Understanding Dementia

1. Understanding Dementia

2. Introduction In February 2009 the Department of Health published the first ever National Dementia Strategy. Within the strategy are 17 key objectives designed to: Make the lives of people with dementia, their carers and families better and more fulfilled (DoH 2009). Objective 13 calls for an informed workforce for people working with dementia. This is to be achieved by effective basic training and continuous professional and vocational development in dementia care. As part of SEPT’s Workforce and Development strategy to support this document, this e-Learning training has been created for all staff involved in health and social care in older people services including primary, secondary and tertiary care pathways providers. DH UK – Dementia or you can order a copy from: Orderline UK

3. Key Points This e learning training course should take learners up to 45 minutes to complete. Learners will be able to stop and revisit at any given point. On completion of this e learning training, learners should be able to: • Understand the definition of dementia • Gain an awareness of incident rates in the UK • Identify the most common types and causes of dementia • Gain an awareness of signs and symptoms of dementia • Recognise the difference between dementia, depression and confused states • Understand where behavioural interventions may be helpful • Identify different methods of communication • Understand why people with dementia may experience difficulties with communication. • Identify communication skills and approaches which may be useful when working with people with dementia. • Understand the need for a positive and effective communication with the person experiencing dementia.

4. Prevalence Key data for the UK as a whole includes the following: • More than 750,000 people in the UK are affected by dementia • It affects one person in six over 80 (late onset) • One in 14 over 65 (early onset) • Dementia is predominantly a disorder of later life, but there are at least 15,000 people who have young onset dementia , click for more information you may wish to view or download the following fact sheet: Fact Sheet Source: alzheimers.org.uk • Approximately two women for every man is affected • It is estimated that there are 11390 people from Black minority ethnic groups (BME) with dementia. Its note worthy that 6.1% of all people with dementia among BME groups is young onset, compared to 2.2% for the UK population as a whole.

5. Projected Impact • The total number of people with dementia in the UK is forecast to increase to approximately 950,000 by 2021 • Increasing to 1,735.000 by 2051 • An increase of 38% over the next 15 years and 154% over the next 45 years • Information taken from Dementia UK: the full report (Knapp, Albanese et al 2007)To view copies of the full report go to: Dementia UK Full Report

6. What is Dementia? The Department of Health (2009) defines the term “dementia” as a syndrome which may be caused by a number of illnesses in which there is a progressive decline in multiple areas of function. Dementia is not a part of the normal ageing process.In essence dementia is a term used to describe a collection of symptoms which for most people are progressive and irreversible. This means the dementia usually gets worse slowly and often over a period of years, meaning that in most cases, the person with dementia can no longer live independently. This can have a profound affect on both the person with dementia and their carers. Additionally, there are different causes of dementia and this will have a direct impact upon the experience of the illness which the person with dementia has. There are currently no cures for dementia but there are medications and other psychosocial interventions/ treatments available. These can improve symptoms in some people and optimise their functioning level, thus increasing their quality of life.

7. Common Types and Causes of Dementia There are a hundred different forms of dementia, with the most common being: • Alzheimer’s disease, affecting 62% of sufferers • Vascular dementia or Multi infarct dementia is attributed to 17% • Mixed Alzheimer’s disease and Vascular dementia account for 10% • Lewy bodies dementia accounts for another 4% • Fronto-temporal lobe dementia is responsible for another 2% and a remaining 2% for Parkinson’s disease • The remaining 3% of cases are related to other causes which may be treatable. • Taken from: ‘A comprehensive free Tutorial for Dementia Management in Primary care, a resource pack for GP’s and patients. Funded by the Department of Health’. (Alzheimer’s Society 2009)

8. Common Types and Causes of Dementia (continued)

9. Rarer, Less Treatable Conditions • Fronto- temporal lobe dementia Factsheet 404, Source: alzheimers.org.uk • Learning disabilities and dementia Factsheet 430, Source: alzheimers.org.uk • CreutzfeldtJakob Disease Factsheet 427, Source: alzheimers.org.uk • AIDS related dementia Factsheet 446, Source: alzheimers.org.uk

10. Other Conditions Of which are caused by physical & psychological pathology include: • Depression (severe forms can mimic symptoms of dementia) Factsheet 444, Source: alzheimers.org.uk • Acute Confusional State /Delirium Delirium PDF, Source: NHS Library • Hypothyroidism Factsheet 442, Source: alzheimers.org.uk • Vitamin B12 deficiency Factsheet 442, Source: alzheimers.org.uk • Tumor Brain tumor associated dementia, Source: find-health-articles.com It is of paramount importance that any underlying physical or psychological causes are eliminated before someone is investigated for suspected dementia.

