Talking to Residents with Dementia

Nursing Assistants (NA) have a difficult but rewarding job, especially in long-term care. The certified nursing assistant (CNA) can work in a nursing home, a hospital, or in-home care. CNAs are the "front-line" workers, giving direct patient care. Because CNAs have such a close, personal relationship with their patients, they form LASTING relationships with both the patient and the family(Ternyak, 2023).

Working with cognitively impaired patients takes a special kind of person. A person with patience, kindness, and understanding. It is not always easy to work with someone who is agitated, angry, or aggressive. The key to working safely is to learn to communicate effectively. You need to know what your residents need and want before they can start "acting out."

CNAs assist residents in doing basic Activities of Daily Living (ADLs). ADLs include bathing, dressing, brushing their hair, mouth care, and eating. When troubled behaviors start, CNAs must learn to control the situation. They need to keep the resident safe using verbal or non-verbal cues. CNAs communicate with many different people during their work hours, including the supervisor, charge nurse, co-workers, physicians, families, and residents (Ternyak, 2023).

Communication is the exchange of information in the form of messages, symbols, thoughts, signs, and opinions (Merriam-Webster, n.d.). There are many different types of communication. Only a few are effective when working with dementia residents (Alzheimer’s Society, 2021; EveryNurse Staff, 2023).

Verbal communication is the most common form to use. It involves the use of words or sounds. It can be spoken or written (Farid et al., 2023). It is important to remember to speak to everyone with kindness, compassion, and respect. Do not yell or speak loudly. Use short sentences so the resident can follow directions more easily. When working with dementia residents, it is the most important part of daily care. Speaking slowly, clearly, and face-to-face is the best way to communicate with dementia residents. Eye contact is very important. The tone of your voice can have an effect on the resident (Alzheimer’s Society, 2021; EveryNurse Staff, 2023; Sharkiya, 2023).

In addition, good listening skills are equally, if not more, important. The CAN may be required to repeat information to ensure that the person with dementia understands what is being said to them. Repetition also helps determine that the CNA understands what the patient is trying to communicate to them (Alzheimer’s Society, 2021; EveryNurse Staff, 2023; Sharkiya, 2023).

Non-verbal communication is the way we communicate without using words (EveryNurse Staff, 2023; Farid et al., 2023). Body language is easy to understand. Anger is very simple to display and hard to control. When assisting a resident, be careful how you stand. Make sure to hold your arms and keep your facial expressions as neutral as you can. If you stand with your arms crossed, you show anger. If you have a frown on your face, you show anger. If you are standing with your hands on your hips, it shows anger. Always be aware of your body language.

Always approach a dementia resident from the front. If you happen to start talking or if you touch them without them seeing you, they may become startled and may try to hit you. Be respectful, and think about the reaction you may cause with your behavior. Identify yourself before speaking and use the resident’s name. This will help spark their memory (Ferman et al., n.d.).

Dementia is a general term that refers to a serious loss of mental abilities such as thinking, remembering, reasoning, and communicating (Alzheimer’s Association, n.d.a.). Alzheimer's is a progressive form of dementia that cannot be reversed. It eventually affects brain functions, erasing memory, communication skills, movement, and behaviors. Alzheimer's residents lose their ability to chew and swallow food. As residents journey through the stages of Alzheimer's disease, they become completely dependent on their caregivers (National Institute on Aging, 2023).

CNAs have to be patient and compassionate while giving care to this special population and remember that they cannot respond like a normal adult. As the disease gets worse, the response of the dementia patient becomes more like an infant. They do not understand what you are saying and cannot communicate what they mean to you. The dementia patient is confused and easily frightened. As dementia gets worse, the resident does not respond to situations with normal social behavior (Alzheimer’s Society, 2021; EveryNurse Staff, 2023; Ferman et al., n.d.).

It is very important to know the different stages of Alzheimer's disease. This allows the CNA to provide better care for the residents. Not all residents have the same signs at the same stage of the disease. One resident may be able to play a musical instrument but not be able to carry on a conversation. Others may be able to read but not to feed themselves. The following chart shows how the resident may change in each stage of Alzheimer's disease (Alzheimer’s Association, n.d.d; Alzheimer’s Society, 2023; National Institute on Aging, 2023).

