The intent of this article is to share communication strategies that when implemented are effective to reduce adverse behaviors and facilitate higher function and quality of life for people with dementia and other behavioral issues. The foundation of understanding what appropriate communication strategies are is to first understand the seven components of communication. If any of these components are missing, the potential for adverse or aggressive behavior increases. This is true for interactions with anyone, regardless of whether the person has a diagnosis of dementia or any other mental health issue.
The seven components of communication are:
- Memory: the process used to acquire, store, retain, and retrieve information;
- Concentration: the ability to focus one's attention;
- Orientation: a person's awareness of who, where he or she is, what time, date it is, and who other people are;
- Language: the communication of thought, including spoken, written, and non-verbal;
- Judgment: the mental process of making decisions
- Visual-spatial ability: the mental processes of how we make sense of what we see, and how objects relate to each other
- Sequencing: doing something in a logical order
Each of these seven components must be present to achieve effective communication. One of the many challenges for a client with dementia, or other behavioral diagnoses, is perception. An individual's perception, or lack of perception, can easily become one's reality, and this can occur quickly. Therefore, it is important to not only understand the components of communication, but to also continuously strive to understand the disease process and approach strategies.
As a part of the interdisciplinary treatment team, each person should strive to improve one's own understanding, attitude, communication and willingness. Understanding the diagnosis and the individual triggers for behavior, while utilizing intervention strategies is fundamental. Communication needs to be resident centered. The interdisciplinary team must be empowered to take ownership, and to share what works and what does not work with each other. A can-do attitude is critical to successfully modifying the approach. Willingness to attempt to identify the cause of the behavior first, before determining how to proceed, is key. Effective communication, validation and a therapeutic approach are crucial.
Leopold Liss, MD, a neurologist and neuropathologist who founded and served as the medical director for the Columbus Alzheimer's Care Center, in Columbus Ohio, said, "Adverse behavior happens when the demand on a person exceeds his, her ability to cope at any given time. If the behaviors don't cause harm, don't medicate the behavior." We as caregivers need to learn different communication problems associated with dementia in order to communicate effectively with our clients. As this disease progresses, clients often lose short-term memory, followed by loss of other communication components. It is important to learn why communication fails, and how to best handle, approach and communicate with a resident with dementia. Knowing how to respond when something goes wrong, and when the client becomes agitated or combative is critical.
Validation has been described as a way to communicate with people who have Alzheimer's disease, or other related dementias. When utilized, validation is an effective way to go into another's reality. As caregivers we often are faced with the task of trying to understand the people we are working with. Validation allows individuals to accept the reality and personal truth of another's experience. It is truly one of the components of utilizing a person-centered care approach. Behavior is a form of communication. As caregivers we must learn to appreciate where the resident is, and go into their reality, despite the observed behavior. Validation enables caregivers to understand where the person is.
Guidelines for effective communication include:
- Don't dismiss what the client is saying
- Don't confront
- Don't shatter their only reality
- Treat clients with genuine respect; remember it is their mind that is affected, not their feelings
- Distract or divert from a stressful event to a more pleasant one; this often can be accomplished with a desirable food item, soothing touch, soothing talk, music, supervised walks or activities
- Find something from a person's long-term memory, and bring it up into working memory; this can
be identified by speaking with the client's family and finding out what they used to like to drink,
or what they liked to do and incorporate that into treatment
- Be creative, and speak in simple terms
- Look for the cause of the behavior - try to identify the trigger
- Distract rather than argue
Examples of good communication include: "I understand why you feel that way" or "I'd be upset too if that happened to me" or "let's have a cup of tea, coffee... tell me about your children." Communication approaches with clients with dementia can be even more difficult for someone with a psychiatric illness. To the resident experiencing a hallucination, any of the five senses can be involved, and these disturbances appear real and vivid. Delusional thoughts are thoughts not based on reality despite evidence to the contrary. It is important to try to communicate with the client where they are at any given time. Whenever possible, you must go into the client's reality.
Communication problems associated with dementia include:
- Marked loss of memory
- Difficulty with word finding and naming
- Decreased comprehension of language
- Semantic difficulties in verbal output
- Reading and writing challenges
- Lack of awareness and consequences of actions
- Difficulty inhibiting behavior
- Problem solving challenges
- Impaired decision making
Communication often fails with the dementia client and other clients with mental health diagnoses due to confusion, listener frustration, poor initiation, slowed response time, and few communication opportunities. Many times caregivers are not aware of how their tone of voice is being perceived. When caregivers rush the client, the client may negatively react. When caregivers provide multiple choices, the client is easily overwhelmed.
Effective communication with a client with a dementia or mental health diagnosis should be an equal partnership. While this interaction is often broken, it can be rebuilt using simple, straightforward strategies:
- Make eye contact
- Say the person's name
- Avoid terms of endearment such as "honey, sweetie, sugar, or baby"
- Identify yourself
- State ideas in positive vs. negative terms
- Do not reason or apply logic
- Erase the words "Don't you remember?"
- Go where the person's reality is
- Provide step by step instructions
- Use non-verbal or tactile cues when something goes wrong
Many times behavior is the means through which the dementia or mental health client communicates what he/she is feeling. Anxiety and fear can be expected when a person feels confused or disoriented. Therefore:
- Try to avoid or ease embarrassing or high pressure situations.
- Remain calm and remove them from whatever is upsetting them
- Try not to take the clients behavior personally - instead try to understand the cause of the behavior.
- Distract rather than argue with the client
- Avoid negative or stressful feedback
- Know the client's predictable behavior patterns and try to anticipate problems
- Assess when to validate their feelings, and when to orient them to reality
- Remember you are part of a team for handling behaviors
- Remain patient
Caregivers must always remember they cannot change the person. Therefore, we have to change our approach, our communication and/or the environment. We can make a difference in the care and lives of a client with dementia, or a psychiatric diagnosis, when we strive to improve our understanding, communication, attitude and willingness.
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Tom Conrad is a COTA with HealthPRO and has more than 20 years of experience treating older adults with dementia and other cognitive disorders.