Say you're a staff nurse on a 30-bed medical—surgical unit at a community hospital. The majority of your patients are age 70 or older, and many of them have dementia, although it isn't usually the primary diagnosis. You're quite skilled in addressing the needs of patients with common conditions—such as stroke, cancer, diabetes, hip fracture, and congestive heart failure—but perhaps you feel less confident about addressing the needs of patients with dementia. In particular, you've seen that these patients' impaired ability to communicate complicates their nursing care. Such impairments vary widely from patient to patient, depending on factors such as comorbidities and the severity of the dementia.
In such a situation you might rely on the approaches to assessment and intervention found in Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia (page 63). These approaches are applicable in a variety of settings and situations, as illustrated by the case examples included in this article. (Case examples were all created by me based on my experience.)
read it | watch it | try it
Watch a video demonstrating the use of various approaches to communicating with people with dementia: http://links.lww.com/A236.
A Closer Look
Get more information on why it's important for nurses to communicate with older hospitalized patients who have cognitive impairment.
Try This: Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia
These are the approaches in their original form. See page 63.
ASSESSING RECEPTIVE ABILITIES
In hospitals and other settings, nurses can use the Try This approaches (outlined on page 63) to assess for language deficits and facilitate communication. The tool offers nine questions that nurses can use to assess a patient's receptive and expressive capabilities. It also recommends ways to make communication easier. For more on why it's important to assess for communication difficulties in such patients, see Why Look for Communication Difficulties in Hospitalized Older Adults with Dementia? page 60. (To view the portion of the video discussing the assessment process, go to http://links.lww.com/A237.
The following short case examples illustrate how you can use the tool to assess and improve communication with patients who have dementia. As noted in some of the examples, nurses often obtain much of the assessment information from family members and other caregivers who are familiar with the patient's communication abilities.
Can the patient understand a yes—no choice?
* Assess whether the patient's “yes” or “no” response is consistent with her or his nonverbal behavior. For example, if a patient denies having pain or discomfort upon questioning but grimaces and guards her or his arm when you palpate the area, the verbal response may not be accurate.
* Are there yes—no questions that the patient consistently answers accurately? For example, ask the caregivers whether the patient reliably reports pain in response to a yes—no question.
* Verify answers to yes—no questions when appropriate. For example, if a patient has verbally denied pain but you suspect that an incision is painful, point to the site and ask whether it hurts.
Can the patient read simple instructions?
* Assess the patient's ability to read and understand simple instructions. For example, when you give the patient a container and written instructions for providing a clean urine specimen, ask her or him to read the directions and describe the procedure to you. Thus, you can determine whether the patient can carry out the action.
* Identify simple and familiar expressions that can be used during hospitalization. Ask family members or caregivers whether they ever communicate using simple written notes that might be useful during hospitalization, such as “I will be back soon.” If English is not the patient's primary language, assess whether these familiar expressions would be better understood if they were written in the patient's primary language. Also determine whether the patient understands any simple English words or phrases. For example, ask the daughter of a Spanish-speaking patient whether it would be easier for her father to understand the sign orienting him to the day of the week if it were in Spanish.
* Use a printer or carefully write out large, bold black letters on white signs for legibility.
Can the patient understand simple verbal instructions?
* Ask caregivers whether the patient understands certain words denoting particular objects better than others. For example, does the patient understand the word “phone” more readily than “telephone” or “toilet” than “bathroom”? Find out what term the patient uses to refer to pain or discomfort (for example, “pain,” “hurt,” “ouch”).
* Identify any simple expressions that the family or other caregivers commonly use in caring for the patient. For example, is the patient cooperative about bathing if you say in a matter-of-fact tone, “It's time for your bath now”?
* Identify any culturally specific words or phrases that caregivers use. For example, a Chinese American patient's family may use the Mandarin Chinese phrase xi shou jian—pronounced “seesau jeeyen”—to remind her to go to the bathroom.
Can the patient understand instructions given with physical cues?
* Ask family members or other caregivers about particular cues that the patient associates with activities of daily living. Ask, for example, whether the patient will brush her or his teeth without help if a toothbrush with toothpaste on it is left near the sink, or get dressed if clothing is set out on a chair.
