What communication strategies could you use to support a person with dementia and hearing impairment?

Abstract

Communication with individuals with dementia requires use of conversational strategies from health care providers. Strategies are provided for issues pertaining to poor comprehension. The strategies promote more successful comprehension and compliance, offset mood disorder, and create ease in the way that health information may be accepted by the patient.

The need for such strategies is pronounced in view of the increasing numbers of individuals with dementia requiring services of health care providers. In 2004, nursing homes of the United States housed 231,900 individuals with Alzheimer's Disease.1 This number is expected to increase significantly with the advancing age of the US population. For example, the number of individuals of age 65 and over, at 39 million in 2008, will reach 72 million by 2030.2 Specifically with respect to Hawai‘i, the Honolulu Heart Study3 of Japanese-American men of ages 71–93 found a prevalence of 9.3% for dementia.

While the types of dementia and levels of severity vary, most if not all of these individuals present with a common problem of communication disorder. Poor comprehension skills are typically at the center of this disorder, and relate in part to poor working memory.4

Poor comprehension is only one of many communication deficits in the individual with dementia. Commonly noted expressive deficits reflect problems. They included decreased vocabulary,5 anomia,6 and vague meanings.7 Pronouns may be used inappropriately.8 The ability to sustain a topic and maintain its coherence is impaired,9 both of which affect the ability to have a conversation. Thoughts may be incomplete as seen in aborted phrases,10 message revisions, and topic shifts that disrupt the flow of conversation.5,11 One can only presume that the disruption also affects the ability to understand a message, especially one that is discursive in nature.

Interactants often exacerbate the problem of declining comprehension skills by talking of things not within the sensory field of the patient using lengthy and complex utterances, and speaking too quickly for processing. The issue of comprehension is partly a matter of coordination between the referents (what one talks about) and the words used to talk about them. For a young infant learning language, the best learning scenario is “joint referencing” where the child moves from mutual eye gaze with the parent to looking at an object with the parent at the moment he or she names it. The word and the world to be talked about co-occur. Maturationaly, a separation between word and referent then sets in to the point that adults can talk about things outside of their environment. For the person with dementia, this adult form of language simply fills the air with little meaning that they cannot understand. It is insufficient to present the word first, and the world to which it pertains later, if at all. To assist comprehension, the order of presentation must be reversed. Consider these examples:

“Mr. Smith, it is time for your shower” (the patient is in a wheelchair, and no shower is in his room).

“Mr. Smith, I have come to take you to your appointment with Dr. X. Are you ready?”

“Well, let's put on your clothes so you can go to breakfast.” (The clothes are hidden in the closet in the patient's room).

In each case, the patient reacts with confusion or hostility and refuses to respond. The nurse is talking about a shower, Dr. X., or clothes, none of which the patient first sees. It is better to wheel the patient to the door of his room and say “Look down the hallway. Do you see that door down there? That's the shower. Now, it's time for your shower. OK?” It is as simple as presenting the world to talk about before one talks about it. Without that contextual support, comprehension falls flat, and agitation is sure to follow.

Poor working memory also impedes the ability to co-reference, that is, the ability to refer one word (such as the pronoun “he”) to its actual referent (what “he” refers to). An example is in the sentences “Your husband told me about your problem. He was very concerned,” where the two underlined words refer to each other across a sentence boundary. Connecting the two words requires more working memory than many individuals with dementia can offer, especially if they are busy trying to understand other parts of the message at the same time. The price to pay for cognitive overload in information processing is an inability to perform the co-referencing of a pronoun to its referent. The remedial response is simple. Avoid pronouns.4 Use the name of the referent instead, even if it leads to a repetition of the word that seems contrived in normal discourse.

Comprehension deficits are sensitive to the stimuli to be understood, and these stimuli can be more or less challenging. On this point, interactants have several ways to assist the individual with dementia. Speech rate is one. Processing speed declines in dementia,12 and so speech rate must decrease as well without losing its normal rhythm and flow. Some speakers achieve a slower rate of speech as measured in syllables per minute of speaking time by producing each word surrounded by pauses. The result is a contrived, telegraphic, stocatto-like melody that reduces an otherwise good sentence into a nonsensical list of separately uttered words. The trick to slower speech is simply to slightly elongate the vowels while maintaining the same intonation.

Cognitive processing for those with dementia is also undermined by the grammatical complexity of the stimuli. Complexity is typically a matter of embedding or conjoining information. These linguistic phenomena involve joining or compressing two sentences into one by a variety of grammatical devices. Two ideas (such as “The nurse will help you” and “She is very skilled) can be combined in any number of ways, such as “The nurse who is skilled will help you” or “The nurse to help you is very skilled” or “Because the nurse is skilled, she will help you.” Whatever the device, when two sentences are put together into one, each always leaves some distinguishing residua behind that is some form of a main verb. So a complex sentence simply has more than one main verb. That replication may determine whether comprehension survives or not in an individual with dementia.

