Module 2 of 2 · 45 minutes
Communication, the environment, and the family
By the end of this module you will be able to
- Adapt communication for each stage of dementia
- Modify an environment to reduce distress
- Respond to walking with purpose and to time shifting
- Support a family through diagnosis, guilt and grief
Work through it
1 interactive for this module, built on the WAJD Teach engine. Nothing moves until you ask it to, and every one has a written version if you would rather read it.
Amara She asks for her mother, who died forty years ago. What do I say?
Nadia There are three options and only one is any good. Correct her, and she learns her mother is dead, freshly, every single time you do it.
Amara That is cruel.
Nadia It is unintentionally cruel, which is why it is so common: people think honesty requires it. Second option, lie. Yes, she is coming, a taxi is on its way. That damages trust and it eventually gets found out.
Amara And the third?
Nadia Respond to the feeling underneath. Tell me about your mother. And now you are having a conversation she can win instead of one she loses.
Amara How do I know what the feeling is?
Nadia It is nearly always in the sentence. She has to get home because the children need her. That is: I am needed somewhere and I am anxious. And that you can actually do something about.
Amara Anything I should stop saying?
Nadia Do you remember. It is a test, it produces failure, and failure produces distress. Supply the information instead. I am Amara, I helped you at breakfast.
Amara Let us talk about the environment. Ours is quite nicely decorated.
Nadia Decoration is not the question. Contrast is. What colour is your toilet?
Amara White. Against a white wall and floor.
Nadia Then some of your residents genuinely cannot see it. Age related visual change reduces contrast sensitivity, and a white object on a white background disappears.
Amara We have people we describe as incontinent.
Nadia Some of whom may have a visibility problem rather than a continence problem. A contrasting toilet seat costs about fifteen pounds and it has solved that in a lot of services.
Amara What else is doing damage without us noticing?
Nadia Shiny floors, which read as wet, so people stop dead or edge round them. Dark mats, which read as holes, so people step over them and fall. And noise.
Amara Noise?
Nadia Three conversations, a television nobody is watching, and a call bell. With impaired auditory processing that is genuinely disabling. Turning the television off is a clinical intervention, and nobody writes it in a care plan.
Amara What about walking? We have residents who walk constantly.
Nadia It used to be called wandering, which was a poor word because it implies aimlessness. They are going somewhere. Find out where.
Amara How?
Nadia The life history and the clock. It is usually work, children or home, at the hour that thing used to happen. And then the answer is a safe route to walk and something meaningful at that time, not a chair and a distraction.
Amara Late afternoon is our worst time.
Nadia It usually is, and it is several things at once. Tiredness, falling light, staff changeover, hunger, and a lifetime of four o'clock meaning collect the children.
Amara So what do I change?
Nadia Put the light on before it starts, not after. Reduce demands at that hour. And put the familiar activity there instead of the bath, because a bath at four o'clock is a fight you have chosen.
Amara Last thing. Families are angry with us.
Nadia Often, and it is very rarely actually about you. They are grieving somebody who is still alive, which has no ritual and no permission attached to it, and the anger has nowhere else to go.
Amara What helps?
Nadia Give them something to do. Help at mealtimes, bring the music she liked, fill in the life history. They stop being redundant visitors, and your care gets better because you now know she worked nights for thirty years. Both of those are true at once, and it costs nothing.
The written material
Communication, and what to do about a false belief
Approach from the front at eye level. Say who you are every time without testing whether they remember. One instruction at a time. Wait, longer than feels comfortable, because processing can take many seconds. Use gesture and demonstration alongside words.
For a false belief, there are three possible responses and only one of them is good. Correcting causes fresh grief every time she learns her mother has died. Actively lying, agreeing that a taxi is coming, damages trust and eventually gets found out. Validation responds to the feeling underneath: tell me about your mother.
The feeling is nearly always the real content. Somebody who must get home to her children is telling you she is needed somewhere and is anxious, and that is something you can genuinely help with.
The environment is doing something whether you designed it or not
Contrast matters more than decoration. A white toilet against a white wall and floor is genuinely difficult to see with age related visual change; a contrasting seat solves a continence problem that was never a continence problem. Crockery that contrasts with the table increases how much people eat.
Signage should be at eye level, use a picture and a word, and be on the door itself rather than beside it.
Flooring: avoid shiny surfaces, which read as wet, and avoid dark mats or strong pattern changes, which read as holes and cause people to step over them or stop dead.
Noise is underrated. Several conversations, a television nobody is watching and an alarm all at once is genuinely disabling with impaired auditory processing. Turning the television off is a clinical intervention.
Light: older eyes need considerably more light, and poor lighting increases misperception and falls. Natural light also supports the sleep and wake cycle, which is where a lot of evening distress originates.
Walking, time shifting, and the family
Walking with purpose, which used to be called wandering, is going somewhere. Find out where. It is often work, children, or home, and it is often at the time of day that activity used to happen. The answer is rarely to stop them and is usually a safe route to walk and something meaningful at that hour.
Distress in the late afternoon has multiple causes: tiredness, low light, staff changeover, hunger, and a lifetime of that hour meaning collect the children or get home from work. Increase light before it starts, reduce demands, and put the familiar activity there rather than the bath.
Families carry guilt, grief and exhaustion, often simultaneously. They are grieving somebody who is still alive, which has no ritual and no permission attached. Expect anger, and expect it to be about the diagnosis rather than about you.
Give them something to do. A family who can help at mealtimes, bring music, or fill in a life history feels useful instead of redundant, and the life history improves your care. Both things are true at once and it costs nothing.
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