Communicating with Cognitively Impaired Persons
Christine L. Williams DNSc, APRN, BC
Ruth M. Tappen EdD, RN, FAAN
OBJECTIVES
To describe nurse and client responses to communication challenges related to cognitive impairment
To differentiate delirium, dementia, and intellectual/developmental disabilities
To delineate therapeutic communication strategies for clients with cognitive impairment
To compare and contrast task-focused and emotion-focused communication
To adjust communication approaches to the severity of the client’s cognitive impairment
▪ INTRODUCTION
Cognitive impairment may occur at any age and may be encountered in the home, clinic, or hospital.1 Some types of impairment can be reversed, others cannot. In either case, cognitive impairment presents a communication challenge to the nurse.
One type of cognitive impairment is dementia, which is caused by degenerative brain disease, such as Alzheimer’s disease (AD), and is usually not reversible.2 Dementia is most common in older adults. Intellectual and developmental disabilities (I/DD) occur before birth or during childhood. They can be treated but usually are not reversible. Although considered a problem of childhood, as treatment of I/DD improves, nurses encounter many more adults with I/DD. Delirium is an acute, potentially reversible event that may occur at any age, although older adults are most vulnerable. An estimated 20% of adults aged 65 and older who are hospitalized develop delirium.3
Because the communication strategies nurses implement with clients exhibiting these different types of cognitive impairment vary somewhat, they will be discussed separately.
▪ DEMENTIA
Dementia is a gradual loss of cognitive ability that usually occurs during old age. Half of all older adults over the age of 85 have dementia.2 It is never a normal or expected part of aging. Dementia occurs with brain pathology and must be evaluated to rule out other causes and determine if the dementia is reversible (e.g., vitamin B12 deficiency or thyroid disease). The most common form of dementia, Alzheimer’s disease, is irreversible, but medications may slow the progression of the illness. Other causes of dementia include chronic alcoholism, stroke, and HIV.3
An individual with dementia gradually loses an array of cognitive abilities, such as memory, calculation, judgment, or orientation. Aphasia, or deteriorating language, is another common cognition-related loss. Anomia (word-finding difficulty) is one of the first signs. This is followed by difficulty verbally expressing thoughts and emotions, as well as difficulty in understanding verbal messages.4 Cognitive losses gradually increase over a period of months or years. Although the individual remains alert, he or she eventually loses the ability to comprehend verbal communications. The result is a slower response to a question or command and frequent miscommunication.
▪ NURSE AND CLIENT RESPONSES TO COGNITIVE IMPAIRMENT
People with dementia were once cognitively intact. Clients’ emotional responses to their cognitive loss will influence their overall mental health and ongoing relationships. As clients develop dementia, different cognitive abilities decline at different rates. They retain many cognitive abilities while other cognitive skills deteriorate. People who are painfully aware of their limitations may be reluctant to try to communicate. They may feel ashamed and withdraw from relationships or activities.5
Frustration, anger, and anxiety are common human responses for any individual who loses the ability to communicate verbally. When losses are gradual and relentless, such as in dementia, decreased self-esteem and depression are common and further interfere with the ability to communicate. With little hope for improvement and frequent awkward misunderstandings, it is not surprising that clients would wish to avoid communicating. Caregivers are also subject to frustration and anxiety when their attempts to communicate with the person who has cognitive limitations are unsuccessful. Mutual
avoidance and withdrawal can be the result.6,7 Many strategies are available for nurses to use to increase their chances of successful communication with these clients (see Table 9-1).
avoidance and withdrawal can be the result.6,7 Many strategies are available for nurses to use to increase their chances of successful communication with these clients (see Table 9-1).
Case example
Mrs. Trescott, age 86, has lived a full and active life. She held positions of responsibility and enjoyed leadership status in her community. She has fond memories of winning her golf club championship several years in a row. Presently, she lives in a long-term care facility and has Alzheimer’s disease. Although she is unable to live independently, she speaks about the indignities of living in a sheltered environment. She is embarrassed about attending group exercise classes because the routines are well below her ability level. At the same time, she can be loud and disruptive in social activities and must be closely supervised because she wants to leave the facility to go shopping on her own.
Table 9-1 Guidelines for Communication with Cognitively Impaired Persons | ||||||||||||||||||||||||||||||||||||
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As you develop knowledge and skill you will be more likely to approach cognitively impaired clients with confidence rather than unease. Approaches to communication must be adapted not only to the person’s ability to understand and respond but to the purpose of the interaction. What is appropriate for assessment may be a barrier to conversation that is designed to facilitate expression of concerns and feelings.
▪ BALANCING THE NEED TO KNOW WITH THE CLIENT’S NEED FOR DIGNITY
During the nurse’s evaluation of the client’s cognitive and communication abilities, the client’s deficits are exposed. This exposure is frequently stressful and embarrassing to the client. It is important for the nurse to be especially supportive and to convey respect for the worth and dignity of the person. Prepare clients in advance for questions that may be difficult to answer. Let clients know that it is okay if they do not know the answer. Some people with dementia wonder aloud about the cause of their cognitive impairment and are self-critical. They may comment that they have become “stupid,” “crazy,” or they are “losing their mind.” You can assure them that their memory problems do not have any relationship to such negative self-evaluations.
To provide safe and effective care, it is often necessary for the nurse to conduct an assessment of the client’s cognitive ability. The Mini Mental State Examination (MMSE) is one test used to evaluate cognitive functioning in several areas including orientation, registration, attention and calculation, recall and language.8 The MMSE is used in assessing clients with cognitive impairment as well as those who are at risk for dementia, such as older adults or those with HIV and chronic substance abuse. The test can be introduced to the individual as a routine series of questions—some of which may be easy and others difficult to answer. A person with dementia will be unable to answer some questions and will commonly react with discomfort and dismay. Therefore, the test-taking situation is less threatening for the client when the nurse has established a trusting relationship and time is allowed to establish rapport before the test begins.
