Dementia and Alzheimer’s

IMPROVING COMMUNICATION

Communcation:

Communication is an expressive or receptive exchange of information which is vital to the functional success and emotional well-being of a person with dementia. Difficulty expressing needs or understanding another person is extremely stressful to both the healthcare professional and the individual with dementia.

Expressive Communication

The ability to express one’s needs and thought in various forms, such as speech, body language, and facial expressions.

Receptive Communication

The ability to understand communication from others, including messages sent via words, body language, and facial expressions.

Bowes In Home Care
Steps To Better Communication

Gain Attention and Trust

Before you attempt to communicate, make sure you have gained the individual’s attention. It is important that the person in your care feels safe with you and the you have his or her agreement and approval to proceed.

Approach from the Front

When you approach an individual, always try to do so from the front so she/he has an opportunity to recognize you. In the later stages of dementia, range of vision may become more limited, so you need to make further adaptations.

Before delivering your message, make direct eye contact (unless culturally unacceptable) and stand or sit in front of the individual before proceeding. During the conversation, maintaining eye contact shows that you are listening, builds trust, promotes respect, and indicates that you care for them.

Nonverbal Messages

A key aspect of communication is nonverbal. In addition to words you use, your tone of voice, body language, and facial expressions also send a message every time you speak. So be careful not to change the meaning of your message with your nonverbal cues.

At any stage of dementia, there is a person behind the name. Let the person know that they have your full attention.

Working in health care may bring you in contact with residents whose chronic confusion or cognitive impairment may cause them to exhibit combative behavior. It is essential to recognize that a resident’s combativeness is a symptom of the need for care, not a sign of dislike or fear of you. Therefore, your ability to assess, understand and work to prevent or modify combative behavior will result in better care for residents and greater work satisfaction for you.

Minimize Distractions

Individuals with dementia are often easily distracted by both sights and sounds. Before communicating, try to eliminate all unnecessary sources of stimulation. If you need to handle the individual’s belongings, ask for permission first.

Addressing Individuals by First Name

Calling a person with dementia by name shows respect, and identifying yourself often helps the individual with orientation. Leading with the person’s name will improve the person’s ability to answer your questions or request.

Avoid Pronouns

Using pronouns when communicating with an individual with dementia can cause confusion and frustration. Pronouns are words like: it, his, she, her, them, and they. You must speak clearly and simply, and avoid pronouns when at all possible.

Philosophies, Purposes & Outcomes Intended

  • Preserve human dignity
  • Instill confidence
  • Reduce injuries to staff and individuals
  • Develop skills for assisting individuals to regain control of themselves

Use Short Sentences

Long sentences are filled with a lot of information which will cause increased confusion for an individual with dementia. Keep all sentences short and to the point.

Wait for a Response

Research shows that the response time for an individual with dementia can be delayed by up to 30 seconds. When communicating with an individual with dementia, allow time for your words to be processed. Be patient and often you will receive the response you seek.

Use Visual or Tactile Cues

Words alone may not be enough to convey the meaning of a message you are trying to send. Use visual demonstrations or tactile/hands- on cues to accompany your words.

Combative Behavior

Any physically aggressive act that causes or intends to cause hurt or damage to a person or object. Some types of behavior you may encounter in healthcare include:

  • Resisting care – for instance. aggressively hampering efforts at bathing or dressing
  • Verbal aggression – such as arguing, cursing, accusing, or threatening
  • Fighting – endangering residents or healthcare workers with punches, kicks and other hurtful acts
  • Catastrophic reaction – sudden mood changes with outbursts that indicate a resident is overwhelmed and unable to control feelings
  • Physiological responses –  heart rate increases, central blood flow decreases constriction of blood vessels, peripheral blood flow increases by dilation, respiration increases and digestion ceases

Causes

Certain types of brain disorders, health condition, psycho-social factors, environmental situation, and care-giving interactions can interfere with the ability of residents to mirror reality. In effect, behavior always occurs within a context of people, places, times, and events.

Dementia is a brain disorder in which both personality and thinking abilities deteriorate. It occurs in organic brain diseases, such as Alzheimer’s, and in other disorders. It worsens over time. As Alzheimer’s residents lose touch with reality, combative behavior may result from an inability to understand what is going on in the care setting.

Other health-related causes may include hearing or visual impairment, acute illness, multiple illnesses and disabilities, hormonal changes, loss of control over bodily function, or disturbances in body image.

