2.1. Effective communication.

        How do I communicate with impaired elders? As a personal caregiver you may provide care to a client who has physical disabilities or impairments that may interfere with communication. The following are some techniques to use in those situations.

Blind or Visually Impaired Elder

• Get the person attention before talking.
• Identify yourself when entering the room.
• Say their name.
• Use common sounds, such as ringing a bell, whistling, etc.
•  Explain what you are doing as you do it.
•  Ask for feedback to check for understanding.
•  Make sure eyeglasses have up-to-date prescriptions and are clean.
•  Print in big, bold letters when necessary.

Deaf or Hearing Impaired Elder

• Make sure you face the client who reads lips.
• Use visual actions to communicate.
• Get their attention before talking to them.
•  Face them when you are talking. Maintain eye contact; avoid turning or looking away while you are talking.
•  Talk at a normal pace.
•  Raise your voice some and lower your tone. DON’T yell. Speak to the side where hearing is best.
• If necessary, use paper and pencil to write messages.
•  Get rid of other noises – TV, radio, etc.
•  Make sure hearing aides are working and are properly inserted.
•  Write down messages.
• Ask for feedback to determine understanding.

Speech Impaired, Aphasic Elder (Aphasia-Trouble speaking or understanding, often result of a stroke)

• Address the person by name.
• Keep communication simple and clear. Speak slowly and use simple words.
• Ask questions that can be answered with yes or no.
• Make message clear, emphasizing key words, limiting details.
• Eliminate unnecessary background noises (to help the client concentrate on what is being said).
• Be patient. Give the client enough time to respond to you. At least 10 seconds is the recommendation. (Time yourself for 10 seconds so you can see how long it is. You’ll be surprised!)
• Use visual devices like a message board, pictures, or gestures.
• Be supportive and positive, avoiding criticism/corrections.
• Pay attention to body language
• Ask the person to repeat if necessary, rather than pretending you understand.

Guidelines for communicating with the cognitively impaired client

Communication with the Cognitively-Impaired Client:

COGNITIVE: 

DEMENTIA IMPAIRED

        What is dementia? Dementia is a gradual decline in mental and social functioning compared to an individual’s previous level of functioning. A client may have memory loss, personality change, behavior problems, and loss of judgment, learning ability, attention and orientation to time and place and to oneself. Alzheimer’s disease is the most common cause of dementia, and we will spend more time on this as it will likely be one of the more frequent causes of cognitive impairment of residents in your facility.

        Alzheimer’s disease is a chronic, progressive debilitating illness. At first the symptoms are mild and might include difficulty remembering names and recent events, showing poor judgment and having a hard time learning new information. At this early stage the person often tries to deny their problems. Most difficulties at this time are with performing IADLs.

        As the disease progresses, the person is unable to judge between safe and unsafe conditions and will need help to dress, eat, bathe and make decisions. There may be personality changes such as increased suspiciousness. Unfamiliar people, places and activities can cause confusion and stress. The person shows less interest in others and wants to withdraw to familiar, predictable surroundings and routines. The person in later stages has difficulty performing basic ADLs.

        Some common behaviors associated with Alzheimer’s disease are rapid mood changes, crying, anger, pacing, wandering, doing things over and over, asking the same question, following people closely and inappropriate sexual behaviors.

        Cognitive impairment refers to difficulty in processing information. There are numerous diseases that cause cognitive impairment, such as Alzheimer’s, Parkinson’s, Multi-Infarct Dementia, and AIDS. All of these diseases affect the brain in different ways to cause the impairment. Care recipients with any of these conditions will require unique caregiving in order to deal with some of the problems present. The symptoms presented will vary from person to person and will depend on the stage of the disease. Some of the common symptoms associated with dementia are as follows, with some examples:

• Gradual memory loss
• Inability to perform routine tasks–dressing, cooking, cleaning
• Disorientation in time and space – don’t know what day it is or where they are
• Personality changes
• Unable to learn new information
• Judgment is impaired – doesn’t know if something is safe or is unable to make choices
• Loss of language skills – can’t remember words, etc.

        Much of the time care recipients with cognitive impairment do not know what they are doing or saying. They have little control over thoughts or behavior. You usually cannot change the care recipient and, instead, must change how you react. This is the most important thing to remember.

• The care recipient is not asking you the same question over and over and over to annoy you.
• The care recipient does not remember and that is why the question is repeated.

        Continue to answer the questions. Look for possible reasons for the repeated questions, such as the need for reassurance, acceptance, or love. Another way to look at this type of behavior is this – to the care recipient, there is no past and no future, but only the immediate present.

        Cognitive impairment (cognition means of or relating to conscious thinking) is a term that simply means someone has lost a large amount of his/her higher intellectual ability. What do we mean when we use the term higher intellectual ability? We mean the ability to think and reason, the ability to use logic. We mean the ability to communicate and the power of memory. We mean all of the mental capacity that we need in order to function as human beings in our daily lives People with cognitive impairment have difficulty in communicating. They have difficulty in understanding what is said to them. They can, at times, become confused about whom you are, and they can be confused about who they are. They can be confused about where they are, what day of the week it is, and what year it is. People who suffer from cognitive impairment do not have the ability to think clearly and logically or they may only be able to do so once in a while. There is no one single condition, illness, or disease that causes cognitive impairment. People with cognitive impairment may have had a stroke, they may be suffering from Alzheimer’s disease, they may have had a head injury, or it may not be known why they have lost the ability to be rational. The only certainty is that there has been some illness, disease or accident that has permanently damaged the parts of the brain that control the ability to think, concentrate, and reason.

