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Overview
Dementia adversely affects patients' receptive and expressive communication abilities, making it more difficult for nurses to assess their needs and provide necessary care. Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia outlines questions nurses can use to assess the nature and severity of language deficits, which vary greatly from patient to patient and over the course of the disease. Best-practice techniques for tailoring communication to each patient's abilities are also discussed. For a free online video demonstrating the use of these approaches, go to http://links.lww.com/A236 .
Say you're a staff nurse on a 30-bed medical—surgical unit at a community hospital. The majority of your patients are age 70 or older, and many of them have dementia, although it isn't usually the primary diagnosis. You're quite skilled in addressing the needs of patients with common conditions—such as stroke, cancer, diabetes, hip fracture, and congestive heart failure—but perhaps you feel less confident about addressing the needs of patients with dementia. In particular, you've seen that these patients' impaired ability to communicate complicates their nursing care. Such impairments vary widely from patient to patient, depending on factors such as comorbidities and the severity of the dementia.
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In such a situation you might rely on the approaches to assessment and intervention found in Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia (page 63). These approaches are applicable in a variety of settings and situations, as illustrated by the case examples included in this article. (Case examples were all created by me based on my experience.)
read it | watch it | try it
Watch a video demonstrating the use of various approaches to communicating with people with dementia: http://links.lww.com/A236 .
Get more information on why it's important for nurses to communicate with older hospitalized patients who have cognitive impairment.
These are the approaches in their original form. See page 63.
ASSESSING RECEPTIVE ABILITIES
In hospitals and other settings, nurses can use the Try This approaches (outlined on page 63) to assess for language deficits and facilitate communication. The tool offers nine questions that nurses can use to assess a patient's receptive and expressive capabilities. It also recommends ways to make communication easier. For more on why it's important to assess for communication difficulties in such patients, see Why Look for Communication Difficulties in Hospitalized Older Adults with Dementia? page 60. (To view the portion of the video discussing the assessment process, go to http://links.lww.com/A237 .
The following short case examples illustrate how you can use the tool to assess and improve communication with patients who have dementia. As noted in some of the examples, nurses often obtain much of the assessment information from family members and other caregivers who are familiar with the patient's communication abilities.
ASSESSING EXPRESSIVE ABILITIES
CHALLENGES
In addition to describing nine assessment questions and interventions related to receptive and expressive communication abilities, Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia includes tips for addressing some of the challenges that may arise in clinical settings. For example, it suggests that when you have a patient whose primary language is not English, you should ask the family for advice on how to more effectively communicate with the patient. You might need to use an interpreter. Gerontology nurses have developed an excellent evidence-based protocol, “Interpreter Facilitation for Individuals with Limited English Proficiency,” to guide the effective use of language interpretation services with older adults in this population.3 Nurses should also keep in mind that cultural influences can affect patients' perceptions of nonverbal communicative gestures, including touch, eye contact, and facial expressions. For example, some cultural groups prohibit touching between the sexes, even in health care situations. (To view the segment of the video discussing the interpretation of the assessment, go to http://links.lww.com/A239 .
COMMUNICATING THE RESULTS
Despite the complexity of assessing communication in patients with dementia, assessment forms in hospital charts usually include only a few variables related to basic skills. Therefore, it's imperative that nurses supplement this basic information with more detail from their assessment for use by other team members. In addition to sharing information verbally, it's important to chart pertinent findings and interventions in the patient's care plan, as in the following examples:
* Document all baseline assessment information and record any variations from baseline when reassessing.
* Document the factors that affect communication both positively and negatively, as well as the interventions that can be used to address conditions that interfere with communication.
* Describe what communication techniques are effective in specific circumstances.
* Document the sources of the assessment information and each person's relationship to the patient (for example, spouse, family member, friend, caregiver).
* Ask caregivers to provide a written list of tips for communicating with the patient and obtain their permission to include it in the care plan.
Speech therapy. Nurses also need to consider whether referring the patient for further evaluation is appropriate. When receptive or expressive skills are impaired by stroke or other acute episodes, speech therapy is often initiated. However, when impairment occurs gradually or is long-standing, the need for speech therapy can be overlooked. (Some clinicians may be unaware of the importance of a speech therapist in evaluating and treating dementia-related communication problems.)
In all health care settings, speech therapy (also known as speech—language services) is increasingly being used to improve the communicative abilities of people in all stages of dementia.4 Speech—language services for people with dementia include counseling, direct therapy, and assistance with developing effective communication techniques.5 For example, speech therapists can teach people in the early stages of dementia about techniques that will improve their word-finding abilities and enhance their communication skills. Referral for speech therapy is especially appropriate when a family member or caregiver expresses a desire to learn how best to communicate with the patient at any stage of dementia. Speech therapists can also provide nurses, physicians, and other hospital staff with valuable, practical assessment and intervention information that will improve communication during the hospitalization. Although primary care providers generally make these referrals, nurses are often in a good position to identify the need and suggest that speech therapy services be considered.
Incorporating results in discharge planning. Hospitalization often provides clinicians with opportunities to inform family members about the patient's medical condition and other aspects of care, such as communication. Therefore, nurses need to incorporate assessment and intervention information into teaching. If the care plan includes detailed information on communication techniques, make copies of this information for the patient. If speech therapy has been provided, ensure that written recommendations are included in the discharge plan. When patients are discharged to institutional settings, such as long-term care facilities, include all pertinent findings with the transfer information.