Likewise, alcohol or drug-related condition, changes in medication, and lack of sleep may induce episodes of combative behavior.

Psycho-social causes of combative behavior may stem from a resident’s feeling threatened by life changes and frustrated by a perceived loss of control. Unable to communicate adequately, a resident may misunderstand your efforts to provide care. He or she may be unable to control feelings, or may withdraw from interaction.

Environmental causes of combative behavior can be varied. Very bright or dime lights, blaring radios and TV’s, intrusive loud speaker messages, cluttered rooms, or the constant traffic of people coming and going can upset residents. A change of rooms, roommates or routines, as well as a disregard for the way a resident likes their belongings arranges, may also trigger combative behavior.

Unskilled care-giving acts that can contribute to combative behavior include being overly authoritarian, making gestures that startle or frighten, rough or hurried handling during care-giving, and impatient, loud or demeaning conversation.

Managing Combative Behavior

In dealing with disruptive or combative behavior, one must determine what the individual is trying to communicate through their behavior. If we don’t act on the message it could lead to further escalation or if we try to suppress the behavior it may come out in some other way which may ultimately be more problematic. To manage the behavior, you need to assess and understand the reason for it or the purpose it serves, develop a care plan based on realistic goals, use strategies to prevent it, and intervene safely when it occurs. Regardless of the circumstances, you must always treat residents with respect and preserve their dignity.

Assessing the Resident

A thorough assessment begins with a review of the patient’s medical, social and work history, and a search for behavior patterns that may repeat. Visit with family members to better understand the resident’s personality, former occupation, hobbies and life experiences. Keep the family informed and enlist their help in modifying the behavior. Talk with the resident to share a closer, more understanding relationship.

Maintain an ongoing, regularly updated assessment of the type of dementia, its severity and progression.

  • If a resident resists care, assess and try to understand the cause. Refusing to be bathed, for instance, may mean an individual’s sense of modesty is being offended by the need to undress in your presence. Refusing dinner or medication may mean a resident has fears of being poisoned. Refusing to cooperate may be a way of exerting power and control, to avoid feeling helpless.
  • If a resident becomes verbally aggressive, realize these are signs that they are losing impulse control. Anything that causes stress can bring on this behavior – from a change in routine to the notion that a caregiver is being overly familiar.
  • If a resident starts a fight, realize that fighting is dangerous and act swiftly. Recognize that fighting happens most often when a resident feels his or her personal space or possessions are threatened. Personality conflicts can also lead to fighting.
  • If a resident has a catastrophic reaction, the care provider most trusted by the resident should intervene. Approach the individual in a calm manner to avoid startling them. Be gentle, but firm. A catastrophic reaction can’t be predicted and thus can’t be prevented. An outburst of crying, anger or fighting is a sudden response to feeling overwhelmed. It occurs most often in the morning, when daily care activity is at its peak.
Formulating a Plan

Work closely with the entire care-giving team to develop a plan for successful management, containment and, where possible, prevention of combative incidents. Make your goals realistic. Begin with the understanding that you’ll probably be unable to stop all behavior problems, and cannot halt the progression of conditions such as dementia. Some realistic goals are:

  • Attend to the safety of the combative resident, other residents, staff, visitors, and the environment.
  • Provide support by having all caregivers stay alert to give aid in combative behavior situations.
  • Increase awareness of behavior that may give clues to the onset of an aggressive act.
  • Containment focuses efforts to decrease the frequency, intensity, duration, and disruptiveness of combative behavior.
Prevention

Our actions should be motivated by the need to protect and teach, not by a desire to punish. Despite a resident’s confusion or cognitive impairment, always try to validate his or her reality and honor the human dignity to which each of us is entitled. Give each resident your respect, shown by words of praise and gestures of support. Encourage a resident’s self-care and functional independence to the full extent of their capabilities. Use the following preventive strategies:

  • Validate the reality of the confused residents. When you enter the resident’s rooms, prepare to “jump into their reality” rather than insisting on yours. If they are convinced it is the 1940’s, let it be so. If they think their morning involves getting ready for work, avoid the urge to make them “get real”. Chronically confused residents will be unable to join you in your reality. So, even if it makes you uncomfortable, join them in their reality, whatever that may be.
  • Watch for clues that combative behavior may erupt, such as agitation, nervousness, frustration, fear, panic, despair, guilt, suspiciousness, hostility, confusion, annoyance, and resentment.
Physical & Behavioral Responses

