Communication, activities help dementia patients

Staff training improves satisfaction as well as care

The challenges of caring for a patient with dementia differ from patient to patient because the symptoms vary greatly between patients. There are, however, ways to communicate and methods to employ that enable patients to retain or enhance abilities and experience less agitation.

"First, we need to remember that dementia is a cluster of symptoms, not just one disease," says Nancy Ledoux, MDiv, chaplain at Hospice Care in Stoneham, MA.

Dementia is characterized by memory loss, confusion, and impaired judgment, but can be caused by a multitude of illnesses such as Parkinson’s disease, multiple strokes, and Huntington’s disease, she says. "Of course, the greatest cause of dementia is Alzheimer’s disease, which accounts for 75% of all dementias," she adds.

Because certain medications and depression can increase confusion in patients, be sure to evaluate the patient’s medications and emotional state before assuming all of the symptoms are attributable to dementia, Ledoux says. Sometimes, minor changes in medication can improve their cognitive function, she adds.

"Although memory deficit is a hallmark of dementia, I don’t believe it is the main challenge we face in caring for patients," says Jan McGillick, MA, senior director of education and outreach for the Alzheimer’s Association of St. Louis. The greatest challenge is learning to communicate in a manner that doesn’t upset or further disorient the patient, she says.

Ledoux agrees. "You have to recognize that the patient has lost some of the capacity for reasoning and communicating that we take for granted. We have to figure out how to communicate in a manner that makes sense to them.

"It’s important to relate to a dementia patient on an emotional level," she points out. "Approach the patient in a happy manner. Even if you’re having a bad day, don’t let the patient see that you’re worried or distracted." The content of your greeting and conversation is less important than the tone of voice and body language you display, she adds.

For example, move slowly and smile, Ledoux suggests. "Always introduce yourself and schmooze a little before taking out the stethoscope. You can comment on the weather or talk about a photograph on a nearby table," she says.

"Even after you begin taking vital signs, go slowly and explain exactly what is going to happen. I know one nurse who places the stethoscope on her chest first to show the patient what she is going to do," she explains.

"Plan extra time with a dementia patient," says Ledoux. If you can take time to keep the encounter calm and nonthreatening, the patient will benefit throughout the entire day, she says. "Even if the patient cannot remember what you discussed or what you did, the patient will remember the calm, reassuring environment you created.

"You need to stop what you’re doing if you notice the patient becoming agitated. Tell the patient that you’re sorry and didn’t mean to upset anyone, and then say that we’ll just do this another time," she suggests.

Montessori activities improve interaction

Home health aides have an opportunity to make a big difference in a dementia patient’s condition, says Kathy Kaiser, RN, BSN, administrator of Menorah Park Home Health Care Services in Beachwood, OH.

A research program that has studied the effect of Montessori-based activities on nursing home patients with memory loss was expanded into the home health arena last year. 

The research is conducted by the Beachwood, OH-based Myers Research Institute, with a grant from the Wolf Family Foundation in London, Ontario, with Menorah Park home health aides and patients.

"We found a 10% increase in a patient’s pleasure and a 20% increase in constructive engagement when Montessori-based activities are used during an aide’s time with the patient," Kaiser says.

At the same time, there was a 3% decrease in patient anxiety. The decrease in anxiety is attributable both to the patient’s involvement in an activity and the ability of the aide to cope better with dementia patients as a result of the training aides receive in the program, she adds.

Because the Montessori method is based on teaching skills in a sequential manner with each component of the activity practiced one component at a time, the activity can be as simple or as complex as the patient can handle, Kaiser says.

All of the activities are designed to improve the patient’s ability to handle normal activities of daily living, even if at first glance, the activities don’t seem to relate to actions such as buttoning shirts, says Gregg Gorzelle, research analyst and project manager for the Montessori program. For example, activities such as stringing beads, lacing, and cutting paper promote use of fine motor skills that can translate to buttoning a blouse.

One of the most beneficial aspects of incorporating these activities into an aide’s interaction with the patient is the social aspect of the aide’s time with the patient, Kaiser says. "Our research shows that the patient is more engaged and less agitated when the aide spends time interacting with the patient," she adds.

The interaction needs to be nonthreatening, and geared toward the patient’s abilities, McGillick points out. You also should speak precisely, she adds.

"Don’t use pronouns or abstract words. [For example, say], Your husband gets home at 4 p.m.,’ rather than He gets home later,’" she says.

Avoid asking questions that make the patient feel as if he or she must make a decision, McGillick suggests. "Rather than asking the patient if he or she thinks it’s a good day to take a walk, just state that it is a good day to take a walk," she says.

Scrapbooks or coffee-table books with big pictures can be good conversation stimulators, she says. Memory books in which the aide helps the patient create a scrapbook of his or her life also is helpful. "Ask the family for basic information to get started and then add to the story with the help of the patient."

By talking with the patient about memories of parents, childhood events, spouse, and children, the aide can engage the patient in a pleasant activity that keeps the patient engaged, McGillick adds.

Questions asked during this conversation should be phrased to elicit more than yes or no answers, she points out. For example, ask, "How did you meet your husband?" rather than, "Did you meet your husband at a friend’s house?"

At Menorah Park Home Health Care, aides who are chosen for the program attend four one-hour training sessions where they learn about basic dementia-care topics, coping skills, Montessori methods, and hands-on applications, Gorzelle says. Aides with the special dementia-care training do receive additional pay as part of their advancement on their career ladder, he says.

Although the financial incentive is appreciated, the aides are most satisfied with the additional knowledge they gain and their increased confidence that they can provide good care, he adds. Because it’s hard to find and keep good home health aides, this program is one more way to improve retention and attract good employees, he points out.

"I would hand-pick the aides to go into this program," Kaiser says. The criteria should include maturity, caring attitude, initiative, few discipline problems, and longevity with the agency, she says.

Kaiser includes longevity as program criteria, because the agency is investing time and money to train the aide and wants to make sure the aide stays for a while.

At this time, Menorah Park is offering the program only to private-duty patients, and there is no charge, Kaiser says. "We are looking at a charge structure that might be $1 to $3 more per hour," she says.

Family members also are very pleased with the program, she says. "They see the aide doing something with the patient, and they notice the patient’s decreased agitation."

One family that especially is pleased is a son and his second wife who live across the street from the patient, Kaiser says. "Instead of recognizing the second wife as a wife, the patient referred to her as that hussy,’" she says. "After using the memory book to look at pictures of the wedding and talk about the daughter-in-law, the aide was able to help the patient recognize and accept the woman as her son’s wife."

[For more information, contact:

  • Nancy Ledoux, MDiv, Chaplain, Hospice Care, 41 Montvale Ave., Stoneham, MA 02180. Telephone: (781) 279-7122. E-mail: ledouxnancy@cs.com.
  • Jan McGillick, MA, Senior Director of Education and Outreach, Alzheimer’s Association of St. Louis, 9374 Olive Blvd, St. Louis, MO 63132. Telephone: (800) 980-9080 or (314) 432-3422. Web site: www.alzstl.org.
  • Kathy Kaiser, RN, BSN, Administrator, Menorah Park Home Health Care Services, 27100 Cedar Road, Beachwood, OH 44122. Telephone: (216) 595-7333. E-mail: kkaiser@menorahpark.org.
  • Myers Research Institute, 27100 Cedar Road, Beachwood, OH 33122. Telephone: (212) 360-8212. Web site: www.myersresearch.org. The institute publishes Montessori-based Activities for Persons with Dementia, a guide to implementing a program within a nursing home. Although the book is geared toward nursing home patients, the many activities described in the program can easily be adapted to home health.]