Be specific and direct with your requests (e.g., “Come with me” as opposed to “What do you want to do today?”).
Use short, simple words and sentences.
Provide few, simple choices (e.g., “Do you want beef or chicken?” as opposed to “What do you want to eat?”).
Eliminate distractions from the environment (persons with dementia are easily distracted and require their full attention to effectively track conversations).
Do not talk louder or in a patronizing manner (recall that patients, even those with severe impairment, still have some sense of how adults are supposed to talk to one another).
Do not command or use a commanding tone (e.g., “Get out of bed!”).
Do not ask questions that rely on memory (this can cause extreme anxiety in patients).
Do not focus on logic or explaining yourself (arguing with patients only makes matters worse, as they lose the ability to use logic).
Do not view behavior problems as intentional. Their disease is to blame for these challenges.
Remain calm and focus on patients’ feelings.
Use touch to reassure and calm them (if “therapeutic” touch has worked in the past).
Don’t take accusations personally (again, their disease is to blame).
Check the validity of accusations (sometimes so-called “delusions” turn out to be true; e.g., someone is really stealing their money).
Provide very simple explanations for events.
Distract to other topics of conversation or activities.
Provide attention for non-repetitive behavior.
Be patient and remain calm (remind yourself that the disease is to blame).
Reassure patients if they think something is wrong or they did something wrong.
Respond to feelings.
Distract.
Write down the answers to FAQs on a card and have them refer to the card.
Remember the old saying, “An ounce of prevention and a pound of cure”? This means that preventing a problem takes a lot less time and effort than actually dealing with it when the problem arises. For example, treating an infection takes a lot less time and effort than amputating a gangrened limb. The “ounce of prevention” idea also holds true when caring for persons with dementia. Namely, it takes a lot less time and energy to prevent behavioral challenges by focusing one’s effort on less severe forms, than to wait and react to more severe behaviors. Preventing behavioral challenges involves altering your communication style and making necessary environmental changes at the first sign of patient upset.
The Challenge of Communication
At some point in time, all persons with progressive dementia suffer from severe communication problems. Such problems concern both expressive and receptive communication. Expressive communication involves finding the right words to let others know about your wants and desires. Expressive communication problems might appear as halting speech, as patients struggle to come up with their next word or phrase. Patients may also use the wrong words. For example, what they want to say is, “I have a headache”. However, what comes out is, “Keys fall behind my glasses.”
Receptive language involves understanding what others are saying. Tracking conversations and following instructions are two examples of receptive language. Along with expressive language deficits, persons with progressive dementia will eventually have difficulties following conversations and instructions.
In consideration of these challenges, let us turn next to specific communication strategies.
Specific communication strategies. In spite of level of impairment, patients are still affected by how we communicate; namely, our nonverbal communication. Patients respond well to staff that are welcoming and non-threatening. The following are several recommendations on how to appear welcoming and non-threatening to patients.
- Approach from the front (to not startle the person).
- Establish eye contact (this will help get their attention).
- Touch if appropriate.
- Act calm and relaxed; use a soothing voice (this will help them remain calm and relaxed, even when they don’t comprehend what is said).
- Speak slowly.
- Provide ample time to respond – Be patient.
Patients also respond to verbal communication. Given that many patients have difficulties tracking conversation, minimize confusion by changing the structure of your speech. Below, are several recommendations on how to structure your speech when talking with persons with dementia.
- Be specific and direct with your requests (e.g., “Come with me” as opposed to “What do you want to do today?”).
- Use short, simple words and sentences.
- Provide few, simple choices (e.g., “Do you want beef or chicken?” as opposed to “What do you want to eat?”).
- Eliminate distractions from the environment (persons with dementia are easily distracted and require their full attention to effectively track conversations).
Our communication style can also increase confusion, agitation, and behavioral challenges, so there are communication styles to avoid.
- Do not talk louder or in a patronizing manner (recall that patients, even those with severe impairment, still have some sense of how adults are supposed to talk to one another).
- Do not command or use a commanding tone (e.g., “Get out of bed!”).
