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Primary Health Care – December 2011 “Building communication bridges with dementia patients is vital”
Communication bridges for patients with dementia
Simple techniques designed to develop interaction and enhance a feeling of wellbeing can improve care and increase practice efficiency, explains Zoë Elkins.
Pressure on nurses’ time in primary healthcare is severe, and may be increased when nurses see patients with dementia who display unusual or challenging behaviour. Patients living with dementia may present symptoms of confusion and agitation when being treated in the primary care centre or even in familiar home surroundings and these can be daunting for health professionals if they are not experienced in caring for these individuals or if they have not been provided with specialised training.
If a response to meeting the special needs of patients with dementia is lacking, these individuals will not receive the best care. Front line staff in any healthcare setting may waste valuable time by communicating ineffectively with patients. The Alzheimer’s Society (2009) has shown, for example, that people with dementia stay far longer in hospital than people without the condition who are admitted for the same treatment. Most nurses have an understanding of dementia at a neuronal level, and are aware that patients with dementia should be cared for holistically so that treatment plans for conditions unrelated to dementia are followed through. However, if primary care nurses are hard-pressed they are unlikely to have enough time to spend with the dementia patient with the result that assessment of what the patient is trying to communicate is compromised, as is the ability to provide reassurance.
Sufficient time should be taken to reach beyond the hurdle of dementia so that care plans can be implemented for conditions that are not dementia related and to investigate changes in the person’s health and overall wellbeing – this will vary from patient to patient. It is not easy to ensure that staff use non-pharmacological and non-physical methods when dealing with challenging behaviour in dementia patients. However, advanced practice nurses should adopt a central role in creating consistency in and between clinical environments (Andrews 2006).
Putting in place a programme in which a personal information sheet is created for each patient with dementia could be found to be a highly valuable way of addressing these issues. The Good Care Group supports clients living in their own homes and has found that a one-page information sheet for each person with dementia allows nurses, carers, and other healthcare professionals to gain a quick understanding of what will help when trying to communicate. Once an effective communication bridge has been achieved, the individual is much more likely to remain calm and anxiety-free, and dialogue with healthcare professionals is significantly improved.
Information sheet point to themes which can span the gap between the intact memories of the past and what needs to be done today and can be used in any setting. Through using intact and positive memories from the past, people with dementia can be gently steered to a position in which they understand and accept the context in which treatment is being provided. When this is achieved, individuals are more likely to remain in a contented state and not slip into a frame of mind that stimulates agitation and anxious questioning because facts about what is happening have not been retained.
The individually tailored information sheet is developed through close study of the person with dementia. It outlines common questions that the individual is most likely to ask, and includes answers that will be accepted most readily. Healthcare professionals need to take on the extra task of reading and understand the briefing sheet, but doing so is time well spent.
It has been shown that smoother care paths, and improved efficiency of treatment implementation, are achieved if the ground rules of the charity SPECAL (Specialized Early Care for Alzheimer’s), are followed. These rules align with notes for a Royal College of Nursing Advanced Nurse Practitioner Forum titled ‘Promoting positive approaches in dementia care’ (Thompson 2010).
When the approach is used, the patient is not contradicted. Attempting to inform and correct a person with short-term memory loss does not achieve results and is a path that should not be pursued. It is far better to go along with the individual’s sense of reality rather than reminding them of what they have got wrong or no longer can achieve.
The approach recognises that individuals with dementia live on a “feelings” level. They always know how they are feeling but are not necessarily aware of why these feeling prevail. Individuals who are unable to store information about facts will retain associated feelings (Feinstein et al 2010).
A patient with dementia having to spend time in an examination room might repeatedly call out for attention, even though the nurse is in attendance. Using phrases with the patient such as: “I have already spoken to you. Everything is fine, and we will complete the tests as fast as possible,” can be devastating because the patient is initially likely to feel inadequate and then not recall what has just happened or been said. The patient is then left with a feeling of negativity which may prompt further calling out for attention. Taking a few minutes to provide quiet assurance for the patient, imparting the feeling that all is well, is a good investment in time. The aim is to ensure that the patient is able to leave the examination room in a contented mood, with the nurse satisfied that a task has been well done.
The SPECAL method stipulates that a patient with dementia should not be asked direct questions, because doing so can quickly elevate the individual’s level of stress. A question is simply seeking information directly, but it is information that people with dementia lack. Posing a question puts strain on the working memory, and, in an instant, unsettles the individual and significantly erodes emotional wellbeing. Asking patients with dementia if they would like to try a particular type of walking aid would appear to be harmless enough, but it should always be assumed that the question could be a stress-inducer. Patients might start wondering if they had used the walking aid before, whether the device was going to be difficult to use, or whether they were going to be charged for using it. Soon, the individual is searching for answers to questions that have not been stored in the working memory, and panic may ensue.