Because most health care providers are not linguists, they have difficulty in restraining the use of complex sentences. For example, it is easy to say “Could you tell me what happened to give you headaches?” There are three main verbs (tell, happened, and give) is low. An alternate, but not demeaning, way to ask for the same information is to speak in short simple sentences: “I have some questions. I need some information. I need some information about your health. May I ask you a question? Do you have headaches? When? What happened?” Each sentence has one verb. Note the overlapping repetition of some words across sentences. While the above example is easy to read, it is not easy to speak in a spontaneous fashion unless it has been practiced as a short scenario of suitable utterances to use across patients.

The easiest way to achieve an absence of complex sentences is simply to speak in shorter sentences. Four to six word utterances are probably best understood.

Another demand of cognitive resources, even in individuals without dementia, is the passive voice in English. Active and passive renditions of the same sentence are seen in “I saw the boy” versus “The boy was seen by me.” Unfortunately, passive voice is everywhere in the speech of health care providers: “Were you seen by Dr. James this morning?” “ These pills are to be taken at noontime,” “The shot was given by the evening nurse,” and so on. In each case, the brain presumably has the linguistic chore of rewinding the contorted sentence back into its simpler active form at which point comprehension occurs: “Did Dr. James see you this morning? Take the pills at noontime. The evening nurse gave the shot.” Passive voice is cognitively difficult to understand for individuals with dementia and should be avoided.

In terms of challenging stimuli to understand, there is also a hierarchy of questions that one may strategically pose. They range from most to least difficult for someone with dementia to answer, again for the reason of cognitive demand. The broadest invitation to collect data is the “Tell me about…” command. It is so open ended that the individual with dementia is unlikely to respond productively. Searching for less divergent information may be more successful with “Wh” questions (what, who, where, when, why, how), but they too are demanding, especially the last two. Unfortunately, once again, they commonly occur in language of health care providers: HOW are you feeling, WHY do you think you have xxx, HOW did you hurt yourself?” The question of “What happened?” fares little better. Although “what” is the easiest of the WH question words, this particular construction is simply a synonym for “how.” When the WH questions are unsuccessful, an interactant can fall back to easier “Yes/no” questions, those that are designed to elicit a “yes” or “no” response.13 Examples: “Did you fall down?” “Does it hurt here?” In the event that there is still no reliable response, binary choice questions are given: “Does it hurt here or here?” Randomly posing questions is not likely to elicit the information that the health care provider seeks. Instead, it requires an adept use of a hierarchy of question types with a rapid fallback to the level at which cognition is able to support an answer. The hierarchy is “Tell me about…” followed by “How” and “why” questions, followed by other WH word questions, followed by Yes/no questions, followed by binary choice questions. After that point, family members may have to act as primary informants.

There are other recommendations in the literature regarding best practices in communicating with someone with dementia.14 For example, a conversant should always start a conversation by first identifying him or herself in the likely event that the patient does not remember one's identity. Likewise, if the patient does not understand, the interactant may repeat him or herself, but the repetition should be exact, not a paraphrase, expatiation or reexplanation using other language structures. That additional language is simply more reason for confusion. A poor memory likes to hear the same thing over several times. Normally, the exact repetition of oneself is not an adult habit, and normal conversants typically repair misunderstood utterances by further explanation. However, this lengthens information and increases the complexity.

Slow up the interaction. Be patient and wait for a response. Maintain a comfortable and pleasant intonation pattern and nonlinguistic communicative style via eye contact, smiles and a relaxed state. While these recommendations seems trite, the rationale is not. Up to 60% of a given message may be conveyed by paralinguistic (primarily prosodic) and nonlinguistic (body language) signals as opposed to the words themselves.15 While comprehension of linguistic stimuli deteriorates with the dementia, that component of the message most readily conveying emotion and mood is still present. The delivery of the words is likely to have more effect on the patient than the words themselves.

Some other suggestions for healthcare workers include closing the door. Extraneous noise is simply more auditory stimuli to confuse the patient. The words are hard enough, let alone having multiple signals to process.

The most direct route to minimize confusion and disorientation is the control exercised by deliberate choice. One can easily provide the patient choices, such as which arm to receive a shot, which liquid (water or cranberry juice) to swallow with medications, and so on.

Be careful when believing that a patient really means “yes” when asked a yes/no question of the sort “Do you want…?” Such questions typically ask the patient to concede to a choice already made by the health care provider. Medical staff frequently ask yes/no questions for things that they want the patient to perform. All questions seek a “yes” response: Do you want your shower now? Do you want to get up now? Shouldn't you get ready for breakfast now? How about sitting up for me now?” We seldom ask a question for which the correct answer is “no.” Individuals with dementia frequently adopt a default response strategy of answering “yes” when they are uncertain of the correct answer, which is most of the time. Medical professionals are surprised when the patient nods “yes” to the question of “Do you want your shot now?” and is then agitated and surprised when a needle is produced. One cannot assume that “yes” means “yes.” Check for comprehension by repeating or showing/gesturing the action.

Many individuals with dementia are characterized as hostile, cantankerous, noncompliant or moody when these traits were not the case premorbidly. These behaviors emanate from specific deficiencies caused by the dementia. With respect to communication, those deficiencies may arise from poor working memory as well as several challenging parameters of the speech and language presented to them by others. Simple techniques as discussed above can be implemented by the physician, caretakers, and family. Their use can help to manage mood and promote some communication where none would otherwise be found. Communication techniques implemented by others can positively affect the lives of those with dementia.16

References

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