COMMUNICATION BETWEEN OLDER PATIENTSAND THEIR PHYSICIANS 0749 0690/00 $8.00 + .oo

Dementia is an acquired syndrome that presents in an increasingnumber of older adults worldwide. It manifests as progressive andpersistent deterioration in memory language and comrnunication, visuo-spatial skills, personality, or cognition (i.e., judgement, problem solving,insight, planning arrd executing tasks, etc.).r3 Several different types ofdementia exist. The most prevalent form is Alzheimer's disease (AD),which accounts for 55% to 65o/" of all Wpes.'.

'' Other types includevascular dementia; mixed dementia (AD plus vascular dementia); de-mentia associated with motor neurone diseases such as Parkinson's,Huntingtonls, ar-rd amyotrophic lateral sclerosis (ALS); Pick's disease;frontotemporal lobe dementia; and Leia.y body disease; among others.The incidence and prevalence rates of dementia in general, and of ADin particulal, are predicted to rise sharply in Norlh American popula-tions in the next 3 decades, presenting considerable communicationchallenges for physicians.s This article presents an ovewiew of the lan-guage speech, and communication profiles of various types of dementia.These profiles provide the necessary backdrop against which the authorspresent strategies that physicians should consider when communicatingwith patients who have dementia. The strategies are based on a model

VOLUME 16 . NUMBER 1 . FEBRUARY 2OOO

ALZHEIMER'S DISEASE ANDOTHER DEMENTIAS

Imolications for Phvsician Communication

J. B. Orange, PhD, and Ellen Bouchard Ryan, PhD

From the School of Communication Sciences and Disorders, University of Westem Ontado,London 0BO); and the Department oI Psychiaby and Of{ice of Gerontoiogical Studies,McMaster Unive$ity, Hamilton (EBR) Ontario, Canada

CLINICS IN GERIAIRIC MEDICINE

153

ORANCE & RYAN

of communication enhancement for older adults that emphasizes theunique skill set arrd needs of each patient within a context of healthpromotion.al' ae

LANGUAGE, SPEECH, AND COMMUNICATION INDEMENTIA

The language, speedr, and communication skills of individuals whohave dementia vary with disease type. The profiles also change with theprogression of the illness through its three clinical stages (mild, moder-ate. arrd severe), with the general pattem being an inexorable decline inexpressive and receptive language and communication skills, and theeme.g"r-r." of speech problemi foi cortically based diseases in the severestage. Table 1 presents salient language, speech, and communicationfeatures of individuals with various types of dementia. The profiles arenot mearit to be exhaustive but rather illustrative of typical pattems.Although there are several common features among the different formsof dementia, it is the unique differences that physicians must take intoconsideration during history taking, assessment, developing a differen-tial diagnosis, counseling, and sharing information with patients andslgnificant others. Readers are encouraged to consult more detailedreviews of the language, speech, and communication profiles of thedifferent tvpes of dementia.l 2& 33 4' s7

For most types of dementia assoclated with primarily cortically-based pathology (e.g. ADI the vocabulary system is preferentially af-fected. For example, patients in the mild stage display subtle word-finding problems that may be mistaken for normal age-related declines.The anomia becomes more obvious in the moderate stage, whereinspoken and written output is described as "semantically empty."3t 4s

Listeners may experience greater difficulty understanding these patientsbecause they use few content words (e.g., nouns, verbs, adjectives) anduse a high proportion of nonmeaningful words and phrdses (e.g.,"these," "something," "things," "maybe she, maybe she, um, to tell you,you know."). Patients in the severe stage range from being mute toproducing strings of unintelligible jargon sometimes containing islandsof intelLigible and apparently meaningful words and phrases.'o -

Deterioration of speech 1i.e., neuromuscular activities of sound pro-duction) is observed often in patients with pathology in subcorticalareas ard subcortical plus cortical regions (i.e., mixed dementia). Speechproblems are presenl l 'requently in patients who have vascular dementiaand dementii associated with'mot-or neuron diseases.l4 2q s3 The errorsare best characterized as a dysarthria or an apraxia of speech (e.g.,slurring, stuttering-like behaviors, groping for sound productiory incon-sistent errors, etc.). Speech problems occur less often in individuals whohave pure AD, ftontotemporal lobe dementia, or the fluent variant ofprirrraqr progressive aphasia. They may develop, however, as a result ofsingle or multiple medication use or the co-occurrence of chronic condi-tions (e.9., stroke, Parkinson's disease, etc.).

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Language use problems; that is, problems with the- social aPpropri-ateness if laiguage] appear in most dementia types during the moderatestage. Patienti with AD and those with primary progressive aphasia inthe"advancing stages may make socially inapPropriate comments s'3e

Patients with" frontotemporal lobe dementia and Pick's disease mlyproduce socially inappropriate statements early in the course of theillless in conceri wit6 ihanges in personality (e.8., unexPectedoutburstsof ar-rser. inappropriate seiually ielated comments, emotional indiffer-ence, itc. ).to 'i itu.illv members'of individuals with dementia are able toidentify ind describe subtle changes in language- use early in the courseof the'illness ard often report

-that these problems are a source of

caregiver strest anxiety, and frustration.t 36 4

LANGUAGE AND COMMUNICATION ASSESSMENT

Physicians are faced with the daunting task of obtaining informationfrom and sharing material with dementia patients, family members, andsignificant otheri who accompdny patienrs to dPpointments. WhereaspKysicians communicate with-dementia patients, family members, andoaiients' sicnificant others primarily in transactional modes (ie, ex-ihanees of"information relited to patient health care needs) family-"-6".. and other care providers communicate with dementia patientsmore frequentlv in interactional modes (e.g, communicating for pur-poses o['erpressing social relations personal feelings, and attitudeq,i't..).- Churri,"t in "dementia patients' ability to comrnunicdte in bofhLransaction aI a nd interactional modes creafe gredI barriers for physicians,health care workers, family members, and friends. The end results ofthese changes for patientt physicians, family members, and significantothers oftei are isolation, hlqh levels of {rusiration and arxiety, the losso{ identity and autonomy oI patients, ar-rd indi{ference among medicaland health care practitioners.

