My mom struggles for words—she tries to explain something by saying “you know—that thing” and then gets frustrated when I don’t understand. When I read the newspaper to her, the articles get jumbled up in her head and she doesn’t know when one article ends and another starts. So, I just read short articles, Miss Manners, that sort of thing. I tell her “that’s the end of the article about former President Obama—this is a new article about the weather on the east coast.”

Caregiver, Pensacola, Florida, 2020

How Dementia Affects Communication

Think about the last conversation you had with a friend or family member. You said what you wanted to say. You understood the conversation and remember what was said. You probably had the conversation while doing something else—fixing breakfast or getting ready for work. You had no trouble understanding the conversation even if there was a lot of noise in the background.

When communicating with a person who has dementia, there are several things to keep in mind. What is the level of the person’s dementia? Is there a hearing loss? What is the setting? Are you having a general, social conversation or do you have a specific goal or task in mind?

A person with dementia has to work harder than you do to say what they want to say. They might not remember what was said a few moments ago and they have trouble talking and doing something else at the same time. Background noise can be confusing and irritating.

General Conversations

The 1st person with dementia I ever worked with was an older man who was also hard of hearing. We were doing some exercises that I hoped would improve his balance. I introduced myself, saying, “Hi, my name is Lauren”. He responded with a smile, saying “Hi moron.” I was shocked at his rudeness and didn’t like being called a moron. He also didn’t seem to understand that he had insulted me. It happened again with another person and I finally realized that “L” is a difficult letter to hear and my 1st client was trying his best to fill in a gap in his understanding. My sister (an ER nurse) thought it was hilarious.

Physical Therapy Aide, Ft. Lauderdale, Florida

General conversations are friendly and informal. They are not usually related to a specific task or goal. General conversations are social, a way to greet people and find out how they are doing. You can begin a general conversation by offering a greeting and asking for an opinion or giving an opinion. You can make a suggestion or ask for an explanation.

A general conversation can be about yourself, about your workday, your hobbies, or your family. It can include positive comments about people you work with or other family members or caregivers. If there is another person nearby you can include that person in the conversation.

You can connect with people by learning about what they liked when they were younger. What music was popular? Who was president? What major events happened in their younger years? Did they serve in the military? Where did they work? Where did they travel? What were their interests and hobbies?

People with dementia—especially moderate or severe dementia—may have difficulty with general conversations. They have difficulty understanding complex questions or statements. For example, instead of stringing together several thoughts or statements it is better to break down your greetings, statements, or questions into short, simple sentences. Listen carefully and use your judgment to determine if the person understood you. Although they may not remember what you talked about yesterday they still want to hear what you have to say, even if you are repeating something said earlier.

Conversations Related to a Task or Goal

Dementia affects goal-directed conversations just as much as it affects general conversations. When you want to complete a specific task, use what is called a “closed question.” This shows interest and invites a person to respond. Ask, for example, “Are you hungry?” or “Are you ready to get dressed?” Closed questions limit the conversation and keep the conversation focused on the task at hand.

Talk slowly and don’t argue. Use gentle persuasion and be positive when giving directions. Share your goals with the resident. Be respectful and relaxed. Keep in mind that the person you are caring for may not share your goal or agree with what you are asking. Or they may not understand what you want. It is very common for caregivers to mistake a response for understanding. At times, we all fake our understanding of a conversation—even those of us without dementia. The following story featuring Randy and Ann illustrates this point. Think about what you would do in this situation.

Strategies and Guidelines for Verbal Communication

Verbal communication is communication with words. It is an important part of daily life. Verbal communication creates positive relationships and lets us know that someone cares. It allows us to express our feelings and gives us the opportunity to assess the well-being of the person we are caring for.

A conversation with a person who has dementia begins with eye contact and an introduction. Starting with something light and conversational such as the weather or what’s happening in the news puts people at ease. Nonverbal gestures such as head nods, a light touch on the arm, and a warm expression create trust.

No matter how severe the dementia, practice these habits:

• Approach from the front, then kneel down to the side.
• Take a deep breath, relax, and offer your hand.
• Take a moment to really look at the person.
• Greet the person using their name, then introduce yourself.
• Avoid standing over the person, which may appear threatening.
• Ask a short, 1- or 2-step question and wait for a reply.
• Be attentive and sympathetic.
• Continue the conversation by asking a followup question.