Instead of directing a question to the patient, it is better to use a statement. Perhaps a line such as: “I have found this walking frame and thought we could see if you like it and might find it useful.” The patient can then feel reassured about retaining total control, and is likely to welcome the friendly consideration being given.
Using the approach entails continuously drawing information from the patient with dementia. The healthcare professional should look for behavioural clues about what generates positive and negative reactions. The nurse, carer or other member of the front line healthcare team may be able to quickly identify certain phrases that gain a positive response and can be used to further develop a communication bridge. By using cues provided by the person with dementia, staff can initiate dialogue as well as provide responses.
Such cues can include the repeating of fond memories. Repetition may be regarded by healthcare professionals as general chatter without particular value. However, by attuning to the message that is being repeated, staff can identify and feed back to the patient with dementia pieces of positive information to secure trust and co-operation.
If a problem, perhaps with understanding the implementation of a diagnostic procedure, for example an ultrasound scan, arises with a patient with dementia, it is always important to protect the patient’s self-esteem so that the individual remains calm, contented, and co-operative. The method suggests that carefully chosen words should be used so that the individual with dementia regards the problem as stemming from the healthcare professional.
Blaming a patient with dementia for a minor difficulty might seem innocuous, but could be damaging if the patient loses self-esteem and becomes withdrawn. Through apparently taking the blame, the healthcare professional attracts the focus of negativity and boosts the patient’s wellbeing by putting the patient back in a position of competence and control. When this happens, the patient’s self-esteem is not reduced and emotional safety is retained.
The SPECAL Photograph Album method likens the memory system to a compilation of photographs. It provides a way of helping front line staff gain an understanding of the way normal memory works, what happens with age, and the significant change occurring with the onset of dementia (Garner 2008, James 2009).
Memories from many years previously are often retained by individuals living with dementia, and the method enables these to be brought to the fore so that they can be used as virtual frameworks on which to overlay current contexts. Benefits of the method are significant and may include achieving a plateau effect in the disease process (Pritchard and Dewing 2001). There is no deluding or lying; the healthcare professional tunes into what is being said and validates positive feelings and comments of the individual with dementia, helping achieve an optimum quality of life.
When a person with dementia finds that his or her mental abilities are declining the individual often feels vulnerable and in need of reassurance and support. Those providing these need to do everything they can to help the person retain his or her sense of identity and feelings of self-worth.
If only a few healthcare professionals or carers are engaged in delivering care to an individual with dementia, continuity of interaction can be achieved, with firm working relationships and trust established.
Good training is essential to ensure that nurses working in primary healthcare settings have the skills required to make them proficient in supporting patients with dementia.
The use of the golden rules below and examples of good practice such as the individualised information sheet developed by The Good Care Group are starting points for health professionals looking to address these issues.
SPECAL golden rules
When caring for or treating a patient with dementia:
- Spend a little more time with them so that you understand their feelings and needs.
- Tune into and respond to intact, positive, memories that patients enjoy talking about.
- Continuously draw information from the patients, and look for behavioural clues about what generates positive and negative reactions.
- Prepare and use information sheets for each person to help create an effective communication bridge.
- Do not contradict the patient, this can be extremely unproductive.
- Do not ask the patient direct questions – these can significantly raise the patient’s level of stress.
- Be ready to assume blame if a difficulty arises.
- Alzheimer’s Society (2009) Counting the cost: caring for people with dementia.
- Gavin J. Andrews (2006) Managing challenging behaviour in dementia. A person centred approach may reduce the use of physical and chemical restraints. BMJ. 2006 1 April; 332(7544): 741.
- Rachel Thompson (2010) Promoting positive approaches in dementia care. Royal College of Nursing Advanced Nurse Practitioner Forum. https://www.rcn.org.uk/__data/assets/pdf_file/0011/359318/Rachel_Thompson.pdf
- Justin S. Feinstein, Melissa C. Duff, Daniel Tranel (2010) Sustained experience of emotion after loss of memory in patients with amnesia. PNAS, 12 April 2010.
- Garner P. (2008 3rd ed.) The SPECAL Photograph Album. Windrush Hill Books. Hawling.
- Oliver James (2009) Contented Dementia. Vermilion.
- Pritchard E.J., Dewing J. (2001) A multi-method evaluation of an independent dementia care service and its approach. Aging & Mental ealhhHealth, Volume 5, Number 1, 1 February 2001, pp. 63-72(10).
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