- cognitive impairment
communication, attention, memory, thinking and problem-solving difficulties usually associated with dementia and delirium.
At present, these large numbers mean that more than half of all people living in aged care in Australia have dementia. Further, one in every 100 people admitted to hospital have a diagnosis of dementia and 5% of attendances at the general practitioner (GP) involve the management of people with dementia (AIHW, 2012).
- dementia
an umbrella term for a number of diseases characterised by progressive decline of brain functions causing changes in memory, perception, personality, language, and cognitive skills, and resulting in difficulties with activities of daily living. People with dementia are at high risk of developing delirium, or temporary confusion.
The challenges of caring for people with dementia cut right across the healthcare sector. People with dementia are vulnerable to healthcare environments because their declining cognitive abilities decrease their capacity to adapt to change, remain independent, and vocalise their needs. All clinicians, independent of their specialty and/or site of care, need to communicate effectively if the care needs of people with cognitive impairment and their families are to be addressed. In this chapter we will provide some resources to help clinicians communicate with and provide safe care for people who are cognitively impaired.
Introduction
Cognitive impairment is not associated with any one particular disease or with any one age group. Cognitive impairment is associated with stroke (Man et al., 2011), traumatic brain injury (Nash et al., 2014), developmental disabilities, chronic disease (Abete et al., 2014; Fan & Meek, 2014), chronic stress and mental illness (Marin et al., 2012).
While age is the primary risk factor for cognitive impairment, other risk factors include family history, education level, physical inactivity and elements such as exposure to pesticides or toxins as well as chronic conditions. Failure to understand and address the underlying causes of cognitive impairment can have a profound impact on the outcomes of care. People with cognitive impairment ‘are at greater risk of adverse outcomes than people who do not have cognitive impairment’ (Draper, Karmel, Gibson, Peut & Anderson, 2011), including delirium.
- delirium
a state of mind caused by an underlying physical condition, characterised by acute onset (usually hours to days) and tending to fluctuate over the course of the day (American Psychiatric Association, 2000).
Delirium is a common condition, affecting up to 50% or more of older people in hospitals and residential care (Harding, 2006). Features of delirium include reduced clarity of awareness of the environment with reduced ability to focus, sustain or shift attention; memory impairment; disturbance of sleep–wake cycle; speech or language disturbance; disorientation to time and place; emotional disturbance; psychomotor behavioural disturbance such as agitation; and hallucination or other misinterpretations (Clinical Epidemiology and Health Service Evaluation Unit, 2006, p. 25).
Delirium remains underdiagnosed in most healthcare settings (Edlund et al., 2006). Undiagnosed delirium leads to negative outcomes for older people. They may have to be kept in hospital for longer, and this means they are at greater risk of experiencing complications (such as an infection or mismedication) and even dying (either in hospital or soon after discharge). Delirium may also lead to a loss of independence and it may exacerbate cognitive decline (van Munster & de Rooij, 2014). It can cause significant distress for people and their families (Morita et al., 2004). Delirium has been classified into three subtypes (Edlund et al., 2006):
Delirium is often distinguished from dementia by virtue of its acute course and reversibility but, as Meagher (2001) points out, the boundary between delirium and dementia can be blurry, particularly where a person has ‘comorbidities, a prolonged delirious state, Lewy body dementia (with its fluctuating course and symptoms that frequently include psychosis), and delirium symptoms that persist beyond the acute treatment phase’. Nevertheless, it is important for us to remember that ‘the presentation of delirium is the same regardless of whether dementia is present because symptoms of delirium will dominate when they co-occur’ (Meagher, 2001).
Rather than relying on medications and/or constraints, clinicians should communicate effectively as this is critical to recognising and responding to someone with cognitive impairment. In particular clinicians need to be aware of and attuned to the possibility of the presence of hypoactive (latent) delirium.
Furthermore, we need to attend to what Hutchinson and Brawer (2011) describe as analogic communication. Analogic communication refers to all embodied communication, including non-verbal cues (Hutchinson & Brawer, 2011). Patients or residents may display through analogic communication that they are uncomfortable, such as by a worried expression or nervous movements. In particular, attention to environmental factors that could be exacerbating delirium is important. Examples are sensory deprivation (for example, a windowless room) or sensory overload (for example, too much noise and activity); isolation from family and friends; absence of familiar objects around the person; frequency of room changes; and, perhaps most frequently overlooked, whether the person has visual or hearing aids and whether they are in place (Meagher, 2001).