11. Alzheimer’s Disease For purpose of achieving the learning outcomes in this module we will be concentrating on the three most common conditions. In addition to these we will also explore ‘depression’ which can be mistaken by non-specialists as a dementia and Acute Confusional States as the latter two conditions may be responsive to appropriate interventions. Alzheimer’s Disease Although the features of Alzheimer’s disease are not dissimilar to other conditions, it is not an umbrella term for dementia as each condition has distinct differences in their clinical and behavioural presentations. No case of Alzheimer’s is the same as people react in different ways. This fact sheet gives a simple overview of the condition. You may wish to download this and use it as a resource. What is Alzheimer's disease? Source: Alzheimer's Society

12. Vascular / Multi Infarct Dementia Vascular dementia has a less predictable decline than Alzheimer’s disease. The condition refers to a syndrome caused by different mechanisms all resulting in vascular lesions in the brain. Early detection and accurate diagnosis is of paramount importance as this type of dementia is partially preventable. There can be relative stability if vascular disease is minimised, but if left untreated there will be further deterioration in the condition after subsequent vascular accidents.There are a number of potentially modifiable risk factors that appear to have an influence on the disease including common cardio-vascular risk factors i.e. smoking, high cholesterol, alcohol abuse, hypertension and obesity.Initial symptoms are often physical in presentation, such as weakness in limbs, slurred speech and dizziness with accompanying short term memory impairment. If a person continues to have minor strokes or ischemic attacks and they remain undetected, there will be an exacerbation of early symptoms and less treatable physical and psychological presentations. Types of Dementia Source: dementiaweb.org.uk

13. Dementia with Lewy Bodies Dementia with Lewy Bodies is caused by abnormal protein deposits which disrupt the brain’s normal functioning. These proteins are also found in the brain stem of people with Parkinson’s disease hence they deplete the neurotransmitter dopamine, which causes parkinsonian symptoms such as shuffling gait, stooped posture, rigidity, rest tremor, slowness and balance problems which regularly lead to numerous falls. For additional information on Parkinsons Disease, click here: Parkinsons UK Source: Parkinsons UKThese deposits also lead to disruption of perception and frequently cause recurrent complex visual hallucinations, fluctuating variations in attention and alertness. Prominent memory impairment may not be evident in the early stages. Other common Alzheimer’s pathology may become apparent as the condition progresses. LBDA Org Source: LBDA OrgAs with all other types of dementia, each person’s experience is different with varying levels of pathology.

14. Acute Confusional states (Delirium) Onset is often rapid over the preceding 24-48 hours. Occurrence is due to underlying physical pathology. There are a number of potential causes, some of the most common being: The following mnemonic ‘DELIRIUM’, taken from the Merck manual of geriatrics, is a useful way of checking possible causes of delirium. Drug use, especially when the drug is first introduced or the dosage is adjusted. It is therefore of paramount importance that medication is reviewed at frequent intervals.Electrolyte and physiologic abnormalities e.g., hyponatremia and hypoxemiaLack of Drugs commonly referred to as withdrawal.Infection, especially urinary tract or respiratory infections.Reduced sensory input e.g., blindness, deafness, darkness or a change in surroundings.Intracranial problems e.g., stroke, bleeding, meningitis, postictal state.Urinary retention and faecal impactionMyocardial problems e.g., myocardial infarction, arrhythmia and heart failure.

