Having to communicate with patients with dementia and/or other cognitive impairment is not just something that will be encountered on an elderly ward or in long-term care facilities. People with dementia get acutely ill too, and can be in A&E, a GP surgery or any ward. Being able to get the most out of communication is of utmost importance, both to the patient and to you.
Get worried about having to take the history? Dodge the patient in the corridor? Flounder about correcting? Not sure how to attempt to diffuse situations with confused patients? This post is for you. There is no perfect walkthrough way to communicate to every patient, but we have some tips.
Redirection instead of correction
This is something I know a lot of people (myself included) struggle with.
When a patient is talking about something you know cannot be true:
- Do you agree with them?
- Do you try to correct them?
The best answer here is a fairly unhelpful “Try to do neither”.
Here’s a scenario…..
Mrs Jones is an 82-year old lady with moderate/severe Alzheimer’s but little other medical history. She has been on the ward for three days, being treated for a lower respiratory tract infection. She is wandering through the ward and looks upset.
You: “Hello, Mrs Jones. My name is ………. and I’m [insert role here]. Is everything okay?“
Patient: “No, no love. I have to find my parents. They don’t know where I am and they’ll be worried. I need to let them know that I’m here and getting better.“
There are several ways to respond to this. It is improbable (but not impossible!) that Mrs Jones’ parents are alive and wondering where she is. ‘Correcting’ Mrs Jones and attempting to orientate her to time and place may cause her to become more upset and angry. Lying to Mrs Jones is not ethical, nor is it helpful to collude with the patient. Perhaps a helpful approach in this situation would be to try to reassure Mrs Jones that you will ensure the necessary people will be informed.
“I can see you’re quite upset, but try not to worry. Your family know where you are and that you are safe. I can get the nurses to give your family a call if you’d like. Who is in your family?“
In this response, you haven’t lied to the patient or colluded with them. Redirection in this sense is a good way to move the conversation on, and avoid distress for the patient (and avoid frustration for yourself!)
Also, see the point on “Validation” later on.
‘Patients with dementia’ are ‘patients’ too…
These are things which should be done with every patient..but have even greater importance in the confused patient.
- “Hello, my name is … and I am [role]“ is missed worryingly often. In the references I’ve included information on Dr Kate Granger’s “Hello my name is…” campaign. If you haven’t read it, I really, really, really recommend you do!
- Find out the patient’s preferred name. Use it. It often helps to start more formal.
- Approach patients from in front whenever possible, to reduce the chance of startling them. These are often patients who are not only confused, but also have some visual and hearing impairment. If I was anxious and confused and someone crept up on me, I reckon I’d get angry!
- Try to be on a comfortable level for both of you: some people can be patronised by having people kneel or sit beside them, many people find it respectful. Whichever feels most natural at the time and with the patient, eye-contact is even more important in a confused patient. Be aware that standing over someone can seem very threatening!
- Patience with your patients 😉 try not to interrupt (but steer the conversation when it’s your turn!)
- Minimise the number of distractions/other sensory stimuli.
- Give the patient the best chance they can of understanding you: glasses, hearing aids, pain-free?
- Do what is natural for you. Some of the tips below contain things that might not feel right for you (some people are ‘feelings’ types and some people not so much). Do what feels natural, and try not to force it 🙂
Consistent schedules, nursing and communication can help to keep a patient calm.
Keep conversation simple
This may seem a bit patronising, but I can rattle off a good few occasions where I have spoken quickly, used words that may be unfamiliar to a patient and asked about 6 questions in one.
So give people time to process what you’re saying. Use familiar words. Refer to things/people by name if you can, rather than him/her/that. One question at a time, one decision at a time. Choice is incredibly important, but too many options can overwhelm!
“Would you like cereal or toast?”…”Hot or cold?”…”Rice crispies or cornflakes?” is much easier to take than “For breakfast do you want toast with jam, or just toast, or porridge or rice crispies or weetabix or cornflakes? And do you want a tea or a coffee or some juice too?”
Similar rules apply when taking a history – one thing at a time, rather than “Any heart disease, lung disease or diabetes?“
Often, as dementia progresses a person’s verbal communication skills deteriorate.
Patients with dementia can be more sensitive to the body language of others, so moving suddenly/unexpectedly is best avoided. Try to make sure your body language reflects what you’re saying.