When patients with dementia are regarded as unreliable commuru-cators or aie unable to provide the necessary details, physicians oftensather observational dati of patients' behaviors. For example, physicialsise observational guides such as the Calga ry-Cambridge Observationorotocol2' or relv oi traditional history-taking procedures. Alternatively,ihvsicians obtain input from sources'such ai ipouses, childrery grand-ihitdt"tr, legal guardians, concerned friendt or neighbors.,Relying onsuch sourcei hai its ortm set of inherent problems including the accuracyand relevance of informatiory the maintenance of confideniiality, and thetime required to gather the in{ormatiolL among others. Several research-ers have addressid in delail the conceptual framework and communica-tion issues within three-party physician-Patient-companion triads l5 Thisarticle, however, focuses on language, speeclr, communication, and cog-nitive issues specifically related to physician-dementia- patient interac-tions and doeinot addiess considerations of the physician-Patient-com-panion triad. Readers are encouraged to consult the other articles in this

ALZI]EIMER'S DISEASE AND OTI]ER DEMENTIAS

issue by Silliman and by Adelmary Greene, ald Ory for more detaileddiscussions of this concept. Commudcating with dementia patients whosuffer language, speech, and communication problems is a formidablechallenge. Physicials should bear in mind that when it comes to de-termining a dementia patient's language, speec[ and comrnunicationskills and optimal ways to comnunicate, they are best served by theinput of speech-language pathologists and other specialists in communi-^ ^ + : ^ - ^ - , l ^ - i - -

S_peech-language pathologists assess the spectrum of language,speech, and communication skills of patients who have dementia. Theyprovide valuable data for the differential diagnosisa and can offer funC-tional strategies that help physicians communicate effectively and inrewarding ways with patients. A detailed discussion of language,speech, and communication assessment protocols for individuals withdementia is beyond the scope of this article; howevel, readers may wishto consult recent reviews on this topic.2, 1r,,30,44 The important issues here,thoug[ are threefold. First, dementia patient-physician communicationcamot be considered in isolation from a comprehensive understandingof the patient's language, speech, communicatiorL hearing, and cognitiveskills. A full understanding is a prerequisite to establishing individual-ized comrnunication strategies that will help guide physicians in theirinteractions. Strategies designed to overcome communication problems,to enhance meaningful exchange of in{ormatiory and to establish andexpand relationships must be based on a patien(s unique skill set (e oco'gnitive, language,

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emotional needs. Second, physicians must acknowledge and act ona patient's need to maintain self-identity and independence throughcommunication. The concept of self and its preservation in even severestage dementia patients is an important consideration in shaping patient-physician comm unication.'o Third, physicians must considei the variouscontexts in which communication occurs with older adults and under-stand the environmental influences on communication (e.g., communityversus institutional dwelling patients, patient-physician relationship,family-patient context, etc.). These issues are three of the primary guid-ing f6ries in the Communication Enhancement Model ievelopeX forolder adults4e and individuals with AD.a1

STRATEGIES

General Considerations

SpeechJanguage pathologists who work on interdisciplinary andmultidisciplinary geriatric assessment-rehabilitation teams commonly re-port that colleagues often ask for a concise list of strategies to facilitatecommunication with dementia patients (often limited to the "top ten"best items!). The view that a generic collection of comrnunication tips canbe distilled from a large body of options reflects an oversimplification ofthe complexity of hurian commuriication. Moreover, such a perspecuve

ORANGE & RYAN

marginalizes individual variability, which is the hallmark of older adultsin general and individuals with dementia in particular This view alsosuggests Lhdt the set of slrdtegies is stafic dnd lhdt the same ophons areusetul over the course ol the disease.

Physicians must keep in mind that effective and rewarding comrnu-nication requires a broad view of communication; that is, it encompassesboth transactional ard interactional modes.T Adopting such a view offersclinicians a larger set of options from which to select suitable strategies.Physicians also must choose and tailor strategies to fit the unique

"and

individual needs of each patient. Invoking generalized stereotypes ofthe communication skills and needs of older adults means that cliniciansfall prey to using inappropriate and often patronizing patterns of com-munication.q'?a a7 Such generalized stereotypes lead to the communica-tion predicament of aginga6 wherein overaccommodated communicationoccurs, undermining the independence and self-identity of the dementiapatient and creating umecessary barriers to interaction.

Physicians also must be cognizart that a set of strategies may workwell for a series of communication problems at one time but not workwell for the same set of problems minutes, hours, or days later. Thisconcept reflects the variable profile of dementia and the uneven effective-ness of strategies. _Moreover, physicians must be very patient whencommunicating with dementia patients. Patients' verbosity, muteness, orthe lack of meaning in their language can test the patience of even themost composed and compassionate cliniciar.

