MY MOM HAS DEMENTIA, and she doesn't remember me. When I was a young girl, she held my hand as I walked to my first day of kindergarten. She celebrated my triumphs and cried with me. She smiled at me when I said my wedding vows and taught me how to be a mom, but today I'm another random piece in a puzzle that she can't put together. Every day her world is brand-new and her ability to put it together continually diminishes. She's terrified of the very world she taught me to embrace. How do I keep her safe and happy? How do I talk to my mom?
I'm also a nurse, so I think I should know the answer. But there's no class I can take or special phrase to learn that will help my mom, or patients like her, understand that I'm here to help them.
The journey of caring for a family member with dementia has given me a unique perspective on communicating with patients with dementia. This article reflects on this perspective and proposes communication techniques that may alleviate nurses' anxieties when they care for these patients.
Preventing communication breakdowns
Communication is essential to our existence. It's both verbal and nonverbal, and can shape our thoughts and actions. Communication remains essential for patients with dementia, despite their diminishing ability to communicate with their caregivers. Observational research has demonstrated links between ineffective staff communication and problem behaviors in patients with dementia.1 These problem behaviors include verbal outbursts, measurable aggression, and withdrawal, all resulting in care disruption and increased stress for nurses and care costs.1
The cost-conscious healthcare environment and the nurse shortage dictate that interventions should be developed to assist nurses in caring for this patient population. However, before communication strategies can be developed, nurses need to be reminded of a few basic principles. An older adult, with or without dementia, deserves respect.2 It can sometimes be difficult to remember that the patient who can no longer perform even basic tasks such as bathing or eating was once a contributing member of society. My mother raised children, maintained a home, and held a job, all with grace and dignity. Today, she needs assistance to bathe and get dressed. These limitations may, at times, make her look childlike, but she's not a child; she's an adult with a terrible disease and deserves the same respect that anyone with a physically limiting disease would receive.
A nurse has an integral role in preserving a patient's dignity and self-respect. The Alzheimer's Society suggests that flexibility, making time to listen to a patient, and showing affection in a way that's comfortable for the patient and caregiver can improve communication.2 However, the time constraints placed on nurses in the healthcare setting, as well as the patient's deteriorating ability to communicate, can create frustration. To prevent the breakdown in communication that may lead to problematic behaviors, nurses should understand dementia from the patient's and family's perspectives.
Take the patient's viewpoint
Many patients with dementia feel as though they're in a new situation every minute of every day. For perspective, imagine opening a novel at the middle and attempting to understand what's happening in the story. The constantly unfamiliar surroundings lead to dependence on a caretaker and separation anxiety when the caretaker isn't there.
My dad cares for my mom and she follows him everywhere. When she can't find him, even in the home that they've lived in for 50 years, she becomes anxious because in her mind she's just visiting.
In the hospital, the nurse becomes the caretaker, but the nurse is a stranger. So, how does a nurse care for a patient who's afraid, anxious, not feeling well, and easily frustrated without provoking difficult behaviors?
Techniques for success
Dementia affects thinking, reasoning, and memory, but the patient's feelings remain intact.2 The suggested methods for caring for patients with dementia encourage nurses to support patients in expressing their feelings. This is easier said than done. My mom will often tell us for hours at a time that she has a “sick stomach or throat.” While my dad and I try to understand what she's attempting to communicate, she becomes offended if we don't acknowledge that she's not feeling well. A simple acknowledgment of the patient's feelings can demonstrate respect and concern that may calm the patient and prevent the need for medication.
Remember four basic rules for interacting with patients with dementia.3
- Stay calm, pleasant, and reassuring, paying close attention to the tone, pitch, and speed of your speech. Stress can be communicated to the patient nonverbally and trigger a negative reaction. Speaking slowly and clearly using a gentle voice and a lower pitch facilitates effective communication.
- Treat the patient with respect. Never talk about patients in front of them; either include them or excuse yourself and the other party. Don't use “baby talk” or a condescending tone of voice.
- Determine the patient's level of impairment. As the dementia becomes more severe, sentences should be simplified, but for a patient with mild dementia, simple sentences may sound disrespectful.
- Learn to understand nonverbal cues. For example, patients with dementia may start moaning or become increasingly restless rather than verbalize that they're in pain. Nonverbal cues will often clarify a problem that patients can't articulate.
Most communication is nonverbal, so nurses should be aware of what their facial expressions, body language, and actions communicate. Nurses with good nonverbal communication skills make eye contact with the patient and demonstrate what they're asking the patient to do. For example, if helping the patient put on a shirt, the nurse should show the patient the shirt while explaining his or her intentions to the patient. Maintain a calm, nonaggressive approach, avoid speaking to the patient with your back turned, and avoid interrupting the patient. Most important, stay calm. These approaches communicate caring and interest to the patient.
Quelling the outbursts
Even excellent communication techniques aren't always enough to prevent problematic behaviors, such as outbursts of verbal or physical aggression. Nurses often care for patients with dementia when they're physically ill, and the combination of physical illness, a strange environment, certain medications, and loss of their caretaker can trigger aggressive outbursts. Patients with dementia become frustrated when they have difficulty expressing their thoughts, so watch carefully for nonverbal clues to an impending outburst.
It seems that my mom is still teaching me lessons. Through the progression of my mom's disease, I've learned better ways to care for patients with dementia. Here are some suggestions for communicating with a patient with dementia during a hospital admission or when the patient is experiencing an outburst.
- Reassure the patient both verbally and nonverbally that he or she is safe. Decrease outside stimulation, reassure the patient again, and redirect the patient to simple soothing activities.
- Be patient and respectful. If the anger is directed at you, make sure the patient is safe, then leave and return when the patient is calmer as if nothing has happened. Interacting with a violent patient endangers the safety of the nurse and the patient.
- Review the event by looking for a reason for the outburst—was the patient in pain, feeling sick, or scared? Remember that the patient may not be able to verbalize the true problem.3
I used these strategies with my mom during an admission to the hospital. Due to an outburst, the hospital staff couldn't evaluate her for 2 hours. During this time she repeated, “Kill me,” and “I just want to leave here.” Of course, this became frustrating for my dad and me, but now I realize that the repetition was her way of telling us that she was scared. We sat next to her and repeatedly reassured her in calm soothing voices that we were there and that she was safe. We didn't pace about the room, get angry at the hospital staff, or demonstrate our own frustration.
Later, when a nurse tried to establish I.V. access and obtain a blood specimen, my mom started to scream. Dad and I reassured her that she was safe and that the nurses were there to protect her. When I distracted her by talking to her about a family vacation, she relaxed and allowed the nurse to insert the I.V. catheter without incident.
Strategies for success
Nurses can improve their ability to communicate with patients with dementia by understanding the limitations these patients experience and exploring reasons for problematic behaviors. Employing effective communication strategies improves the quality of patient care and reduces stress for the staff and family members as well as the patient.
Head to www.nursing2017.com for more information on caring for patients with dementia.
Reducing distress and medication use in patients with dementiahttp://journals.lww.com/nursing/Fulltext/2017/05000/Reducing_distress_and_medication_use_in_patients.7.aspx
Best practices for engaging patients with dementiahttp://journals.lww.com/nursing/Fulltext/2014/11000/Best_practices_for_engaging_patients_with_dementia.13.aspx
What to do about sexually inappropriate behavior in patients with dementiahttp://journals.lww.com/nursing/Fulltext/2015/09000/What_to_do_about_sexually_inappropriate_behavior.15.aspx