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 among 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, and 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 depression and certain medications 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 patients’ 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.

Health care workers who visit patients at home 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 being conducted with Menorah Park home health aides and patients by the Beachwood, OH-based Myers Research Institute, with a grant from the Wolf Family Foundation in London, Ontario.

"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 in tone 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 are 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 special dementia-care training receive additional pay as part of their advancement on their career ladder, he says.

Kaiser includes employee longevity as a program criterion 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.