Productive time spent listening to patients is, of course, a criticalcorrsideration. Physicians should be prepared to listen and not iust hearwhat their dementia patients are saying. Attentiveness to content can beproblematic especially in cases in which patients spoken language lacksmeaning. Only the shrewd and insightfui physician can piecd tojether apatient's stdng of partially meaningful sentences based on his or herbackground knowledge of the patient and on the fact that word errorsoften are related semantically to the target or intended word (e.g., theuse of the word "relative" for the intendid word "brother").

The amount of time spent communicating with older adults andparticularly patients with dementia is especially important in the currentclimate of increased financial pressures brought on by govemment cut-backs in health care funding, managed health care progrims, and escalat-ing health care costs. Effectlve, individualized, and respectful commum-cat ion w i th o lder adu l ts lakes no more f ime than abrupt , pa t ron iz ingtalk that is based on negative stereotypes of aging.3, Althbugh thesigeneral considerations are not profound, they do have real-world impli-cations and are important considerations in the everyday practice ofphys ic idns who care fo r dement id pa t ien ts .

Specific Options

A growing body of literature describes communication enhance-ment considerations for patients who have dementia.4 6 11,32 41,43,51,53 The

topics range from making adiustments at the single word and sentencelevels, to considering a patient's li{e history when asking guestionsor choosing a conversation topic. Orange et aPB describe a host ofcommunicalon strategies for physicians in their interactions with Alz-heimer's patients. Th6ir discuisibn focuses on a comprehensive set ofstrategies emanating ftom different factors that influence communica-tion. Their strategies are drawn from the literature concerning observa-tional and experimental data on communication with individuals whohave dementia. The following discussion of strategies is an updatedpresentation of their options.-

Figure 1 presents factors that influence comrrrunication. The strate-gies outlined in Appendix I and hiShliEhted subsequently are drawlirom each factor. The scope o{ this arficle Iimits the number of strategiesthat can be listed and disiussed. Physicians should guide their selectionof strategies based on the unique needs of each patient as determinedby an individualized assessment of skills, their own creativity, an over-aiching desire to help patients retain their dignity, and a motivation tooptimiZe the wellbeing and competence of patie_nts.ae In addition, physi-cians must be aware oI and accept the fact that choosing and implement-ing strategies is not an exact science. No algorithm exists that dictatesho'w and "when to invoke particular strategies. This can be disquietingand frustrating for patienti and physiciani, especially considering the

ALZHEMER'S DISEASE AND OTI]ER DEMENTIAS

Figure 1. Factors influencing communication with individuals who have Alzheimer's diseaseand other lorms of dementia.

ORANGE & RYAN

multiple limitations of time constraints, financial restrictions, and acurrent pervasive trend in clinical health care toward "instant coffee"responses to complex health care needs. Accepting that patient needsvary widely and adjusting communication to suit individual needs on amoment-by-moment basis admittedly is difficult and sometimes impos-sible. Acknowledging these considerations, however, is an importantstep toward enhalcing communication with dementia patients. Some-times clinicians' strategies work; sometimes they do not!

Language

Several researchers note that dementia patients understand spokenlanguage best when their partners minimize the use of jargon, lirrk ideasacr6ss ientences using the full names of people or piaces rather thanambiguous and indefinite pronouns, and ask questions that require littleeffort by patients to search deteriorating mental dictionaries a 11 52' 5s

Physicians should minimize the use of figurative terms in their spokenlanguage because dementia patients often interpret such forms literally.It can be challenging to adjust vocabulary and to modi.$., sentencestructure and type. Elevating to a conscious level that which is or hasbeen automatic for decades is indeed difficult; however, modificationsin the language used by physicians can have impotant supportiveeffects on communication.

Cognition

The strong link between language and cognitive systems relative tocomrnunicative performance means that dementia patients are at greatrisk of isolation. t he hallmark problems in demenLia are progressiveimpairments in recent memory attention, and language, with relativepreservation of long-term memory stores, especially personal memorywithin the autobiographical memory system (e.g., remembering whereyou were when President Kennedy was shot, or, for Canadians, whereyou were when Paul Henderson scored the winning goal in the 1.972Canada Cup Canada-Russia hockey series!). Physicians must be pre-pared to call upon the relatively intact cognitive systems and preservedautobiographical memory stores to optimize communication.

Speech

Speaking slower is often cited as a usefu1 strategy for dementiapatients.ss The recommendation is based on the well documented sloweripeed of cogritive processing observed in older adults. Slower speechuiorl" ,tny 6ff"t orlly limite; help.s' Physicians must adiust noi onlyhow they say things, but what they say. The practice of pausing betweensentences and pausing longer for patients to respond to questions is nodoubt more effective than speaking words more slowly within sentences.Concomitant adjustments in vocabulary and sentence type and lengtfu

ALZHEIMER'S DISEASE AND OTHER DEMENTIAS

among the other considerations listed in Appendix 1, are essential firstconsiderations.

