the ABCs of ADLs

ADLs are Activities of Daily Living.  They are the parts of the day that we rarely stop and consider until we or our loved ones are unable to perform them without assistance.  ADLs are bathing, dressing and toileting, the very private parts of our personal care, something we do alone, a time when we value our privacy.

When an Alzheimer’s patient begins to have difficulty successfully completing the ADLs, you can be sure that more than just memory loss is to blame.  Many intellectual deficits hamper the patient’s ability to complete their personal care ritual.  Remember, Alzheimer’s disease is brain injury.  It’s not that the patient won’t take a bath, but that he or she can’t take a bath.

Many newsletters have covered the four As of Alzheimer’s.  When understanding why a patient can no longer perform their ADLs consider the impact of these disabilities.

Amnesia – memory loss.  What is initially damaged is recent memory or the ability to store new information, like a conversation as it occurs.  Distant memories may remain intact, but if they can’t process and store information, they may forget that you just reminded them to brush their teeth.

Aphasia – communication difficulties, both in expressing themselves and understanding what you say to them.  A patient may not be able to speak clearly, which is more obvious than when a patient can’t follow everything you say.  Maybe they can pick up every third word or so, then they might get the gist of what you are saying.  Or they might rely on your body language and tone of voice to give them meaning to your words.

Apraxia – inability to perform preprogrammed body movements, the things we normally do on “automatic pilot,” without any concentration.  Think how severely ADLs are affected by the patient who can’t remember how to unbutton their shirt, brush their hair, turn on the taps, etc…

Agnosia – inability to recognize familiar people and things.  Consider the agitated patient in the bathroom.  The caregiver may be the spouse of 45 years – but the patient doesn’t recognize them.  Then they look up at the mirror and see two more strangers – the caregiver’s and their own reflection.  No wonder they’re not cooperating, they can’t understand why there are so many people in the bathroom when it should be a private time!

Other intellectual deficits impacting ADLs include:  inattention to time and a shortened attention span; inability to plan and complete activities; increased activity that is purposeless, repetitive, and compulsive; inability to control their temper; need for immediate gratification and self preoccupation; increased refusal to participate.

After reading the four As and other intellectual deficits, you can see why bathtime and other ADLs can be the most difficult times of the day.  The ABCs of ADLs may help.

Acute Awareness – Until you understand the patient’s limits you will be frustrated by their disabilities.  Bearing in mind that it is can’t not won’t can help.  Also, be aware of how the environment is affecting your patient.  Is it too hot or cold?  Is it too dimly lit or is there a glare?  Is there confusing background noise from the TV?  Consider how the patient is feeling.  What can you do to help them feel more safe and secure?  How is your approach and attitude affecting the patient?

Break it down – Offer the patient step-by-step instructions.  Don’t say “now take your clothes off.”  Instead, say “unbutton your shirt,” demonstrate how, and give the patient time to understand and respond.  Praise the results every step of the way.  Breaking it down into small steps mean it will take a little longer, but you will be encouraging your patient to help themselves as much as they are able to!

Calm Communication – Many times the patient’s attitude reflects the attitude of the caregiver.  If you are uptight and anxious about bathtime, the patient will sense your mood.  AD patients respond to mood as much or more than your words.  Try a gentle touch and soft voice.  Remember not to be drawn into an argument.  Your patient will always say “but I’ve already had my bath.”  Be matter-of-fact but always calm, cool, and collected.

Other tips for bathing:

Adhere to lifelong rituals.  Don’t try a shower on someone who has always taken a tub bath.  Consider the time of day.  Would a bath help relax the patient for bed?  Or does the patient sundown in the evening?  What time of day best meets the patient’s need?

Engage the necessary home modifications:  grab bars, hand-held showers, nonslip mats, shower bench.  Using a big towel may help the patient feel more secure.

Consider the temps – is the room the right temperature?  Check the water temperature too.

Cover the mirrors – it can enhance the patient’s feeling of privacy.

Use humor – never laugh at the patient, but with them.  Humor is the key to soothing rattled nerves.  When you laugh, your body naturally relaxes.  If you are relaxed, you patient is more likely to be.

If giving a tub bath, a little water will do.  Many patients are afraid of stepping into a tub of deep water.  Some caregivers report that coloring the water helps the patient see it, and therefore is less fearful.  Don’t try to wash their face first.  It’s like a frontal assault.  Start at the feet and work up.  If you are gentle in your approach, they’ll relax enough for you to wash their face.

Other tips for dressing:

The biggest problem is getting the dirty clothes away.   Get those dirty clothes out of sight.  Over in the corner won’t do; they will find them and put them back on.  Some caregivers resort to buying several of the same outfits because the patient insists on wearing the same thing over and over.

Simplify the routine.  Think about all the pieces of getting dressed:  deciding what to wear; finding it in the closet; maneuvering buttons and snaps; getting it on in the right order.  We perform these small steps without much thought.  But each one of these tasks can be insurmountable for the patient.  Choose clothes for the patient or offer a choice of two outfits.  Lay the clothes out in the right order.  Think of what you can do to make the process easier.

If you don’t want them to wear it, get it out of the closet.  Caregivers are sometimes shocked by the golden oldies their patient retrieves from the depths of the closet.  It may be time to clean out the closet.  Be certain the clothes that remain fit and are appropriate for the season.  If you have to buy new clothes, consider buying garments that are easy to get on and off and ones that will wash well.

Other tips for toileting:

Establish a routine.  Take your patient to the bathroom every two hours.  Don’t ask “do you need to use the bathroom?” the answer will invariably be “no”, and then the patient will have an accident.

Be sure the patient’s diet provides enough fiber and fluid for regularity.  Constipation can be a problem for patients and can be a source of agitation.  A warm drink can stimulate a bowel movement.  One caregiver found a mug of warm prune juice worked for her patient.  He thought it was coffee.

Be attentive to signs of restlessness, wandering, or tugging at clothes.

Never shame or ridicule.

Restrict fluids in the evening if nighttime wetting is a problem.

Use a bedside commode, protective bedding, and adult diapers.  Do not refer to them as “diapers” in front of the patient.  Call them “briefs or pads.”

If your patient pulls at their pad or rips it up, consider soft mittens or offering rags for the patient to hold and tear up instead.

safety and activities
products and information


Products for home safety.
1-800-642-2112  //

Independent Living Aids, Inc.
Adaptive aids for assistance with activities of daily living.
1-800-537-2118  //

One Step Ahead
Mostly products for early developmental (baby stage) but has some safety items that may be useful.
1-800-274-8440  //

The Alzheimer’s Store
Provides unique products and information for those caring for someone with Alzheimer’s disease.
1-800-752-3238  //


BiFolkal Productions, Inc.
Creating opportunities for older adults to remember and share their stories, aids for reflection and expression.
1-800-568-5357  //

Eldersong Publications, Inc.
Creative materials for older adults:  mind joggers, trivia, music therapy, and reminiscing.
1-800-397-0533  //

 The Alzheimer’s Store
Provides unique products and information for those caring for someone with Alzheimer’s disease.
1-800-752-3238  //

Print version of the ABCs of ADLs: The ABCs of ADLs (PINK SHEETS)