23: Late Stages: Communication and Activities

This program will:

• Teach you about the changes in communication capacities in the late stages
• Provide some principles and strategies for communication
• Present principles and ideas for activities appropriate for the late stages

• There are no easy answer when its comes to the care of another
• Our hope is to offer you useful information and guidelines for caring for someone with dementia
• These guidelines will need to be adjusted to suit your own individual needs

• Problems with speech and language increase considerably
• Difficult for a caregiver to know what the person needs
• Close observation of body language is important
• Any utterance or gesture should be viewed as an attempt to convey meaning

What was wrong with this interaction?

• A. Mary failed to read Robert’s non-verbal message.
• B. Robert was being uncooperative by not following directions.
• C. Too many directions were given at once.
• D. Mary focused on the task rather than on Robert.
• E. All of the above.

Choice A: Mary failed to read Robert’s non-verbal message, is a very good possibility.

• When people have difficulty making their needs known with words, they will use non-verbal ways of saying what they need

Choice B: Robert was being uncooperative by not following directions, is a possibility.

• Robert may be acting out because his needs were not being met

Choice C: Too many directions were given at once, is also a good possibility.

• Persons in the later stages of dementia have low attention span and difficulty concentrating on a message or task

Choice D: Mary focused on the task rather than on Robert, is another good answer.

• Robert’s frustration could have been avoided if Mary had been “person-focused” with her care rather than “task-focused”

Choice E: All of the above, is the best choice

• Expressive speech: Forming words
• Receptive aphasia: Cannot understand what is being said
• Receptive speech: Understanding words
• Expressive aphasia: Know what they want to say but cannot make the words come out

• Auditory cortex: Part of the brain that “hears” what is being said
• Wernicke’s area: Part of the brain where understanding occurs
• To improve communication, caregivers should
• Engage with the person
• Speak clearly and simply
• Use gestures and facial expressions
• Say the important word last

Verbal:

• Words
• Other utterances
• Non-verbal:
• Facial expressions
• Posture
• Gestures
• Clothing
• Eye contact
• Position relative to person

• Verbal abilities in the late stages
• Poor vocabulary
• Repeat words or phrases
• Echo what others say
• Use poor grammar and diction
• Speak only in jargon
• Make noises that lack apparent meaning
• Understanding is poor to non-existent
• Caregiver strategies
• Rely more on the emotional and behavioral messages and body language to understand their needs
• Use body language, facial expressions, voice tone and inflections
• Non-verbal communication skills are valuable tools in providing care

• Frustration
• Anger
• Sadness
• Fear

• Resistance to care
• Agitation and aggressiveness
• Wandering
• Combativeness
• Withdrawal

• Sense of awareness and well-being
• Emotional expression
• Recognizing emotions in others
• Express pleasure and displeasure

• TAKE INTO CONSIDERATION
• Hearing and vision loss
• Fatigue
• Check eye glasses and hearing aids
• Short attention and concentration difficulties
• CONVERSATION GUIDELINES
• Introduce yourself
• Sit close and make eye contact
• Use preferred name
• Speak clearly and slowly in a normal tone
• Pleasant demeanor
• ENVIRONMENT
• Quiet setting without distractions
• Comfortable, familiar setting

• Speak softly, clearly, and slowly
• Use nouns
• Say the important word last
• Give simple directions, one at a time
• Related to the task at hand
• Close to the time they need to be carried out
• Use a “positive” mode
• Use pleasant expressions, pictures, gestures and demonstration

• Attentive and respectful
• Make eye contact
• Be patient
• Listen and allow time for a response
• Don’t interrupt or correct
• Observe non-verbal messages
• Focus on emotional communication
• Double check their message
• If they digress or lose their train of thought
• Repeat last words said
• Summarize what was said
• Ask appropriate questions
• Repeat or restate things as needed
• Take a break if frustration develops

• Affirm emotional content of message
• Reflect back what you believe is the meaning

• Validate emotions
• Rephrase or restate concerns
• Be aware of person’s history
• Redirect to reduce anxiety

• Careful listening and observation of body language and context
• Gentle touch
• Ask permission
• Observe for signs of objection or resistance

• Obtain permission to or at least provide a “warning” of what is to take place

• Enjoy quality time with their affected loved ones
• Gently stroke their arm
• Hold their hand
• Read to them
• Sit with them

• As death approaches, people need gentle care and family
• Attend to spiritual needs
• Should be part of hospice care

• Dementia causes changes in the brain that affect speech and understanding
• Expressive and receptive aphasias can lead to expressions of frustration
• Nonverbal forms of communication become more important
• Observe facial expressions, body language, context, and the tone of utterances
• Consider the person’s vision and hearing loss and the communication environment
• Give simple, positive directions
• Attend to the person and the emotional content
• Use empathy and validation
• Convey a pleasant attitude
• Listen and observe
• Use appropriate, gentle touch
• Continue to show respect

• Meaningful and pleasurable activities
• Interaction with family or staff
• Diversions
• Purpose is to affirm dignity and provide pleasure and opportunities for success

• Recognize age & gender
• Consider interests, personal preferences, beliefs, culture, life experiences and functional capacities
• Have purpose and meaning
• Reinforce retained capacities
• Give pleasure
• Allow for success at their level of abilities
• Show respect and affirm dignity

• Self-Care (Personal Care)
• Bathing, dressing, grooming, eating, toileting
• Make it a social time
• Compliment
• Singing
• Recite poems/rhymes
• Family stories
• Show respect, reinforce retained capacities, and recognize personal preferences

• Watching bird in an aviary
• Enjoying a garden
• Visiting with a children’s group
• Listening to music
• Singing
• Attending services

• Folding towels or napkins
• Stirring batter
• Group activities
• Shelling peas

• Walking
• Chair exercises
• Passive exercise

• Meaningful and pleasurable activities are essential for quality of life
• Activities can involve self care, productivity, or leisure
• Physical exercise is an important activity that can be modified to the person’s level of ability
• All activities should respect individuals and their personal preferences and interests, affirm their dignity, give pleasure, have purpose and meaning, reinforce retained capacities, and allow for success

Written by:
Catherine M. Harris, PhD, RNCS.
Mindy J. Kim-Miller, MD, PhD

Edited by:
Sasha Asdourian

www.LightBridgeHealthcare.com

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