        Although many people with cognitive impairment are elderly, being old does not always mean that someone has a diminished mental capacity. But regardless of why your clients have cognitive impairment, coping with this situation can be very difficult. It takes patience and compassion. Above all, as a health care professional, you must remember that these patients do not have the ability to function and think as you do. We use our powers of thought, concentration, memory, logic, and language to cope with the world around us. For these people, those skills are absent or severely damaged. As a result, they cannot understand what they see and what you say. Many times, this will leave them frightened and confused. And more importantly, it leaves them dependent on you as a professional.

        And the confusion and difficulty in communicating with these clients can be quite frustrating. So, make no mistake about it: working with a client who has a significant degree of cognitive impairment can often be very difficult. However, it is important to realize that these interactions are a two-way street; the situation is difficult for the client, as well. So when you are caring for someone who is confused, uncooperative – perhaps even aggressive – it is absolutely natural to feel frustrated. But remember: the client is doing the best he/she can and their feelings of confusion and fear are probably just as intense as your feelings of frustration.

        A PRACTICAL APPROACH TO WORKING WITH CLIENTS WHO HAVE COGNITIVE IMPAIRMENT fortunately, with the proper attitude and some simple techniques, working with in these situations doesn’t have to be painful for you or your clients. Here are some basic tools that can help you when you are working with a client who has cognitive impairment.

        Patience: You will need a lot of patience. The natural instinct when interacting with another adult is to assume that he/she is at your level of emotional and intellectual ability. This is not true of the client with cognitive impairment. This is a simple idea to understand, but many people have difficulty remembering this.

        Non-verbal communication: Most of us think of communication as what we say or the words we use. But much of our communication is non-verbal. The tone of your voice, the loudness or softness of your speech, the speed at which you talk, the way you stand, and where you stand when you speak to someone – all of these are forms of non-verbal communication. People with cognitive impairment may have lost the ability on an intellectual level to understand what you are saying. But their other senses are completely intact. They will, often, respond to how you speak to them rather than what you are saying. It is often best to stand where the person can easily see you. Making eye contact is important. Avoid touching the person until you are sure he/she won’t feel threatened by physical contact. Never pull or yank on someone if you want that person to move, change positions, stand up, etc. When you first approach someone, try and do so slowly; don’t rush at them.

        Verbal communication: You don’t have to be talk down to these people. However, until you have established otherwise, it is sensible to be gentle when talking to these clients. Speak slowly and clearly. Try and keep your language at a basic level. Give them time to process what you are saying, and try and remember that it may take them far longer than you imagine to completely grasp the meaning of what you have said. It also helps to keep your communication simple and direct. Don’t be afraid to repeat what you have said, and don’t be surprised or frustrated if you have to. And don’t forget: although you may remember something that was said to you earlier in the day or earlier in the week, these clients may forget something that was said to them just an hour ago. Constant repetition and reinforcement will help clients to remember. Do not speak quickly, and make sure that you use simple language…

        Flexibility: Perhaps nothing is more important when working with a client who has cognitive impairment than flexibility (And the opposite is also true: nothing is more harmful when working with these clients than being stubborn or rigid). What do we mean when we use the term flexible? It means simply that you adjust to the demands of the situation. It means that you are able to change your plans. It means that you realize what is/isn’t important, and that you know that getting the task done is far more important than how you do it.

        Priority setting: All too often, health care professionals see their job as a series of tasks that need to be accomplished. That is true, but working with people is very complex. Many times it is simply not possible to do everything you need to do and want to do in the way you want to and when you want to. Situations change and people change. If you are not able to clearly see what, at any given time, is the most important priority, your job will be very difficult. Ask any experienced health care professional and he/she will tell you: in order to function efficiently, it is very important to know and decide what is most important, but you also need the ability to see that the situation has changed and to understand that a new, more important priority has replaced the previous one.

        Regular routines: Because the person with cognitive impairment has difficulty remembering people, places, and situations, he/she can be helped by establishing reliable routines. If it is possible, try and arrange for the same PCW to work with the same clients. Try and find a routine for daily activities that is simple, does not change, and will be easy to remember for the client. Be careful to slowly introduce changes into the client’s daily routine, and try and explain these changes as clearly as possible. And if you tell the client that you are going to do something, make sure that you follow through on your promise. The client may surprise you by remembering what you said (e.g., you will in his/her home at 9 in the morning to help them get dressed) and may become disoriented if you do not keep your word. Example: Imagine that you need to assist a client in getting out of bed and getting dressed. You are very busy and you have a lot of other things you need to do for other clients, as well. But the client you are working with is resisting all of your efforts. He doesn’t want to get up, and he doesn’t want to get dressed. You can’t understand why, and he can’t tell you. You can try and force the issue, but when you do, he begins to get agitated. You need to determine what the most important priority is, and what the best way to accomplish that goal is. Perhaps in this situation you have more time than you think. You might be able to sit quietly with this person for a bit and give the person a few minutes in which to adjust. Perhaps you can accomplish the task in steps; this will also give the client time to adjust. Also, you might be able to move to another task with another client. It may not be important – really important – that the client get dressed right at that time you had planned. Always ask yourself: Can you change your priorities to make your day and the clients run a bit smoother?