Clients should be advised to do their best in answering assessment questions and should be assured that not knowing an answer does not necessarily mean that something is wrong. Because testing can be uncomfortable for people with cognitive impairment, such questions should be reserved for special purposes, including evaluation of clinical progress and research. Quizzing clients and thus exposing their deficits whenever care is given is not helpful because it can harm self-esteem. Quizzing is quite different from a therapeutic strategy designed to stimulate cognitive activity. If the goal of the interaction is maintaining or regaining cognitive function, it is more helpful to involve clients in conversation about topics they choose or in activities they enjoy.
▪ ENGAGING THE CLIENT IN COMMUNICATION
The goals of communication for people with cognitive impairment include understanding the client’s needs, sharing experiences, and engaging the client in his or her own care. Table 9-1 presents some general guidelines that will facilitate successful communication with clients who have cognitive impairment.
Reality orientation is a strategy that involves providing information to people with cognitive impairment to help them maintain contact with reality.9 For example, the nurse uses reality orientation in the following statement: “Mr. Jeffrey, my name is Beverly Tomez and I am your nurse. Today is Wednesday, January 23rd, and you are in the hospital.” This statement is intended to reduce anxiety by reinforcing orientation to time and place. Although this strategy is not harmful when used occasionally, it has limited usefulness for interacting with a person who has dementia.9 Many people with dementia become embarrassed or frustrated when they realize that they have forgotten the date or where they are. Further, they are likely to forget the information in a few minutes; reminding them over and over again is not helpful. Displaying a clock and calendar where they can be easily seen is more useful (and less threatening) because the information is available when the person needs it.
Facilitating Trust
Establishing trust with a person who has dementia is a challenging but not impossible task. When a trusting relationship is established, the goals of care are much easier to achieve. The person with dementia will remember that you are trustworthy, although he or she may not remember all of the details of the experience that led to the feeling of trust.
Case example
You are a nurse in a long-term care facility and a resident has an appointment with a specialist in a location off the unit. The nursing assistant is trying to persuade the resident to accompany her to the appointment, and the resident is anxious and reluctant to get onto the elevator. Hoping to gain the resident’s cooperation, the nursing assistant tells the resident that her son is waiting and she must get into the elevator if she wants to see him. What would you do?
The short-term effect of the dishonesty in the case example is that the resident may get into the elevator. Later, the person with dementia may become disruptive and uncooperative and will be unlikely to trust what the nursing assistant tells her. A better approach would be to encourage a trusted family member or consistent caregiver to be present at the time of the appointment, to allow extra time to accompany the resident, and to ensure that the caregiver uses a calming approach. If the resident becomes agitated upon leaving the unit, this is an issue that can be discussed with the family and interdisciplinary team. It may be possible for a small dose of an as-needed medication for anxiety to be given in advance of the appointment or perhaps the care provider can come to the unit for a meeting.
Avoid talking about the person with cognitive impairment in his or her presence. Address the client directly instead of speaking to a nearby family member or coworker. Use the client’s formal name and ask what he or she would like to be called. Avoid endearments such as “Dear” or “Mamma,” which imply a social relationship rather than a professional one. Remember, clients with dementia are adults, although some of their behavior may seem childlike.
Task-Focused Communication
When nurses request specific information from clients, such as, “Are you in pain?” or give directions, such as, “Take this medicine,” they are using task-focused communication. The following approaches are guidelines for this type of interaction.
Because the individual may have difficulty understanding complex messages, keep your messages simple and direct. Present one idea at a time. Ask for what you want rather than what you do not want. For example, it is easier for people with dementia to understand a statement such as, “Hold the glass with both hands” than it is to understand and follow a negatively worded command such as, “Careful, don’t spill your drink!”
Complex questions are also unlikely to produce a useful response. Asking two questions at once is confusing even to the person without cognitive impairment. Asking “why” requires analysis of reasons for behavior and sounds like a challenge or confrontation. For example, “Why did you put your coat on? It’s hot outside!” This question is unlikely to produce a positive response. Instead, it would be better to preserve the person’s sense of dignity with a supportive response. “Let me help you put your coat away. It is very hot out today. I don’t think you will need it.”
Do not overburden people with cognitive impairment with unnecessary information. In orienting them to a new living environment, for example, it may be more appropriate to include essential information about their immediate surroundings at first (such as where the bathroom is and how they can call for help) rather than an orientation to the entire unit. Allow for slower processing of information and give additional time for questions.
To gain your clients’ cooperation, avoid increasing their anxiety. A statement such as, “If you can’t stay in bed, I will have to put the side rails up!” is not likely to gain cooperation. Clients may not remember the details of such a threat a few minutes later, but they will feel less secure in their new surroundings. When the nurse remembers to plan care to accommodate people with cognitive deficits, less frustration will occur.
By giving simple choices and allowing some flexibility, the nurse empowers clients to participate in their care. For example, the nurse asks, “Would you like to wash your face?” (while handing the washcloth to the client), thereby encouraging the person to choose to participate rather than become the passive recipient of care. Do not pretend to provide a choice, however, if you are not able to accept a “no” response.
Arguing with someone who is cognitively impaired is unlikely to gain cooperation and will only escalate frustration and agitation. For example, Mrs. Silva shouts at the nursing assistant, “You stole my teeth!” Rather than defending herself and arguing that Mrs. Silva misplaced her own dentures, the nursing assistant wisely responds, “Let me help you find your dentures, Mrs. Silva.”
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