The Importance of Good Communication Skills

Communicating with a person with a dementing illness, such as Alzheimer's disease, can be a terribly difficult task. Often in the early stages of a dementing illness, people have trouble finding the words to express their thoughts, or may be unable to remember the meaning of simple words or phrases; but these problems are usually minor inconveniences or frustrations. The later stages may be much more difficult with language skills quite impaired, resulting in nonsensical, garbled statements, and great difficulty in understanding.

When people cannot comprehend what is being said, or cannot find the words to express their own thoughts, it can be painful, frustrating, and embarrassing for everyone. The following are some suggestions of things to think about when communicating with an impaired person.

Your Approach - You Set the Tone

• Think about how you are presenting yourself. Are you tense? Frowning? Are you being bossy or controlling? People with dementia are often extremely aware of nonverbal signals such as facial expression, body tension and mood. If you are angry or tense, they are likely to become angry, anxious, or annoyed.
• Try a calm, gentle, matter-of-fact approach. You set the mood for the interaction. Your relaxed manner may be contagious.
• Use a non-demanding approach - try humor, cajoling, or cheerfulness. Humor or gentle teasing often helps caregivers through difficult moments. Convincing someone to get out of bed or go to the bathroom is usually easier if you can make a game or joke of it. Ordering or demanding may be much less successful with some people.
• Try using touch to help convey your message. Sometimes touch can show that you care, even when your words don't, or when you are not understood. Some people shy away from being touched, but most find a gentle touch reassuring.
• Begin your conversation socially. Winning the person's trust first can often make a task much simpler. One way of doing this is to spend time chatting before approaching the task at hand. For example, you might spend ten minutes talking about weather, or family members, or some reassuring topic, to help get the person in a relaxed frame of mind. Again, you are creating a pleasant mood.

Things to Think About When You Speak

• Talk to the person in a place that is free from distractions, such as equipment noise, television, or other conversations. People with dementia often have very little ability to screen out distractions.
• Begin conversations with orienting information. Identify yourself, if necessary, and call the person by name. After creating a relaxed atmosphere, explain what it is you propose to do.
• Look directly at the person and make sure you have his or her attention before you begin to speak. If you cannot get the person's attention, wait a few minutes and try again. Move slowly. Gently touch an arm or hand to gain attention, while saying the person's name several times. Be careful not to startle him or her.
• It is important to be at eye level with the person, especially when talking to someone who is very impaired or who is hard of hearing.
• Speak slowly and say individual words clearly. This is particularly important for people with hearing problems or those who are in the later stages of dementia.
• Use short, simple sentences. People with dementia may not be able to remember more than a few words at a time. Pause between sentences and allow plenty of time for the information to be understood.
• Ask simple questions that require a choice of a yes/no answer, rather than open-ended questions. For example, instead of saying, "What would you like to wear today?" you might say, "Do you want to wear this green dress or this red one?" or "Is this the dress you would like to wear today?"
• Use very concrete terms and familiar words. As people become more impaired, they lose the ability to understand abstract concepts. Thus, you may need to say, "Here is your soup at this table," instead of "It's time for lunch." They may also revert to words from childhood or earlier in life, so that "Do you need to go to the bathroom?" may not be understood as easily as "Do you have to pee?"
• Talk in a warm, easygoing, pleasant manner. Try to use a tone of voice that you would like people to use with you.
• Keep the pitch of your voice low. Sometimes when people don't immediately understand us, we have a tendency to shout. This will simply upset the person with dementia and will make communication more difficult.

When Doing a Task Together

• Try to focus on familiar skills or tasks. People with dementing illnesses gradually lose the ability to learn new tasks, but may be able to do familiar work, hobby-related tasks or household chores even when very impaired.
• Give choices, whenever possible. For example, choosing whether to take a bath before or after dinner, or choosing which of two shirts to wear, may help the person continue to feel some sense of control over life.
• Allow plenty of time for the information to be absorbed. People with dementia often need much more time to absorb simple statements or instructions. Allow a moment of silence before gently repeating an instruction. This requires a lot of patience on the part of caregivers.
• Repeat instructions exactly the same way. It may take a number of repetitions before the person responds. If, after allowing for plenty of time, the instructions are still not understood, try using different key words, or demonstrating what you want the person to do.
• Break the task down into simple steps. Most of our daily tasks are very complex activities; the concepts of "getting dressed" or "taking a bath" may be too overwhelming and abstract for a person with a dementing illness. Instead, the person may be able to respond better to small, concrete steps - one part of the task at a time. For example, the first step in getting dressed might be unbuttoning pajamas. The second step might be taking the right arm out of the sleeve. Find out which steps the person is able to do and encourage those. Gently help with steps that are most difficult. Although this technique takes time and practice, doing tasks together can become more successful and pleasant.
• Modify the steps as the person becomes more impaired. You may need to break the tasks into even smaller steps, or you may need to gradually begin doing some of the steps that the person was able to do previously. Again, this takes time and patience on the part of the caregiver, but can be very rewarding for both the person with dementia and the caregiver.
• Praise sincerely for success. We all need to hear that we are doing a good job, and for people who are losing their abilities it may be particularly important. Praise doesn't need to be long or "gushy," but may be a simple "Thank you" or "You did a nice job."