* Use physical cues to get the patient's attention before beginning any verbal interaction. For example, gently touch the patient's hand and look her or him directly in the eyes before beginning to talk.
* Reinforce all verbal instructions with congruent nonverbal communication. For example, upon admission and frequently during the hospitalization, demonstrate how to use the call light and show the patient how you will respond to it.
* Use touch to direct patients' actions, but avoid touching the face or head. For example, take a patient's hand or touch the elbow when guiding her or him to the bathroom.
Can the patient make a choice when presented with two objects or options?
* Ask caregivers whether the patient better understands certain words when being asked to make a choice between objects. For example, a patient may refer to chicken, beef, pork, and fish as “meat” and not understand words such as “ham.”
* Assess whether yes—no choices are too simplistic and might be perceived as condescending; offer more complex choices according to the patient's abilities. For example, ask caregivers, “How do you usually involve John in decisions about daily activities, such as what he would like to do during the day?”
ASSESSING EXPRESSIVE ABILITIES
Does the patient have difficulty finding the correct word?
* Identify words that the patient commonly substitutes for particular words or phrases. When one patient I know wants to know how soon something will take place, she says “clock.” Ask caregivers, “Are there any words that Esther commonly uses when she wants something specific?”
* If you are having difficulty understanding the meaning of a word the patient uses, ask her or him to describe or point to the object or something similar. For example, say to the patient, “I'm not sure what you're saying. Can you point to something that looks like that object?”
* Recognize that patients who have difficulty finding the right word may feel frustrated. Acknowledge her or his feelings and your limitations, offer support and understanding, and allow the patient enough time to respond. For example, say to the patient, “I'm sure this is frustrating for you and it may be especially difficult because we don't know each other very well, but let's go slowly and I'll do my best to understand what you're saying.”
Does the patient have difficulty creating sentences or a logical flow of ideas?
* Identify key concepts in the conversation and ask for feedback. For example, say to the patient, “I'm guessing that you're asking a question about what your doctor just told you—is that what you want to know?”
* Ask family members or caregivers whether the patient has been evaluated by a speech therapist and consider whether that might be appropriate for performing further assessments and recommendations. Suggest to the family member, “When people with dementia have difficulty expressing their thoughts, sometimes a speech therapist can help identify ways to improve communication. Has that ever been considered, and would you like to explore that as part of the discharge plan?”
Does the patient curse, use offensive or aggressive language, or exhibit aggressive or combative behaviors?
* Recognize that such behaviors are usually attempts to communicate in the only way the patient is able to at the time. Acknowledge the patient's feelings and provide reassurance. For example, say to the patient, “I'm sure it's frightening to be in a strange place with so many people you've never seen before, but we are doing our best to find out what's causing your pain so you can feel better and go home soon.”
* Ask caregivers about conditions that are likely to cause anxiety or result in disruptive behavior. For example, ask a family member, “Could you tell us about anything that is particularly disturbing for your father? For example, does he get upset when he has blood drawn or has to go for an X-ray?”
* Ask caregivers about the ways in which the patient expresses frustration. For example, say, “Sometimes people with dementia begin to use language—like cursing—that was not a part of their usual conversation. Is this something that your father does, and is there anything we should be aware of that precipitates this kind of behavior?”
* Ask caregivers about conditions that are likely to cause assaultive or otherwise threatening behavior. For example, say, “Sometimes people with dementia do things that are threatening to their caregivers, like pinching, hitting, grabbing, or touching inappropriately. Has your mother done anything like that? If so, can you tell us what circumstances might cause these behaviors, and explain how you handle these episodes?”
* Recognize that combative behavior may indicate that the patient has unmet needs. For example, a patient needing to use the bathroom may throw the water pitcher when nobody answers the call bell.
Does the patient avoid verbalization altogether or mutter in tones that may seem meaningless to others?
* Ask caregivers whether the patient communicates verbally or nonverbally in ways that seem meaningless, and how they react to these situations. For example, say, “Sometimes people with dementia repeat certain words, phrases, or sounds that seem meaningless. Have you noticed that your wife does this? Can you tell us what conditions cause that behavior and what you do when it happens?”