- Do not ask questions that rely on memory (this can cause extreme anxiety in patients).
- Do not focus on logic or explaining yourself (arguing with patients only makes matters worse, as they lose the ability to use logic).
- Do not view behavior problems as intentional. Their disease is to blame for these challenges.
Managing Paranoia, Delusions, & Hallucinations. Paranoia, delusions and hallucinations are very common in persons with dementia. Try not to panic. These bizarre behaviors are much easier to manage in persons with dementia than in patients with psychiatric problems.
- Remain calm and focus on patients’ feelings.
- Reassure them that you are there to help – use your name and theirs.
- Use touch to reassure and calm them (if “therapeutic” touch has worked in the past).
- Don’t take accusations personally (again, their disease is to blame).
- Check the validity of accusations (sometimes so-called “delusions” turn out to be true; e.g., someone is really stealing their money).
- Provide very simple explanations for events.
- Distract to other topics of conversation or activities.
Managing Repetitive Statements or Questions. Repetitive statements and questions are annoying to family and staff. While you can never eliminate this repetitive behavior, it can be reduced if you take the following steps.
- Provide attention for non-repetitive behavior.
- Be patient and remain calm (remind yourself that the disease is to blame).
- Reassure patients if they think something is wrong or they did something wrong.
- Respond to feelings.
- Distract.
- Write down the answers to FAQs on a card and have them refer to the card.
Always Rule Out Medical Problems First
The development of progressive dementia like Alzheimer’s disease is usually very gradual. It begins by causing a slight loss of thinking abilities. Most often, memory is affected first. Later, other thinking abilities are affected, and, eventually, individuals lose control over some of their bodily functions.
While it is impossible to predict the specific course of progressive dementia, suspect medical problems if there is an abrupt change in a person’s behavior. Be sure that this sudden change in behavior is not on account of a medical condition (e.g., Urinary Tract Infection, constipation, fever, toothache, and sinus infection), sensory impairment (e.g., visual and/or hearing loss), or medication side effects or drug interactions. Should you notice sudden changes in patients’ behavior, be sure to rule out potential medical causes for their behavior.
Before completing this program, let us briefly review some of the major points that were discussed throughout these modules.
Environmental Approach to Challenging Behaviors
Recall that an environmental approach attempts to identify specific things in the person’s environment that might be causing the problem behavior. These environmental influences come before and after challenging behaviors.
Environmental influences that come before behavior are called antecedents. Common antecedents for persons with dementia are noise, boredom, and difficult interactions with others.
The following what, when, who, what, and where questions will help you figure out other possible antecedents of problem behavior.
- What happened immediately before the behavior?
- When did the behavior occur?
- Who was around?
- What activity was going on?
- Where was the patient?
The consequences of behavior allow us to better understand the purpose of a particular behavior. Recall that problem behavior can serve more than one purpose. Problem behavior can:
- reduce stimulation
- increase stimulation
- help a person escape from an unpleasant situation
- get attention from others.
After figuring out the purpose of problem behavior and changing the situation such that the behavior becomes unnecessary, you will find that the behavior “problem” disappears.
Understanding Problem Behavior and a Commitment to Non-Restraint Treatment Strategies
Behavior “problems” are adaptive for persons with dementia. Patients are doing the best with what they have left of their skills. Screaming, moaning, hitting, pacing, might be their way of telling us that something isn’t right. This is their new language, their new adaptive form of communication. This adaptive behavior should not be taken away.
It is important to allow all behavior in persons with dementia, the “good” with the “bad” (from the perspective of other people). As providers, our role is to support all behavior for as long as possible, because one day all will be lost to the disease. Even though so-called “problem” behavior is disruptive, it might very well be the only “voice” the person has left. This “voice” allows us to know whether a person is in pain or otherwise suffering. Therefore, instead of blocking problem behavior, we should try to figure out when and why it occurs so that we can make more dangerous forms of communication (e.g., aggression) unnecessary. Moreover, and most importantly, we can help patients with whatever is causing them distress – both expeditiously and humanely.
Copyright © 2020 Kyle Ferguson, Ph.D.