Date:
Author: Alison Pilnick, Professor of Language, Health and Society, Manchester Metropolitan University
Original article: https://theconversation.com/two-of-the-best-ways-to-respond-to-people-with-dementia-who-think-they-are-in-a-different-time-or-place-251521
Approximately one quarter of hospital beds in acute wards – wards for patients who need close care for a sudden or severe medical conditions – are occupied by someone living with dementia in the UK.
The sights, sounds and smells of a hospital environment, and the lack of familiar carers, can be a significant challenge for people with dementia. Many healthcare staff feel that they do not have sufficient training to care well for them.
This can lead to some staff using less effective communication methods to reduce distress and anxiety in dementia patients. Some carers, for example, might try to “correct” patients with dementia who seem confused about their surroundings or may use therapeutic lying – when lies are told to alleviate the distress of a patient with dementia – to avoid upsetting patients further. Our research shows that there are two approaches that are more effective.
Managing competing realities
Dementia affects people’s abilities to use language, to understand other people’s use of language and to remember things. One common challenge is the presence of competing realities, where the person with dementia is oriented to a different time or place. These competing realities are often grounded in the person’s previous experience of a career or family role. For example, they may believe a parent is coming to take them home, or that they need to leave urgently to pick up their own child from school.
Managing these competing realities can be difficult for carers in any setting. It is particularly difficult in an acute ward, where staff may know little about the background of a patient admitted for treatment for an urgent medical need such as a fracture or infection. Competing realities can be a major source of distress for a person with dementia, who might not recognise where they are or that they have any medical need, and can’t understand why they are not simply able to leave when they ask.
Over recent years, my colleagues and I have been using video recordings of everyday ward interactions to identify the communication challenges that occur when caring for people with dementia.
We have developed training in communication skills focused on specific challenges. For example, dealing with refusals of medically necessary care, responding to talk that is hard to understand and closing interactions effectively. Most recently, we have focused on dealing with competing realities and the distress that these can cause.
Responding effectively
We found there are four ways in which staff tend to respond, but that only two of these are effective in addressing distress.
The first way is to confront or challenge the patient’s reality. For example, telling a person who believes they are at home that they are actually in hospital. It is understandable why staff might do this, but we found that it does not usually lead to agreement, and instead can make distress worse.
The second way is to go along with the patient’s reality. For example, by agreeing that a deceased family member such as a parent or spouse will be coming to visit or collect the patient later. While this might work as a short-term strategy, it is time-limited because the promised event will never happen. This can ultimately make distress worse. Wider debates on “therapeutic lying” to people with dementia suggest it should only be done if carefully thought out and planned, and only then as a last resort.
Read more:
Is it OK to lie to someone with dementia?
The third way is to find some aspect of the patient’s reality that is shareable, without fully entering into it. For example, if a patient says their (deceased) father is coming to collect them, a member of healthcare staff might ask “Do you miss your dad?” This avoids lying, but responds to the emotional tone of the patient and enables a sharing of feelings.
For a person worried they have left a child or a pet alone at home, a healthcare professional might say “Your neighbour is looking after everything at home”. This provides general reassurance without confirming or challenging the specifics. For a patient who repeatedly asks to go home because they do not recognise their medical need, asking “What would you be doing if you were at home?” can identify a need or desire – such as having a cup of tea, a walk, or watching the TV – which could be met in the hospital environment.
Alternatively, staff used diversions. The topic of conversation can be shifted away from the issue that was causing distress, towards something else they could engage the person with.
This sometimes drew on the immediate environment – the view out of the window, for example. Sometimes they proposed an alternative activity, such as walking to a day room, or getting a drink. When no other possibilities were available, they sometimes asked the person with dementia a question that could lead into a different conversation.
These approaches are relevant for carers in any setting. Even in the context of a busy, pressured environment where carers may know very little about a person, the small differences in the way they communicate can have a profound effect on the care and wellbeing of those living with dementia.