Talking to people who know the patient well (nursing staff, relatives, friends) can be useful in discovering how they react to different types of stimuli and how best to approach communicating with them.
A good collateral history
A great deal of knowledge can be gained from those who care for a patient with more severe stages of dementia. Knowledge of what behaviour is normal (fidgeting, certain conversational habits), and knowing responses to pain should be paramount to any healthcare professional in terms of understanding your patient and allowing them to get the best care possible. Carers can usually offer tips on coping with a person’s individual behaviour, helping to identify triggers and reassurance techniques.
Avoid a large volume of direct questions
“Do you know who this is?“, “Do you know who I am?“ – outside of an AMT (abbreviated mental test) or other cognitive test, these type of questions are best avoided. Direct questions such as this can be very upsetting and frustrating to patients if they can’t answer. This goes back to the idea of giving choices rather than complex questions. If you can use visual cues, even better.
Validation and re-iteration
Acknowledge what the person has said to you, even if it seemingly has no relevance to what you asked. If a person isn’t understanding the language you use (and it’s that and not a hearing issue!) try to rephrase or ask something in a different way.
Use visual cues – holding a cup when asking if they want tea or coffee, putting your hand to your chest when asking about chest pain/heart attacks/other medical history etc.
Validation involves addressing the emotions behind what is being said rather than focussing on factual accuracy of the person’s thought.
If a patient is talking about being at work, instead of telling them they’re in hospital not at work, try asking about their work life. Where have they worked at? What have they done for jobs? Did they get tea breaks? Tapping in to pleasant memories can also serve to calm as well as redirect, as can discussing something that can then happen (for example the cup of tea!).
This can validate the person’s feelings and redirect them, rather than trying to reorient them to our reality.
Positive rather than negative
You are sat in front of a red button and a blue button.
Every time you stand up, you’re sat back down by someone with no reason.
Every time someone passes you or engages with you, all they keep saying to you is “Don’t stand up. Don’t press the blue button.“.
I bet you’re thinking about standing up and the blue button?
Again, with redirection 🙂 Changing “Don’t leave the bay!” to “Let’s sit down here for a little while.” can do the trick.
Use physical contact to communicate your care and affection, and to provide reassurance – don’t underestimate the reassurance you can give by holding or patting the person’s hand or putting your arm around them, if it feels right.
Remain aware of socio-cultural issues!
Talking to the non-verbal patient
Just because a patient themselves can not verbalise, doesn’t mean you should refrain from talking to them. Letting the person know of the plans can be reassuring if they can understand, and listening to a kind reassuring voice (even if the words aren’t understood) can allay anxiety. A lot of this is also very dependent on what you feel comfortable doing as a person.
This in itself could be a whole article for me!
I’m a big believer that ‘Challenging behaviour’ is a person’s reaction to an unmet need (or needs).
If I’m not happy/hungry/need a wee: I tell people, I find out how/where I can satisfy my want, and I can then go ahead and moan/eat/wee.
If I’m trying to talk to someone and they’re just NOT GETTING what I’m saying, I get frustrated.
If you can no longer communicate your needs effectively, frustration is a natural response. If you cannot express your frustration effectively this can present as challenging behaviour.
- Perseveration (repetition)
- Physically or sexually inappropriate behaviour
Try to identify triggers.
Distraction, validation, attempting to understand and meet needs are all key in reducing these symptoms. Try the VERA approach!
Validate: acknowledge the person’s behaviour as a personal expression, not simply a symptom of the dementia.
Emotional connection: understand the emotional context behind the behaviour.
Reassurance: Anything from presence and a calming voice, to a gentle hand on their arm.
Activity: being occupied is a great anxiety-reliever! This can help to reduce agitation and give the person the feeling of purpose.
See the VERA Framework in the references for some examples.
StarWards () Cambridge University Hospitals NHS Trust, online www.brief-encounters.org/patients-with-dementia/
http://hellomynameis.org.uk/ – Dr Kate Granger’s campaign for better communication
VERA framework communicating with people who have dementia, by Blackhall A et al, Nursing Standard 26, 10, 35-39
Edward Leigh, How to communicate with patients with dementia, online http://www.kevinmd.com/blog/2014/10/communicate-patients-dementia.html