## Chapter 3

## 

## Guidelines for 

##  Communication

> *"It's not what you say, it's how you say it. . . ."*
>
> *Mom*

Communication is the process of sending and receiving messages that
allows us to relate to one another. Through communication we convey our
thoughts and feelings, wishes and ideas. It helps us express who we are.
Communication is more than talking and listening with words. It involves
attitude, tone of voice, facial expressions, and body language. A
resident with Alzheimer's disease may experience problems expressing
himself with words and understanding what others are saying.

### 

### Changes In Communication

Although there will be variations from individual to individual among
people with Alzheimer's, language is usually affected early in the
disease, and communication becomes harder as time goes by. Common
language changes include:^1^

-   Not recognizing a word or a phrase, almost as if the word were in a
    foreign language;

-   Not being able to name things;

-   Using a general instead of a specific word (saying "that girl"
    instead of "Jane" or "my daughter");

-   Getting stuck on ideas or words, repeating them over and over;

-   Easily losing a train of thought;

-   Using silly, tactless, or rude language in conversation;

-   Increasingly poor comprehension of the written word, and a gradual
    worsening of the ability to write;

-   Returning to a native language, or combining languages;

-   Speaking less often, or using only a few words or nonsense
    syllables;

-   Relying on nonverbal gestures more.

### Actions Speak Louder Than Words

As verbal communication becomes increasingly difficult for a resident
with Alzheimer's disease, she may retain the ability to understand and
use nonverbal communication. Be aware that she will be very sensitive to
your mood, facial expression, tone of voice and body language. These
nonverbal messages will convey your "true" message more so than the
actual words that you use.

#### Pay special attention to your body language. ^2^

-   Always approach the resident from the front and avoid sudden
    movements.

-   Use eye contact to get and keep the resident's attention.

-   Be aware of your stance to avoid sending a negative message.

-   Use positive and friendly facial expressions.

-   Use nonverbal gestures such as pointing, gesturing and touching.

##### Be aware of the tone you use. ^3^

-   Speak slowly and distinctly.

-   Use a gentle and relaxed tone of voice --- a lower pitch is more
    calming.

-   Convey an easygoing, non-demanding manner of speaking.

-   Be aware of your feelings and attitude, because they are often
    communicated, unintentionally, through tone of voice.

The reverse is also true. The resident's behavior will gradually become
her primary mode of communication. Ask: Is something being communicated
through behavior that can no longer be expressed in words?

### 

### Helping The Resident With Alzheimer's Communicate: 

### Your Approach To Listening ^4^

-   **Be patient and supportive.** Let the resident know that you are
    listening and trying to understand what he is saying. Never show
    through words, gestures or facial expressions that you are impatient
    to move things along. Say instead, "It's okay, Bill, take your
    time."

-   **Show your interest.** Smile, maintain eye contact, lean forward
    and show that you care about what the resident is saying. "I really
    want to hear what you have to say."

-   **Offer comfort and reassurance.** If the resident is having
    difficulty expressing himself, let him know that it is all right.
    Encourage him to continue.

-   **Listen for a response.** It may take up to thirty seconds for the
    resident to figure out what you have said and come up with the right
    words in response. Be careful not to interrupt.

-   **Avoid criticizing or correcting.** Don't tell the resident that
    what he is saying is incorrect. Instead, listen and try to find the
    meaning in what is being said. Repeat what was said if clarification
    is needed.

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-   **Don't argue.** If the resident says something you don't agree
    with, let it be. It's impossible to have a rational argument with
    someone who has lost the capacity to be rational. Arguing only makes
    things worse. Respond to the feelings being expressed, then distract
    the resident by changing the subject, asking for his help, or
    offering an alternative activity.

-   **Offer a guess.** If the resident uses the wrong word or cannot
    find a word, try helping them out ("Is it a spoon you're thinking
    about, Bill?"). If you understand what he means, it may not be
    necessary to provide the correct word. In either case, be careful
    not to cause unnecessary frustration by correcting the resident or
    acting impatient.