Improving Nonverbal Communication

Nonverbal communication is communication without words. Facial expressions, eye movements, hand gestures, body language, and movements of the arms and legs are examples of nonverbal communication. Tone of voice and how well you listen and pay attention are nonverbal skills that matter just as much as verbal conversation. Some residents may understand gestures better than the spoken word.

How you dress, your posture, how you approach a person with dementia, and how close you stand to a person are also examples of nonverbal communication. Even silence is a form of nonverbal communication.

Touch is a powerful form of nonverbal communication. Touch can be friendly, frightening, soothing, dominant, or supportive. Touch has different meanings depending upon your culture, gender, age, and situation.

The way you speak carries nonverbal information. Your tone can reveal calmness or impatience, affection or disapproval, confidence or fear. When you are talking, the loudness of your voice and its tone and rhythm are communicating additional information. If you are hurried, frustrated, or angry, a person will pick up on your mood and body language more quickly than your verbal communication.

How the environment looks is a form of nonverbal communication. A clean, nicely decorated room with good lighting is supportive. It encourages people to interact. A drab room with harsh lighting and little decoration has the opposite effect—it shows a lack of support and respect. Some studies have shown that people say they don’t like other people when they see them in unattractive rooms.

Nonverbal communication using hand gestures and unhurried movement reinforces your words. If the person does not answer right away, be patient and wait a bit. It’s okay to be silent, which is calming and reassuring—especially in social conversations.

Develop good communication skills by:

• Listen respectfully, giving your full attention.
• Understand cultural and generational differences.
• Provide comfort using gentle, appropriate touch* and reassurance.
• Redirect to a pleasant activity if the person is feeling anxious or upset.
• Avoid arguments.

*Appropriate touch refers to professional and ethical behavior while considering the individual’s religious, cultural, and personal preferences.

Practice these habits:

• Approach in a calm and relaxed manner.
• Slow your own movements.
• Re-introduce yourself at each encounter.
• Address the person by a preferred name or title.
• Use short, simple sentences.
• Use hand gestures and appropriate touch to communicate your intentions.
• Avoid a condescending tone.

Communicating with Residents Who are Non-Communicative or Non-Responsive

As dementia progresses, verbal communication becomes increasingly challenging. Toward the later stages, verbal language may disappear altogether. People living with dementia may make nonverbal attempts to communicate, but these are often ignored, misinterpreted as “challenging” or judged incomprehensible. Communication difficulties are not only misinterpreted as signifying that people with dementia have nothing to contribute, but that they have lost the desire to participate in the social world (Ellis and Astell, 2017).

A lack of social interaction leads people with dementia to withdraw from social life and has a negative impact on caregivers as well. When faced with someone who has lost the ability to speak, caregivers often withdraw from those they care for. This may be due to discomfort on the part of caregivers who distance themselves as a method of coping with the demands of the situation. Finding alternative methods of communication has the potential to improve not only the quality of life of people with advanced dementia, but also the job satisfaction of care staff (Ellis and Astell, 2017).

Using nonverbal communication, such as soothing music, sounds, movements, appropriate touch, and facial expressions, has the potential to keep people with advanced dementia in the social world. Examples include:

• Encouraging participation in art: drawing, scribbling, painting
• Using scents and smells to evoke memories
• Holding hands
• Using photos and pictures
• Playing favorite music or tunes
• Singing
• Movement and dancing

Validation Therapy

Validation therapy is a type of interactive cognitive therapy developed by Naomi Feil for use in older adults with cognitive disorders and dementia. It arose from Feil’s experience as a young adult watching what she felt was the failure of reality therapy in this patient population. She developed validation therapy as a method of working with patients she described as severely disoriented.

Validation therapy focuses on accepting the reality of the person living with dementia by focusing on the emotional content of a person’s words or expressions. The aim is to reduce negative feelings and enhance positive feelings. Validation therapy is implemented through the use of certain communication techniques, including using nonthreatening words to establish understanding; rephrasing the person’s words; maintaining eye contact and a gentle tone of voice; responding in general terms when meanings are unclear; and using appropriate touch (Scales et al., 2018).

Validation theory explains that many (very) old, disoriented people, who are often diagnosed as having Alzheimer type dementia, are in the final stage of life, trying to resolve unfinished issues in order to die in peace. Their final struggle is important, and caregivers can help them. Validation techniques offer disoriented older adults an opportunity to express what they wish to express, whether it is verbal or non-verbal communication. When disoriented older adults can express the things that may have been suppressed for many years, the intensity of the feelings lessen, people communicate more, and are less likely to withdraw into further stages of disorientation (VTI, 2021).