15. Acute Confusional states (Delerium) continued The person is often confused and disorientated in time and place and depending on severity, there may even be clouding of consciousness. They may become restless and agitated, with these behaviours possibly being exacerbated by hallucinatory experiences. This is where a person may see, feel, hear or taste things which others around them do not. The condition is usually transient once the person receives appropriate treatment for the underlying pathology. REMEMBER, delirium can occur in people with dementia so it is extremely important that the individual’s ongoing physical health and well being is continually monitored.

16. Depression Depression in its severe form in older people can often be mistaken for dementia by non specialists as the person exhibits symptoms consistent with dementia, but the cause is pre existing psychological illness rather than a degenerative one.It is often of short and abrupt onset where dementia is insidious and cognitively debilitating in nature. As with clinical depression the causes may be re-active and often linked to some form of psychosocial stress or Endogenous pathology, where there is no identifiable external factor. Endogenous manifestations include persecutory delusions, where people may present suspicion, often claiming that others are trying to harm them. They also have negative, false fixed ideas of low self worth and poor health. Sometimes they experience nihilistic delusions where the person believes they are no longer their self or parts of their bodies are missing i.e. “I am dead”, “I have no bowels”.

17. Depression (continued) The prominent cognitive symptom of depressive dementia is loss of shortterm memory accompanied by reduced alertness and impaired concentration. It isimportant to note that people with this condition have an awareness ofcognitive impairment (Cummings and Benson 1992) on careful testing memory andlanguage functioning are intact: http://alzheimers.about.com/od/glossary/g/pseudodementia.htm Source: Alzheimers.com Psychomotor retardation is also evident. This means the person may be slow intheir movements and speech is often slow and monotonous. Sometimes there isevidence of emotional blunting or agitation and anxiety.Once detected, this condition will respond favourably to antidepressant therapyand other psychotherapeutic interventions.It is therefore significantly important that a comprehensive psychological& cognitive assessment is completed before a diagnosis of dementia is explored.

18. Common Features Dementia is an umbrella term for a collection of clinical presentations which will vary according to the stage and nature of the condition.

19. Impaired Cognitive Functioning This is the umbrella term for the disturbance or decline in all our intellectual processes. It involves all aspects of thinking, reasoning and remembering things. This will ultimately have a profound impact on a person’s judgement and severely affect all aspects of a person’s ability to engage in everyday life. Anecdotal examples of each of these experiences will follow. Memory Problems Memory problems are commonly seen as a key symptom of dementia. Initially it is characterised by fluctuating short term memory (recent events). The person may forget appointments or significant dates but during this period they will usually remember past events related to their childhood or adult years (long term memory). Problems with new learning and impaired working memory are evident i.e. the person may not be able to repeat something you have just told them (new learning), or they might appear to forget how to put their coat on for example (working memory). As the condition progresses, their long term memory invariably becomes disrupted. Last time I saw my sister was 2 years ago, granted she did seem a bit more forgetful but we all become forgetful as we get older don’t we? When I arrived at the care home today she did not even recognise me and kept on saying her husband was coming home for tea...but he died in the Second World War. It’s so sad I wish l didn’t live on the other side of the world.

20. Disorientation to time, place and person During the early stages of dementia, a person may regularly forget recent events, names and places but will often respond to prompting or reality orientation. However, as the condition progresses they may have little or no recollection of self or others. This can be extremely distressing for both the person with the condition and their loved ones. The neighbours have brought mum home several times this week. She has been found walking up and down the street claiming she cannot find her house. I am really worried as a local taxi driver brought her home in the early hours of the morning. He told me she could not recall any of her personal details. Inability to carry out daily activities As poor concentration and distraction becomes evident people start to neglect their personal hygiene and dressing. They start to find it increasingly difficult to cater for their everyday needs. At its worse it may be necessary to activate 24 hour care due to the risk of self neglect. Dad was found by a local shopkeeper wandering aimlessly up the high street. He was only wearing his shirt and underpants and he looked so dishevelled, as he hadn’t even washed or shaved. When I visited today his cupboards were bare and he was eating his meals on wheels lunch with his hands. He seems to have forgotten how to use a knife and fork.

