Transcript Communication With Cognitively Impaired Patients

Communication
With Cognitively
Impaired Patients
Objectives

To differentiate between delirium and dementia

To describe nurse and client responses to
cognitive impairment

To delineate therapeutic communication
strategies for clients with cognitive impairment

To compare and contrast “task-focused” and
“emotion-focused” communication

To adjust communication approaches to the
severity of the client’s cognitive impairment
Introduction
 There
is a growing number of individuals
living to old age world wide
 Healthcare
settings see a larger number of
individuals older than 65
 Baby
boomers are turning 60 at rate of 1
every 8 seconds for next 15 yrs.
Introduction, con’t.
 Cognitive
impairment is NOT a normal
condition in old age…it is more common in
the aged
 Older
adults who are hospitalized are at
high risk for cognitive impairment during
their hospital stays


May be a symptom at time of admission
May develop during hospitalization
Two Common
Cognitive Impairment Types
 Dementia
 Delirium
Dementia
 Gradual
loss of cognitive ability that
usually occurs during old age
½
of all adults over 85 have dementia
 Caused
by degenerative brain diseases,
chronic alcoholism, HIV, CVA (Stroke)
Alzheimer’s Disease
 Most
common cause of dementia
 Irreversible
 Drugs

available to slow the progression
Aricept®, Cognex®, Exelon®, Razadyne®,
Namenda®
Symptoms of Dementia
2


or more cognitive abilities are lost
Apraxia
Impaired ability to carry out motor activities in
spite of having normal sensory abilities and
understanding the task
Aphasia
Difficulty verbally expressing thoughts and
emotions, as well as difficulty in
understanding verbal messages
Emotional Responses to
Cognitive Impairment
 Influences
their overall mental health
 As
awareness of limitations occur: clients
may be reluctant to communicate and
begin to withdraw
 Feelings
of shame, frustration, anger,
anxiety and depression occur
Typical Response by Caregivers
 Frustration
 Mutual
and Anxiety
avoidance and withdrawal
 Depression
Balancing the Need to Know
With the Client’s Need for Dignity

During the nurse’s evaluation of the client’s
cognitive and communication abilities…


Client can experience stress, embarrassment
May feel “stupid”, “crazy”, etc.

Nurse can comfort client by conveying respect
for the worth and dignity of the person

Let clients know it is OK to not know answers to
questions (they are not stupid or crazy)
Mini Mental State Examination
(MMSE)
 Test
used to evaluate cognitive functioning
in several areas including orientation,
registration, attention, calculation, recall
and language
 Assure
client that not knowing an answer
does not necessarily mean that something
is wrong
Engaging The Client
In Communication

Goal




Understand client’s needs
Sharing experiences
Engaging the client with their own care
Reality Orientation

Orients client with reality

Calendar and Clock on Wall


Statements: “My name is….and I am your nurse today”,
“Today is Tuesday May. 15th, 2007, and you are in the
hospital”
Repetition of information
Facilitating Trust
 Establishing
trust is challenging
—not impossible
 The person with dementia will remember you
are trustworthy
 Allow extra time so you don’t have to rush client
 Use a calming approach
 May need to add anxiety medication if needed
 Always address client (don’t discuss them in
their presence!)
Task-Focused Communication
 Examples:


“Take this medication”
“Are you in pain?”
 Keep
messages short, simple and direct
 Only present one idea at a time
 Ask what you want, rather than what you
don’t want


“Hold the glass with both hands”
Not “Careful, don’t spill your drink”
Task-Focused Communication, con’t…
 Avoid


complex questions:
For example instead of “Why did you put your
coat on? It’s hot outside!”
Say instead “Let me help you put your coat
away. It is hot outside today. I don’t think you
will need it.”
 Don’t
overburden client with unnecessary
information (orient them slowly to unit)
Task-Focused Communication, con’t…
 Avoid


If you say “If you can’t stay in bed, I will have
to put the side rails up!”
The client may not remember the directive a
few minutes later, but may feel less secure in
their new surroundings
 Give

increasing anxiety
simple choices
For example ask “Would you like to wash your
face?” (while handing them a washcloth)
Task-Focused Communication, con’t…
 Avoid



arguing:
If a cognitively impaired person states, “you
stole my teeth!”
Arguing only excalates frustration and is
unlikely to help you gain cooperation
Simply responding “Let me help you find your
dentures” would be a wise response
Emotion-Focused Communication
 Clients
with dementia DO form therapeutic
relationships with their nurses
 Despite
their memory deficits, they have
the same emotional needs as others
Emotion-Focused Communication, con’t…
 Most
communication is nonverbal
 Therefore nurses must be observant for




Facial expressions
Posture
Tone of voice
Gestures
 Anxiety
(body tension, wide eyes)
 Anger (banging hand, yelling, clenched fist)
Emotion-Focused Communication, con’t…
 Discouragement,


Slumped posture
Head propped up with hand
 When


Depression, Fatigue
agitation occurs…
Look for situational cues
Ask for validation (eg, “you seem frightened”)
Emotion-Focused Communication, con’t…
 If
a person has limited speech…assume
that he or she hears and understands you

More communication will occur
 Sit

down before beginning a conversation
This communicates that you have time for this
person
•Allow and even encourage
expression of emotions
Review Case Example
in Textbook on Page 83
Review Tables 7-1 and 7-2
Adjusting Communication to the
Stage of Dementia
 The
number of words a client uses will
diminish
 Mutism (speaking less and less) becomes
more frequent until verbal communication
ceases altogether
 Eventually the individual seems unaware
of his or her surroundings altogether
Adjusting Communication
to the Stage of Dementia, con’t…
 Adjust
the amount of time needed for the
nurse to spend with the client
 It is important to remember that the client
may understand more than you realize
 Continue to use a calming voice
 Continue to address the client by their name
 Continue to use gentle touch on arm or
shoulder to focus their attention
 Use supportive facial expressions (smile, eye
contact)
Delirium
 Occurs
over a short period of time (hours or
days) and constitutes a medical emergency
 May
be caused by:
 Fever (eg: Pneumonia, UTI’s)
 Electrolyte Imbalance
 Sensory disturbances
 Adverse reactions to drugs
Delirium, con’t…
 Rapid
identification is critical so corrective
action can occur
 Nurse



must use:
Calming approach
Unhurried actions
Soothing tone of voice
 Must
be closely monitored to prevent harm
and to manage rapidly changing condition
Delirium, con’t…
 It
is much better to use close observation
by a person to maintain safety than it is to
use restraints
 May need to educate families how to
communicate best with delirious client
 Help the client to explore tubes and lines
with you as you guide their hands and
briefly explain what they are touching
 Develop a consistent approach