* Because verbalizations that seem meaningless may be the patient's only way to communicate, ask caregivers if they know what any such verbalizations mean. For example, say, “Sometimes people with dementia use certain words, phrases, or sounds that don't make sense to others. Does your mother do that, and do you know what she means?”
* During the hospitalization, identify any conditions that precipitate seemingly meaningless vocalizations and do what you can to prevent or alleviate these episodes. For example, if the patient repeatedly called out his wife's name after the lab technician drew his blood, try to schedule blood drawing for times when she is visiting.
In addition to describing nine assessment questions and interventions related to receptive and expressive communication abilities, Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia includes tips for addressing some of the challenges that may arise in clinical settings. For example, it suggests that when you have a patient whose primary language is not English, you should ask the family for advice on how to more effectively communicate with the patient. You might need to use an interpreter. Gerontology nurses have developed an excellent evidence-based protocol, “Interpreter Facilitation for Individuals with Limited English Proficiency,” to guide the effective use of language interpretation services with older adults in this population.3 Nurses should also keep in mind that cultural influences can affect patients' perceptions of nonverbal communicative gestures, including touch, eye contact, and facial expressions. For example, some cultural groups prohibit touching between the sexes, even in health care situations. (To view the segment of the video discussing the interpretation of the assessment, go to http://links.lww.com/A239.
COMMUNICATING THE RESULTS
Despite the complexity of assessing communication in patients with dementia, assessment forms in hospital charts usually include only a few variables related to basic skills. Therefore, it's imperative that nurses supplement this basic information with more detail from their assessment for use by other team members. In addition to sharing information verbally, it's important to chart pertinent findings and interventions in the patient's care plan, as in the following examples:
* Document all baseline assessment information and record any variations from baseline when reassessing.
* Document the factors that affect communication both positively and negatively, as well as the interventions that can be used to address conditions that interfere with communication.
* Describe what communication techniques are effective in specific circumstances.
* Document the sources of the assessment information and each person's relationship to the patient (for example, spouse, family member, friend, caregiver).
* Ask caregivers to provide a written list of tips for communicating with the patient and obtain their permission to include it in the care plan.
Speech therapy. Nurses also need to consider whether referring the patient for further evaluation is appropriate. When receptive or expressive skills are impaired by stroke or other acute episodes, speech therapy is often initiated. However, when impairment occurs gradually or is long-standing, the need for speech therapy can be overlooked. (Some clinicians may be unaware of the importance of a speech therapist in evaluating and treating dementia-related communication problems.)
In all health care settings, speech therapy (also known as speech—language services) is increasingly being used to improve the communicative abilities of people in all stages of dementia.4 Speech—language services for people with dementia include counseling, direct therapy, and assistance with developing effective communication techniques.5 For example, speech therapists can teach people in the early stages of dementia about techniques that will improve their word-finding abilities and enhance their communication skills. Referral for speech therapy is especially appropriate when a family member or caregiver expresses a desire to learn how best to communicate with the patient at any stage of dementia. Speech therapists can also provide nurses, physicians, and other hospital staff with valuable, practical assessment and intervention information that will improve communication during the hospitalization. Although primary care providers generally make these referrals, nurses are often in a good position to identify the need and suggest that speech therapy services be considered.
Incorporating results in discharge planning. Hospitalization often provides clinicians with opportunities to inform family members about the patient's medical condition and other aspects of care, such as communication. Therefore, nurses need to incorporate assessment and intervention information into teaching. If the care plan includes detailed information on communication techniques, make copies of this information for the patient. If speech therapy has been provided, ensure that written recommendations are included in the discharge plan. When patients are discharged to institutional settings, such as long-term care facilities, include all pertinent findings with the transfer information.
You might also consider whether referral for follow-up speech therapy is appropriate, even if the patient didn't receive speech therapy during hospitalization. For example, if no prior evaluation by a speech therapist has been performed, ask patients who are in the early stages of dementia whether they would be interested in having one. When caring for people who are in the more advanced stages of dementia, consider asking family members or caregivers if they would be interested in such a referral. (To view the video chapter discussing strategies and resources to enhance communication and safety, go to http://links.lww.com/A240.
