Thursday, September 9, 2010

Effective Communication with Alzheimer’s Patients

Effective communication, both verbal and nonverbal, is essential to quality care. The breakdown in communication between a person with Alzheimer’s Disease and his or her caregiver leads to frustration. For caregivers, living with a person who no longer remembers them and their relationship is painful. Understanding the language and communication problems that occur with Alzheimer’s Disease can help caregivers develop realistic expectations and improve communication as the disease progresses.

People communicate both verbally and nonverbally. Verbal communication is an exchange of words or noises that express thoughts or emotions. Nonverbal communication consists of gestures, facial and body expressions, touch and tone of voice.

Memory disorders such as Alzheimer’s Disease affect the ability to use and understand both nonverbal and verbal communication. People with Alzheimer’s Disease do not understand information coming to them. While their sense of hearing and eyesight may be fine, the brain systems that make sense of incoming information may not be able to process it properly. What they hear, see or read may not make sense. Some information may get lost; other signals become confused. The end result is that people with Alzheimer’s Disease often are unable to understand what is going on around them and may react in confused or inappropriate ways.

Effective communication requires speaking and being heard. It is important to listen carefully to people with Alzheimer’s Disease, because what they say may not be easy to understand. Listen for key words and phrases which, taken alone, may not make sense, but in the context of the situation may have a great deal of meaning.

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Nonverbal Communication

Nonverbal communication, often called body language, is an important part of how people communicate. Nonverbal messages are sent through gestures, body movements, facial expressions, touch, tone of voice and speed of words.

When people lose their word skills, nonverbal communication becomes critical. Sometimes people with Alzheimer’s Disease who no longer understand spoken words depend on body language for their information. It is especially important that caregivers be aware of their own body language and the messages it sends. In addition, caregivers should learn to read the body language of people with Alzheimer’s Disease to help figure out what their needs are and how they are feeling. Remember that a smile can help connect, reassure and calm a person with Alzheimer’s Disease even after the ability to use and understand language is gone.

Tips and Techniques

1.      Use all senses, such as vision, hearing, touch, smell and taste;
2.      If a person seems to ignore you and is unreceptive, leave him or her alone for a few minutes. Tell the person that you understand that they want to be alone and that you will return;
3.      Be sensitive to nonverbal messages. Be aware of your own nonverbal communication and use it to help calm, cheer or encourage;
4.      Make nonverbal messages match your words. Smile when you greet someone and wave when you are saying goodbye;
5.      Adopt positive, pleasant nonverbal behaviors to reassure and encourage. Look at facial expression and body posture to determine what is pleasurable or uncomfortable. Remember that you may be conveying emotions, such as sadness or irritation, through your actions more than through your words. If you are in a hurry, frowning or speak quickly and angrily, a person with Alzheimer’s Disease will react to your emotions.

Verbal Communication and Language Changes

People with Alzheimer’s Disease experience changes in their ability to use words. At first they may have a hard time finding the exact word to use in a sentence. Later, they may have a great deal of trouble finding most words and have to use many “filler” words to talk. In the latter stages of the disease, there may be very little language though they are trying hard to speak. They may use nonwords, speak gibberish and be unaware that they are not making sense.

It is important to recognize that communication is a two-way street. Effective communication requires both speaking and being heard. Caregivers must listen carefully to people with Alzheimer’s Disease because what they say may not be easy to understand.

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Tips and Techniques

1.      Use simple, short sentences. Organize your thoughts into the shortest sentences possible;
2.      Say the person’s name. Establish eye contact. Speak clearly, calmly and repeat as needed. Be aware of hearing difficulties;
3.      Look for clues, such as eye contact or facial expression, that the person heard you. Does the person respond appropriately? Which of the person’s words or actions are the actual response?;
4.      Act out the message. Point to the object you are talking about;
5.      Address the person by their familiar name or nickname.

Communication and Alzheimer’s Disease

The steady loss of communication skills is one of the hallmarks of Alzheimer’s Disease. The information presented in this section explains some of the behaviors and offers tips and techniques for making communication clearer during each stage of the disease.

Early in the disease, people with Alzheimer’s Disease are often aware of gaps in their communication. If they are aware of language difficulties, they may try hard to cover them. They may make up stories, or act indignant, tough, stubborn, nervous or anxious. Or they may admit their difficulty coping with a particular task of problem. Many people withdraw and avoid troublesome situations that might reveal their problems with communication. They don’t want others to see them fumble at a task they could once do easily.

Keep in mind that people with Alzheimer’s Disease may have trouble with some tasks because they don’t remember the purpose, task or instructions given to them. Sometimes all that is needed is gentle reminders.

Stage One: Early

Closely related words are substituted for forgotten words. When you can’t make out what a person with Alzheimer’s Disease needs, point to the objects in question while asking questions like: “Do you want your purse? Your comb?” The person will have trouble understanding and following directions. Keep your sentences short and your directions clear. “Mother, fold the scarf.” “Put the scarf in the drawer.” “Close the drawer.”

Tips and Techniques

1.      Discuss important business during the morning when everyone is fresh;
2.      Focus on one topic at a time;
3.      Use specific words, names of people and objects;
4.      Do not use pronouns or general language;
5.      Words or events may be forgotten. Don’t take it personally if birthdays or other special events are forgotten.

Stage Two: Middle

At this stage, recall and word recognition decrease and attention span is shortened. A person with Alzheimer’s Disease may change the subject often. You may need to repeat the same question or sentence many times and in different ways before it’s understood.