21. Problems with Speech and understanding People often forget common words used in everyday language. A person may start to find it difficult to identify everyday objects and experience problems in communicating the right terms or using the correct language. Initially dad would forget what certain things were called; instead of asking for a cup he would say something like can I have one of those things I drink tea out of? Now I get really frustrated as he cannot identify many everyday objects. The other day I asked him to put his watch on and he came back with a glove in his hand….he couldn’t remember what I had asked him to do. Difficulty in completing familiar tasks Tasks or activities which were automatically completed become impossible. My sister used to forget sequential activities such as making a cup of tea but with some gentle encouragement she would be able to complete the task. Everything is so muddled now. Yesterday, I found her putting her washing in the fridge and she got very agitated and angry when I told her what she was doing. She continued to insist her washing machine had broken down and told me to get the hell out of there.

22. Problems with Speech and understanding (continued) Misplacing things Initially people will misplace and forget where they have left certain personal belongings but they will eventually come across them. However, as the condition progresses they may become suspicious and start accusing others of stealing things from them. This can be extremely distressing for both the person with dementia and their carers or loved ones. My brother’s neighbour called me in a distressed state last night. Apparently he was shouting and cursing at her claiming she had stolen his wallet…. they have been neighbours for fifty years, he even called the police! Decline in personal ability to cater for themselves As the condition reaches its latter stages, the person with dementia will become increasingly dependent on others to meet their daily needs. At the most advanced stage mobility becomes hindered and loss of bladder and bowel control is a common experience. Last year dad managed to make himself a meal and drinks with visual written prompts around the house, but he became so forgetful he just wasn’t looking after himself. He ended up dehydrated and was showing signs of malnutrition; he stopped going shopping and was in such a muddle. His personal hygiene became poor and he has been dressing in clothes inappropriate to prevailing weather conditions. We are now looking in to residential and care facilities because he is at such a risk of accidental harm and self neglect.

23. Hallucinations These are experiences which affect one or more of our five senses. People may hear (auditory), see (visual), smell (olfactory) taste (gustatory) or feel (tactile) something in the absence of any external stimuli. I asked to see my mother’s Community Mental Health Nurse today as I am extremely worried. Mum seems to be picking at the air and dusting herself down, she keeps saying insects are crawling all over her and its really upsetting for us. Delusions Delusions are false beliefs which are fixed and resistant to reason or argument, and not in keeping with the person’s cultural or religious background (Lyttle 1986). Often the delusions are accompanied by hallucinations. In the following case it would be an olfactory hallucination causing persecutory delusions. My grandfather believes his neighbours are running gas through his air vents and he thinks they are trying to kill him. I try to reassure him this isn’t the case but he becomes very angry and accuses me of being in on it.

24. Confusion A person with dementia’s attention and behaviour appears to become detached from people and events occurring around them. Concentration and judgement becomes impaired. Initially carers say their loved ones seem to engage in a series of purposeless activities. I went to see Dad on the ward today and he appears increasingly confused, he did not even recognise me. He kept wandering around picking up things along the way. When I arrived today he was carrying someone else’s shoes, a box of tissues and a tablecloth. He became so angry when the staff attempted to take them from him. Personality and Mood Alteration Certain existing personality traits may become magnified or the person may behave in a way that is increasingly out of character. This is a very troublesome experience for both the sufferer and their loved ones. This can put immense strain on relationships and the concerns expressed by others may exacerbate hostile reactions. At the beginning we noticed mum was becoming short tempered but that was born out of pure frustration. Now she uses obscenities and physical aggression for no apparent reason. Her mood can change in an instant she can be shouting and cursing one minute then switch back to her true soft and gentle self.

25. Confusion (continued) Impaired Judgement As the condition progresses, people with dementia may lack insight into potential risks to health and safety. A person may unintentionally leave gases on or hot pans unattended. Last week a neighbour found dad’s door wide open during the early hours of the morning. This week he left the gas on which caught light to his coat which he placed on the counter next to the cooker. Thank god the home help had just arrived. Behavioural changes Behavioural changes can appear out of character or existing behavioural traits may become exaggerated. Changes may be subtle at first but gradually increase as the condition progresses. I feel mortified when my father keeps undressing himself. He appears oblivious to the staff and other residents and when anyone attempts to intervene he becomes really angry.....he never used to swear.