What's the evidence to support the use of the Try This approaches? Although an abundance of literature delineates strategies for communicating with people who have dementia, few studies have examined the effectiveness of specific strategies. The studies by Small and colleagues cited in Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia examined communication between people with dementia and their family caregivers during activities of daily living.1, 6, 7 Their study on the effectiveness of 10 commonly recommended communication strategies (including simplifying speech, paraphrasing, avoiding interruptions, controlling environmental distractions, and engaging the person's attention) supports the use of the techniques listed in the Try This approaches.7 A study by Perry and colleagues of communication strategies nurses used in caring for people with dementia supports the use of many techniques—including those that are cited in the Try This approaches—with emphasis on the need for conversational strategies and interactions to address individual abilities.8 Specific conversational strategies identified included repeating key words, maintaining topics, and avoiding interruptions.
Why Look For Communication Difficulties in Hospitalized Older Adults with Dementia?
Because dementia affects the processes involved in perceiving, understanding, and responding to verbal and nonverbal information, it impairs communication. Consequently, caregivers of people with dementia, including family members and clinicians, need to use techniques that will help them exchange information with and interpret communication by patients. Family members and other caregivers usually develop patterns of verbal and nonverbal communication. These patterns are likely to change during the course of dementia, as verbal skills diminish and the patient becomes more reliant on caregivers.1
I have seen communication become so specific and intricate over time that family members and caregivers feel as though they've developed a new language, one that only they and the person with dementia can understand.
Hospitalization disrupts these communication systems. Changes in environment, routine, and caregivers can compromise the communication process. This disruption can be minimized by incorporating effective communication techniques into the patient's care plan. Nurses can first assess the person's usual abilities and then use techniques that are based on an understanding of the patient's typical methods of communicating, as described in the Try This tool entitled Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia, found on page 63.
The scope of the problem. Communication difficulties frustrate people with dementia and their caregivers. Dementia affects basic language skills, which are categorized as receptive (decoding and understanding information) or expressive (conveying information). In addition, basic language skills are dependent on cognitive abilities that are also affected by dementia, such as forming memories, solving problems, and thinking abstractly. To further complicate matters, many other conditions common in older adults who have dementia—such as delirium—can exacerbate communication problems. These other factors may also play a role2:
* vision or hearing impairment
* environmental factors such as the noise from nearby conversations, excessive sensory stimulation (such as that produced by flashing lights and intermittent beeping of unfamiliar equipment), and unaccustomed glare or dim lighting
* the absence of familiar caregivers
* cultural and language differences between the patient and clinical staff
* medical conditions and adverse medication effects that compromise mental status anxiety
Nurses must identify these kinds of interference in their assessment. For example, you can try to ensure that people who usually wear eyeglasses or hearing aids have access to them at all times. When compromising conditions cannot be addressed before your assessment, note that in the patient's chart and do the assessment at another time. For example, when a patient's mental status is compromised by the effects of anesthesia, document that the assessment should be postponed. Similarly, the presence of many conditions, including delirium, that affect mental status—even when the patient doesn't have dementia—should be considered when assessing any aspect of functioning.
Go to http://links.lww.com/A236 to watch a nurse assess a patient with dementia for communication difficulties and discuss how to intervene when such difficulties exist.
View this video in its entirety and then apply for CE credit at www.nursingcenter.com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.
For more information on assessing communication difficulties in older adults with dementia and other geriatric assessment tools and best practices, go to www.hartfordign.org, the Web site of the John A. Hartford Foundation—funded Hartford Institute for Geriatric Nursing at New York University College of Nursing. The institute focuses on improving the quality of care provided to older adults by promoting excellence in geriatric nursing practice, education, research, and policy.
For more information on the teaching of geriatrics, go to the Fundamental Geriatric Curriculum Resources Web site at the Hartford Institute: www.hartfordign.org/resources/education/bsnPartners.html. The featured slides can be used in any educational setting.
Go to www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.