Nonverbal

Facial expressions, gestures, body posture, and odrer asPects ofbody language are but a'few of the nonverbal features that should bealigned closely with language and speech adjustments, especially forpai ients in the ear ly and middle c l in i ia l s tages of demenf ia . Physic iansihould monitor thiir use of nonverbal behaviors, ensuring that theysupport and are synchronous with their language and speech. Mis-mit'ched features (i.e., saying you are pleased to see the patient butshowing clearly wlth your-body"language that you are in a hurry to leaveor are inattentive) can create misunderstanding ard lead to reluctance bydementia patients to communicate. Patients in the late clinical stage ofdementia rely heavily on nonverbal cues to help understand spokenwords. For example, severe-stage patients consider multiple nonverbalbehaviors such as posture, gesfures, facial expressions, and eye contact,among othert to determine whether the speaker is calm and attentiveo. uo-iio.r" and frustrated. Physicians must keep in mind the value ofthe gestures that accompany talk and their strong influence on patients'comprehension.

SensoryPhysicians must be ful1y aware of the influence of age-related and

acquired sensory impairments on communication. Headng and visionplay key roles in communication, and problems with these senses arehighly prevalent among older adults. Agairy the importance of a compre-hensive assessment of systems that support communication is apparent.Audiologists are helpful in determining the nature and extent of hearingproblems. More importafltly, audiologists can provide specific recom-mendations regardirig the use of assist'ive listening devicei (e.g., hearingaids, telephone and television volume controls, portable and comPacthearing amplification systems, frequency modulation (FM) hearing sys-tems, etc.) that help optimize hearing and communication.

Environments

Properly designed physical environments can enhance commuruca-tion. Locations that are relativelv free of "noise" (i.e., sound, vision,smell, touclr, and gustatory districtions) help optimize Patients'atten-tion. The configuration and location of furniture can facilitate interaction(e.g., U-shape irrangement of chairs, round versus square tables, etc.).iribilr"kitn describei communication-impaired environments (i.e., bothphysical and attitudinal) that act as barriers to effective and rewardingcommunication. A communication-impaired environment is a settingthat offers few opportunities for successful, meaningful communication.

ORANGE & RYAN

Such an environment is characterized by (1) lack of sensitivity to thevalue of communicatiory (2) rules that restdct quantity and quality ofcommunicatiorr, (3) lack of viable communication partners, (4) few rea-sons to ta1k, (5) iack of privary (6) limited acce-ssibilrty (7) limitedsensory stimulatioo (8) peiceived lack of self-worth by others, and (9)communicaiion perceived bv others as valueless.

Medications

Several categories of medications are well known to have adverseeffects on languige, speech, and cognition. A discussion of the effectsbv the differe-nt fimilies of druss is bevond the scope of this article;h'owe.r"r, readers may wish to c-onsult the review bir Vogel- in whichshe discusses the effeits of different classes of drugs on language, speech,communication, and cognition.

Conversation

Holding a conversation with an acquaintance wiJh whorn one sharesinterests is iften relatively easy. Describing how one holds that conversa-tiory however, is much more difficult. The strategies to carry on aconversation with dementia Patients, like all other strategies discussedin this article, vary somewhit with the stage of the disease. Severalresearchers addresi conversation-based stratagies for individuals whohave dementia.lz 33' 32 40 The most salient conversation strategies areoutlined in the Appendix.

Education

Education is a primary risk factor for the development of dementia B

That is, patients with a lower level of education are at greater risk ofdevelopiirg dementia. The type, locatiory and extent oI education alsohave imp6rtant implicationi on language and commlnication fot de-mentia patients. For example, the development and extent of one'svocabulirv is related to boih formal and informal educational experi-ences. Physicians must consider the effects of education-on patients'useand understanding of language, speech, and nonverbal behaviors'

Emotions

Communication not only involves the exchange of information butserves to establish, maintain, and change relationslips. Inherent in thislatter component of communication is the emotional element. Emotionsmust be eipressed and understood. This need is particularly importantfor dementia patients who otherwise are at Sreat risk of being emotion-allv distant from others as a result of their dementia and the negative."irror-rr" of others to the presence of the dementia.'6 Physicians shouldconsider communicatin&

- when necessary, at an emotive level using

ALZHEMER S DISEASE AND OlI IER DEMENTIAS

speech, language, and nonverbal behaviors that signal trust, understand-ing, and attentiyeness. This means a slower rate of speech (approxi-mately 120 words per minutet direct eye contact when ippropriati (seeupcoming section on culture and ethnicity), reassuring touch and ges-fures whin appropriate, ard language thai signals the"patients'feelingsand one's own feelings.

Style

Communication style is a vague term that, like conversatiorl is fareasier to have than to describe. Terms such as outgoing, shy, quiet, agood listener, a real talker, are exanples of a layperson's terms forcommunication style. Physicians must be cognizant of their communica-tion style and its influence on interactions with dementia patients.

Gender

Men and women communicate differently.sa The effect of genderon communication-for example, male physicians communicating withfemale dementia patients (a corrunon profile among the > 85-year-oldcohort of dementia patients)-may be small, but noneLheless requiresconsideration. Physicians should consider how they structure their lan-guage and use nonverbal behaviors relative to the gender of the personwith whom they are communicating.

lntra- and lntergeneration

A large body of literature exists on intra- and intergeneration com,munication in older adults.1, As Ryan et ala6 have argued, communica-tion between young and older adults can be problematic because of age-and infirmity-based stereotypes of older adults. Potential barriers toeffective communication are related to the interqenerational nature ofmost patient-physician encounters. Some of thesi barriers include theinterpretation of behaviors (e.g., not hearing what was just said) in termsof stereotypes (i.e., hearing impairment rather than the possibility thatthe speaker_ did not articulate clearly). Similarly, physicians could pre-sume that the older person is interested mainly in past events as com-pared with current events.22

Culture and Ethnicity

Few studies have examined systematicallv the effects of culture andethnicity on communication with dementia patients. Elliottls describesin her book on cross-cultural awareness effective communication srrare-gies for older adults of different ethnic origins. Physicians should con-sider the influences of their value and belief systems as well as those oftheir patienl and their patients' religious and spiritual considerations,among others, in their communicatio"n with dementia patients.

