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Communicating in Dementia


Broad term used to describe a group of symptoms including, impairment in memory, ... Perfectionism & standards of care. Response to protest, refusal, no' ... – PowerPoint PPT presentation

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Title: Communicating in Dementia

Communicating in Dementia
  • Dr. Aideen Lewis
  • Principal Clinical Psychologist
  • Department of Old Age Psychiatry
  • St. Vincents University Hospital Dublin

What is dementia?
  • Broad term used to describe a group of symptoms
    including, impairment in memory, intellect,
    judgement, language, insight and sometimes acute
    sensitivity to the built and social environment
  • IMPAIRMENT in an interaction between the person
    (their life history, who they always have been)
    and the neurological changes of dementia

Model of behaviour problems in dementia
Neurodegener- ative Changes
(Zarit Zarit 1998)
Challenges of dementia
  • Memory impairment initially short term memory
    (memory for new events)
  • Memory ability fluctuates
  • Presence of good memory ability for old memories
    but poor retention of new information can
    frustrate and confuse she can remember where
    her room is but she never knows where her handbag
    is, I think she puts it on a bit
  • Memories are EMOTIONAL some emotional memories
    will be retained when others are forgotten Im
    always nice to him and he never remembers my name
    but he hates Maggie and never forgets her name!

Memory/intellectual impairment
  • Difficulty learning new tasks
  • Failure to remember staff members with a
    resulting failure to build relationships
  • Slower processing and difficulty following long
    instructions or doing tasks that require
    sustained attention e.g. reading a book requires
    you to remember characters etc., cooking you need
    to remember what you just did and when you did it
  • Fear and intense anxiety due to forgetting where
    s/he is and why

Challenges of Dementia I -Communucation
  • Dysarthria difficulties in the production of
    speech/does not affect understanding of language
    or the ability to decide what you want to say/no
    disruption to reading or writing skills
  • Dysphasia difficulties in the production and
    understanding of language, reading and writing
  • Depression affect the will to communicate/
    speech is often sparse, quiet, monotone
  • Confusion reduced recognition, difficulty with
    memory, inability to think clearly, confusion
    about where they are and who they are with

Challenges of Dementia II
  • Body clock distrubances and disorientation leads
    to lack of awareness of time, confusion
  • Difficulties consciously co-ordinating action of
    complex motor tasks (Dyspraxia ) eg. Dressing,
  • Delusional beliefs sometimes function to help
    the person deal with memory loss eg. Who stole my
    money? It makes more sense to believe someone
    stole from you than to think you cannot remember
    where you put the money

Challenges of Dementia -III
  • Wandering Presents problems in terms of
    ensuring the persons safety. Try to see why
    they are doing it. Person may be hovering in a
    place for a reason, person may be avoiding
    something, person may feel psychologically lost
    and walking is a physically expression of this,
    person may be anxious or stresses
  • Depression/apathy may make the person difficult
    to engage. Challenging because it feels hopeless
    and difficult to change

Challenges of Frontal-Lobe Dementia
  • Inappropriate behaviour that is out of character
    e.g. masturbation or verbal abuse can be due to
    inability to monitor and inhibit behaviour
  • Perseveration (broken record) repetition of
    patterns or requests person cannot shift from
    one idea or action to another
  • Lack of empathy or caring due to difficulty
    taking another persons perspective
  • Mood swings due to difficulty monitoring and
    inhibiting emotional response

Other neurological challenges
  • Agnosia inability to identify object by sight
    alone, speech by hearing alone and so on. Visual
    agnosia inabiltiy to name or demonstrate use of
    object without touching it and a lack of
    recognition of the objects meaning or character
  • Spatial agnosia inability to find way around
    even familiar places
  • Prosopagnosia inability to recognise familiar
    faces (familiar voices often resolves difficulty)
  • Anosognosia (one side neglect) person may not
    see their own body as a whole and may deny that
    their left hand belongs to them

Challenging Behaviour - an attempt to communicate
  • Definition of challenging behaviour
  • Behaviour of such an intensity, frequency or
    duration that the physical safety of the person
    or others is likely to be placed in serious
  • or
  • Behaviour which is likely to seriously limit or
    deny access to and use of ordinary community

Sample Referral
  • Patient has become increasingly difficult (
    agitated, aggressive, unmanageable ). Please

  • A function of being human
  • Purpose to convey information about needs
  • Both verbal non verbal aspects - (Birdwhistell
  • Non verbal communication (NVC) refers to all
    vocal and non vocal behaviour which conveys

Purpose of NVC
  • To totally replace speech/verbal commun.
  • Compliments embellishes the spoken word
    encoding of emotions is a main function
  • Initiates and sustains verbal communication
  • Defines relationships by influencing others -
    affiliation/liking dominance/control
  • Self presentation i.e. who I am

