Understanding dementia — what is happening, and seeing the person first

Let's start with a doorstep.

It is half past nine on a Tuesday morning. Joan opens her front door before you can knock. She is eighty-one, dressed, smiling, and holding a tea towel. "Oh good," she says, "you're here about the boiler." You are not here about the boiler. You are her new carer, and this is your third visit. On the first visit she called you by her sister's name. On the second she told you, twice, about the day her husband proposed, in exactly the same words, eight minutes apart.

Nothing about this morning is a crisis. But everything about it is dementia — and how you understand what is happening inside Joan's mind will shape every single thing you do with her from now on.

This course builds on the Foundation course, Dementia Awareness. We assume you already know the basics: that dementia is a group of symptoms caused by diseases of the brain, that it is not a normal part of ageing, and that people with dementia deserve the same respect as anyone else. At Core level we go further — into judgement. Not just *what* dementia is, but what it feels like from the inside, how it changes from person to person and month to month, and how a thoughtful carer works with it rather than against it.

**One sentence to hold onto.** If you remember nothing else from this course, remember this: *dementia is caused by disease, but it is lived by a person — and your job is to care for the person, not to fight the disease.* The doctors and nurses look after diagnosis and treatment. You look after mornings, meals, moods and dignity. That is not the small half of the job. Ask any family: it is the half that decides whether life is still good.

**What is actually happening in the brain?**

The word "dementia" is an umbrella. Underneath it sit many different diseases, each damaging the brain in its own way. You do not need medical detail — diagnosis is never your job — but knowing the broad shapes helps you make sense of what you see.

**Alzheimer's disease** is the most common cause. The Alzheimer's Society describes it as a disease in which proteins build up in the brain and damage nerve cells, usually starting in the areas that manage memory. That is why new memories are often the first thing to slip: the person can tell you about 1962 in colour and detail, but not about breakfast. Older, deeper memories were laid down when the brain was healthy, and they last longest. Joan's proposal story is not her "living in the past" to annoy anyone. It is her mind walking on the firmest ground it has left.

**Vascular dementia** comes from problems with blood supply to the brain — often after a stroke, or many tiny ones. Because the damage depends on where the blood supply failed, it looks different in every person, and it often changes in steps: a plateau, then a sudden drop, then another plateau. If someone seems suddenly worse after a period of being stable, that is always worth reporting, because sudden change can also mean something treatable, like an infection.

**Dementia with Lewy bodies** brings particular features: vivid visual hallucinations (the person may see children or animals that are not there), alertness that swings within a single day, movement that becomes stiff or shuffling, and sleep that gets noisy and active. One thing worth knowing and passing on if you ever hear a medication conversation happening: people with this type can react badly to certain medicines, which is one more reason decisions about medicines are never ours to make.

**Frontotemporal dementia** often starts younger — in the fifties or even forties — and typically shows first not as forgetting but as changes in personality, behaviour or language. A polite man may become blunt. A careful woman may start spending oddly. Families often say, "The memory's fine, but he's not himself." That, too, is dementia, and the person is not being rude on purpose.

Many people, especially in later life, have a mix of these. And here is the useful truth behind all the labels: **you will never care for a type of dementia. You will care for Joan.** Two people with the same diagnosis can be as different as any two people anywhere. The label tells you a little about what may be harder for the person. It tells you nothing about who they are.

**What it might feel like from the inside**

Try this thought experiment, slowly.

You wake up in a room you do not fully recognise. You know it should be familiar — there is a feeling of "mine" about the bedspread — but the certainty is missing. A stranger comes in. She seems kind, and she knows your name, which is unsettling, because you do not know hers. She wants you to get undressed and have a wash. You are an adult. You have washed yourself for eighty years. Who is this person, and why is she in your bedroom?

Now add this: you cannot hold on to her explanation. She may have told you who she is — the words arrived — but they slid away before they could settle. All you are left with is the feeling of the moment: confused, exposed, a little frightened, and determined not to show it.

If you hold that experiment in mind, most "difficult behaviour" stops being mysterious. Refusing a wash is not stubbornness; it is dignity defending itself. Asking the same question five times is not attention-seeking; it is a mind that genuinely does not know it already asked, feeling the same worry fresh each time. Following you from room to room is not clinginess; it is the sensible act of staying near the one landmark that feels safe — you.

People who write about their own dementia — and many do, especially in the early years — describe some common threads: the exhaustion of working ten times harder to do ordinary things; the fear of being talked over and written off; the relief when someone slows down and treats them as a whole adult. Feelings outlast facts. A person may forget your visit entirely, yet be left with the warmth of it all afternoon — or the upset. **People forget what you said long before they forget how you made them feel.** That is not a slogan. In dementia care it is a practical planning tool.

**How common is this? A sense of scale**

You are not caring for a rarity. The Alzheimer's Society estimates that close to a million people are living with dementia in the UK, and that number is expected to rise as we all live longer. The NHS notes that most are over sixty-five — but dementia is not only an older person's condition, and younger people are diagnosed too. Around one in eleven people over sixty-five is affected, on Alzheimer's Society figures. Behind each of those people stands a family doing its best, often tired, often guilty about being tired. When you walk into a home like Joan's, you are walking into all of that. It helps to know the scale, and it helps more to remember that in this house, the only number that matters is one.

**Person-centred care: the idea this whole course stands on**

A researcher called Tom Kitwood changed dementia care with a simple, radical idea: the person is not fading away behind the disease. Personhood — the sense of being someone, of mattering — survives, and it is kept alive *between people*. Every interaction either feeds it or starves it.

