Communication Skills

for Coping with Difficult Behaviors

by Marjorie J. Graf, RN, ARNP

Difficult behaviors in individuals suffering from dementia may be caused by changes in the person’s ability to communicate and understand information. The following are some tips for communicating with the cognitively impaired person.

approachING a person

• Pay attention to how you feel and how you are presenting yourself to someone with dementia. Do you feel tense? Tired? Angry? Anxious? People with dementia become extremely aware of non-verbal signals such as facial expression, body posture, and mood. Angry or tense non-verbal signals from you are more likely to provoke angry and anxious responses.

• Set the mood for interaction with a calm, gentle, matter-of-fact approach.

• Humor, cheerfulness and cajoling will help you get through difficult moments. Convincing a person with dementia to do something is easier when you make a game or joke out of it. Ordering or demanding may be less effective with some people.

• Use touch to convey your message of caring. Most people find touch reassuring.

• Gain the individual's trust and attention with social conversation such as the weather or family members to promote a relaxed frame of mind. When the person has become relaxed, you can often get to the task at hand more effectively.

Environment and approach in interacting

• People with dementia have diminished ability to screen out distractions. Talk to the individual in a setting that is free from such distractions as television or other conversations.

• Begin the conversation with orienting information. Identify yourself, call the person by name, and explain what you plan to do.

• Gain the person’s attention by looking directly at the person before you speak. When people have progressed to the later stages, it may take time to gain their attention.

• Often a gentle touch or saying the person’s name several times will initiate contact. Move slowly and be sure to give the person time to respond.

• Be sure to be at eye level with the person, especially when they are hard of hearing or quite impaired. Speak slowly, using short, simple sentences. Pause between sentences to give the person time to process the information.

• Ask simple questions that require a choice of yes/no responses rather than open-ended questions. Offering a choice may allow the person to assist in simple decision-making.

• As people become more impaired, they lose the ability to understand abstract concepts. Keep terms concrete and familiar. For example, instead of asking "are you thirsty" say, "here is a glass of water for you to drink."

• Use a tone of voice that you would like others to use with you, keeping the conversation pleasant and talking in a calm, easy-going manner. Keep the pitch of your voice low. Shouting can be upsetting and startling to the demented person.

Approaching tasks with a demented person

• People with dementia lose the ability to learn new information but may be able to do familiar work, hobbies, or household chores.

• People with dementia lose the ability to learn new information but may be able to do familiar work, hobbies, or household chores.

• People with dementia need more time to absorb simple statements and instructions. Do not rush the process; allow a moment of silence before repeating an instruction. This requires much patience on the part of the caregiver.

Non-response to information

• If a cognitively impaired person does not respond, repeat the instructions in exactly the same way. It may take a number of repetitions before the person is able to understand and respond. If there continues to be no response, change the key words or demonstrate what you want the person to do.

• If you are having difficulty being understood by the person, ask yourself, "how can I say this more simply."

• People with dementia lose the ability to perform more than one step when executing a task. Instead of asking a person to perform a task, "brush your teeth," break the task down into "one step at a time" to simplify the task and promote success. Be sure you know which steps of a task a person can do and provide encouragement. Be gentle with the steps that are more difficult. Again, patience is the key.

• If both of you are getting frustrated, it may be better to drop the task affectionately and approach again in the future. Sometimes just a hug and changing the subject will be enough time. At other times, you may have to leave the room to relax and calm yourself.

Difficulty understanding the impaired person

• Listen actively and carefully to what the person is trying to say. If you do not understand, ask the person to repeat. If you think you understand, let the person know by repeating the information or rephrasing.

• Focus on a word or phrase that makes sense and repeat that back to the person for clarification.

• You may not understand the words but can recognize the emotional tone of the person. Acknowledge the person’s feelings even if you cannot understand the words.

• Your calmness and patience will create a caring environment and encourage the person to keep trying to communicate with you.

Communication Don'ts

• Don’t argue with a person who is cognitively impaired. It is important to remember that he/she has lost the ability to be as rational or logical as they were prior to dementia.

• Don’t give orders to the person. No one enjoys being bossed around and the tone of your voice will be readily understood.

• Don’t tell the person what he or she cannot do. Instead, keep directions positive and provide distraction.

• Don’t be condescending. It is difficult not to use a condescending tone when speaking slowly and using simple words and phrases. However, a condescending tone may provoke an angry response.

• Don’t ask questions that require a good memory. People with dementia have memory loss and may feel humiliated and embarrassed about not being able to respond to your questions.

• Don’t talk about people in front of them. It is impossible to know how much an individual with dementia understands and this may vary from time to time.

When verbal communication fails

• Try distraction to diffuse an angry or anxious mood. Such activities as a walk, having a cup of tea or a snack, or turning on music or television will diffuse an angry or anxious mood.

• It is better to ignore an abusive verbal outburst if you cannot think of an immediate positive response. Responding to the conversation with a contrasting mood (i.e., making a positive, cheerful comment instead of an angry reply), apologizing or just dropping the subject may change the emotional tone of the conversation.

• Try other forms of communication that do not involve words. Familiar songs, gentle touching or massage, favorite foods, or walking together can convey affection and demonstrate understanding more effectively than words.

If you feel your physical safety is threatened

• Stand out of reach of the person.

• Leave the scene to prevent injury.

• Call for help — call neighbors, family members, friends, or physician.

• Call police as last resort. Often a uniformed person can be threatening to a demented person.

References

Eliopoulos, Charlotte. "Manual of Gerontologic Nursing." St. Louis, MO: Mosby-Year Book, Inc., 1995.

"Early Diagnosis or Alzheimer’s Disease Raises New Issues." Parent Care Advisor. Horsham, PA: LRP Publications, September 1997.

Robinson, Anne; Spencer, Beth, and White, Laurie. "Understanding Difficult Behaviors." Ypsilanti, MI: Eastern Michigan University, 1996.

Teri, Linda and Schmidt, Amy. "Understanding Alzheimer’s – A Guide for Families, Friends, and Health Care Providers." L. Teri, University of Washington, 1993.