26. Loss of interest and initiative People often lose interest and volition in previous activities or hobbies they used to gain pleasure from. The lady next door was always in the garden pottering about, she would spend hours on it and it used to look so beautiful. Now she just wanders out and stares at it, her expression is so blank and she seems to have lost all interest in it. Disturbed Sleep Disorientation and confusion often leads to reversed or disrupted sleep patterns. I am so tired as my husband is sleeping periodically through the day, but during the night he just wanders around the house saying ‘Where am I’ or ‘Where is everybody?’

27. Loss of interest and initiative (continued) Agitation and Restlessness These symptoms are usually caused by one or many of the complex experiences already explored in this section. However, it is important that other potential underlying physical factors such as pain or infection, for example, are eliminated. Consideration should also be made to the person’s underlying emotional and psychological well being. Dad is much more relaxed since he started to take the antibiotics. He still has his moments but he is much more responsive to prompting and reassurance. He is back to enjoying our afternoon walks now. For more information go to: Alzscot.org Source: Alzscot ORG

28. Behavioural interventions Behavioural interventions may typically involve working with those individuals who provide care or support for someone with dementia.Behavioural interventions may be helpful when working with individuals who present with challenging behaviours and risk issues (e.g. wandering, aggression, safety issues and sexually inappropriate behaviour).There are different ways of working with people who present with behaviour that challenges. Here is one example: • Changing those events that happen before the behaviour • This can be considered to be the most important way to change behaviour. • This involves changing or modifying the environment so that behaviour is less likely to happen in the first place. • E.g. adapting a ‘busy’ environment by reducing noise, modifying lighting and the number of people present.

29. Communication disorder Communication disorder becomes apparent during the course of all types of dementia, varying according to disease type, duration and other factors such as pre-morbid skills, personality and environment.Research shows communication represents one of the major problems for carers and families of the person with dementia (Touzinksy 1998) Communication is a basic part of human life. For people with dementia their ability to communicate can be significantly impaired (Bryan, Maxim 2006)

30. Communication disorder (continued) This in turn can have a profound affect on their loved ones and carer’s abilities to communicate effectively with them; ultimately it will impact negatively upon the care process and the quality of life for the person with Dementia. Communication skills should be pivotal to the care planning process. The Joseph Rowntree Foundation (2001) state that communication skills “are an essential element of good care”This module has been designed to assist learners in developing or refreshing their understanding of communication skills and identify approaches which may be useful in improving the quality of life and care for the person with dementia.

31. What is Communication? Communication involves the exchange of thoughts, messages or information, as by speech signals, writing or behaviour: http://www.thefreedictionary.com/communication Source: The Free Dictionary

32. So how do we communicate? Where do you think each method of communication belongs? Why do we communicate? For the person with dementia the reasons are the same!!!

33. What are the benefits of Good Communication?

34. Time to reflect The following message was written by the Author of “Dancing with dementia” and “Who will I be when I die” five years after her diagnosis of dementia. Try to understand how hard it is for us…It’s just that you can’t see the missing bitsThat we are having to cope withoutChristine Bryden (2009)

35. Let’s look a little deeper Try to visualize yourself in a building with many rooms and corridors, you cannot find yourself back to the starting point because everywhere looks so unfamiliar, people are approaching you that you have never met before but they seem to know you. There are other people around you who seem muddled and you cannot communicate with each other. The people that seem to know you tell you that you cannot go home to your spouse or partner because they are no longer around. Sometimes these people want to take you to the toilet, sometimes they want to bath you, and dress you in clothes you do not like, they give you food you do not like because when you try to tell them it comes out disjointed and garbled, it’s almost like you are speaking an alien language. They keep telling you to stop crying. How would you feel...? TAKE A LITTLE TIME TO THINK ABOUT THIS.

