Communicating with the Cognitively Impaired Alzheimers and Dementias

417 -Communicating with the Cognitively Impaired
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

Objectives
~ Define cognitive impairment
~ Explore symptoms of cognitive impairment in
~ Alzheimer’s
~ Dementias
~ Fetal Alcohol Spectrum Disorders
~ Review APA Treatment Guidelines for counselors working with persons with Alzheimer’s
~ Identify methods for effective communication
~ Learn how to handle difficult behaviors
~ Identify specific issues and interventions for a person with a FASD
Symptoms of Cognitive Impairment
~ The development of multiple cognitive deficits manifested by both
~ (1) memory impairment (impaired ability to learn new information or to recall previously learned information)
~ (2) one (or more) of the following cognitive disturbances:
~ (a) aphasia (language disturbance)
~ (b) apraxia (impaired ability to carry out motor activities despite intact motor function)
~ (c) agnosia (failure to recognize or identify objects despite intact sensory function)
~ (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
Symptoms of Cognitive Impairment
~ Other Symptoms
~ Attention
~ Perception
~ Insight and judgment
~ Organization
~ Orientation
~ Processing speed
~ Problem solving
~ Reasoning
~ Metacognition

Causes of Cognitive Impairment
~ Wernike-Korsakoff’s Syndrome
~ Vascular Dementia
~ Stroke
~ Impeded blood flow to brain
~ Alzheimers
~ Fetal Alcohol Spectrum Disorders
~ Brain Injury (Car accident, football, fall, boxing)
~ (Temporarily) Hyper or Hypo-glycemia
Screening for Cognitive Impairment
~ The AD8 (PDF, 1.2M) and Mini-Cog(PDF, 86K) are among many possible tools.
~ Patients should be screened for cognitive impairment if:
~ The person, family members, or others express concerns about changes in his or her memory or thinking
~ You observe problems/changes in the patient’s memory or thinking
~ The patient is age 80 or older(12)
~ Low education (IQ, FASD, stroke…)
~ History of type 2 diabetes
~ Stroke
~ Depression
~ Trouble managing money or medications
~ Episodes of delirium (confusion/disorientation)

Important Aspects of Management
~ Important aspects of psychiatric management include
~ Educating patients and families about
~ the illness
~ treatment
~ sources of additional care and support (e.g.,support groups, respite care, nursing homes, and other long-term-care facilities)
~ the need for financial and legal planning due to the patient’s eventual incapacity (e.g., power of attorney for medical and financial decisions, an up-to-date will, and the cost of long-term care)
Important Aspects of Management
~ Behavior oriented treatments
~ Identify the antecedents and consequences of problem behaviors
~ Reduce the frequency of behaviors by changing the environment to alter these antecedents and consequences.
~ Stimulation-oriented treatments
~ recreational activity, art therapy, music therapy, and pet therapy, along with other formal and informal means of maximizing pleasurable activities for patients
~ Emotion-oriented treatments
~ supportive psychotherapy can be employed to address issues of loss in the early stages of dementia
~ Reminiscence therapy has some modest research support for improvement of mood and behavior
~ Tolerate, Anticipate, Don’t Agitate
Communication
~ Written, oral, body language/signs
~ Let the client write, draw or speak to communicate
~ Use real objects when possible. (i.e. an apple)
~ Use picture books, posted lists
~ Story boards can be utilized to discuss a behavior incident
~ Use assistive devices when needed (glasses, hearing aids, large font)
~ Have spare reading glasses, hearing assistance (~$150) as people may misplace them
~ Get their attention
~ Orient them to who you are and why you are there
~ Establish rapport before jumping into “business”
~ Get the person’s attention by identifying her by name
Communication
~ Use simple language
~ Speak slowly and distinctly
~ Ask them questions directly
~ Make eye contact
~ Turn on lights if it is too dark, but avoid so much light as to cause glare
~ Set a positive mood (sometimes laughter helps)
~ Avoid using medical jargon
~ Have client explain what he heard from you
~ Repeat as many times as needed
~ Write down instructions

Communication
~ Do not give multipart instructions
~ Instead of asking, “would you like to come in and sit down and have a snack?,” use simple statements such as, “sit down here,” and “here’s a snack for you.” Break long discussions into several short talks ~10 minutes
~ Don’t use abstract concepts / Use yes or no, simple, answerable questions
~ Instead of saying
~ “Are you sleepy” say, “Do you want to go to bed.”
~ “Are you thirsty” say “Would you like some tea?”
~ “Are you depressed” say “Would you like to [preferred activity]?”
~ “What shirt do you want to wear” say “Would you like to wear the read or the blue shirt?”
Communication
~ Eliminate distractions
~ Other people
~ Animals (unless the animal helps the person feel calmer)
~ TV/Radio
~ Involve family and friends
~ Listen with your eyes, ears and heart
~ If they are having difficulty finding a word, ask for information about the missing word.
~ If he cannot remember “pizza” but wants to tell you what he ate, ask what it looks like
~ Communicate in a place that is comfortable for the person
~ Don’t argue over the correct answer.
~ He may call you his mother and mean his wife.
~ Also remember he may be speaking his reality. If he says it is winter even though it is the middle of July, it may feel like, look like, and be what “winter” is for him.
Communication
~ Remember the good old days. Remembering the past is often a soothing and affirming activity. Many people with dementia may not remember what happened 5 minutes ago, but they can clearly recall their lives 5 years earlier.
~ Avoid asking questions that rely on short-term memory, such as asking the person what they had for lunch.
~ Try asking general questions about the person’s distant past
~ Reality orientation therapy (ROT) is a psychosocial approach that employs formal or informal classes that reorient the client by means of continuous stimulation with repetitive orientation to the environment, e.g., location, date, names, and personal information.
Communication
~ Activities such as category sorting and games are used to:
~ Stimulate language
~ Increase active engagement in the environment
~ Decrease purposeless behaviors

