The patient with dementia: Communication tips | Geeky Medics

3/4/15, 7:20 PM

THE PATIENT WITH DEMENTIA: COMMUNICATION

TIPS
Having to communicate with patients with dementia and/or other cognitive impairment
is not just something that will be encountered on an elderly ward or in long-term care
facilities. People with dementia get acutely ill too, and can be in A&E, a GP surgery or
any ward. Being able to get the most out of communication is of upmost importance,
both to the patient and to you.
Get worried about having to take the history? Dodge the patient in the corridor?
Flounder about correcting? Not sure how to attempt to diffuse situations with confused
patients? This post is for you. There is no perfect walkthrough way to communicate to
every patient, but we have some tips.
WARNING: reading this article & considering these tips may seriously affect your
communication skills.
Redirection instead of correction
This is something I know a lot of people (myself included) struggle with.
When a patient is talking about something you know cannot be true:
Do you agree with them?
Do you try to correct them?
The best answer here is a fairly unhelpful Try to do neither.
Heres a scenario..
Mrs Jones is an 82-year old lady with moderate/severe Alzheimers but little other
medical history. She has been on the ward for 3 days, being treated for a lower
respiratory tract infection. She is wandering through the ward and looks upset.

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The patient with dementia: Communication tips | Geeky Medics

3/4/15, 7:20 PM

You: Hello, Mrs Jones. My name is . and Im [insert role here]. Is

everything okay?
Patient: No, no love. I have to find my parents. They dont know where I
am and theyll be worried. I need to let them know that Im here and
getting better.
There are several ways to respond to this. It is improbable (but not impossible!) that Mrs
Jones parents are alive and wondering where she is. Correcting Mrs Jones and
attempting to orientate her to time and place may cause her to become more upset and
angry. Lying to Mrs Jones is not ethical, nor is it helpful to collude with the patient.
Perhaps a helpful approach in this situation would be to try to reassure Mrs Jones that
you will ensure the necessary people will be informed.
For example:
I can see youre quite upset, but try not to worry. Your family know where you are
and that you are safe. I can get the nurses to give your family a call if youd like. Who is
in your family?
In this response you havent lied to the patient or colluded with them. Redirection in this
sense is a good way to move the conversation on, and avoid distress for the patient (and
avoid frustration for yourself!)
Also, see the point on Validation later on.
Patients with dementia are patients too
These are things which should be done with every patient..but have even
greater importance in the confused patient.
Hello, my name is and I am [role] is missed worryingly often. In the
references Ive included information on Dr Kate Grangers Hello my name is
campaign. If you havent read it, I really, really, really recommend you do!
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Find out the patients preferred name. Use it. It often helps to start more formal.
Approach patients from in front whenever possible, to reduce the chance of
startling them. These are often patients who are not only confused, but also
have some visual & hearing impairment. If I was anxious and confused and
someone crept up on me, I reckon Id get angry!
Try to be on a comfortable level for both of you: some people can be patronised by
having people kneel or sit beside them, many people find it respectful. Whichever
feels most natural at the time and with the patient, eye-contact is even more
important in a confused patient. Be aware that standing over someone can seem
very threatening!
Patience with your patients

try not to interrupt (but steer the conversation when

its your turn!)

Minimise the number of distractions/other sensory stimuli.
Give the patient the best chance they can of understanding you: glasses, hearing
aids, pain-free?
Do what is natural for you. Some of the tips below contain things that might not
feel right for you (some people are feelings types and some people not so much).
Do what feels natural, and try not to force it
Consistency
Consistent schedules, nursing and communication can help to keep a patient calm.
Keep conversation simple
This may seem a bit patronising, but I can rattle off a good few occasions where I have
spoken quickly, used words that may be unfamiliar to a patient and asked about 6
questions in one. So give people time to process what youre saying. Use familiar words.
Refer to things/people by name if you can, rather than him/her/that. One question at a
time, one decision at a time. Choice is incredibly important, but too many options can
overwhelm!