-   **Focus on feelings, not facts.** Sometimes, the emotions being
    expressed are more important than what is being said. Look for the
    feelings behind the words. At times, tone of voice and other actions
    may help you to understand how the resident is really feeling. Help
    the resident to name his feelings: "You look sad."

-   **Limit distractions.** Find a place that is quiet, so that you
    won't be interrupted and the resident can focus on what he wants to
    say.

-   **Encourage non-verbal communication.** If you don't understand what
    he is trying to say, ask them to point or gesture.

> **Always speak to a resident with Alzheimer's as though he can
> understand every word you are saying . . . because his ability to
> understand you may outlast his ability to speak appropriately in
> return.**
>
> **Be respectful and kind --- *always!***

### Your Approach To Communicating^5^

When communicating with a resident with Alzheimer's, words must be
chosen carefully. The following techniques will make it easier for the
resident to understand you.

##### Get the resident's attention before speaking.

-   Approach from the front, slowly.

-   Get on the same level or height as the resident to whom you are
    speaking.

-   Maintain eye contact (without staring).

-   Use gentle touch, as appropriate.

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-   **TIP:** Address the resident by name. This is not only courteous,
    but also helps orient the resident and get her attention.

##### 

##### Set a good tone.

-   Use a calm, gentle, matter-of-fact manner.

-   Smile, and speak with a low-pitched, reassuring tone of voice.

-   Introduce yourself, no matter how obvious it seems.

-   Start with social conversation to help the resident relax, and to
    gain her trust before moving on to the task.

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-   **TIP:** If you leave the room, or are interrupted, start over.

##### 

##### Slow down.

-   Expect things to take longer; the resident is doing the best she can
    with an impaired memory.

-   Don't act rushed or impatient, and ask one question at a time.

-   Give the resident time and encouragement to process and respond to
    your request.

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-   **TIP:** If you need to repeat information, do so using the same
    words and phases as before.

##### Simplify.

-   Speak clearly and distinctly.

-   Use short, familiar words and avoid long explanations or requests.

-   In a group situation, allow only one resident to talk at a time.

-   Turn questions into answers. For example, say "The bathroom is right
    here," instead of asking "Do you need to use the bathroom?"

-   Emphasize key words, such as, "Here is your *coffee.*"

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-   **TIP:** Communicate one idea or task at a time, and break tasks and
    instructions into clear, simple steps, giving one step at a time.

##### 

##### 

##### Use nonverbal cues.

-   Demonstrate your requests by pointing, touching or beginning the
    task for a resident.

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-   Use written explanations for reminders or when verbal ones seem too
    confusing.

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-   **TIP:** If you don't understand what the resident is saying,
    encourage her to point or to gesture.

##### Pitfalls to avoid

-   Avoid expressions such as "Hop in!" which may be taken literally and
    cause unnecessary confusion.

-   Avoid pronouns. Instead of saying "Here it is," try "Here is your
    hat."

-   Turn negatives into positives. Instead of saying, "Don't go there,"
    try saying, "Let's go here."

-   Avoid quizzing. Some reminiscence can be healthy, but avoid asking
    "Do you remember when...?" or using statements like, "You should
    know who that is."

-   Avoid arguing.

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-   Don't talk down to the resident, and don't speak to others about her
    as though she isn't there*.*

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-   **TIP:** Always speak to the resident as if she can understand every
    word you are saying, because the ability to understand often
    outlasts the ability to speak appropriately in return. Always be
    respectful and kind*.*

> **Tips for Better Communication**

-   Be calm and supportive.

-   Focus on feelings, not facts.

-   Pay attention to tone of voice.

-   Identify yourself and address the resident by name.

-   Speak slowly and clearly.

-   Use short, simple and familiar words.

-   Ask one question at a time.

-   Allow enough time for a response.

-   Avoid the use of pronouns, negative statements and quizzing.

-   Use nonverbal communication such as pointing and touching.

