Positive communication in dementia care
Positive communication in dementia care
What is dementia?
Dementia is a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive functioning and, thus, the ability to process thought beyond what might be expected from ‘normal’ ageing. As a consequence, dementia affects: memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement. The impairment in cognitive function is commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour and/or motivation (Dementia Care UK, 2019).
How can we communicate effectively to support people with dementia?
I have worked on dementia wards for 15 years and, through these experiences, I’ve seen how important it is for communication to remain consistent throughout. I personally find non-verbal communication very useful in dementia care as verbal communication is often restricted.
Touch based communication
According to The Alzheimer’s Society (2012) touch can be used as a means to reassure, and provide comfort and connection. Furthermore, a paper by Hansen et al (2016) recognises that touch stimulates the production of oxytocin which is a chemical in our brain that leads to feelings of closeness, safety and, importantly, decreased anxiety. As oxytocin is released, another chemical is decreased - the hormone cortisol. Cortisol is a stress hormone that can have detrimental effects on physical health and mental wellbeing.
Additionally, there is a lot of new research on the impact of limited touch in dementia care (termed ‘touch deprivation’) and how this can lead to feelings of isolation, anxiety, poor trust, insecurity and decreased sensory awareness. As a consequence this can result in challenging behavioural responses and/or expressions. This research to me demonstrates that the use of touch - and physical closeness - may be the most important way to communicate to acutely ill (and aged) persons that they are important as human beings.
However, it is important to ensure that the patient is comfortable with touch by carefully reading over patient notes or asking the question of the patient directly where possible.
I understand this is a challenging topic and, consequently, many staff feel unsure or uncomfortable doing this. In this case, you could ask for some support from a manager or some training on how touch is appropriate and how it can be used to support patient care and wellbeing.
Below are some examples of how we can build touch into our daily interactions:
• Shaking hands
• Patting or holding their hand
• Patting or rubbing their shoulder or back
• Putting an arm around them
• Giving a hug
My experience of building touch into patient care
I have a patient on my ward who likes having her hair put in curlers and blow dried and all the ‘chit chat’ that goes with the typical hairdresser experience. This is something I would do for my nan as a child so I am actually pretty good! She even requests me now when ‘booking in’! The sense of self care, combined with human interaction, allows her to – for a short time at least – feel free from the dementia and all its restrictions. This allows her to explore and reflect on how she is feeling, think about what she remembers from her past and allow all the memories to come to the surface. Importantly, she can have a laugh and a joke (she has a great sense of humour!) which is great for mental health. Getting regular hair appointments is something my patient did for 50 years on a monthly basis, so this feels like a solid part of her routine now – which is great for her wellbeing and for stimulating memory.
But there are more than social benefits to this routine, as I can also use this time with her to check in and see how she is doing more broadly in terms of her health. For example, I am able to consider?
How she is looking – e.g. Is her complexion good and do her eyes look OK?
How is her breathing and her hearing?
How are her teeth/gums?
How is she communicating? Is there any noticeable difference from last month?
Communication through sense of smell
Sense of smell can also be a useful tool in reigniting memories in dementia patients. For example, I remember one particular shift where a new patient came to the ward with advanced communication challenges. Before looking at ways to support through a needs assessment, my first job was to help her get settled in. Whilst I was showing her around the ward and the rest/sleeping area a laundry trolly went past. I watched as she noticed this and how her facial expression lit up: I was reading her non-verbal body language. Her expression seemed to be of joy/excitement/happiness at the passing laundry trolly which made me wonder what the connection was. I noted this is her notes and carried on with the tour to help get her settled in.
However, on my next shift I was thinking about ways to explore the laundry trolley response further. I wondered if she had worked in laundry before? Maybe she had a cleaning job at a hotel or hospital?
While there was no evidence of this in her notes, what seemed to really ignite her facial expressions was the smell of the clean laundry. To try and figure out more, and also try to understand her preferred ways to communicate, I started folding some clean towels by her one day to see if I could get a response. Within minutes she was standing up next to me smelling the towels, smiling and she started helping me fold them. I was pretty flabbergasted as, until that point, we had not managed to get very much communication out of her, and her dementia had been assessed as severe. The smells had, in whatever way, reignited a memory in her brain of possible employment, maybe. Since that day, this patient helps fold all the clean laundry and, with some support, she also irons some bedding for her bed. This would, usually, be done by staff but as this is something she enjoys doing there is no harm in getting her involved in the process and routine – as mentioned previously – is really supportive of wellbeing.