ORANGE & RYAN

Roles and Relationships

Traditionally, North American physicians have been considered theleaders in making health care decisions on behalf of some older adultpatients. This role helps shape patient-physician commur.dcation. In par-ticula4 the current cohorts of older adults, especially among some ethnicgroups, may be less inclined to ask questions of their physicians concem-ing their health or of recommended health care treatment options. Someolder adults may prefer a passive role in the physiciar-r-patient relation-ship. The passive communicative role assumed by some older adultsmay lead to serious negative consequences regarding their health careoptions. For example, older adults may not ask questions concerningthe potential side effects of prescribed medications that otherwise couldbe quite harmful. Sirnilarly, spouses of patients who have AD may notquestion their physician who does not recommend (or for that mattereven consider) that their husband or wife attend supportive day treat-ment and activity programs.

Perceptions and Aftitudes

The work of Ryan et al,a6, a3 Hummert et a1,23 Kemper,2a and Coup-land et all2 hlghlights the importance of how negative stereotyped per-ceptions and attitudes of aging car"r shape lalguage, speech, and commu-nication directed toward older adults. Physicians' perceptions of theincompetence and dependence of older adults, especially of dementiapatients, can lead to the use of patronizing, overaccommodated commu-nication described within the model of the communication predicamentof aging.n6 This pattern of communication has been described as second-ary baby ta1k'! or elder speak.'?a Features include shouting, exaggeratedintonation and high pitdl the use of imperatives, repetitions, and petnames or nicknames, among other features.'?l Physicians must be awareof their own negative stereotyped perceptions of and attitudes towardolder adults and work toward eliminating their use of overaccommo-dated communication.

CONCLUSIONS

The importance of communication in establishing and maintainingpatient-physician relationships is well known and discussed thoroughlyin the other articles on doctor-Datient communication in this issue. Lesswell knowo however, are the affects of dementia on the communicationpattems between patients and physicians. The multiple factors thatinfluence communication between Datients with dementia and theirphysicians are diverse and compler, with numerous layered and interre-lated effects among them.

The discussion of communication enhancement strategies is notcomplete without one last reminder of fundamental considerations.

ALZHEMERS DISEASE AND OTI]ER DEMENTIAS

Firstly, communication with dementia patients requires physician knowl-edge of the patients' language, speech, and communication skills asobtained th-rough a comprehensive assessment. Skills vary wifh the rypeof dementia and chalse over the course of the disease. Commulicationenhalcement strategies are, to some degree, disease- and stage-depen-dent. Secondlv, phvsicials must use a rarpe of strategy options tooptimize not;nly ihe exchalge of information, but the istablish men tald expansion of their relationship with their dementia patients. Physi-cians, like many other health care professionals who work with dementiapatients, must call upon a large repertoire of communication options.Furthermore, physiclans must acknowledge and appreciate that the ef-fectiveness of strategies may be inconsistent among patients who havethe same profile of communication problems. Finally, physicians mustrealize that there are no prescribed approaches to communicating withdementia patients. Creativity, flexibility, and above all a sense that pa-tients have unique and individual needs, should act as he1pful guidesin cadng for patients with dementia.

References

1. Adelman RD, Creene MG, Charon R: The physician-elderly patient-companion t adin the medical encounter: The development of a conceDtual framework and researchagenda. Cerontologist 27:7Ze 734. ]rc97

2. Bayles KA, Kaszniak AW: Communication and cognition in normal aging and dementia. Bostory ColleSe-Hill Press/Little Browo 1987

3. Bayles KA, Tomoeda CK: Caregiver repot of prevalence and appearance order oflinguistic symptoms in Alzheimer's patients. Gerontologist 31:210 276,199L

4. Bayles KA, Tomoeda CK: Understanding and caring for dementia patients: A se es-TucsorL Canyonlands Publishing, 1995

5. Beisecker AE: The influence of a companion on the doctor-elderly patient interaction.Health Communication 1:55 70, 1989

6. Bourgeois MS: Communication treatment for adults with dementia. J Speech Hear Res341831-344, 1991

7. Brown G, Yule G: Discou$e Analysis. Cambridge, Cambridge University Press, :19838. Canadian Study of Heatth and Aging Working Group: Canadian study of health and

ageing: Study methods and prevalence o{ demenfia. Can Med AssocJ 150:899-q13, 19949. Caporeal LR: The paralanguage of caregiving: Baby talk to the institutional aged. J

PeIs Soc Psvchol 40:876 a84, 19a710. Causino Lahar MAC, Obler LK Knoe{el JE, et al: Cornmunication Pattems in end-

stage Alzheimer's disease: Pragmatic analyses. L Bloom RL, Obler LK De Santi S, etal (eds): Discourse Analysis and Applications: Sflrdies in adult clinical populations.Hillsdale, Nt Lawrence Erlbaum, L994, pp 217 235

