Communication or Language Problem

September 19, 2007

As Alzheimer’s disease progresses, language problems become more evident. The patient may ramble on, almost incessantly, in what may appear to be irrelevant, disorganized, repetitious, and fragmented sentences. In more advanced cases the patient may mumble unintelligible phrases or remember only a few key words which may be used in appropriately. Eventually the patient may be unable to speak at all. For most families, the patient’s loss of effective speech is the most upsetting of all the Alzheimer symptoms. While confusion and memory loss may frustrate the family, the demented individual may still be perceived as the “same person.” It is when Alzheimer patients have lost the ability to speak that families experience their loved ones as different from the persons they once knew. The family may believe that thoughts and feelings can no longer be shared with the patient; this may lead to fears that the patient experiences suffering without being able to communicate it.Family members who are concerned about such issues must remember two important points. First, the severity of the patient’s language impairment may not be an accurate indication of the degree of dementia. The symptoms and presentation of Alzheimer’s disease may take many forms. In some patients, deficits in language may occur early in the illness, yet for other patients, language may remain relatively intact, while attention span, memory, or visualspatial reasoning and coordination may be impaired.

Patients who have trouble vocalizing and producing logical speech may give the false impression that they are stupid or very impaired. Conversely, one might erroneously assume that if persons can repeat spoken instructions or read a set of directions, they should be able to carry them out. Not infrequently, such patients are judged to be cantankerous for not following directions (e.g., to eat or take medication at a certain time), when in fact they have severe problems in comprehending or executing directions. The second point to keep in mind is that spoken words are only part of a communication process. Patients with Alzheimer’s disease may communicate their needs and feelings through nonverbal means (i.e., facial expression, body posture, and actions).

Families concerned about communication problems in the Alzheimer patient should first have auditory (hearing) and visual (seeing) perception and acuity tests performed, providing corrective devices (i.e., hearing aids or glasses) when appropriate. Families may also opt to have a speech therapist evaluate the Alzheimer patient who exhibits language problems. Such an assessment can help the family understand the type of speech disturbance the patient is experiencing, and also provide them with tips on how best to communicate with their loved one. The following are some general considerations to keep in mind when communicating with the Alzheimer patient who has language problems.

Communication Aids for the Alzheimer Patient Who Has Problems Understanding Others

The Alzheimer patient has difficulty in correctly understanding what is going on in the surrounding world. First, older people in general have many more problems with their vision and hearing, which can cause confusion and uncertainty. Alzheimer patients have an added difficulty: they must make sense of (Le., identify, organize, and process) the information that does reach their senses. This obstacle is compounded by difficulties pertaining to attention span, concentration, and memory. A demented person may be able to repeat verbal instructions or read written directions without necessarily understanding, remembering, or being able to act upon them. Similarly, the patient may be able to understand a statement when delivered face-to ­ face, but fail to comprehend what is said over the telephone.

The following suggestions should be helpful in communicating messages to the Alzheimer patient -

1. Make certain the patient hears you by speaking loudly (but not so loud as to frighten), standing face-to-face, and maintaining eye contact.
2. If you do need to raise your voice to be heard, lower the tone (pitch). A high-pitched voice may suggest to the patient that you are upset. The tone of your voice should always reflect calmness, reassurance, and the sense that you are in control of the situation.
3. Use overemphasis and exaggerated facial expressions to stress your point. Hand gestures and pointing to objects can be very beneficial in conveying a message.
4. Distracting or competing noises and activities should be eliminated. Alzheimer patients experience tremendous difficulty sorting out stimuli and focusing their attention.
5. Use short words and simple sentences (no more than four words) conveying only one message or thought.
6. Begin each sentence by addressing the patient by name and by identifying yourself if necessary. Use only nouns; avoid the use of pronouns (e.g., it, she, they).
7. Ask only one simple question at a time. Do not include complex or multiple choices in a question (e.g., “Do you want to visit John or Cousin Sue, or wait and go shopping later?”). If you must repeat a question, attempt to repeat your words exactly.
8. Break each task into simple steps and ask the person to do one step at a time. Most of the things that we ask the patient to do (e.g., get dressed, take a bath, brush teeth) are actually composed of a number of sequential tasks. The Alzheimer patient may not be able to sequence the events.
9. Speak slowly and wait for the person to respond. What seems like a long and unproductive silence to you may ret1ect the Alzheimer patient’s attempts to concentrate, comprehend, and formulate a response. If the response does not come in one or two minutes, repeat your question exactly.
10. Use humor in your communication whenever appropriate and encourage the patient to express humor, especially in difficult and trying situations.
11. Even with patients who have severe language problems, do not assume that the patient never understands you. Abilities fluctuate and it is inconsiderate and demeaning to talk in front of the patient as though he or she were not there.