When You Are Having Trouble Being Understood

• Listen actively and carefully to what the person is trying to say. If you do not understand, apologize and ask the person to repeat it. Let him or her know when you do understand by repeating it or rephrasing it.
• Try to focus on a word or phrase that makes sense. Repeat it back to the person and try to help him or her clarify what is being said.
• Respond to the emotional tone of the statement. You may not understand what is being said, but you may recognize that it is being said angrily or sadly. Saying, "You sound very angry," at least acknowledges the feeling, even if you cannot decipher the words.
• Try to stay calm and be patient. Remember the person is not doing this on purpose and is probably even more frustrated than you. Your calmness and patience will help create a caring atmosphere that will encourage the person to keep trying.
• Ask family members about possible meanings for words, names, or phrases which you do not understand. Sometimes people with dementia talk in a kind of code that may make sense to people who have known them for a long time. A name called over and over may be a close friend or relative from the past whose memory is reassuring. "Let's go down that street to my house," may be a very logical way of referring to a long corridor and room, when the names for these places have disappeared from memory. Language from childhood, such as names for bathroom habits or pet names for things, may reappear in the person's vocabulary. While it is helpful to use their words (e.g., "pee" or "tinkle"), it is important to continue to treat them as adults, not children.

Things Not To Do

• Don't argue with the person. This always makes the situation worse. Furthermore, it is important to remember that a person with dementia no longer has the ability to be rational or logical to the extent you do.
• Don't order the person around. Few of us like to be bossed around and the person with dementia is no exception. Even when your words are not understood, your tone of voice will be.
• Don't tell the person what he or she can't do. State directions positively instead of negatively. Instead of "You can't go outside now" try "Let's sit down here and look at these pictures."
• Don't be condescending. It is hard not to use a condescending tone of voice when you are speaking slowly and in short sentences. However, a condescending tone is likely to provoke anger, even if the words are not understood.
• Don't ask a lot of direct questions that rely on a good memory. Often our attempts at being sociable involve asking people about themselves. Remember that people with dementia have memory loss and may feel humiliated or angry if you ask questions they can no longer answer. Try rephrasing. For example, instead of "Who is this in the picture?" say "This must be your daughter." This approach allows the person to reply gracefully and noncommittally if he or she is not sure.
• Don't talk about people in front of them. It is easy to fall into the habit of talking about people in front of them when they can no longer communicate well. It is impossible to know how much someone with dementia understands, and this may vary from moment to moment.

When Verbal Communication Fails

• Try distracting the person. Sometimes simply diverting the person's attention to other activities (e.g., going for a walk, changing the subject, offering a snack, turning on the television) may be enough to diffuse an angry or anxious mood. Try again later.
• Ignore a verbal outburst if you can't think of any positive response. It is much better to ignore angry or agitated statements than to become angry yourself. You might also try apologizing and letting the subject drop, or changing the emotional tone of the conversation. (e.g., making a positive, cheerful comment, instead of an angry reply)
• Try other forms of communicating. There are lots of ways of communicating that don't involve words. Familiar songs, gentle touching, massage, favorite foods, or walking together can often demonstrate concern and affection more effectively than words. These modes of communicating can also help soothe a troubled person and take the edge off difficult moments.

Prepared at Eastern Michigan University in collaboration with the Alzheimer's Association (ADRDA) - Greater Ann Arbor Chapter with a grant from the Department of Mental Health. Authors: Anne Robinson, Beth Spencer, and Laurie White

Copyright September, 1988. These materials may be duplicated with proper acknowledgment.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

For further information about Alzheimer's Disease or related disorders, contact the Alzheimer's Association at:

• Alzheimer's Association of the Great Plains, 402-420-2540 or 1-800-487-2585 (Helpline)
• Midlands Chapter, 402-572-3010 or 1-800-309-2112 (Helpline)