All health care professionals must be skilled at effectively communicating with patients who have dementia. Some professionals may erroneously assume that only those employed in long-term care, assisted living facility, and other similar places need these skills. However, patients with dementia visit medical practices, acute care hospitals and other health care centers. This article will provide a framework to effectively interact with patients who have dementia.
Go along to get along
This tip is the most critical skill to acquire. When a patient with dementia says something that is factually incorrect, intuitively, it may seem completely appropriate to correct the untrue statement. However, current research has found that line of reasoning is actually counterproductive. Trying to correct the patient may cause them to become agitated.
Naomi Feil, MSW, ACSW, founder of the validation method, believes it is important for professionals to recognize that these seemingly unusual verbal statements and bizarre actions are usually an effort to resolve past issues. Professionals need to react with patience and empathy rather than being dismissive.
In her article “Communicating with the Confused Elderly Patient,” Feil gives examples of the how the validation method works to help communication between the patient and professional. The following material, based on an actual case experience, is an excerpt from this article. Below you will find a less effective and more effective professional response.
Less effective response
Patient: “Doctor, I have to go home now to feed my children.”
Physician: “Mrs. K., you can’t go home. Your children are not there. You are 96-years-old. Your children are grown and live far away.”
The above physician response may anger the patient and escalate their feelings of stress. It doesn’t help to try to correct their statements.
More effective response
Patient: “Doctor, I have to go home now to feed my children.”
Physician: “You must have been a good mother. You must miss your children.”
In this scenario, the physician acknowledged the patient’s statement without causing any undue stress. After making the above comment, it is time to gently redirect to the current situation. For example, you can follow the above response with this statement, “Now, let’s talk about your leg. I understand you were having some pain …” The validation method has proven to be successful in both improving the well-being of the patient as well as reducing stress among professionals.
My mother has Alzheimer’s disease. This communication strategy has proved very helpful. During one afternoon visit, I said to my mother, “I understand you went to the beauty salon this morning. Your hair looks beautiful.” My mother then sternly stated, “I didn’t go to the beauty salon this morning!” Of course, I knew she did visit the salon, but I didn’t correct her. I simply stated, “OK, but your hair looks very pretty.” She then thanked me for the compliment.
In summary: Don’t correct, redirect.
Get their attention. Be sure you have their attention before beginning to speak. Always approach the person from the front, never from behind, which can startle people. Identify yourself, and call the patient by their by preferred name.
Be at their level. Move your head to be at the same level as their head. Bend your knees or sit down to reach their level. Do not stand or hover over them — it is intimidating and scary. They can’t focus on you and what you are saying if they are focused on their fear.
Look carefully at non-verbal behaviors. As a patient’s dementia advances, their verbal skills diminish. A patient may be in pain and not able to verbally express their physical symptoms. Look carefully at facial expressions and gestures. For example, do they grimace when moving their arms? Recently, while visiting my mother at her long-term care facility, we noticed that she was not fiddling with something, typically her clothes. Fiddling with something is part of her baseline behavior. We noticed her hands were clenched. This was a red flag that something was wrong. An infection was discovered and treated. Within two days, she was back to her fiddling.
Keep it simple. Give one-step directions. If you must ask multiple questions, ask only one question at a time. Use short, simple, and familiar words. Speak at a slightly slower rate pausing frequently to give the person time to process what you are saying. Identify people and things by name, rather than saying he/she or him/her.
Turn negatives into positives. Instead of saying, “Don’t do that,” say, “Let’s try this.” Here is another example: Say, “Let’s go here,” instead of, “Don’t go there.”
Rephrase rather than repeat. If the patient has difficulty understanding what you’re saying, find a different way of saying it. Assuming there is not hearing issues if the patient didn’t understand the words the first time, it is unlikely they will understand them the second time.
Be patient. Encourage the person to continue to express their thoughts, even if they are having difficulty. Be careful not to interrupt.
Avoid asking, “Do you know who I am?” Outside of a mental status examination, this question often causes the patient to become frustrated. Beth Kallmyer, MSW, senior director of constituent relations for the Alzheimer’s Association, strongly advises against this type of quizzing. She recommends a friendly introduction, even if you have worked with the patient for an extended period of time, such as this statement, “Hello Mary. I am Barbara, your nurse.” I have personally witnessed many well-meaning professionals in acute care hospitals saying to a patient with dementia whose family members have arrived to visit, “Do you know who these people are?” I have seen patients become very agitated, and some even began to cry. Also, encourage visitors to not quiz patients in this manner.
Memory loss does not mean a complete lack of all cognitive functioning. Patients may have memory loss, but many people in the early and mid stage of the dementia can still process information very efficiently. When my mother was in the mid-stages of Alzheimer’s disease and living at home, we once took her to the emergency department due to a hypoglycemic episode. While my mother was on the ED bed, a nurse standing right next to her looked at me and said, “Does she wear diapers?” I was bracing for an earthquake! My mother is very sweet, but she doesn’t appreciate those types of questions. She let the nurse have it! She said to the nurse, “I’m not a baby. I do not wear diapers!” The nurse apologized to my mother. She later privately apologized to me and said, “I’ve learned a valuable lesson.”
As an FYI, at the time of the visit, my mother was urinary incontinent and used adult diapers. However, we never used the word, “diapers.” We always used the term, “underwear.”
By using the above strategies, you can help improve both the satisfaction and clinical experience of patients with dementia.
Edward Leigh is founder and director, Center for Healthcare Communication.