Communication Aids for Patients Who Have Trouble Expressing Themselves

Alzheimer patients frequently have considerable difficulty expressing themselves, which can lead to feelings of frustration in both the patient and the family. Such problems in communication may precipitate an emotional outburst in the patient (e.g., bursting into tears or storming out in a fit of anger), because it is felt that no one understands. How you attempt to help the demented person’s self-expression will depend upon the type of difficulties the patient experiences as well as his or her personality and temperament.

For instance, some patients who suffer from anomia, or difficulty in naming things, may become quite annoyed and even angry if a caregiver intervenes to provide the correct word. Such patients may find it hard to accept their disabilities and their increasing dependence upon others. Some patients may feel less frustrated and be appreciative if they are sup­plied with the correct word rather than left on their own to search and struggle for it. If the patient has used the wrong word and you are not certain what is being talked about, you may ask that the object be pointed out and described.

At other times, the only way to determine what a patient is trying to communicate is to make a series of guesses. In some cases this may require taking into consideration not only the words the patient has provided, but also the manner in which they are presented (e.g., anxiously concerned, assertive and demanding, nervous and restless). For example, a patient may constantly make some inquiry about food. Efforts to explain when the next meal might arrive or describing the menu seem not to alleviate the concern. Such a patient may be expressing fears of being cared for properly and the need for reassurance.

For patients who can say only a few words, or shake and nod their heads, it is necessary to set up a regular routine and a standard set of questions for checking on their well-being. If these patients appear to be in distress. go through a checklist of what might be ailing them, proceeding slowly and checking on one point at a time (e.g., Are you hungry? Are you cold? Do you need to use the bathroom?). Point to body parts rather than naming them (e.g., Does this hurt?). The key points to remember are: convey your patience and concern to the demented person, and check each of your guesses with the patient to determine their correctness.

Nonverbal Communication

Much of this section has made reference to the manner in which the caregiver and the patient may communicate without the use of spoken language (i.e., through posture, gestures, and facial expressions). This type of communication actually goes on all the time even when speech is used (e.g., avoiding eye contact when ashamed, tensing body posture when angry, tapping the hand or foot in impatience). It is extremely important for the family member to read or interpret what the patient’s behavior is conveying, and to also be aware of the nonverbal messages that are sent to the patient.

In communicating with the Alzheimer patient, first determine if the patient is receptive and listening to what is being said. The receptive, attentive patient will appear relaxed in facial expression and in muscle tone, will extend a hand or offer verbal greeting, will smile and nod to statements, will sit or stand still, will maintain eye contact, will lean forward or cock the head to one side to hear better. A nonreceptive listening patient turns away from the speaker, avoids direct eye contact, does not nod in affirmation or ask questions for clarification, may appear confused, appears restless or walks away, frowns, has general body muscle tension, fidgets or shakes, may appear anxious, or pulls away from physical contact. If the patient appears to be nonreceptive because of some negative emotional state (e.g., fear, panic, or anger), it may be best to leave him or her alone rather than risk escalating feelings. You may want to let the patient know that you realize he or she does not want to talk now and that you will return later. Never try to force a patient to do something.

The following are some suggestions on how to increase your ability to express yourself with the nonverbal patient -

1. Caring for the Alzheimer’s patient can generate chronic feelings of fatigue and frustration. You must be careful, however, not to convey these feelings through body language, as they may upset or agitate the patient. Strive to maintain a calm exterior and remain pleasant and supportive.
2. Even a severely demented and non-communicative patient needs affection. Smile, hold the patient’s hand, place your arm around the person, or provide an occasional hug.
3. Touching can also be a more direct and effective technique for communication, e.g., redirecting the patient back to the task at hand, inhibiting an undesirable response, or calming and reassuring the patient.
4. Look directly at the patient, and sense the person’s receptiveness, if necessary hold off on your communication until later when he or she is more able to listen
5. Use gestures, point, touch, and hand the patient objects. Use pantomime or direct action for purposes of demonstration and imitation (e.g. brushing the teeth).

Communication with an Agitated Patient

A final and important point concerns how to recognize growing agitation and negative emotion in a patient. Frustration, fear, hostility, and aggression in the Alzheimer patient may be communicated through general increase in body movement and agitation, such as restless, rapid pacing; kicking doors or rattling door knobs, pushing furniture about, making firsts or waving arms, Facial changes, such as grimacing, frowning, or darting eyes; changes in voice, such as an increased volume, speech, and tone and physical changes, such as rapid breathing, widening of the eyes, dilating pupils. and tightening of muscle tone. When a patient demonstrates such signs of agitation, approach the person with calmness and reassurance, reduce the surrounding stimulation (e.g. turn off the television or radio, and have others move away), remove dangerous objects from the area; do not pressure the patient or make additional demands, and make certain that all your communications, both verbal and nonverbal language. are consistent. In such stressful situations, the patient’s memory loss may work to your advantage. Distracting the patient or removing the individual from the situation may make it difficult for him or her to remember what was so upsetting.

Posted in Alzheimer's Disease Disorder