed to take care of personal needs. Instrumental or functional ADLs are the skills needed to function within society and within the community.

For all levels of dementia, grab bars, transfer poles, assistive tableware, and other type of assistive equipment promote independence and reduce caregivers’ physical strain.

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 a person living with dementia with their ADLs, encourage them to express their wishes. Always try to understand why a person might be refusing help. 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 “Do you want orange juice or apple juice?” Engage the client. Be empathetic. Examples of empathetic responses include “You must be cold” or “Are you uncomfortable in that chair?” “What would help now?”

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

• Make eye contact (where culturally appropriate).
• Be calm.
• Do not crowd.
• Be aware of your body language and vocal tone.
• Slow the speed of your movements and speech.
• Approach from the front—don’t sneak up on the person from behind.

3.2 ADL Strategies: Mild Dementia

A person with mild dementia may need very little help, if any, with basic activities of daily living. They can dress themselves, bathe, do tasks 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 your client 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.

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.

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 set up, close or direct supervision, and initial guidance or assistance are required for planning and safety due to their executive function decline.

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 cloths in order.
• Provide 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, provide artificial saliva if needed.
• Visit the dentist on a regular basis.

Eating

• Ask for food preferences.
• Set up the meal before serving.
• Open packages and uncover trays.
• Provide adaptive utensils as needed.
• 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.

Toileting and Incontinence

• 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.

3.4 ADL Strategies: Severe Dementia

In the severe stage, a great deal of independence is lost, and around-the-clock supervision may be needed. 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, food choices will need to be modified 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 great deal of set-up 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

• 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).
• 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 client.

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 clients 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.