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Maximizing communication with the Alzheimer's patient.

Those who interact with individuals with a diagnosis of dementia of the Alzheimer's type know the difficulties in communicating with these patients. Their communicative deficits have been well documented and may include poor memory, poor judgement, poor word finding skills, poor comprehension of spoken and written material, poor expressive language skills, verbal perseverations of words and ideas, poor topic maintenance, poor turn taking, poor discourse skills, and general disorientation or confusion. While these patients may be able to speak clearly, they have difficulty in communicating their thoughts, needs and ideas.

While certainly devastating to the individual, these deficits can have an equally negative impact on the communication partner. Anyone who needs to converse with an Alzheimer's patient faces a variety of potential difficulties which may set the stage for communicative breakdown and frustration. The authors have been involved in training programs designed to maximize communicating with the Alzheimer's patient. It is our feeling that family, friends, physicians, nurses, aides, orderlies, volunteers, and staff members of long-term care facilities can learn some strategies to make conversing with Alzheimer's patients more effective, efficient and, hopefully, less frustrating.

While our workshops outline seventy "helpful hints" for communication enhancement with individuals with a wide variety of diagnoses, here were will highlight those targeted to the Alzheimer's patient. These suggestions may need to be tailored to the particular individual and the specific type of interaction--that is, they will apply to most, but not all, individuals or situations.

It is exceedingly important, first of all, for conversation partners to understand the true nature of the deficit. For example, verbal perseverations (the repetition of a previous response, or part of a previous response) are very common in dementia. If a patient gives the same response several times, it is more accurate to view this as perseveration rather than an indication that the individual is making the same mistake over and over again. It indicates an error pattern, not a series of independent wrong answers.

It is also important for all involved to set their expectations appropriately. If it is known that the patient, for example, needs several repetitions before understanding a question, prepare for this and do not set yourself up for being frustrated each time this occurs. We encountered one resident who, each night for months, packed some of her belongings and went to the nurse's station to "check out" of her "hotel room." Each night the nurse involved became agitated, resenting the need to coax the woman back to her room, convince her to stay, and then unpack the resident's things. After realizing the absolute predictability of the behaviors, though, the nurse began to use an empty suitcase and "play along," anticipating what was to happen. In short, the nurse took control of the situation based on her knowledge of the resident's behavior. Soon, the pattern ceased.

It is important to use gestures and facial expressions when communicating with Alzheimer's patients. What is not understood in verbal language may be better understood in body language. This means that you should make sure that your are clearly visible (not in shadows or glare), facing the individual and speaking without obstructions. When giving directions, demonstrate what you are asking them to do, in addition to telling them. If indicated, write down the instructions and leave them where the patient can easily find them. While it is usually true that receptive language skills (listening and reading) are impaired in Alzheimer's, reading comprehension can be better than verbal comprehension. This is because written material can be reviewed several times, while auditory information is fleeting.

Speak more slowly and a bit more loudly.

Alzheimer's patients need extra processing time, both for taking information in and for producing a response. They may also benefit from moderately increased loudness, not only because so many older patients have hearing losses of varying degrees, but because slightly increased volume serves as an attention-getter. It is not necessary, however, to shout. This is both inappropriate and demeaning.

Stick to a topic for awhile. Shifting from one subject to another "loads" the processing demands of the patient's language system. The use of several repetitions is often very helpful. If you plan on having to do this, it will ease the frustration you might feel in having to repeat yourself over and over again because the individual did not respond. Know what to expect, plan on it and do it.

Keep your sentences and questions short and simple. Do not explain too much; restate your thought simply, rather than try to reword it. Don't use uncommon words and don't say too much at one time. Don't ask too many questions at once. If there are some important answers that you need, try to introduce the topic slowly. Build up to the important questions, having established the topic first.

Whenever possible, give the patient choices in responding, rather than leaving it open-ended. For example, instead of asking "Which sweater do you want to wear?" which places full responsibility on the patient to announce his or her choice, take out two sweaters, show them to the patient and ask "Do you want the beige one or the blue one?" while gesturing appropriately toward each. To the extent possible, give the patient as much of a participatory role as possible. When you are not communicating effectively, both parties lose a great deal of power. Provide the patient with as much communicative power as you can. Even if you have to "fake" compliance, include your patient in decision-making situations.

Accept any form of communication you can get. That it, don't insist upon correct words or sentences. Gestural responses can be quite expressive and productive. Serve as a facilitator, not as a teacher or therapist. Give hints to aid responding. Don't dare the patient to answer, help him. Remember, the goal is communication, not language rehabilitation. Whatever gets the message across should be accepted.

Pay attention to the environment in which you are communicating. Avoid distractions. Too often we interact when it is clear that the patient is distracted by the various stimuli around, e.g., the others in the room, the objects we are holding, the clothes we are wearing, our activity level, etc. Try to establish maximum attention prior to communicating. Make sure the lighting is appropriate and that there is a minimum of competing noise. Often the Alzheimer's patient has difficulty in differentiating foreground sounds from background sounds. It is important to decrease the competition. While not true of all cultures, in America eye contact is very important when communicating. We do not like communicating with someone who is wearing dark glasses. It makes us uncomfortable because we are lacking an important aspect of interpersonal contact. Take advantage of this fact and maintain eye contact with your patient. This establishes a connection which may help maximize communicative effectiveness.

Do not infantilize your patient. While it may be true that a particular patient may not understand the exact words you are saying, he may very well understand your tone. Using a childlike intonation pattern is demeaning and can be perceived as such by the patient. Do not use such expressions as "Do we want our sweater?" but structure your sentences as you would when speaking with any other adult, as in "Do you want your sweater?" It is also inappropriate for you to discuss the patient in front of him or her. While this may be difficult to avoid at times, try anyway. Here again, the patient may not be understanding the exact content of your words, but he may be understanding your glances, your facial expressions, etc. and know that you are talking about him.

Allow for as much speaking as possible. While this also may be difficult, the more the patient converses, the greater the probability that he will communicate what he means. When the patient lapses into reminiscing, allow it, even encourage it. It is a means of lowering anxiety and can be quite entertaining if you have the right attitude about it.

Finally, it is very important for you to be a good listener. This can be time-consuming, and time is often in short supply. Nevertheless, whenever possible, serve as a communication partner and listen to your patient. Listen not only to the words. These may be deceivingly off-target. Listen to the affect underlying the words. This is often perfectly on-target. Respond to the emotion and see through the errors or confabulations of the patient's message.

It has been said that the ability to communicate is the essence of being human. When communication skills are impaired, one is left qualitatively less human. This is a devasting state, one which isolates and can result in depression, which further isolates the individual. To the extent that our suggestions are helpful, use them. Alter them to suit your personal style as well as the unique needs of your position and your patients. If you can enhance your ability to converse with an Alzheimer's patient, both the patient and you will benefit.
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Author:Mandel, Ellen
Publication:Nursing Homes
Date:Sep 1, 1993
Previous Article:Finding out what's "special" about SCUs.
Next Article:Recruiting RNs to long-term care.

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