11. Clark LW: Interventions for persons with Alzheimer's disease: Strategies for main-taining and eniancing communicative success. Topics in Language Disorders 15:47-66, 7995

12. Coupland N Coupland J, Giles H: LanSuage, society and the elderly: Discourse,identity and ageing. Ox{ord, Basil Blackwell, 1991

13. Cummings JL, Benson DR Loverme S: Reversible dementia. J Am Med Assoc 243:2434-2439,1980

14. Cu lrings JL, Darkins A" Mendez \4 et al: Alzheimer's disease and Parkinson'sdisease: Comparison of speech and language alterations. Neurology 38:680-684 1985

15. Elliot G: Cross-cultural awareness in an aging society: Effective strategies {or communication and caring. Hamjltor! Ontario, McMaster Universit, 1999

ALZTIEIMER'S DISEASE AND OTHER DEMENTIAS

Firstly, communication with dementia patients requires physician knowl-edge of the patients' language, speech, and communication skills asobiained throirgh a comprehensive-assessment. Skills vary with the typeof dementia and change over the course of the disease. Communicationenhancement strategies are, to some degree, disease- and stage-depen-dent. Secondly, physicians must use a range of strategy options tooptimize not only the exchange of informatior; but the establishmentand expansion of their relationship with their dementia patients. Physi-cians, like maly other health care professionals who work with dementiapatients, must call upon a large repertoire of communication options.Furthermore, physicians must acknowledge and appreciate that the ef-fectiveness of shategies may be inconsistent among patients who havethe same profile of communication problems. Finally, physicians mustrealize that there are no prescribed approaches to communicating withdementia patients. Creativity, flexibility, and above all a sense that pa-tients have unique and individual needs, should act as helpful guidesin caring for patients with dementia.

References

1. Adelman RD, Crcene MG, Charon R: The physician-elderly patient-comparion triadin the medical encounter The development of a conceptual Iranework and researchagenda. CeronLologirt 27:72q-7 :4. o87

2. Bayles KA, Kaszniak AW: Communication and cognition in normal aging and demen-tia. BostoD College-Hill Press/Little Browr! 1987

3. Bayles KA, Tomoeda CK: Caregiver repo* of prevalence and appearance order oflinguistic s)'rnptoms in Alzheimer's patients. Gerontologist 31:210-216, :1991

4. Bayles KA, Tomoeda CK: Unde6tanding and cadng for dementia patients: A seies.Tucsorq Canyonlands Publishin& 1995

5. Beise&er AE: The influence o{ a companion on the doctor elderly patient interaction.Health Communication 1:55-70, 1989

6. Bourgeois MS: Communication treatment for adults with dementia. J Speech Hear Res34:831 844, 1991.

7. Brown G, Yule G: Discourse Analysis. Cambridge, Cambddge Unjve$ity Press, 1983B. Canadian Study of Health and Aging Working Group: Canadian study oI health and

ageing: Study methods and prevalence of dementia. Can Med Assoc J 150:899 913, 19949. Caporcal LR: The paralanguage of careglving: Baby talk to the institutional aged. J

Pers Soc Psvchol 40:87ffi84. 198110. Causino Lamar MAC, Obler LK Knoefel JE, et al: Communication patterns in end

stage Alzheimer's disease: Pragmatic analyses. Jt, Bloom RL, Obler LK De Santi S, etal (eds): Discourse Analysis and Applications: Studies in adult clinical poPulations.Hillsdale, N, Lawrcnce Erlbaum, 1994, pp 2L7t35

11. Clark LW: Interventions for pe$ons with Alzheimer's disease: Strategies for main-taining and enhancing cominunicative success. Topics in Language Disorders 15:4766. 1995

12. Coupland N, Couplartd t Giles H: Language society and the elderly: Discourse,identity and ageing. Oxford" Basil Blackwell, 1991

13. Cumrnings JL, Benson DF, LoVerme S: Reversible dementia. J Am Med Assoc 243:24342439,'1980

14. Cummings lL, Darkins A" Mendez \4 et al: Alzheimer's disease and Parkinson'sdisease: Compa son of speech and lanBuage alterations. Neurology 38:680 584, 1985

15. Elliot G: Cross-cultural awareness in an a#ng society: Effective strategies for .ommuni-cation and ca ng. Haiilto4 Ontario, McMaster Universiiy, 1999

156 ORANCE & RYAN

16'FeilN:Thevalidationbrcakthrough:simPletechniquesfolcommuni{atingwithpeoPle-" *iit-r ;;.q1zh"i-".'s-tvpe Dementi;" Baltimore, Heilth I'rofessions Press'.1994

fZ. C"r.*'li, l""""tt V Analysis of conversational toPic shifts: A muttiple case study

Brain Lang 58:92 114, 199718 e;;i^-i,"o.".g. fd: The analysis of convemation skills oI older adults: Curent

researdr and iinical approaches. Joumal of Speech-Language Pathology and

Audioloev 20:123-135, 19ab1r. a;;ilk"'d;