The CNA needs to pay attention to each stage so communication can continue. In stage 1, the resident may be irritable or make rude comments. You must not take anything the resident says personally. If your feelings get hurt, the resident will notice and continue the rude behavior. In stage 2, a lack of impulse control can make providing care very difficult. Good communication skills involve good listening skills. Look at the resident, see what their body language indicates, and respond calmly and quietly. Do not overreact to impulsive behavior.

As the stages progress, sleep habits change. If the resident is having trouble sleeping, use short "rest" periods during the day and keep the resident busy with activities while awake. It is easier to let the residents sleep whenever they want to, but remember, if they sleep during the day, they will not sleep at night (Alzheimer’s Association, n.d.c).

Sundowning is a special and difficult behavior. It is when the resident gets confused at the end of the day, in the early evening. The cause is unknown, but fatigue may play a factor. A few tips to reduce sundown symptoms include soothing music, keeping the lights on, and having familiar items in the resident's room (Alzheimer’s Society, 2021; Alzheimer’s Association, n.d.b; Ferman et al., n.d.).

Communication is difficult, but if safe approaches are used, the resident will respond better and with less agitation. Always approach the resident from the front, not from the back. Sit or stand right in front of the resident to maintain eye contact. Keep the environment quiet and calm. Turn off the television and radio. This will reduce agitation and allow the resident to better hear and understand what is being said. If the resident is in a noisy area, take the resident to a quiet area. Give the resident time to respond to you.Speak in a calm and gentle tone using short sentences. Use simple words they can understand. Only discuss one topic at a time. Speak in your normal tone of voice; do not shout or yell. Do not use "baby talk," as this may agitate the resident.  Never contradict the resident, as that is a sure way to get into trouble. Arguing only makes the bad behavior worse (Alzheimer’s Society, 2021; EveryNurse Staff, 2023; Ferman, PhD et al., 2020).

When assisting with ADLs, go slowly. Do not expect the resident to agree with all aspects of care. Do not ask the resident if they want a shower, but say, "It is time for your shower now." If the resident refuses, do not argue (EveryNurse Staff, 2023; Ferman, PhD et al., 2020).

Remember to be aware of your body language. It speaks volumes. If you stand in front of the resident with your arms crossed in front of you, the resident may think you are angry. If you have a frown on your face, the resident will respond in kind (Alzheimer’s Society, 2021; EveryNurse Staff, 2023; Ferman, PhD et al., 2020).

The following are some tips from the Alzheimer's Society on how to talk to dementia residents in a safe and efficient manner (Alzheimer's Society, 2021):

• Let the resident know you are listening; turn off the TV
• Keep good eye contact
• Give resident time to answer
• Do not argue or correct
• Focus on feelings, not the facts
• Call resident by name
• Use short, simple words and sentences
• Ask one question at a time

If these simple tips are followed, communication with a dementia resident will be easier. One of the most common mistakes in communicating with elderly/dementia residents is speaking loudly or using "baby talk” or words of endearment such as honey, sweetie, and dearie (Alzheimer’s Association, n.d.-d). It is best to avoid using those terms of endearment. Always treat your residents with respect. Never talk down to them (EveryNurse Staff, 2023).

There are many practical methods to enhance communication between a CNA and an individual with dementia. A recent study reviewed the need for improved communication between patients with dementia and their healthcare staff. In this specific case, these healthcare staff (who had diverse backgrounds in academia, research, and patient-facing roles) were surveyed and identified several key features of improved communication (Collins et al., 2022).

Three key themes emerged. These included:

• Awareness, knowledge, and experience
• Communication approach
• Personalization

All three of these are key to optimizing communication between the healthcare provider and their patient with dementia (Collins et al., 2022).

First, awareness and knowledge of how to interact. This includes being aware of body language, tone, and the actual method of verbally communicating. Without them, it is difficult and frustrating to communicate with another adult who is unable to communicate as expected. Likely it is also frustrating for the person with dementia if they are aware of their deficits. Previous experience is helpful. Knowledge and awareness are not enough to enhance communication. Knowledge must be implemented with lived experience (Collins et al., 2022).

