By Sharon Roth Maguire, MS, RN, GNP-BC, chief clinical quality officer for BrightStar Care
It's probably not a surprise to anyone reading this that communicating with individuals living with dementia is one of the more challenging things that your caregivers do during their work day. While some caregivers seem to be “dementia whisperers,” most express some degree of frustration when trying to understand what their residents living with dementia are trying to tell them or when they as caregivers are trying to explain something or engage the person living with dementia in a common daily task. The frustration is real and can end up contributing to unintended consequences like ignoring the resident or, in the worst case scenario, contributing to verbal or physical abuse of the resident. None of us want that for the resident or for the staff member, so what is the best approach to training caregivers how to communicate with residents living with dementia? It's a combination of both art and science.
The Science
The basics of aging and the basics of dementia are essential to include in your training of your caregivers. Be sure they understand the normal and expected changes to the sensory system that all of us experience as we age: the impact of diminished hearing, vision, smell, taste, and touch should be emphasized. Sensory changes common in aging can significantly impact communication in everyday life and even more so with dementia. Strategies to optimize sensory functions should be taught to all caregiving staff. For example, is lighting adequate so as not to cast shadows on the caregiver's face making them look scary to an older adult with poor vision? Is there intense brightness causing glare leading to hesitation in movement which might be inadvertently interpreted as lack of cooperation? Are caregivers speaking clearly in a tone and pitch that will be best heard by an older adult – slightly louder, but not shouting, and lower to optimize the older adult's ability to hear the caregiver and follow through on the caregiver's request? Are eyeglasses on, clean, in good repair, and the right ones (not belonging to their roommate or spouse – it happens!)? Are ears clear of wax build up which is common in old age and will impact hearing? Are hearing aids in and in the correct ear, turned on, in good repair and the right ones (you get the idea)? These age related changes can be demonstrated with simple interactive sensory change kits available through various training supply companies or you can even make your own—have caregivers wear eyeglasses purchased at a drugstore slightly smudged with Vaseline, place cotton balls in their ears and have them do a few simple tasks like read a menu, answer a question such as “What shoes and socks would you like to wear to church on Sunday?” from a few feet away. You can have fun with this but also have them reflect on what this means for the older adults they care for and how they as caregivers will change the way they communicate with their residents.
As far as the basics of dementia, be sure caregivers understand that dementia is an illness not a choice or a way of being difficult. Show photos to caregivers comparing a normal brain with the brain of someone with dementia to help caregivers see that there is a very real impact on the brain's ability to function when someone has dementia. As the saying goes, a picture is worth a thousand words. Describe the common changes that occur in dementia that impact communication; especially impactful is discussion of the 4A's of Alzheimer's Disease: amnesia, agnosia, apraxia, and aphasia. Giving real life examples of these symptoms can be quite impactful and lead to greater understanding by the caregivers of the communication challenges related to the disease. One simple example I often use is that of the character Ariel from the Disney movie, “The Little Mermaid” when Ariel is using a fork to comb her hair—that's a type of apraxia—why does Ariel do that? She's not trying to be funny but rather, because at that moment, Ariel's brain isn't working quite right. We shouldn't get frustrated with Ariel, but rather just give her the right object to comb her hair. There are many dementia training toolkits available that provide simple exercises to demonstrate these symptoms and are a great interactive addition to the training you may already provide. The caregivers will better retain this type of training as opposed to sitting in a classroom listening to a presentation or watching a video. Have the caregivers also share real life examples of experiences they may have had when caring for persons living with dementia that they would like to better understand or led to frustration on their part. The trainer should explain what may have been going on as related to the disease and ask the group to brainstorm on a dementia sensitive approach. This tactic gives caregivers some immediate actions or approaches to put in place the very next time they are caring for a resident.
The Art
This is where caregivers can really excel by thinking of themselves as the artist or the interpreter or the guide. As persons living with dementia become less able to communicate, we need to be able to fill in the blanks by “listening” to their non-verbal communication and appreciating each movement, sign, or signal as part of a beautiful piece of artwork or a symphony. Caregivers in many instances need to finish the painting or complete the symphony; be that interpreter or guide to achieve the masterpiece—effective communication—so that the resident will feel powerfully understood, cared for, and safe. To train this, I often have caregivers think of an interaction they may have had with a pet. Most pets cannot speak but yet you know what they need or want by observing them, listening to them, anticipating what they might want or need based on their habits or tendencies. You are the pet's interpreter or guide to a happy life. Have them describe how they care for a beloved pet. It's fun to watch the lightbulbs go off with this as they realize that they have to be the one to “provide for” the resident. I also like to do an interactive exercise during which I give out a card with a scenario on it, something like “I have a headache.” or “My tooth hurts.” or “I'm tired.” that one caregiver will need to demonstrate to another caregiver without using full sentences and only the words up, in, yes and no. The group then switches roles. At the end of each interaction, a reflection session is held to talk about how that felt for both of the caregivers and what they will do differently. It's a very thought provoking exercise with many “aha” moments.
Communicating well with persons living with dementia is essential to the type of person-centered environment we all strive to achieve in our care settings. The subject deserves as much attention in your training as proper transfer and handwashing techniques, perhaps even more.
Sharon Roth Maguire, MS, RN, GNP-BC, oversees the BrightStar Care clinical-quality platform including operationalizing the client care experience, designing clinical operational systems for domestic and international BrightStar Care locations, and managing clinical policies and procedures. For more information on BrightStar Care, visit www.brightstarcare.com.