36. Socially inclusive communications The ability to relate to people experiencing communication problems can impact upon all areas of care, in either a negative or positive way.Let’s now look at the possible consequences of good and poor communication

37. Possible consequences of good and poor communication

38. Communication and the person with dementia For people experiencing dementia the area of the brain that deals with understanding and interpreting what is said gradually dies. This in turn acts as a barrier to verbal interaction and understanding. Dementia impairs a person’s ability to receive and understand information and the ability to express information is often affected, these troublesome symptoms are exacerbated by loss of memory, disorientation, impaired concentration and attention. Some examples include: • Difficulty in saying words • Saying a related word not the right one • Not being able to understand what is being said to them • Grasping only parts of what is said to them • Deterioration in the ability to write and understand the written word • Able to talk about distance past but not recent events • Loss of social conventions of conversation e.g. taking turns • Difficulty in communicating emotions appropriately • Repetitive verbalisations • Confabulation where a person talks fluently but does not make any sense. Gaps in memory…are filled by fabricated dialogue.

39. For communication to work For communication to work it is necessary that everyone can convey and understand the message. The key to positive experiences is a clear and concise understanding of an individual’s unique communication patternsIt is therefore of upmost importance that a clear assessment of an individuals communication skills is completed for all service users and incorporated into their individual care plans. This will ensure their ability to be understood is maximised and assist carers in optimising the person’s level of daily functioning, independence and ultimately improve their quality of life.

40. For communication to work What information should be considered? Information such as: • How much does the person understand? • Can they express their needs wants and wishes? • Situations the person finds distressing. • Hearing and visual impairments. • Primary language and cultural background. • Health problems, pain for example, this can often be an underlying cause of challenging behaviour. • Existing speech impairments • An individual’s unique communication patterns. • SEPT has a comprehensive therapeutic tool (My life story) for staff to use in order to develop strong and meaningful relationships and interactions with the person with dementia and their loved ones. my life story folder Source: SEPT Staff handbook

41. Body language It is important to recognise that for people experiencing dementia non verbal language (Body language) is often their only means of expressing themselves Also remember a person with communication problems may pick up on your negative body language such as sighs and raised eyebrows for example.An ability to be sensitive and responsive to non verbal behaviour is a key skill for staff to develop when working with people with dementia. This skill is possessed by us all and is often based on instinct or our primitive heritage, for some it may be more developed than others.

42. What is non verbal behaviour? When you watch most people, you will see they communicate non-verbally; how often have you been in a social environment and observed other peoples non verbal behaviours which have revealed clues about the nature of their relationships and interactions. It is important to remember Non verbal communication varies culturally. It is therefore necessary to find out about a persons cultural background to avoid misinterpretation.

43. Non verbal communication

44. Verbal Skills The emphasis so far has been on non verbal behaviours because as we have already identified verbal memory and language skills will be impaired to a lesser or greater degree depending upon the nature and course of the Dementia .This does not however mean non verbal communication is exclusive but should be supplemented with verbal communication

45. Verbal Skills (continued) • Verbal skills include: • Questioning 1. Using closed questions which elicit yes no answers will minimise over complication i.e. “Mrs B would you like a cup of tea with your breakfast? 2. ”An open ended question would sound something like this “Mrs B would you like tea, coffee, apple juice , toast or cereal for your breakfast?” Too much information!! • Clarifying This is where you try to break down complicated communications I.e. Mrs B states “I am sad …. Breakfast, where’s my husband …..It’s all too difficult?” • Response Mrs B am I right in thinking you are missing your husband? Are you saying you would like your breakfast now? Are you saying you would like help you get your breakfast? Your response should be broken down into closed questions and dealt with one by one. • Reflection This is where you try to identify the underlying emotions of feelings a person may be feeling. I.e. Mrs B repeatedly says “It’s not good it’s not good I…….wa…..” Mrs B also appears slouched and has her arms folded tightly across her body. • Response Mrs B you seem upset are you in pain?