As mentioned above, there are many potential ways in which communication can be modified to make it easier to effectively communicate with a person living with dementia. Whether it be using more direct (but gentle) commands to facilitate task completion or listening more closely and using repetition to make sure that both the CNA and the patient understand the current situation, modified communication tactics can assist the CNA in providing individualized care for their patient with dementia (Collins et al., 2022).

Lastly, personalization is key. Not every dementia person manifests the same symptoms. Some may be withdrawn and “in their own world,” while others may be aggressive and combative. Depression frequently accompanies dementia and may affect how the person with dementia interacts with their caregivers. Different tools can be used to assist with communication. Some people may do well with visual instructions (picture boards). Others may do better with gentle guidance from their caregiver. A relationship needs to be established with the person to ensure they are viewed as more than just the “patient with dementia” (Collins et al., 2022).

It is important to note that communication needs may change over time as the dementia progresses and a person becomes less able to communicate.

Scenario/situation/patient description:

Seventy-three-year-old Bettie is a resident in a long-term care facility. She has been experiencing memory loss for several years and is slowly becoming less able to remember her grandson when he comes to visit her every other day. This is concerning to him because she had been “pretty with it,” based on his description, until recently. Her behavior has become more withdrawn, and she is easily irritated when disturbed. She is able to feed herself without any issues but recently began experiencing incontinence and has been requiring a Depends during the day and night. Lately, she has been sleeping during much of the day, has a very restless and emotional few hours in the early evening, and does not sleep at night. Over the last few weeks, she has also been found wandering the halls.

Intervention/strategies:

Bettie appears to be in the first and transitioning to the second stage of dementia. Her behavioral changes could indicate her frustration with her new level of functioning, although she is likely not to have any control over these behaviors. During times when she appears withdrawn, she should be gently approached and allowed to lead the interaction. If she chooses to talk, the CNA should listen attentively and interact as appropriate. If she does not wish to interact, the CNA could sit with her (if time and workload allow) or leave her to her thoughts while making sure the environment is safe and her needs are met. During times of irritability or emotional distress (early evening), gentle attempts could be made to calm her, but she should not be forcefully reoriented to reality.

Regardless of the current behavioral or emotional state, communication should always be conducted with neutral body language and standing directly in front of the person. “Baby talk” should be avoided, and the conversation should be conducted in a respectful and dignified way.

Her ability to care for herself appears to be somewhat declining. In the case of incontinence, she should be assessed for skin breakdown and provided with the appropriate tools to maintain her independence. This could include the use of Depends and easier access to a restroom, if possible. Her safety is of utmost importance.

Since she has started to wander at night, she should be monitored more closely. This can be done by using a bed alarm, if available, or by providing closer supervision. She could potentially be moved closer to the central hub of the unit, although this may not help with sleep issues if there is noise during the night. Soothing music, dim lights, and a relaxing environment may be the most useful to help her relax and prevent wandering. Again, safety is a top concern.

Discussion of outcomes:

Bettie appears to be moving into the middle stage of dementia. She will continue to worsen as the disease progresses. Early intervention now may help protect both her physical and emotional well-being. Proper communication can enable her to communicate and function to the highest of her ability. While implementing the above interventions may not change her clinical picture, it may help her feel safer and well cared for.

Strengths and weaknesses:

This case study was fairly straightforward, and an intervention was suggested for each symptom. However, each individual with dementia is different, and a successful approach for one may not work for another. This is where personalization, connection, experience, and awareness become incredibly important. A CNA must have both knowledge and practical experience to know what they can do to facilitate better communication when they become aware that the patient with whom they are connecting has dementia. Gentleness and compassion will always be necessary to care for those with dementia.

Caring for and communicating with dementia residents can be rewarding but challenging. CNAs work closely with dementia residents and with patients with dementia in the home care setting. It is imperative that patience, kindness, and understanding be displayed. Learning to talk effectively with dementia residents makes the CNA's job easier and safer. Remembering to approach persons from the front, speaking softly, and using simple words and phrases will make your work more pleasant and likely include less resistance from your residents.

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