Communication: Spaced Retrieval
~ Spaced retrieval training (SRT) is an intervention that gives individuals practice at successfully recalling information over progressively longer intervals of time.
~ SRT is increasingly being used to teach new and forgotten information and behaviors to persons with dementia.
~ Train persons with dementia to improve orientation to place
~ Look at activity calendars and daily schedules
~ Train a person with a hip fracture and dementia to remember to lock her wheelchair brakes before standing or transferring
Communication: Spaced Retrieval
~ SRT encourages recalling information over increasingly longer periods.
~ When retrieval is successful, the interval is increased. If recall failure occurs, the participant is told the correct response and asked to repeat it.
~ Intervals, therefore, are manipulated to facilitate production of a high number of correct responses.
~ Strength of association between concepts in semantic memory depends on how often they are activated.
~ Where are you?
~ What do you do when you get up in the morning?
~ Here do you keep your glasses?
~ What do you do before you get out of your wheelchair / Tell me how to get out of your wheelchair
Specific Tips for Persons with a FASD
~ Don’t expect the person to be reasonable or to act their age.
~ Go for a few “Yes” responses first. Use short questions you think the person will answer “Yes” to, just to get them out of being stuck in the “No” loop.
~ Be nonjudgmental.
~ Start with a clean slate.
~ Be extra attentive to your nonverbal and paraverbal communication.
~ The person with FASD may not understand all the words you’re using when they’re going through a crisis, but they are likely tuned in to your appearance and sound.

Specific Tips for Persons with a FASD
~ Don’t get frustrated that you just dealt with this same type of issue yesterday.
~ It may seem like the same issue, but to the person it’s likely a completely unique and unrelated crisis.
~ It’s not that they aren’t paying attention; it’s that their brain isn’t letting them make the connection.
Handling Troubling Behaviors
~ Try to accommodate the behavior, not control the behavior
~ For example, if the person insists on sleeping on the floor, place a mattress on the floor to make him more comfortable.
~ Remember that we can change our behavior or the physical environment.
~ Changing our own behavior will often result in a change in our loved one’s behavior. (Frustration -> frustration)
~ Check with the doctor first.
~ Behavioral problems may have an underlying medical reason, i.e. pain or experiencing an adverse side effect from medications.
Handling Troubling Behaviors
~ Behavior has a purpose. People with dementia typically cannot tell us what they want or need. They might do something, like take all the clothes out of the closet on a daily basis, and we wonder why.
~ To be busy and productive
~ Because they are too hot or cold, uncomfortable
~ Always consider what need the person might be trying to meet with their behavior—and, when possible, try to accommodate them.
Handling Troubling Behaviors
~ What works today, may not tomorrow because:
~ Multiple factors influence troubling behaviors
~ Natural progression of the disease process
~ The key to managing difficult behaviors is being creative and flexible in your strategies to address a given issue.
~ Behavior is triggered. It occurs for a reason.
~ It might be something a person did or said
~ It could be a change in the physical environment.
~ The root to changing behavior is disrupting the patterns that we create.
~ Try a different approach
~ Try a different consequence. (Positive redirection)

Other Tips
~ Create routines and stick to them
~ Eliminate distractions from the classroom/home environment
~ Use a cue if the person starts getting distracted or agitated
~ Only post necessary information such as schedules, classroom/facility expectations, and information that is to be used for instruction/daily living.
~ Show what the process or the completed project looks like first
~ Establish clear starting and ending times
~ Watch the person to ensure he doesn’t lose focus
~ Practice reciprocal conversations
~ Activities from the Social Skills Toolbox
Summary
~ Working with people with cognitive impairment can be frustrating
~ It is important not to confuse chronological age with communicative age
~ KISS
~ Eliminate distractions
~ Don’t expect short-term memory
~ Use pictures, lists, storyboards
~ Spaced retrieval training has shown effectiveness in improving memory in people with cognitive impairments
~ Many people with a FASD will present in mental health practices without a FASD diagnosis.
~ Many clients who misuse alcohol and/or try to self detox can precipitate a cognitive impairment through
~ Thiamine deficiency
~ Stroke
~ Conduct ongoing assessments for cognitive impirments

~ University of Kentucky FREE CEs for nurses, social workers and CNAs
~ Alzheimer’s Care Curriculum