There is a cardigan in almost every care home. It was bought by a daughter who chose it carefully, it is warm and soft and exactly the right size, and the resident will not wear it. She pulls at it. She takes it off within minutes of it being put on. Eventually somebody writes in the notes that she refuses to wear appropriate clothing, and the cardigan becomes a small daily battle that nobody wins.
There is a gentleman too. He will not sit in the dining room. He eats perfectly well in his own room, or in the quiet corridor, or standing at the servery, but the moment he is settled at a table with five other people he becomes agitated and leaves. The notes say he is resistant to communal dining and may be socially withdrawn.
Both of these entries describe what happened. Neither of them asks the question that matters: what does this actually feel like from the inside?
We are very good at recording that a resident refuses something. We are much less good at asking what we are asking them to tolerate.
Sensory processing is not a preference
ADHD is associated with atypical sensory processing, and a 2025 systematic review and meta-analysis found higher sensory sensitivity, sensory avoidance, sensory seeking and low registration across ADHD samples compared with control groups. This is not a matter of taste, and it is not fussiness. It describes a nervous system that receives and interprets sensory information differently.
Importantly, it works in more than one direction. Some people are easily overwhelmed by noise, light, touch, smell or busy environments. Others actively seek movement, pressure, strong flavours or background sound. Some do not register a sensation at all until it becomes intense. The same resident may be overwhelmed by the dining room and simultaneously desperate for something to do with their hands.
So when a label is unbearable against the skin, that is not a mild dislike being expressed dramatically. For some people it is closer to a persistent, low-level pain that makes it genuinely difficult to think about anything else. And a person who cannot easily explain that, or who has learned across a lifetime that complaining about it gets them called difficult, will do the only thing left available to them. They will take the cardigan off.
Why this matters more in dementia care than anywhere else
Today's care home generation grew up before ADHD was recognised, so almost none of them carry a diagnosis. They spent decades managing their own sensory environment without ever knowing why they needed to: cutting labels out, choosing the same soft jumper repeatedly, avoiding certain restaurants, eating the same narrow range of foods, sitting near the door.
Moving into residential care removes most of that control in a single afternoon. Someone else now chooses the clothes, the mealtimes, the seating, the television volume, the laundry detergent, the room temperature and when the hoover runs. A person who spent sixty years quietly engineering a tolerable sensory world is placed in one designed by other people, and then recorded as having become agitated.
Dementia compounds this in two ways. It can make it harder to articulate what is wrong, and it can erode the lifelong strategies a person used to cope. The distress may be no greater than it ever was. What has changed is their ability to manage it or to tell you about it.
The four labels worth translating
If you look at behaviour charts through a sensory lens, the same four phrases keep appearing. Each of them is a description of an outcome that has been mistaken for an explanation.
"Refuses appropriate clothing." Consider fabric, seams, labels, waistbands and layers before considering refusal. Ask the family what she wore by choice for the last forty years, and buy that.
"Agitated at mealtimes." The dining room is often the most sensorily demanding room in the building: cutlery on crockery, several conversations at once, a television nobody is watching, staff moving constantly, food smells, and an expectation of sitting still throughout. A quieter table or a smaller dining space is a reasonable adjustment, not giving in.
"Fussy eater." Texture, temperature, smell and presentation can matter as much as taste. A lifelong narrow diet does not usually broaden because someone has moved into care. Worth saying clearly: new swallowing difficulty, dental pain, weight loss or appetite change must be assessed clinically, and never assumed to be sensory.
"Resists personal care." Showering combines interruption, undressing, temperature change, water on skin, loss of control and a long sequence of steps. Any one of those may be the actual obstacle, and each has a different solution.
What to try before the behaviour chart
None of this requires a diagnosis, and none of it is expensive. Before recording a pattern as challenging behaviour, work through the environment first.
Rule out the clinical causes properly, because sensory distress is a possibility and not a conclusion. Pain, infection, constipation, delirium, medication effects and dental problems all present as agitation, and they come first.
Then change one thing at a time and watch. Turn the television off during conversations and mealtimes. Offer a quieter place to eat. Cut the labels out. Ask before touching, and say what you are about to do. Warm the bathroom before personal care. Notice whether distress clusters at particular times, in particular rooms, or around particular tasks, because that pattern is your evidence.
And record what works, in the words that will help the next person on shift. "Finds the dining room overwhelming; offer the quiet table by the window and seat away from the television" tells a new member of staff exactly what to do. "Refuses the dining room" tells them nothing at all.
The question underneath
Person-centred care asks what has changed for this person. Neurodiversity-informed care adds a second question: who has this person always been?
When a daughter says her mother has never been able to bear a polo neck, or that she has eaten the same four meals since 1978, that is not an anecdote. It is clinical information about a lifelong sensory profile, and it belongs in the care plan. The ADHDementia screening tool exists to gather exactly that kind of history and turn it into practical adjustments.
The cardigan is not a battle to be won. It is information. And a resident who is finally allowed to be comfortable will often stop doing all the things that got them labelled in the first place.