Validation therapy states that:

1. Very old people struggle to resolve unfinished life issues before death.
2. Caregivers should use a basic, empathetic attitude that respects and values very old people without judgment.
3. Caregivers should use specific techniques for individual as well as group work, based on the needs of the individual and his or her phase of resolution (VTI, 2021).

Situations in Which Validation Therapy Is Useful

The use of validation in dementia care is a way of demonstrating to the client that their feelings, thoughts, and opinions are acknowledged and respected by the caregiver. A combination of validation and reminiscence helps confused clients experience joy from their earlier life and contributes to their overall quality of life (Zeman, 2015).

Validation therapy is useful in any situation in which a caregiver, family member, or professional must interact with a person who has dementia. Because validation therapy provides techniques for approaching and communicating with a person with dementia, it is particularly helpful in preventing a reaction that might escalate into an unwanted behavior. It is also useful for calming and diffusing challenging behaviors.

Reality Orientation Therapy

Mostly, I think the desire to “reorient” a person with dementia is that of the caregiver, not the resident. It can be really irritating when someone doesn’t share your reality—it seems obvious what the date is, what town you’re in, and who your daughter is. I think sometimes caregivers feel they’re doing something positive when they constantly correct and remind a person experiencing memory problems. They don’t understand how frustrating it is to be scolded and corrected all the time.

Physical therapist, West Palm Beach, Florida, 2021

Reality therapy or reality orientation is based upon the idea that a person who has lost contact with reality can be guided back to reality and that this process will help a person accept and deal with the reality of their situation. First proposed for use in confused, older adults, reality therapy is intended to support a client’s own insights into the truthfulness of their situation.

For people who are confused or disoriented, reality therapy is designed to improve cognitive and psychomotor function. It is often employed to help clients focus on their immediate surroundings. With this technique, caregivers actively and repetitively present information needed to orient clients to the time and day, as well as their environment and the people around them. This process is most helpful for the person in early stages of dementia (Zeman, 2015).

For most of us, being oriented to reality is essential. But reality orientation isn’t helpful if the person is in mid- to late-stage dementia. Short-term memory loss and cognitive deficits make it impossible to remember or even understand much of this information. Trying to get the individual to focus on reality when significant confusion and cognitive loss are present can increase confusion and cause agitation (Zeman, 2015).

Joining Residents in Their Own Reality

When a person with dementia has a delusion or hallucination, or another type of challenging behavior, “getting into their reality” may allay fears, address a problem behavior, or help the caregiver figure out its cause. This often leads to simple, commonsense solutions. It also helps improve the quality of life for the individual by fostering trust in the caregiver and reducing dependence on medications to manage negative behaviors.

Validation Therapy vs. Reality Orientation

Validation therapy and reality therapy differ in a number of ways. Validation therapy deals with a person’s feelings. It is not intended to improve a person’s cognition or to delay cognitive decline. It is intended to draw people out, encourage communication, and validate a client’s personal truth. When used consistently, validation therapy can reduce the number and intensity of challenging behaviors, decrease the use of drugs used to treat these behaviors, and provide comfort to the person with dementia.

Reality orientation, on the other hand, is intended to reduce cognitive decline using repetitive activities that reinforce name, date, place, and time. It is based on the belief that continually and repeatedly telling or showing certain reminders to people with mild to moderate memory loss will result in an increase in interaction with others and improved orientation. This in turn can improve self-esteem and reduce problem behaviors (Takeda et al., 2012).

An individual’s physical and mental condition is only part of what makes them tick. The roles they fill in contemporary life as well as their culture, ethics, spiritual beliefs, education, and the choices they made in earlier life are unique to each person. Commonsense dementia care addresses the needs of the person with dementia, not just the dementia in the person we care for (Zeman, 2015).

For healthcare providers working with a client who has dementia, Stephanie Zeman, in her book Kisses for Elizabeth: A Common Sense Approach to Alzheimer’s and Dementia (2012), recommends the following guidelines when working with a person with dementia:

• Imagine yourself in the person’s place.
• Avoid reality orientation except for early-stage dementia.
• Validate the person’s feelings.
• Practice good communication skills and encourage independence.
• Avoid judgement, arguing or saying no.
• Consider the whole person, not just the dementia.
• Learn to use “feel goods” such as a hot bath, a cup of coffee, going to a movie, or even offering a piece of chocolate.
• Arrange for meaningful and important activities each day.
• Keep your sense of humor and use it wisely.
• Remember that religion can be a comfort.
• Expect the unexpected.