Communicating with those with Dementia

Stage-dependent Goals
Caregivers need to communicate differently with those with dementia at different stages of the disease. As the disease progresses, more skill is required to convey messages and establish mutual understanding. It is important to remain flexible and aware of how effective different techniques are in different situations. As dementia progresses from early to late stages, communication strategies, goals, and expectations need to change.
In the early stages, the goals of communication are to:

  1. Maintain as near to normal communication and interactions as possible.
  2. Keep the person socially engaged.

In some ways, these are relatively easy goals to achieve, because the main communication problem involves word finding.

In the middle stages, the goals of communication are to:

  1. Maintain a shared pattern of communication through turn-taking and other social forms.
  2. Maintain a two-way flow of communication.

In the late stages, the goal of communication is to maintain communication by emphasizing non-verbal techniques.

Communication Strategies
Research on the best ways to communicate with care recipients who have dementia have identified four strategies that are effective:

  1. Show respect
  2. Decrease environmental stress
  3. Empathy and validation
  4. Focused communication

These four strategies build on each other and are best used in combination.
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Show respect
The first way to show respect is to address the care recipient by her/his preferred name.  The second way of showing respect is to use good manners such as saying “please” and “thank you.” The third way of showing respect is to invite the care recipient to participate in something rather than telling or demanding them to do it.  The fourth way of showing respect is to give priority to the care recipient’s agenda over yours. Attend first to what the care recipient wants or needs before you attend to what you want.

Decrease environmental stress
Those with dementia can react very negatively to stress. For a person with dementia, even a small amount of stress can produce what is known of as a catastrophic reaction (serious emotional reactions characterized by emotional outbursts, agitation, and sometimes physical aggression).
The best strategies for decreasing environmental stress include:

  1. Reducing noise and distractions.
  2. Maintaining consistent routines and rituals such as mealtime and bedtime.
  3. Decreasing the “hustle, bustle, and rush” around the person.
  4. Use calm voice tones and slow movements.
  5. Giving the person with dementia time to comprehend and respond.

Empathy and validation
The goal of this strategy is to affirm the feelings behind the message that the person with dementia is sending rather than focusing on the content of the message. The task for the caregiver is to carefully observe the emotions, behaviors, and environment of the care recipient, and then reflect back what the caregiver believes is going on.
Strategies for showing empathy and validation include:

  1. Rephrasing what you observe (e.g. “You look thirsty”).
  2. Asking questions about who, what, when and how.
  3. Mirroring the care recipient’s words back to acknowledge that you are listening.
  4. Matching with words the emotional expressions that the care recipient displays (e.g. “You look worried”).
  5. Reinforcing the behaviors using smiles and gentle touch.
  6. Reminiscing about memories to distract the care recipient to reduce her/his distress.

Communication Don’ts

  1. Avoid pointing out errors. There is generally no need or benefit to correcting errors made by the care recipient. Pointing out errors may cause distress and agitation.
  2. Avoid arguing. Arguing won’t improve the care recipient’s ability to remember. It will only make the situation worse.
  3. Never invalidate emotions.  Affirming the care recipient’s feelings is important.
  4. Don’t criticize, scold, or embarrass the care recipient.
  5. No matter how busy you are, never rush the care recipient.
  6. Never force the person to do something s/he doesn’t want to do.

Communication Do’s

  1. Face the care recipient directly, maintain eye contact while communicating, and attract her/his attention before beginning.
  2. Be at the care recipient’s eye level. If the person is standing, you should be standing, and if the person is sitting, you need to be sitting.
  3. Orient the care recipient frequently. Provide frequent cues about who, what, when, where, and why.
  4. Provide continuity by continuing on the same topic without changing focus too often. If the topic is going to change, provide orientation.
  5. Try to help the care recipient find the words that s/he may be “stuck” on trying to remember.
  6. Simplify your instructions to only one or two topics. Keep sentences short, simple and direct. Repeat nouns rather than using pronouns.
  7. Try to ask easy questions. If there are choices, limit the number of choices to two if possible.
  8. Use pleasant facial expressions and tone of voice, pictures, hand signals, and pantomime to convey your message.
  9. Give the care recipient time to respond. Offer clues about how the person can answer the question if necessary.
  10. Remember that good communication is a two-way exchange. If the care recipient is having difficulty holding up her/his part of the conversation, try to help her/him to participate.

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