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Person-Centred Communication In Patients With Dementia

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approaches to dementia care, communication, dementia awareness, education and training

In my second year of medical school at the University of Nottingham, I was set the task of researching an aspect of clinical communication skills that interested me. I chose to focus on communication with people with dementia – a set of skills that, due to the UK’s aging population, is likely to be required more by my generation of healthworkers than by any generation before. The following account is the summary of my research and a reflection on my own first interactions with patients with dementia.

There is a growing nationwide problem regarding poor treatment outcomes of people with dementia, who fill one quarter of UK hospital beds, yet whose disorientation and language loss can often leave them misunderstood or overlooked by clinicians. To improve dementia care, the General Medical Council has recommended a style of “person-centred” communication involving respect, good explanation skills and patience, the features of which I shall now explore.

Respect

Respect can be shown to patients with dementia by not pre-emptively assuming brain dysfunction or adjusting communication in a patronising manner. Elderspeak, the “baby talk” commonly used to address older patients, including higher pitch and diminutives such as “sweetie”, has been shown in studies to double the rates of resistance to care, such as withdrawn or aggressive behaviour. Daunted by my first interaction with a person with dementia and eager to act empathetically, I began with “how are we feeling today?” and regretted this when he replied “not sure about you but I’m okay!” He, of course, must have found the use of “we” very insulting. After all, I am sixty years younger, yet my elderspeak treated him as I would a small child. When initiating future consultations I must firstly assume full mental capacity; I should only adjust to simple sentences and increase non-verbal actions - smiling and nodding - if the patient seems confused. Elderspeak should be avoided.

Explanation skills

The patient was confused when I explained my intention to take his medical history, but I was initially unsure of how to rephrase myself more clearly. I then noticed the bright light from the window shining into the patient’s eyes, repositioned his chair in the shade, and repeated my explanation in simpler sentences, which I could tell was effective as he nodded and stopped frowning. Altering the environment like this is one technique for reducing confusion. Having researched explanations in dementia further, I will consider in future using the person’s name often, using pictures, repeating myself patiently, not moving between topics too quickly and even playing soft background music, which has been shown in studies to improve sensory awareness and concentration.

Patience

The Alzheimer’s Society describes how a person with dementia may have a reduced vocabulary or become “stuck” on sounds. Such barriers to self-expression can lead to loss of confidence and anxiety so the patient should never be rushed into an answer. I have previously noticed my own habit of asking double questions without waiting for a response, in an attempt at clarification. This can be confusing for anyone, but particularly so for those with dementia. I did not want the patient to believe that I was impatient, so when he was unsure about his medications, I suppressed my instinct of asking “any pills when you wake up? Do you have prescriptions?” and waited while he deliberated. Eventually he removed a prescription from his pocket and showed me his list of medications, proving that I must value pauses to avoid “outpacing” the patient.

In summary, person-centred communication simply means to respect the identity of a patient with dementia. I have practised this with mild dementia through respectful language, sensitivity to the environment and interviewing at the patient’s pace. The most valuable thing that I have learned from the written testimonies of much more experienced carers is to always take the time to see things from the patient’s point of view – to put the “person” at the “centre” - so I intend to use resources such as the Alzheimer’s Society’s “This is me” leaflet to further allow me to place myself in my patients’ shoes.

“It’s useful to go out of this world and see it from the perspective of another one.” Sir Terry Pratchett, who died of Alzheimer’s disease complications in 2015.

Resources that I have found useful

http://www.scie.org.uk/dementia/after-diagnosis/communication/conversation.asp
https://www.alzheimers.org.uk/info/20064/symptoms/90/communicating_and_language
http://www.alzheimers.org.uk/thisisme
http://www.careuk.com/care-homes/talk-dementia
10 helpful hints for carers by A. House and J. Andrews.

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