Things to remember
Many clients lose consciousness towards the end of life yet still have some awareness of others’ presence in the room. This suggests that the patient can hear what is being said, for example, or feel someone holding their hand. It’s important to always remember this as, saying things under the assumption that someone cannot hear simply because they cannot communicate with you verbally could be incredibly disrespectful and unprofessional. I once heard a nurse say “is he dead yet?” In the presence of a patient and almost instantly the patient’s heart rate went up and there were signs of internal panic. This must have been very distressing for the patient to hear and it was also very distressing for me as a nurse supporting end of life care as this removed all dignity and the possibility of a ‘good death’ (Alzheimer Scotland, 2005). The term good death does, however, sit very uncomfortably with many. However, having a good death is crucial to dignified end of life care, which is what many dementia patients are, inevitably, facing. There is a really insightful article in Psychology Today on the meaning of a good death, and it’s worth having a read to further your understanding and remove the stigma associated with talking about death: see https://www.psychologytoday.com/gb/blog/understanding-grief/202003/what-is-good-death
I’ve also written an article for CACHE Alumni, on navigating loss as a care professional, which you can find here; https://www.cachealumni.org.uk/Public/News/Articles-folder/Loss_And_Grief_Andi_Smart.aspx?WebsiteKey=f50a7342-ef7c-4741-9b60-1983d5c33bab
Tips for better communication
First and foremost, always remember that communication happens both consciously (verbal – speaking) and unconsciously (non-verbal - body language, facial expressions, tone of voice). This means, that, if we act in an encouraging, positive and/or confident manner we bring optimism and reassurance to the conversation. However, on the other hand, if we appear impatient, resentful and/or unhappy then we can bring negativity along with aa sense of doom and gloom. So, firstly, starting the conversation with a cheerful, positive approach is key.
As well preparing yourself for the conversation you should also consider the environmental set up: is the room busy? Is the TV too loud? Is the traffic noisy? If this is the case, find a space that offers less distractions. This is because a person with dementia may already feel that life is chaotic and confusing., so the added ‘noise’ increases these negative feelings.
Another thing I have learnt is that everyone has a good and a bad time for talking - dementia or no dementia - so it’s important to be considerate of this. Think about whether the person prefers to talk in the morning or in the evenings? Is it usually best for them to talk before or after a meal? Observing will help you figure this out and you can refer to notes in care plans as well as asking colleagues or the patient’s family for their guidance too.
I always try to meet the person’s eye level as this can help them to focus and also help me see that I have their attention. It also encourages feelings of respect, rather than standing over someone and speaking down to them. Body language is really very important so make sure you are open and relaxed. You could also sit close to the person (but not too close as to encroach on personal space) to help with initiating a conversation.
When speaking, always ensure you speak slowly, keep to topic and allow lots of processing time - this might make the pause feel slightly uncomfortable, but it is worth it for the patient. Do not raise your voice or tell a patient off – this is unacceptable and can be very distressing and possibly instigate challenging behaviour. You should use short sentences with an emphasis on conversation rather than lots of questions as this can feel daunting. If the patient is finding it hard to understand what you are saying then break this down into smaller chunks of information or focus in on one topic, but re-phrase rather than repeat, and park the others until you get another time to speak – it’s important not to overload the person. Finally, always include the person with dementia in the conversation and this will help to further inform and develop their sense of self and sense of identity.
To conclude, research clearly shows that dementia patients require many different methods of communication. From verbal, to non-verbal such as touch or smell, this combined approach is needed to ensure the ‘voices’ of those with the condition are heard. Consequently, smell, sight, touch, sound and taste are all possible avenues to memories and, the emotions and experiences these contain. Research does, however, recognise a gap in the use of touch as a means to supporting communication and wellbeing and, thus, there is a need for more training and development in this area to ensure staff are confident in delivering this much-needed human interaction with care and confidence.
Alzheimer Scotland, (2005). Letting go without giving up: Continuing to care for the person with dementia: Edinburgh, Alzheimer Scotland.
Alzheimer’s Society, (2012). The later stages of dementia’ Factsheet 417, London: Alzheimer’s Society.
Dementia Care UK (2019). What is dementia? Cited on: https://www.alzheimers.org.uk/about-dementia/types-dementia/what-dementia - accessed 28 09 20
Hansen, N., Jørgensen, T., and Ørtenblad, L. (2006). Massage and touch for dementia. The Cochrane database of systematic reviews. Volume 9, pages 223 – 265.