You might also consider whether referral for follow-up speech therapy is appropriate, even if the patient didn't receive speech therapy during hospitalization. For example, if no prior evaluation by a speech therapist has been performed, ask patients who are in the early stages of dementia whether they would be interested in having one. When caring for people who are in the more advanced stages of dementia, consider asking family members or caregivers if they would be interested in such a referral. (To view the video chapter discussing strategies and resources to enhance communication and safety, go to http://links.lww.com/A240 .
CONSIDER THIS
What's the evidence to support the use of the Try This approaches? Although an abundance of literature delineates strategies for communicating with people who have dementia, few studies have examined the effectiveness of specific strategies. The studies by Small and colleagues cited in Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia examined communication between people with dementia and their family caregivers during activities of daily living.1, 6, 7 Their study on the effectiveness of 10 commonly recommended communication strategies (including simplifying speech, paraphrasing, avoiding interruptions, controlling environmental distractions, and engaging the person's attention) supports the use of the techniques listed in the Try This approaches.7 A study by Perry and colleagues of communication strategies nurses used in caring for people with dementia supports the use of many techniques—including those that are cited in the Try This approaches—with emphasis on the need for conversational strategies and interactions to address individual abilities.8 Specific conversational strategies identified included repeating key words, maintaining topics, and avoiding interruptions.
Why Look For Communication Difficulties in Hospitalized Older Adults with Dementia?
Because dementia affects the processes involved in perceiving, understanding, and responding to verbal and nonverbal information, it impairs communication. Consequently, caregivers of people with dementia, including family members and clinicians, need to use techniques that will help them exchange information with and interpret communication by patients. Family members and other caregivers usually develop patterns of verbal and nonverbal communication. These patterns are likely to change during the course of dementia, as verbal skills diminish and the patient becomes more reliant on caregivers.1
I have seen communication become so specific and intricate over time that family members and caregivers feel as though they've developed a new language, one that only they and the person with dementia can understand.
Hospitalization disrupts these communication systems. Changes in environment, routine, and caregivers can compromise the communication process. This disruption can be minimized by incorporating effective communication techniques into the patient's care plan. Nurses can first assess the person's usual abilities and then use techniques that are based on an understanding of the patient's typical methods of communicating, as described in the Try This tool entitled Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia, found on page 63.
The scope of the problem. Communication difficulties frustrate people with dementia and their caregivers. Dementia affects basic language skills, which are categorized as receptive (decoding and understanding information) or expressive (conveying information). In addition, basic language skills are dependent on cognitive abilities that are also affected by dementia, such as forming memories, solving problems, and thinking abstractly. To further complicate matters, many other conditions common in older adults who have dementia—such as delirium—can exacerbate communication problems. These other factors may also play a role2:
* vision or hearing impairment
* environmental factors such as the noise from nearby conversations, excessive sensory stimulation (such as that produced by flashing lights and intermittent beeping of unfamiliar equipment), and unaccustomed glare or dim lighting
* the absence of familiar caregivers
* cultural and language differences between the patient and clinical staff
* medical conditions and adverse medication effects that compromise mental status anxiety
Nurses must identify these kinds of interference in their assessment. For example, you can try to ensure that people who usually wear eyeglasses or hearing aids have access to them at all times. When compromising conditions cannot be addressed before your assessment, note that in the patient's chart and do the assessment at another time. For example, when a patient's mental status is compromised by the effects of anesthesia, document that the assessment should be postponed. Similarly, the presence of many conditions, including delirium, that affect mental status—even when the patient doesn't have dementia—should be considered when assessing any aspect of functioning.
Watch It!
Go to http://links.lww.com/A236 to watch a nurse assess a patient with dementia for communication difficulties and discuss how to intervene when such difficulties exist.
View this video in its entirety and then apply for CE credit at www.nursingcenter.com/AJNolderadults ; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.
Online Resources
For more information on assessing communication difficulties in older adults with dementia and other geriatric assessment tools and best practices, go to www.hartfordign.org , the Web site of the John A. Hartford Foundation—funded Hartford Institute for Geriatric Nursing at New York University College of Nursing. The institute focuses on improving the quality of care provided to older adults by promoting excellence in geriatric nursing practice, education, research, and policy.
For more information on the teaching of geriatrics, go to the Fundamental Geriatric Curriculum Resources Web site at the Hartford Institute: www.hartfordign.org/resources/education/bsnPartners.html . The featured slides can be used in any educational setting.
Go to www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.
REFERENCES
1. Small JA, Gutman G. Recommended and reported use of communication strategies in Alzheimer caregiving. Alzheimer Dis Assoc Disord 2002;16(4):270–8. [Context Link]
2. Miller CA. Nursing for wellness in older adults: theory and practice. 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2004. [Context Link]
3. Enslein J, et al. Evidence-based protocol: interpreter facilitation for individuals with limited English proficiency. J Gerontol Nurs 2002;28(7):5–13. [Context Link]
4. Kim ES, Bayles KA. Communication in late-stage Alzheimer's disease: relation to functional markers of disease severity. Alzheimer's Care Quarterly 2007;8(1):43–52. [Context Link]
5. Haak NJ. Maintaining connections: Understanding communication from the perspective of persons with dementia. Alzheimer's Care Quarterly 2002;3(2):116–31. [Context Link]
6. Small JA, et al. Communication between individuals with Alzheimer's disease and their caregivers during activities of daily living. Am J Alzheimers Dis Other Demen 2000;15(5):291–302. [Context Link]
7. Small JA, et al. Effectiveness of communication strategies used by caregivers of persons with Alzheimer's disease during activities of daily living. J Speech Lang Hear Res 2003;46(2):353–67. [Context Link]
8. Perry J, et al. Nurse-patient communication in dementia: improving the odds. J Gerontol Nurs 2005;31(4):43–52. [Context Link]