Tips and Techniques

1.      Give stimulation that can be sensed emotionally, like music and touch;
2.      Present objects with the quality of moderate novelty. Things that are familiar enough so that they do not frighten or confuse, but unusual enough so that they interest;
3.      Give touch in a systematic way. Stimulate the person’s forehead, cheeks, ears, neck, shoulders, back, forearms, hands, feet and lower legs through small circular stroking movements. Use skin lotion to protect the skin;
4.      Stimulate smell with bread, wood, soft soap, fur, camphor, yarn, etc.;
5.      Comb the person’s hair and give him or her the opportunity to look in the mirror;
6.      Stimulate taste buds;
7.      Elicit listening behavior and maintain attention by touching;
8.      If the person speaks only in single words, then you should speak in single words. However, note that the person may be able to understand better than he/she can talk;

Stage Three: Late

Toward the end, a person with Alzheimer’s Disease loses almost all ability to communicate or understand. Both long- and short-term memory are severely impaired, and he or she is totally dependent on the caregiver.
1.      Continue speaking warmly, quietly and with eye contact;
2.      Pat or stroke the person. Touch with love;
3.      Smile. After all else is lost, a smile can calm and bring joy.

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11 Steps to Improved Communication

1.       Get the Person’s Attention; Use Eye Contact: Securing eye contact helps to get the individual’s attention and gets them to focus on what you are saying. A gentle touch can also accomplish the same thing. Remember that your facial expressions help communicate your intention. Maintain contact and extend yourself to the person to convince him that you want to talk to and be with him. Look directly at the person to get undivided listening attention before you speak; identify yourself at the beginning of each interaction.

2.      Speak Clearly, In Short, Direct Sentences; Use One-Step Commands: Keep it simple. Complex or abstract subjects will be difficult for them to follow. Talk about things that are seen, heard, touched or smelled. Be matter of fact; ask “yes” or “no” questions as much as possible.
  1. Avoid open-ended questions;
  2. Ask questions that include limited choices: “Would you like to go for a ride or take a walk?”;
  3. Be direct; say exactly what you mean. People with Alzheimer’s Disease find it difficult to understand hints or suggestions. Instead of saying “Do I look like I have nothing to do?”, say “I am busy now. I will come back.”;
  4. Be concrete. “We are going to have company today.”
  5. Be literal. Nonliteral terms are used frequently in conversation: “That dress is a knockout;” “This dessert is heavenly.” People with Alzheimer’s Disease find it increasingly difficult to understand nonliteral terms;
  6. Present a limited number of choices and give positive direction (for example, “Now it is time to take a shower,” not “Would you like to take a shower now?”
3.      Be Willing To Repeat And Rephrase:
  1. Repeat yourself and restate critical facts several times. Restate and rephrase what is not understood: use simpler words to express your ideas and be brief. Remember that at some point, logical explanations will be meaningless and persistence in explaining leads only to frustration;
  2. Use simple subject-verb sentence combinations;
  3. Left-branching sentences (“Because Ben left the house without his coat, his mother was upset”) are more difficult to process and require more memory than right-branching sentences (“His mother was upset because Ben left the house without his coat.”);
4.      Don’t Use Slang: Consistently use the same word for the same thing, and use the word most familiar to the person. (“It is time to go to the bathroom [or toilet], Frank.”) However, vary the introduction of a topic, such as bathing, if it triggers resistance;

5.      Keep Your Tone Warm and Empathetic: Provide affectionate encouragement; use diversion and humor to overcome resistance;

6.      Ask Simple Questions: Closely related words are often used instead of forgotten words. When you can’t make out what a person needs, point while asking simple questions: “Do you want your sweater? Your necklace?”;

7.      Avoid Pronouns – Use Specific Words And Names For Clarity: Use names so it is clear who you are talking about. Don’t say “he,” “she” or “that group.” Also be sure to call a person with Alzheimer’s Disease by the name he or she is most comfortable with.

8.      Write Big, Clear Messages and Post Them: It may be helpful to have signs on room doors (such as bathrooms) or a “911” tag posted on the telephone;

9.      Use Your Nonverbal Skills:
  1. Use illustration. Drawings and photographs give additional cues and jog the memory;
  2. Enhance what you say with frequent gestures. Additional physical cues and emphasis increase the chance of successful communication;
  3. Avoid environmental distractions. Noisy and busy surroundings are distracting. It is easier to get and keep someone’s attention in a quiet environment;
  4. If verbalizations do not make sense to you, search for important clues. Smile to connect with the person.
10.  Praise and Encourage the Person; Show Affection: Be patient. If you or the person become frustrated, take a break and try again later. Remember that a person with Alzheimer’s Disease will sense when you are tired, stressed or in a hurry, and may become upset or confused as a result. Although they are not able to comprehend the reasons for them, people with Alzheimer’s Disease still seem to sense emotions such as frustration, anger and happiness. A quiet, soothing voice, gentle touch or a calm presence may reassure and calm someone who is confused or upset.

11.  Be Patient!:
  1. Give the person time to respond. If a verbal or nonverbal response does not occur in one to two minutes, repeat the exact set of words and gestures;
  2. Do not attempt to force a person to do anything. If he or she will not cooperate, leave for five or 10 minutes and then try again;
  3. Do not assume that one set of behaviors, whether positive or negative, will stay the same. Simple changes in the environment, such as a different nurse or a room change in a nursing facility may cause behavior changes.

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