-;;zzoia FG: Alzheimer's disease: clues to the cause Post Med

89:11,57-8,1991,0. ;;1;"d-1, McBwney DH, Moossy t et al: The dissol ution^ of ,language

in Pick s

disease with neurofibrillary tangles: A case study lJr n Lang l4:rb ro'-rvof,

,1. il;;;";t ML, a6eotyP; of iire elderlv and patronizing sPeech L. Flummert ML'-'

ivi"*"'.. Itl, N"."t o.i,i' 1f 1"d";, tttt"'p'erso"at Co-mu"iiairon in older Aduldrood'

Thousand Oaks, Cal, Sage 1994 pP 162-18422. Hummert VL, Rtan tb: touard under'rardint varidt jon! in Pdtroni/ ing talk ad-

drer.ed to older;dul l . : t \ lchol inSui*l i ( lcafure" ol 'care dnd contlol Lnlerndnonal

lournal of Psv, hol inguisf ic\ l2 l4a lbq lqq6T. fi;;;";; Mi, wt"fio'- ll't, Nussbaum JF (eds): Interyersonal cornrnulication in

older adulthood fhou-and Oak' Cal Srge lqq4

za. f"-p". i,;Efa"rspeak": Speech accom;odation io older adults Agjng and Cogni

tio l:1729zs. iii*pi". O, r".guage changes in,dementia oI the Alzheimer type lt? Lubinski R (ed):

Deminria and Cnrnmuni(dLion. Phi ladelPhid Mo'b1' lool pp qB J14

26. K;ii.ht il"i"onen & Sulkava R, et aj: Pattern ot |anguage imP-airment is different-"

ir-r eU}t"l-".'" aisease and multj-hfarct dementia Brain Lang 38:364-383' 1990

27. K;'t" i, Silverman J: The Calgary-Camb dge Communication Guides Med Educ

30:83-9 , 1996zS. L;bi""kl R ("at, Oemenfa and Communication Philadelphi4 Mosby' 1991

is. i"il"ki R:' Environmental considerations for elderly patients' -L -Lubinski R (ed):

- o.-"t , iu dnd Communi(.rt ion lhladelphia' Mo\b) l i lql Pp 2c7-274

SO. i.1b;ski R, Orange JB: A framework lo'r the assessn-rent ana treatmcnt of firnctional"-

-"-r-""i..ti"" i""dementia. In Worrall ! Frattali C (eds): Neurogenic communication

disorder\: A fun' t jondl ,rPProdch \ew Yorl lhieme' i .n qre: '31. Lund and Manchester GrauPs: Clinical and neuroPathological-critena ior hontoemPo-

r . r l dempnha . i \ eu ro l Neu iosu rg f sv (h ia t r v 57 :4 lb4 l8 ' l ' l q4 - ,32. Ministrv of Citizenship, Culture and Recreation: Real Stories: hnhancrng cortunuruca-"'

ii."" rrit*"." tt*lth Jire professionals and seniors and families Toronto' 1996

g:. i;"trti" N4 wllittuker jB, G'ramigna GD: Discourse toPic manag-ement in senile demen---

iio ot tnu'eUtt"l-"r's type J Speech Hear Res 38:1054 1066' 1995

34. i;;* j;, Snowden J, irian" dMA" et al: Frontal lobe dementia and motor neuron

drsedte. I \pLtrol Neuroturg Pt)rhiatrv 6l:21-12 loao

:s. NiJofui lf, olf"r L, Albe; M,-et al:6mpty speech in Alzheimer's disease and fluent

aphasra. J sp"erh HPdr Res 28:405 4l0 lq85Jo. Cirang. jB: Tcrtpectivet ol fdmily member- resJrdi.ng communication 'hanqe' l l r""

r.il'i"ti i' O"-!"tia and Commrlnication Philadclphia' Mosby lq9l' PP 168-186

t b;; ; ; ; ' l ; . a; i ;- i l ,Jt." n, Enhancrng communr'drion in dcmentia of rhe Al/hei-

mer r"Lvpe. lopic_ In Ceri.r lr ic Rehrbi l i tdl ion l4:50_75' lqqS

:s. 6r".eJfe, \aoifov DW Lever J, et al: Alzheimer's disease: Physician-Patient commum

cdrio;. Cdn f. l jn i 'hl t i . ian 40 l lb0 l lhR, lw43e. c;.;;; l;; P."""ck'1, K.,tesz A: Pragmatics in- jr9:Ta.!-!b-e^i:rnentin and Pdmarv

orosr;ssivc aphasia. lournal of Neu rol irgui ' l ics I l : l \J- l l / 1""t '

+O 6*?""- ig,-f , i*". B:tonr enational di-c"ourse and cognit ive impairment: Implicdi i ' rns="

i.;;";t'";;;" ;isease. Journal of speech Language Pathologv and Audiology 20:139-

15O 1996lf. Orone" lB, Rvrn tB. Meredith cD, el dl: ApPtical ion of lhe cornmuni 'dt ion enhance' ' '

i , l " i?oa"i f" |- fone Lerm.are residenl- wrrh {/heimer' ' dised-P lopi(- in Ldngudge

Disordeis 15(2):20 55, 1995

ALZHEIMER'S DISEASE AND OTHER DEMENTIAS 167

42.

44.

46.

48.

49.

50.

51 .

52.

53.

55.

56.

57.

58.

