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Hartford Foundation Institute for Geriatric Nursing and the Alzheimer's Association. PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the inte d 33rnet at www.hartfordign.org . E-mail notification of usage to: hartford.ign@nyu.edu. 33U33ddd9d633-q.+ *+W7,FURTHER READING,urther Reading on this Topic$NN.PPR`  pTry This Dementia Series Volume 1, Number 7, Fall 2004 Series Editor: Marie Boltz, APRN, MSN, GNP Communication Difficulties: Assessment and Interventions By: Della Frazier-Rios, RN, MS and Cora Zembrzuski, APRN, MSN, CS, PhD (cand.) WHY: Dementia impairs a persons ability to communicate effectively. It reduces the ability to: decode and understand information (receptive language) the ability to encode and therefore express information (expressive language). Ability to mediate actions through internal speech is also reduced, thus decreasing the persons capacity to plan and problem-solve. These language deficits are compounded by other dementia-related impairments including: memory loss decreased attention span impairments in judgment insight abstraction visuospatial abilities. The combination of language deficits and other dementia-related impairments results in serious communication difficulties for older adults with dementia. The hospital setting, with its unfamiliar faces and routines, and the effects of acute illness, often exacerbate these difficulties. As a result, hospitalized older adults with dementia may be unable to: understand explanations follow directions report symptoms and needs ask for help develop and maintain relationships with staff that would support their acceptance and cooperation with treatment and care. These problems have profound implications for patient care and outcomes. TARGET POPULATION: Hospitalized older adults with diagnosed or suspected dementia, many of whom also have vision and hearing losses, depression, and other acute and chronic medical conditions. BEST PRACTICES: Because the patients language deficits and other cognitive impairments are caused by his or her dementia, responsibility to facilitate communication lies with the clinician. Awareness of the kinds of language deficits that are common in dementia will help with this task. The impact of dementia on language abilities varies greatly, however, from one person to another. Thus, an assessment of the persons particular deficits and communication patterns is essential. This assessment is based on observation and history obtained from the patient when possible and the family, if any. Findings from the assessment will help the clinician structure interactions with the patient in such a way as to: compensate for language and other impairments support retained abilities facilitate understanding In addition to assessing the patients language deficits and communication patterns, the clinician should gather other information about the patient that will help staff: communicate in a relevant way interpret unclear verbalizations anticipate needs. Such information includes: patients preferred name the names of close relatives daily routine, including eating, sleeping, activity, and toileting patterns upsetting situations potentially calming interventions, and sources of comfort and reassurance. The patients family and significant others are the best source for this information. For persons with dementia, behavior is frequently a form of communication. Non-verbal behaviors, such as: agitation restlessness aggression combativeness are often an expression of unmet needs (e.g. pain, hunger, thirst, or toileting need). Repetitive vocalizations and changes in tone, urgency, or rapidity of speech can signify unmet needs, even if the specific verbalizations are meaningless. Clinicians should try to interpret the meaning of these behaviors rather than dismissing them as symptoms of the dementia. TOOLS to Assess Language Deficits and Facilitate Communication: Assessment of specific receptive and expressive language abilities is needed in order to understand the patients communication difficulties and facilitate communication. ASSESS RECEPTIVE Abilities Facilitate Communication by: Can the patient understand a yes/no choice? Ask simple, direct questions that require only a yes or no response. Can the patient read simple instructions?Provide instructions in a place that is easily visible to the patient.Can the patient understand simple verbal instructions? Use short, simple sentences. Use one-step instructions to enhance the individuals ability to process, e.g. its time to wash (smile;pause) Avoid slang, idioms, nuances.Can the patient understand instructions given with physical cues?Use gestures. Model the desired behavior (e.g., eating). Be sensitive to the fact that although the person may not understand words, he/she often can read your body language, sincerity, and mood.Can the patient make a choice when presented with two objects or options?Limit choices too many options will cause confusion and frustration. ASSESS EXPRESSIVE Abilities Facilitate Communication by: Does the patient have difficulty finding the correct word?If you are sure of the word the person is trying to say, repeat it. If not sure, dont guess because that will increase persons confusion and frustration.Does the patient use metaphorical speech?Dont correct. Validate by encouraging patient to express feelings. Ask family members about possible meanings.Does the patient have difficulty creating sentences or a logical flow of ideas? Listen for meaningful words and ideas. Try to identify key thoughts/ ideas. Do not dismiss person as totally confused.Does the patient curse, use offensive or aggressive language, or exhibit aggressive or combative behaviors?Dont reprimand. React to emotion not words Validate feelings. Assess for unmet needs, such as those related to: pain hunger thirst toileting misperceived threats, etc.Does the patient avoid verbalization altogether or mutter meaninglessly in various tones? Read nonverbal communication. Anticipate needs. General Communication Tips: If the patients primary language is not English, determine whether he or she can communicate more effectively in that language; ask the family; and use an interpreter if necessary. Identify hearing and vision impairments; ask about prior use of assistive devices (hearing aids and glasses) and assure use of these devices in the hospital. Reduce environmental distractions that compete for attention when conversing with the patient. Approach from the front, make eye contact, address the person by name, and speak in a calm voice. Talk first; pause; touch second, reducing the persons sense of threat. Avoid verbal testing or questioning beyond the persons capacity. Avoid use of the in-room intercom which may confuse and frighten the patient. Do not argue or insist that the patient accept your reality. Be aware of memory impairments in addition to communication difficulties: for example, if a patients short-term memory is less than a few minutes:, it is dangerous to leave the patient alone even if he or she seems to understand the direction, wait here likewise, it is unwise to expect the patient to use a call light to get help. For patients with very impaired short-term memory, each encounter with a staff member may be perceived as the first encounter, even if the staff member just left the room and returned a few minutes later. Try This Dementia Series is developed by the John A. Hartford Foundation Institute for Geriatric Nursing and the Alzheimer's Association. PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu. Further Reading on this Topic Alzheimer's Association. (2000). Day to Day Care: Communication. Available at: http://www.alz.org/Care/DaytoDay/communication.asp Feil N, and DeKlerk-Rubin V. (2002). The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimers Type Dementia, 2nd edition. (Baltimore: Health Professions Press). North Carolina Department of Health and Human Services, Division on Aging. (2000). Acute hospitalization and Alzheimers disease: A special kind of care. Available at: www.dhhs.state.nc.us/aging/alzbook.pdf. Small JA, and Gutman G. (2002). Recommended and reported use of communication strategies in Alzheimer caregiving. Alzheimer Disease and Associated Disorders. 16(4):270-278. Small JA, Geldart K, and Gutman G. (2000). 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