Communication with people experiencing cognitive impairment can be challenging. The very nature of cognitive impairment is that the deficit to mental functioning makes it difficult for the person to relate to others in terms of articulating meanings and interpreting what is being communicated. Yet communication is vital to ensuring safe, quality care that meets the individual needs of a person. You need to be acutely aware of what and how you are communicating and how the cognitively impaired person could receive your communication and, in turn, respond to you and others. We consider these issues later in the chapter. First, let’s turn to a practice example to orient our subsequent discussion about communication approaches and strategies.
Tom (79 years old) was diagnosed with Alzheimer’s disease a couple of years ago. He lives at home with his wife, Betty. Following a visit to the GP, he was admitted to the local hospital. Tom, an extremely tall man, has been finding it difficult to get comfortable in the hospital bed. Since admission, four days ago, he has been pacing up and down the ward a lot, even though he is very tired. He has been causing the nursing staff some concern.
For example, Tom stares at people fiercely, which they find intimidating. He suddenly shouts at other people as they walk across his line of sight, pointing and giving them a ‘look of disgust’. Yet, when the ward gets really busy, he just sits in the chair beside the nurses’ station, turning the pages of the various magazines and newspapers from a table nearby.
Every once in a while he tears a piece of paper from what he is looking at and jumps up from the chair and tries to give it to staff passing by, insisting that they take it. When they refuse or say they will look later, he gets very upset.
On his second day in the hospital, Tom started rearranging things in the ward. He moved a television to face a different way and moved chairs from people’s besides and lined them up along the corridor. Tom has been refusing to comply with requests specific to personal care routines and eating. Because he has been sitting near the nurses’ station at meal times, one registered nurse had his breakfast put on a table in front of him there but when they came to take the tray, he had barely touched it. He did keep his cup of tea and finished it.
Yesterday, he hit out at nursing staff who were trying to get him to put clean pyjamas on. When his wife came to visit later in the day, she had no difficulties getting him to put clean pyjamas on, with some prompting on what to do and minor assistance with the buttons on the top. Although no assessment of his behaviour has been completed, ward staff have noted on his medical record that he is ‘agitated and aggressive’.
Analysis and reflection
The hospital environment presents a daunting, unfamiliar world to the person with dementia and is generally over-stimulating, frustrating and confusing. For staff charged with delivering care in the acute setting, people with dementia present significant challenges which usual workplace routines are ill-equipped to accommodate. In the scenario in practice example 9.1, the experiences of Tom and the staff exemplify these problems.
Often, nursing staff are frustrated by having to manage patients who are aggressive, and believe that they could be doing more important tasks (Moyle et al., 2010). These are the very staff often displaying negative attitudes towards people with dementia. Just as worrying is that senior staff often express concern about how patient’s cognitive challenges impede the delivery of technical aspects of care (Moyle, 2010).
To address patients’ agitation and aggression, nursing staff often request pharmacological interventions; that is, they drug patients (Weitzel et al., 2010). However, people with dementia are at higher risk of potentially serious adverse effects from antipsychotic medication, making it a poor course of action, and one which can often promote further behavioural and clinical issues (Banerjee, 2009). When patients are aggressive, they are often restrained – this can further exacerbate the aggression. Even when staff have strong reservations about using restraints, the culture of work and organisational policies may lead them to initiate the use of restraints (Ludwick, O’ Toole & Meehan, 2012).
Therefore, being formally identified as agitated and aggressive does not bode well for Tom. Consider for a moment the situation from Tom’s perspective. As a person with dementia, he may be struggling to understand the ward environment or to verbally express his thoughts and feelings. He may be experiencing some of the effects of dementia, such as a decreased attention span, impaired judgment, decreased insight and diminishing visual and spatial abilities. The behaviours associated with dementia should be first considered as a form of communication – communication of an unmet need.
Unfortunately, patients’ unmet needs are commonly overlooked as part of clinical assessment. The usual practice in any healthcare setting is to collect information and then make a judgment based on that information – this is clinical assessment. Using a commonsense label (‘aggressive’) to describe patients’ behaviour in formal documentation is not assessment. On the contrary, such labelling is likely to promote adverse behaviours in colleagues and invite avoidable negative outcomes.
When a person is struggling to understand what is going on around them, they will feel vulnerable. When they express that vulnerability in ways that are not the norm, this is because they are ill and likely suffering from cognitive impairment. To classify patients on the basis of such behaviours and risk stigmatisation of the patient is unprofessional.
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