Emotional Responses

  • Anxiety – muscle tension
  • Fear – tingling in the hands or limbs
  • Anger – stomach ache
  • Frustration – chest pain
  • Irritability – cold sweat
  • Panic – racing heart
  • Despair – feeling faint
  • Guilt – “freezing”

Cognitive Responses

  • Can’t concentrate – desire to run away
  • “I am a failure” – drinking / drug use
  • “It’s my fault” – taking anger out on someone else
  • End result will be a catastrophe – sleeplessness
  • Can’t make decisions – hiding or isolating
  • “Others” are to blame – quitting
  • Things will never get better – avoiding
  • “I bear sole responsibility for what happens”

Historical

  • What has happened in the last several times the person was in this environment?
  • What are the historical consequences of the behavior from long ago?

Social Environment

  • Territorial
  • Lack of interactions with family / friends
  • Lake of privacy
  • Someone else exhibits maladaptive behavior
  • Certain people the individual dislikes
  • Someone looking or active threatening, annoyed or angry
  • Imitation of staff behavior
  • Presence of family members, old friends, etc.
  • Attention being given to someone else, resulting in lack of attention

Physiological Issues

  • Accidents / falls
  • Physical ailments
  • Improper positioning
  • Eating certain foods (especially disliked or “allergic foods”)
  • Not enough to eat
  • Too long since last food/drink
  • Being awakened too early

Medication

  • Taking certain medications
  • How recently medication was taken

Interaction

  • With your words and actions, “mirror” such qualities as kindness, patience, good humor, respect, and friendship. Often, a resident may draw reassurance from you, and “mirror” your good will in their responses
  • Approach slowly from the front to avoid startling the resident. Don’t appear afraid or unsure of yourself even though you may be shaking on the inside
  • Allow the resident more space when they are angry. By aware of your position. Watch so that you don’t do something intentionally or unintentionally to intimidate the individual
  • Keep at arm’s length and one small step away from the individual whether standing or sitting
  • Bring yourself to eye level
  • Move with the individual, not ahead or after the individual
  • Speak deliberately and respectfully, with short words and sentences
  • Identify yourself and the care you’re planning to provide
  • Don’t argue
  • Don’t demand
  • Don’t promise anything that you can’t deliver
  • Listen carefully and respond to the problem and not the words (or observe carefully in the case of a nonverbal individual)
  • Accept and acknowledge the individual’s statements as expressions of their feeling
  • Often, a resident won’t be able to remember or carry out a series of tasks, so break the tasks into single acts – Out of bed, Into the bathroom and Use the toliet, etc.
Communicating with Alzheimer's Patients

As a result of physiologic changes caused by Alzheimer’s disease, affected people may not communicate well with others. They are not creating these obstacles on purpose, and are probably as frustrated as their friends and family about the communication problems.

People with Alzheimer’s disease may:

  • Use certain words repeatedly
  • Invent new words to describe familiar objects
  • Have difficulty finding the appropriate words
  • Revert to speaking in a native language
  • Use offensive words
  • Frequently lose their train of thought
  • Speak less often
  • Use gestures to communicate instead of words

You can help the person with Alzheimer’s disease by being a good listener. Let the person with Alzheimer’s know that you are listening and that you are trying to understand them. Maintain eye contact to show them that you care about what they are saying. Encourage them to continue trying to express their thoughts, even though they may have difficulty doing so. Don’t interrupt them, no matter how long it takes them to think about and describe what they want. Avoid criticizing or correcting their speech or actions. Don’t argue with them.

Follow these tips for improving communication with a person affected by Alzheimer’s disease:

  • Respond calmly and express support
  • Use a gentle, relaxed tone of voice
  • Use positive and friendly facial expressions
  • Don’t approach the resident from behind – always from the front
  • When beginning a conversation, identify yourself and address the person by name
  • Speak slowly and clearly
  • Use short, simple, familiar words
  • Break tasks and instructions into clear simple steps
  • Ask one question at a time and allow enough time for a response
  • Avoid using pronouns (“he” or “she”), instead, identify people by name
  • Avoid negative statements and questions (“You know who that is, don’t you?”)
  • Use nonverbal communication such as pointing and touching
  • Don’t talk about the resident as if they weren’t there
  • Be patient, flexible, and understanding