NVC as communication
  • Freud (1905) If his lips are silent he chatters
    with his fingertips betrayal oozes out of him at
    every pore
  • Abercrombie (1968) We speak with our vocal
    organs but we converse with our whole body

Goals of communication
  • All interactions/communications are attempts to
    attain goals
  • The goals are desired behaviour in others,
    attainment of particular relationships or
  • Goals are underpinned by needs
  • When a goal or need is denied, the result is
    continuous corrective action to attain the

you could at least look at me when I'm talking to
Why can't you understand what I'm saying?
I'm only trying to help why are you getting upset?
I showed you yesterday how to do this
Please hurry up I have to do the other patients
I don't know why I bother
Please don't hit me
Stop wandering around!
I thought you liked me, why don't you recognise
You act like you can't speak but you can tell me
to get lost
Things are not right, I know there's something
wrong but I can't put my finger on it
What are you doing to me? Help!
Why can't you understand me?
Did you steal my money?
I'm scared
Who are you?
There is too much noise
what's that?
I can do it myself, I'm not a child
What? I don't understand
This is humiliating
No I will not sit down, I'm waiting here for my
daughter she's visiting soon
Where am I?
Why are you taking my clothes off? Stop it!
Goal of challenging behaviour
  • Challenging behaviour can be viewed as corrective
    action in an attempt to communicate (verbally
    non verbally) about an unmet need or emotional
  • Includes physical, psychological/emotional,
    social spiritual needs
  • Corrective action is less sophisticated, more
    primitive because of cognitive decline in dementia

  • Physical care
  • Safety
  • Belonging
  • Intimacy
  • Personal space / territory
  • Love and attention
  • Emotional expression
  • Control
  • Independence

Multiple Pathways to Behaviour
Care practices Attitudes of carers Relationships
Architecture Interior decoration Layout
Behaviour (i.e. mood, thought, speech and action)
Dementia Sensory handicaps Physical
handicaps Ill health pain Medication
Life history Attitudes Beliefs
expectations Habits Needs
Solving the problem
  • who is having the problem
  • who is managing the problem with least distress
  • what legitimate needs are not being met (carer
  • listening actively to hear the problem
  • observing the problem

Behavioural Analysis - ABC
  • Principles of behavioural work
  • All behaviour unique to individual
  • All behaviours have a purpose
  • The pathways to behaviour are multifaceted
  • Behaviour is complex
  • Responses to behaviour need to be individual
  • Avoid thinking in group behaviours

(No Transcript)
Practical Suggestions
  • rule out treatable intercurrent illness
  • awareness of the limits of B.Mod with people who
    have dementia
  • building a clear comprehensive picture of the
    individual, carer and the environment and the

Factors within the Patient/Client
  • Type of dementia /course of the illness
  • Degree of cognitive impairment /nature of
  • Intercurrent illness
  • Medication
  • Pre-morbid personality
  • Pre-morbid mental health
  • Current mental health (incl. Depression

Factors within the Patient/Client contd..
  • Life History of individual
  • Previous lifestyle
  • Habits at home at work
  • Beliefs expectations
  • Interpersonal attitudes
  • Attitudes towards violence
  • Sources of stress
  • Methods of coping with change stress
  • Levels of independency
  • Control issues
  • Relationship quality

Factors within the Carer I
  • Adjustment to role of carer
  • History of caring ( can work for against)
  • No.of stressors on carer
  • Perception of the stress
  • Degree of ambivalence towards caring / patient
  • Anger / disappointment at how things have turned
  • Own history of adaptation adjustment

Factors within the Carer II
  • Attributions of Behaviour
  • Formulation of own stress response as abnormal
  • Fear of blame / failure
  • Perfectionism standards of care
  • Response to protest, refusal, no
  • Ability to observe, reflect, establish
  • Relationship factors (quality, rules etc.
  • Envy /Resentment Dynamic

Ethical Issues
  • Central issue of power physical frailty
    cognitive impairment. Making decisions
    unnecessarily, subtle persuasion and not
    listening to views
  • Denying rights in the name of care e.g. use of
  • Use of behavioral therapy and environmental
    modification without consultation
  • Infantilising activities
  • Conflict of interest between patient and family
    (precedence of needs, confidentiality of
    information, boundaries)
  • Issues of consent

Personal Issues
  • Increased contact with issues of bereavement,
    loss death professionals ability to sustain
  • Shock at closeness of death to clinical practice
  • Facing own mortality death
  • Challenge to religious personal beliefs
  • Influence of earlier disaster/trauma on devt. of
    mental illness in late life
  • Confrontation with fantasy reality of own
    significant others ageing
  • Attributions re. resistance