46. Good practice The way you deliver your verbal skills is important too:Communicate a normal TONE of voice, loud or high pitched verbalisations can be anxiety provoking. • Pace Speaking slowly and clearly this will promote understanding. • Pauses Will allow the person time to assimilate what information they can pacing communications will also help to minimise further confusion and agitation. Always wait for an answer, if the person does not answer try again. • Diversion or Distraction This is where you divert a person’s attention away from repetitive or preoccupying feelings for example.Finally remain calm, show you are listening and smile when appropriate.

47. Good practice (continued) Regardless of the stage of dementia it is so important to focus on working creatively with the person with dementia to find alternative ways of communicating. Remember it is a two way process.We have already identified the Trust’s Life story books, the benefits of being aware of our own non verbal communication and being sensitive to the individual’s unique communication patterns.In recent years the use of talking mats as an aid to communication with the person with dementia has been researched and found to have positive outcomes .The Social Care institute of Clinical Excellence completed a research study which showed that using talking mats improved communication for all people at all stages of dementia. Using 'Talking Mats' to help people with dementia to communicate Source: rf.org.ukTalking mats offer a low cost tool which families and staff can use. Click here to view a video of Talking Mats being used with a person with Dementia http://www.talkingmats.com/news.htm Source: talkingmats.comFor further information on talking mats and training go to http://www.talkingmats.com/dementiatraining.htm Source: talkingmats.com

48. Communication checklist • Ensure you have a full knowledge of the person’s unique communication patterns i.e. Mrs B tends to wander around a lot more when she needs the toilet. • Position yourself in line with the person’s vision and maintain balanced eye contact, unwavering eye contact can be interpreted as confrontational. • Do not invade a persons personal space…do not assume the person is hard of hearing because they are old!!! • Always adopt a calm and approachable posture this will promote feelings of safety and security. • Check for any sensory impairments i.e. hearing and eyesight. • Listen carefully and keep checking for understanding. • Keep sentences short and simple. • Give short, clear and precise instructions allow time for what you have said to be interpreted and repeat if necessary. • Promote understanding by giving instructions such as “you clean your teeth with it “ • Always promote independence do not be tempted to complete activities of daily living for someone who is able to respond to non verbal and verbal prompts • Modify gestures which may be distracting • Listen for and learn to recognise the feelings and emotions rather than the words.

49. Communication checklist (continued) • Always promote independence do not be tempted to complete activities of daily living for someone who is able to respond to non verbal and verbal prompts • Modify gestures which may be distracting • Listen for and learn to recognise the feelings and emotions rather than the words. • Checklist - continued • Use non verbal behaviour such as tone of voice, touch and the way you move to convey messages to the person with difficulty in understanding language. • Offer verbal prompting “good” and “that’s right” • Non verbally demonstrate the activity you are helping the person to complete i.e. mimic brushing your teeth or shaving. • If you are actively engaging in self care with someone less able to attend to their needs independently give a commentary of exactly what you are going to do in advance, as this will promote feelings of security. • Modify gestures which may be distracting • Use head nodding in agreement and shaking it to disagree • Supplement your speech with gestures such as thumbs up or ok. • Never shout this will only serve to distract and frighten the person. Caring can be a stressful experience at times and may sub-consciously influence your pattern of communication. • If you feel frustrated take time out and return a minute or two later (along as persons safety is not compromised)

50. Communication checklist (continued) • Never be Judgemental i.e. “that’s him he’s a nasty aggressive man” • Remember remain calm and be aware of your non verbal behaviour as the person with dementia may recognise negative non verbal clues. • Do not patronise a person, conversation should be simple but remain on an adult level to preserve dignity and self esteem. • Incorporate information in your conversation which tells the person where they are, what is happening around them and who they are with, this will make them feel more secure and less confused. • Avoid too many choices present only one at a time. • It may help to ask questions which require only yes no answers. • Be aware of environmental factors which may interfere with communication i.e. competing noises such as TV or radio always make sure the environment is conducive for communication. • Make sure glasses, hearing aids and dentures are correctly prescribed and well fitting. • Ensure the environment has adequate signage. • To access a more comprehensive free downloadable fact sheet on communication and Dementia (written by the Alzheimer’s Society) click on the link below Communication and Dementia Source: alzheimers.org.uk