Adults with Alzheimer's in nursing homes who are talked to like children are more resistant to care, according to research reported earlier this year at the 2008 Alzheimer's Association International Conference on Alzheimer's Disease (ICAD 2008) in Chicago.
As effective pharmaceutical treatments and prevention for Alzheimer's remain elusive, some researchers are focusing their efforts on improving quality of life and care -- including communication. One study determined that there is a correlation between how nursing home staff communicates with residents who have dementia and the residents' subsequent resistance to care. Another investigated how families work to maintain normalcy and coherence during dinner time conversation when a family member with Alzheimer's is included.
"The style of communication that we use with people with Alzheimer's influences how they feel about themselves and how well they respond to those providing care," said Sam Fazio, PhD, Director, Medical and Scientific Relations at the Alzheimer's Association. "With the growing prevalence of Alzheimer's, it will be increasingly important for healthcare providers, caregivers and families to understand the effect Alzheimer's has on communication and, perhaps more importantly, the impact their communication may have on the individual's quality of life."
The growing population of adults with Alzheimer's presents complex challenges to care providers. Kristine Williams, RN, PhD, and colleagues at the University of Kansas School of Nursing explored the relationship between how nursing home staff communicates with those with dementia and subsequent behaviors that disrupt care, or resistiveness to care (RTC). Specifically, the study examined whether nursing staff "elderspeak" affected RTC behaviors.
The researchers defined elderspeak as overly caring, controlling, and infantilizing communication, similar to "baby talk." Common features are simplified grammar and vocabulary, substitution of collective pronouns, and overly intimate endearments.
RTC increases nursing staff stress, time needed to provide care, and costs of care. At the same time, RTC may actually indicate unmet needs that the person with Alzheimer's is unable to communicate in a conventional way.
Twenty nursing home residents with dementia were filmed during bathing, dressing, oral care, and other care activities (2005-2006) and the sequences subsequently analyzed (2006-2008, and ongoing) for nursing staff communication (normal talk, elderspeak, or silence) and resident behavior (cooperative, resistive to care, or neutral). Residents and staff in Special Dementia Care Units in three skilled nursing facilities in Kansas were used for the study. The mean age of residents in the sample was 82.9 years, with a range of 69 to 97. Cognitive test scores indicated a relatively homogeneous sample in the moderate stage of dementia. Staff participants were primarily (78 percent) certified nursing assistants. The remaining staff participants included nurses, therapists, and social workers who were involved in direct care.
The probability of RTC behavior varied significantly with the type of nursing staff communication. Residents with dementia were more likely to resist care when nursing staff used elderspeak communication; they were more likely to cooperate with care when normal adult communication was used.
The Resistiveness to Care Scale (RTCS) is a measure of the occurrence of and intensity of behaviors of persons with dementia including those that disrupt care. It assesses 13 behaviors including grabbing objects, saying no, adduction [holding the arms or legs tight against the body], grabbing a person, pulling away, clenching teeth, crying, screaming, turning away, pushing away, hitting/kicking, threatening, and moving the body in the opposite direction from staff. Each occurrence of the 13 RTC behaviors was scored by duration and intensity. The total RTC score was the sum of multiplying the duration of each incident by its observed intensity providing a weighted score within a possible range of 0 (no resistiveness) to 156 (maximum resistiveness).
When elderspeak communication was used, the probability of RTC was .55 (CrI = .44 - .66). In contrast, the probability of RTC was .26 (CrI = .12 - .44) when staff used normal adult communication. Silence resulted in a probability of .36 (CrI = .21-.55) for RTC.
"This study suggests that there is an association between communication style and resident behaviors," Dr. Williams said. "This may significantly impact nursing care and how nursing home staff should best be trained to communicate with residents with Alzheimer's. Future research is needed to test whether interventions that reduce nursing staff elderspeak communication will contribute to greater cooperation with care for persons with dementia."
Over their years together, family members often develop assumptions and expectations about their conversational roles and responsibilities. With the onset and progression of Alzheimer's, the person with dementia becomes less able to speak as others have always expected him or her to. Impaired word finding is often the first, most noted difficulty. Shortened attention span and/or impaired recent memory results in the individual no longer being able to follow another speaker's retelling of the day's events. In an attempt to participate in the conversation, the person with dementia may say something that shows confusion or misunderstanding. He may initiate an unrelated topic because he cannot remember what had just been discussed. These responses are not normally anticipated and may leave caregivers in a momentary quandary as to how to continue conversations.
Jeanne Katzman, CPhil, CCC-SLP of the University of California Los Angeles, examined the effects of Alzheimer's on family conversation at dinnertime. Thirty (30) families in which one member had recent onset of Alzheimer's participated in the three-year study, which began in 2001. Each family had two videotaped dinner conversations which were later transcribed and analyzed for both verbal and gestural communication. The goal was to document ordinary family communication based on naturally occurring conversation and to analyze problematic sequences.
According to Katzman, responses of healthy family members to utterances of the Alzheimer's individual were found to follow certain predictable patterns. When a response was unexpected and disrupted the normal flow of conversation, healthy family members often were observed to continue their talk almost if the person with Alzheimer's had not spoken. The healthy family members tended to pause - a sign that the utterance was indeed heard - but did not respond verbally. In such sequences, the healthy speaker's lack of response framed the Alzheimer's individual as a non-participant.
Katzman found that other families responded to each problematic utterance. In extended, multigenerational families (n=7), a healthy family member might respond with an explanation of the utterance and then speak for the person with Alzheimer's. Conversations between families with only two members (n=21) organized problematic talk in a greater variety of ways. Responses often took the form of rewording; the healthy speaker suggested what the other wanted to say, expanded upon it, and brought the contribution of the family member with Alzheimer's to a close.
"This initial research leads to an improved understanding of daily communication between people with Alzheimer's and their families. This will be used to develop new training programs that focus on facilitating conversation between family members," said Katzman. "The goals are for caregivers to have the opportunity to adjust their conversation with the changing communicative and cognitive abilities of their loved ones and for people with Alzheimer's to experience healthier participation in family discussions."