-   Offer assistance as needed.

-   Don't talk about the resident as if he wasn't there.

-   Have patience, flexibility and understanding.

> Source: *Steps to Enhancing Communication,* Alzheimer's Disease and
> Related Disorders Association, Inc. 1997.

### Sources

1\. Adapted from *"Home Is Where I Remember Things," A Curriculum for
Home and Community Alzheimer Care,* by Lisa P. Gwyther, Duke Alzheimer's
Family Support Program, Duke University Medical Center, Durham, North
Carolina, 1997.

2-5. *Steps to Enhancing Communication,* Alzheimer's Disease and Related
Disorders Association, Inc., 1997

**Resources And Further Reading**

1.  *Caring for People With Dementia: A Training Guide,* published by
    The Training Collaborative, a joint project of the Alzheimer's
    Association, Maine Chapter; the Alzheimer's Care Center, Gardiner;
    Muskie School of Public Service at the University of Southern Maine;
    and the Maine Alzheimer's Project, April 1998. For more information,
    contact the Maine Alzheimer's Association at 1-800-660-2871.

2.  *Caregiving at a Glance: Fingertip Help for Families Taking Care of
    People With Alzheimer's Type Illnesses,* (Second Edition), by Lin E.
    Noyes, Family Respite Center, Falls Church, Virginia, 2000. To
    order, contact the Maine Alzheimer's Association toll-free at
    1-800-660-2871, or visit our web site at
    [www.mainealz.org](http://www.mainealz.org/).

3.  *"Home Is Where I Remember Things:"* *A Curriculum for Home and
    Community Alzheimer Care,* by Lisa P. Gwyther, Duke University
    Medical Center, Durham, North Carolina, 1997. To order, contact the
    Maine Alzheimer's Association toll-free at 1-800-660-2871, or visit
    our web site at [www.mainealz.org](http://www.mainealz.org/).

4.  *Talking to Alzheimer's: Simple Ways to Connect When Your Assist
    With a Family Member or Friend,* by Claudia J. Strauss, New
    Harbinger Publications, Oakland, CA 2001.

-   You can also order the following brochure by calling the Alzheimer's
    Association toll-free at 1-800-660-2871, or call your local chapter.

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-   *Steps to Enhancing Communication: Interacting With Persons with
    Alzheimer's Disease,* Alzheimer's and Related Disorders Association,
    1997.

**Appendix 3.1**

**[Communication Guidelines]{.underline}**

***Get the resident's attention before speaking***

-   Approach from the front, slowly

-   Get on the same level or height as the resident

-   Maintain eye contact

-   Say the resident's name; use gentle touch, as appropriate and
    tolerated.

***Set a good tone***

-   Use a calm, gentle, matter-of-fact approach

-   Speak with a low-pitched, reassuring tone of voice

-   SMILE

-   Introduce yourself, no matter how obvious it seems

-   Start with social conversation to relax the resident and gain his or
    her trust before moving on to the task

-   If you leave the room or are interrupted, start over.

***Slow down***

-   Expect things to take longer; the resident is doing the best that he
    or she can with an impaired memory

-   Don't act rushed or impatient

-   Give the resident plenty of time to respond to a question or request

-   If you need to repeat information, do so using the same words as
    before.

***Simplify***

-   Speak clearly and distinctly

-   Use short, concrete, familiar words and proper names for people and
    objects

-   Communicate one idea or task at a time

-   Use nonverbal gestures to demonstrate what you want him or her to
    do.

***Reassure***

-   Talk the resident through the situation

-   Ask him or her to help

-   Use gentle humor

-   Reassure and praise frequently.

***Pitfalls to avoid***

-   Talking louder

-   Arguing, reasoning, giving long explanations, and reality
    orientation

-   Commands (Do "with," not "to") and negative language (e.g., "No."
    "Don't.")

-   Talking down to the resident as if to a small child, or talking
    about the resident as if he or she is not there.

***Be patient and kind. Focus on the resident, not the disease.***