Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia

Best Practices in Nursing Care for Hospitalized Older Adults with dementia from The John A. Hartford Institute for Geriatric Nursing and the Alzheimer’s Association

Issue Number D7, Revised 2007
Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing
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WHY: Dementia impairs a person’s ability to communicate effectively. It reduces the ability to decode and understand information (receptive language) and the ability to encode and, therefore, express information (expressive language). Ability to mediate actions through internal speech is also reduced, thus decreasing the person’s capacity to plan and problem-solve. These language deficits are compounded by other dementia-related impairments, including memory loss, decreased attention span, and impairments in judgment, insight, abstraction, and visuospatial abilities. The combination of language deficits and other dementia-related impairments result in serious communication difficulties for older adults with dementia. The hospital setting, with its unfamiliar faces and routines, and the effects of acute illness, often exacerbate these difficulties. As a result, hospitalized older adults with dementia may be unable to understand explanations, follow directions, report symptoms and needs, ask for help, or develop and maintain relationships with staff that would support their acceptance and cooperation with treatment and care. These problems have profound implications for patient care and outcomes when the patient is hospitalized.

BEST PRACTICES: Because the patient’s language deficits and other cognitive impairments are caused by his or her dementia, the responsibility to facilitate communication lies with the clinician. Awareness of the kinds of language deficits that are common in dementia will help with this task. The impact of dementia on language abilities varies greatly, however, from one person to another. Thus, an assessment of the person’s particular deficits and communication patterns is essential. This assessment is based on observation and history obtained from the patient when possible and the family, if any. Findings from the assessment will help the clinician structure interactions with the patient in such a way as to compensate for language and other impairments, support retained abilities, and facilitate understanding. In addition to assessing the patient’s language deficits and communication patterns, the clinician should gather other information about the patient that will help staff communicate in a relevant way, interpret unclear verbalizations, and anticipate needs. Such information includes the patient’s preferred name and the names of close relatives; daily routine, including eating, sleeping, activity, and toileting patterns; upsetting situations; potentially calming interventions; and sources of comfort and reassurance. The patient’s family and significant others are the best source for this information.

For persons with dementia, behavior is frequently a form of communication. Non-verbal behaviors, such as agitation, restlessness, aggression, and combativeness are often an expression of unmet needs (e.g. pain, hunger, thirst, and/or toileting needs). Repetitive vocalizations and changes in tone, urgency, or rapidity of speech can signify unmet needs even if the specific verbalizations are meaningless. Clinicians should try to interpret the meaning of these behaviors rather than dismissing them as symptoms of the dementia.

TARGET POPULATION: Hospitalized older adults with diagnosed or suspected dementia, many of whom also have vision and hearing losses, depression, and other acute and chronic health issues.

MORE ON THIS TOPIC:
Best practice information on care of older adults: GeroNurseOnline.org.

Alzheimer’s Association. (2000). Caregivers: Daily Care: Communication. Retrieved November 20, 2006, from www.alz.org/Care/DailyCare/communication.asp.

Feil, N., & DeKlerk-Rubin, V. (2002). The validation breakthrough: Simple techniques for communicating with people with Alzheimer’s type dementia (2nd ed.). Baltimore: Health Professions Press.

Feil, N., & DeKlerk-Rubin, V. (2003). V/F validation: The Feil method: How to help disoriented old-old. (Rev. ed.). Baltimore: Health Professions Press.

North Carolina Department of Health and Human Services, Division of Aging. (2000). Acute hospitalization and Alzheimer’s disease: A special kind of care. Retrieved November 20, 2006, from www.dhhs.state.nc.us/aging/alzbook.pdf.

Silverstein, N.M., & Maslow, K. (Eds.). (2006). Improving hospital care for persons with dementia. NY: Springer Publishing Co, Inc. Small, J.A., & Gutman, G. (2002). Recommended and reported use of communication strategies in Alzheimer caregiving. Alzheimer Disease and Associated Disorders, 16(4), 270-278.

Small, J.A., Geldart, K., & Gutman, G. (2000). Communication between individuals with Alzheimer’s disease and their caregivers during activities of daily living. American Journal of Alzheimer’s Disease, 15(5), 291-302.

Small, J.A., Gutman, G., & Makela, S. (2003). Effectiveness of communication strategies used by caregivers of persons with Alzheimer’s disease during activities of daily living. Journal of Speech, Language, and Hearing Research, 46, 353-367.

TOOLS TO ASSESS LANGUAGE DEFICITS AND FACILITATE COMMUNICATION: Assessment of specific receptive and expressive language abilities is needed in order to understand the patient’s communication difficulties and facilitate communication.

ASSESS RECEPTIVE ABILITIES/FACILITATE COMMUNICATION BY:

Can the patient understand a yes/no choice?     /     Ask simple, direct questions that require only a yes or no response.

Can the patient read simple instructions?     /     Provide instructions in a place that is easily visible to the patient.

Can the patient understand simple verbal instructions?      /      Use short, simple sentences. Use one-step instructions to enhance the individual’s ability to process, e.g. it’s time to wash (smile; pause); I will help you (pause and proceed). Avoid slang, idioms, and nuances.

Can the patient understand instructions given with physical cues?      /      Use gestures. Model the desired behavior (e.g., eating). Be sensitive to the fact that although the person may not understand words, he/she often can read your body language, sincerity, and mood.

Can the patient make a choice when presented with two objects or options?     /     Limit choices; too many options will cause confusion and frustration.  

ASSESS EXPRESSIVE ABILITIES/FACILITATE COMMUNICATION BY:

Does the patient have difficulty finding the correct word?     /     If you are sure of the word the person is trying to say, repeat it. If not sure, don’t guess because that will increase the person’s confusion and frustration.

Does the patient have difficulty creating sentences or a logical flow of ideas?     /     Listen for meaningful words and ideas. Try to identify the key thoughts and ideas. Do not dismiss person as “totally confused”.

Does the patient curse, use offensive or aggressive language, or exhibit aggressive or combative behaviors?     /     Don’t reprimand. Respond to the emotion not the words. Validate feelings. Assess for unmet needs, including those related to misperceptions, hunger, thirst, toileting needs, pain, etc. (See Try This: Assessing Pain in Older Adults with Dementia)

Does the patient avoid verbalization altogether or mutter meaninglessly in various tones?     /     Read nonverbal communication. Anticipate needs.

GENERAL COMMUNICATION TIPS

• If the patient’s primary language is not English, determine whether he or she can communicate more effectively in that language; ask the family; and use an interpreter if necessary.
• Identify hearing and vision impairments; ask about prior use of assistive devices (hearing aids and glasses) and assure use of these devices in the hospital.
• Reduce environmental distractions that compete for attention when conversing with the patient.
• Approach from the front, make eye contact, address the person by name, and speak in a calm voice.
• Talk first; pause; touch second, reducing the person’s sense of threat.
• Avoid verbal testing or questioning beyond the person’s capacity.
• Avoid use of the in-room intercom which may confuse and frighten the patient.
• Do not argue or insist that the patient accept your reality.
• Be aware of memory impairments in addition to communication difficulties: for example, if a patient’s short-term memory is less than a few minutes, it is dangerous to leave the patient alone even if he or she seems to understand the direction, “wait here;” likewise, it is unwise to expect the patient to use a call light to get help. For patients with very impaired short-term memory, each encounter with a staff member may be perceived as the first encounter, even if the staff member just left the room and returned a few minutes later.

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