Feeding it looks like this: using the name the person prefers. Asking before doing. Offering real choices, small enough to manage — "the blue cardigan or the red one?" rather than "what do you want to wear?" Noticing what they can still do and making room for it. Talking *to* them in their presence, never *about* them.

Starving it looks like this — and good people do these things by accident when they are rushed: talking across the person to a relative. Doing tasks at speed to a body rather than with a person. Scolding ("I've just told you that"). Testing ("Do you remember who I am?"). Baby talk. Deciding that because the person forgets, the visit "doesn't really matter". It matters. The feeling remains after the facts have gone — you know that now.

So at Core level, your first practical skill is this: **know the person deliberately.** Not by accident over months, but on purpose, from the start. Learn the shape of their life: what they did for work, who they loved, what music played at their wedding, what they take in their tea, what they are proud of, what frightens them. Families are usually delighted to be asked — being asked tells them you see their mother, not a diagnosis. Some families keep a "This is me" style one-page profile (the Alzheimer's Society publishes one); if there is such a sheet, read it, and if there is not, you can gently suggest one. A carer who knows that Joan ran a school kitchen for thirty years has an entirely different morning available to her — "Joan, I could use your eye on this — how do you get scrambled eggs right?" — than a carer who only knows Joan forgets things.

**Living well is the goal — and it is realistic**

It is easy to hear "no cure" and think "nothing to be done". The opposite is true. NICE — the body that writes national care guidance — is clear that people with dementia should be supported to stay active, connected and involved in decisions about their own lives, and that support for the person and their carers makes a real difference to how life goes. There is everything to be done; it is simply done in the currency of days rather than cures. A good day, with a walk, a laugh, a task that felt useful and a meal that was enjoyed, is a genuine clinical outcome. You are the person most able to deliver it.

Living well also rests on rights. A diagnosis of dementia removes none of them. The person keeps the right to make choices, take everyday risks, spend their money, refuse a wash, and be consulted about their own life — and where a decision is truly beyond them on the day, the law has careful rules about who may act and how, which we cover properly in a later lesson. For now, hold the headline: **the starting assumption, always, is that the person can decide — and your job is to make deciding easier, not to take deciding away.**

**Your role and its limits — the boundary that runs through everything**

You are not a nurse, a doctor or a diagnostician, and this course will never ask you to be. You will not diagnose a type of dementia, adjust a medicine, or decide what a symptom means. What you will do is something professionals cannot: you will see the person often, closely, and in their real life. That makes you the eyes and ears of the whole team around them.

So your Core role has a rhythm you will meet in every lesson of this course: **notice, support, record, escalate.** Notice the change — Joan more muddled this week than last, a new shuffle in her walk, food untouched. Support the person through the moment in front of you, kindly and without argument. Record what you actually saw, in plain words, with the date — "Joan didn't recognise the kitchen this morning; settled after tea," not "Joan confused as usual." And escalate — tell the family, your senior, or in the arrangements where you work directly with a family, suggest the GP — whenever something changes, because in dementia, *change is information*. A sudden worsening over days is not "just the dementia getting worse"; the NHS notes that infections, pain, constipation and medicine problems can all cause sudden confusion, and many of those are fixable. The carer who says "this is new since Friday" out loud, to the right person, quickly, is doing skilled work.

**A few myths worth clearing out**

Because dementia is common, half-truths about it are common too. Three are worth naming now, so they never shape your care.

*"It's just old age."* It is not. Plenty of people reach a hundred with sharp minds. Forgetfulness that disrupts daily life is a sign of disease, and the NHS encourages anyone worried about their memory to see a GP — partly because other, treatable things (low mood, thyroid problems, vitamin shortages, medicine side effects) can look like dementia. If a family member says "it's just his age, no point bothering the doctor", you can gently pass on that a check is always worthwhile.

*"There's nobody in there any more."* You will sometimes hear this said, even kindly, even by exhausted relatives. Everything in this course says otherwise. The person is there — reachable through feeling, music, touch, humour and familiarity long after conversation fades. Care built on "nobody in there" becomes handling. Care built on "she's in there, and I can reach her" stays human.

*"Nothing can be done."* Diagnosis opens doors: treatments that can help some people for a time, support for the family, planning while the person can still have their say, and — every single day — care like yours, which no laboratory can bottle.

**Back to the doorstep**

So — Joan, the tea towel, the boiler. What does all of this look like in the next sixty seconds?

You do not correct her. Being told "I'm not the boiler man, I'm your carer, we've met twice" would win the fact and lose the morning: she would be left with the feeling of being wrong on her own doorstep. Instead you meet her where she is: "Morning, Joan! No boilers for me, I'm afraid — I'm hopeless with them. I was hoping for one of your cups of tea." You are in. She is smiling. The kettle goes on, and the visit begins with her feeling like a hostess, not a patient.

Later, you notice the post is piling up unopened, which is new. You mention it to her daughter and put a line in the notebook. That is the whole job in miniature: the person first, the moment handled with warmth, the change noticed and passed on.

In the rest of this course we will slow down each part of that morning: how to communicate when words are failing (Lesson 2); how the home itself can help or fight her (Lesson 3); what to do when distress boils over (Lesson 4); how to make meals, washing and the long middle of the day go well (Lesson 5); how rights, risk and safety fit together (Lesson 6); and how to look after the family — and yourself — for the long haul (Lesson 7).

For now, one last thought. Years from now, Joan will not remember your name. She may not remember that anyone came at all. But every visit will have left its residue of feeling — of being liked, of being capable, of being safe in her own kitchen. Stack up enough of those mornings and you have not just done a job. You have kept a person's world warm while a disease tried to cool it. There is no more skilled work than that.