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The patient with dementia: Communication tips | Geeky Medics

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Would you like cereal or toast?Hot or cold?Rice crispies or

cornflakes? is much easier to take than For breakfast do you want toast with
jam, or just toast, or porridge or rice crispies or weetabix or cornflakes?
And do you want a tea or a coffee or some juice too?
Similar rules apply when taking a history one thing at a time, rather than Any
heart disease, lung disease or diabetes?
Non-verbal communication
Often, as dementia progresses a persons verbal communication skills deteriorate.
Patients with dementia can be more sensitive to the body language of others, so moving
suddenly/unexpectedly is best avoided. Try to make sure your body language reflects
what youre saying.
Talking to people who know the patient well (nursing staff, relatives, friends) can be
useful in discovering how they react to different types of stimuli and how best to
approach communicating with them.
A good collateral history
A great deal of knowledge can be gained from those who care for a patient with more
severe stages of dementia. Knowledge of what behaviour is normal (fidgeting, certain
conversational habits), and knowing responses to pain should be paramount to any
healthcare professional in terms of understanding your patient and allowing them to get
the best care possible. Carers can usually offer tips on coping with a persons individual
behaviour, helping to identify triggers and reassurance techniques.
Avoid a large volume of direct questions
Do you know who this is?, Do you know who I am? outside of an AMT
(abbreviated mental test) or other cognitive testing these type of questions are best
avoided. Direct questions such as this can be very upsetting and frustrating to patients if
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they cant answer. This goes back to the idea of giving choices rather than complex
questions. If you can use visual cues, even better.
Validation and re-iteration
Acknowledge what the person has said to you, even if it seemingly has no relevance to
what you asked. If a person isnt understanding the language you use (and its that and
not a hearing issue!) try to rephrase or ask something in a different way.
Use visual cues - holding a cup when asking if they want tea or coffee, putting your
hand to your chest when asking about chest pain/heart attacks/other medical history
etc.
Validation involves addressing the emotions behind what is being said rather than
focussing on factual accuracy of the persons thought.
If a patient is talking about being at work, instead of telling them theyre in hospital not
at work, try asking about their work life. Where have they worked at? What have they
done for jobs? Did they get tea breaks? Tapping in to pleasant memories can also serve
to calm as well as redirect, as can discussing something that can then happen (for
example the cup of tea!).
This can validate the persons feelings and redirect them, rather than trying to reorient
them to our reality.
Positive rather than negative
Imagine this.
You are sat in front of a red button and a blue button.
Every time you stand up, youre sat back down by someone with no reason.
Every time someone passes you or engages with you, all they keep saying to you is
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Dont stand up. Dont press the blue button..

I bet youre thinking about standing up and the blue button?
Again, with redirection

Changing Dont leave the bay! to Lets sit down here

for a little while. can do the trick.

Physical touch
Use physical contact to communicate your care and affection, and to provide
reassurance dont underestimate the reassurance you can give by holding or patting
the persons hand or putting your arm around them, if it feels right.
Remain aware of socio-cultural issues!
Talking to the non-verbal patient
Just because a patient themselves can not verbalise, doesnt mean you should refrain
from talking to them. Letting the person know of the plans can be reassuring if they can
understand, and listening to a kind reassuring voice (even if the words arent
understood) can allay anxiety. A lot of this is also very dependent on what you feel
comfortable doing as a person.
Challenging Behaviour
This in itself could be a whole article for me! Im a big believer that Challenging
behaviour is a persons reaction to an unmet need (or needs).
If Im not happy/hungry/need a wee: I tell people, I find out how/where I can satisfy my
want, and I can then go ahead and moan/eat/wee.
If Im trying to talk to someone and theyre just NOT GETTING what Im saying, I get
frustrated.

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If you can no longer communicate your needs effectively, frustration is a natural

response. If you cannot express your frustration effectively this can present as
challenging behaviour.
Some examples
Wandering
Restlessness
Agitation
Incontinence
Perseveration (repetition)
Paranoia
Sleeplessness/sundowning
Hallucinations
Physically or sexually inappropriate behaviour
Try to identify triggers.
Distraction, validation, attempting to understand and meet needs are all
key in reducing these symptoms. Try the VERA approach!
VERA
Validate: acknowledge the persons behaviour as a personal expression, not simply a
symptom of the dementia.
Emotional connection: understand the emotional context behind the behaviour.
Reassurance: Anything from presence and a calming voice, to a gentle hand on their
arm.
Activity: being occupied is a great anxiety-reliever! This can help to reduce agitation
and give the person the feeling of purpose.
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See the VERA Framework in the references for some examples.

References
StarWards () Cambridge University Hospitals NHS Trust, online www.briefencounters.org/patients-with-dementia/
http://hellomynameis.org.uk/ Dr Kate Grangers campaign for better communication
VERA framework communicating with people who have dementia, by Blackhall A et al,
Nursing Standard 26, 10, 35-39
Edward Leigh, How to communicate with patients with dementia, online
http://www.kevinmd.com/blog/2014/10/communicate-patients-dementia.html
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=130

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