Powell AL, Hale MA, Bayer AJ: Symptoms oI communication brcakdown in dementia:Care$ pe(eptions. European Joumal of Disorders of Communication 30:&5 75, 1995Rau MT: Coping with communicafion challenges in Alzheimer's disease. San Diego,Singular Publishin& 1993Rjpich D: Diflerential diagnosis and assessment. In Lubinski R (ed): Dementia andCommunication. Philadelphia, Mosby, \99'1, pp 188-222Ripich DN, Terrell B: Patterns of discourse cohesion and coherence in Alzheimer'sdisease. Joumal of Speech and Hearing Disorders 53:8 15, 1991Ryan EB, Ciles It Bartolucci G, et al: Psycholinguistic and social psychological compo-nents of commr.nication by and with the elderly. Language and Corimunication6t'l-24,

'1986

Ryan EB, Hummert ML, Boich LH: Communication predicaments of aging: Patronizingbehavior toward older adults. J Language and Social Psychology 1311,4+166, 1995Ryan EB, Kwong See S, Meneer WB, et al: Age-based perceptions of convercationalskills among yor-urger and older adults. -In Hummet ML, Weimann IM, Nussbaum JF(eds): Interyersonal Communication in Older Adulthood. Thousand OaIs, Sage, 1994pD 15-39ilyan EB, Meredith SD, Maclean I\4 et al: Clanging lhe way we talk with elders:Promotjng health using the communication eniancement model. Int J Aging HumDevel 41:89-107, 1995Sabat SR, Collins M: Intact social cognitive abiliry and selflood: A case study ofAlzheimer's disease. American Joumal o{ Alzheimer's Disease L4.11,-1,9,

'1999

Santo Pietro Mt Ostuni E: Successful communication with A.lzheimer's disease pa-tients. Boston, Butterworth, 1997Small JA" Kemper t Lyons K: Sentence comprehension in Alzheimer's disease: Effectsof grammatical complexiry speech rate, and repetition. Psychol Agng 12:3 17,'1997Strong Mt Grace Gl\4 Orange JB, et aI: Cognitive impairment in amyotophic lateralsclerosis: A prospective clinical neuropsychological, language, speech motor pe or-mance and MR spectroscopy study. Neurology, in pressTannen D: You iust don't understand: Women and men in convercation. New York,Ballantine Books, 1990Tomoeda CK Bayles KA, Boone D, et al: Speech rate and syntactic complexity eflectson the auditory comprehension oI Alzheimer patients. J Commun Disord 23:151-161,1990Vogel D: E{fects of drugs on communication disorders. San Diego, Singular Publish-rng, 1994Webster Ross G, Cummings JL, Benson DFr Speech and language alterations in demen-tia syndromes: Characteristics and teatment. Aphasiology 41339-352" 1990Zol E Dobrcs & White L: Interactive communicatjon: Group activities for the elderlywith cognitive impairments. Bisbee, Ariz, Imaginart 1996

Aildress reprint requesls lo

J. B. Orange, PhDSchool of Cornmunication Sciences and Disorde$

Elborn CollegeUniversity of Westem Ontario

Londo[ Ontado, Canada N6C 1H1

168 ORANGE & RYAN

APPENDX 1.

LANGUAGE

. U-s€ directly _worded, simple active declaratiye sentences (e.g.,"These red pills are for the pain in your knees.")

. Use yes/no questions or closed-ended questions (e.g., "Does yourdaughter live in London?" or "Does your daughter live in Londonor St. Marv's?")

. Place modifiers after nouns (e.g., "Is your pain mild or severe?,,versus "Do you have severe pain or is it just mild pain?")

. Consider saying the target word(s) the patient is hiving difficultyrecalling (i.e., anomia); frovide the *o.d1"; ir-t u tespectf"ul manner;do not correct repeatedly or always supply the target word(s)

. Avoid using ambiguous-and indeiinite'tirins and n"onspecific'pro-nouns (e.9.. thirg, that. there, those, this)

. Avoid figures of speech because patients may interpret them liter-ally (e.g- "Ok, so your son cut you off the line. Then what didyou. do?" or "Le(s go for a spin [i.e., in the walker/ wheelchair].,,)

. Avoid technical terms and jargon

. Limit use-of open-ended questions for moderate and late stagepafients; these question typ_es provide too many answer optioisand force patients to search for and retrieve words frorn theirdetedorating mental dictionaries (e.g., "Is the pain in your shoul-der [pausel or e lbow?" versus "Where is your pain?")"

. First learned language may emerge with coexisting decline incurrently used language as dementia progresses through to mod-erate and severe stages; use family members or others as transla-tors or learn a few socially used terms from the patients' firstlarguage

. Avoid giving instructions or bJormation over the phone; under-standing over the phone is usually much poorer than in person

COGNITION

. Be the memory trigger for patients; provide options from patients,long-term memory so that they can select topics for discussion;this helps minimiie patients' searches of their iemory stores

. Use patients' personal, long-term memory (i.e., autobiographicalmemory) as a source for topics of communication

. Minimize effects o{ poor mimory on communication:Give written instructions in single stepsGive ample_time for patients to respond verbally; do not interrupt

. Do not cbnfront patients who confabulate; reality orientation doesnot work; aromia and poor memory of people, places, or eventsmav lead to improbable storres

ALZ IEMER'S DISEASE AND OTHER DEMENTIAS

. Maintain patients' attention by using their name, askingspecific questions, using gestures or light touch on distalparts (hand, ankle, wrisf etc.)

SPEECH

. Use pauses and syllable and word stress to highlight information(e.g., "Did your daughter [pause] or your son [pause] call you?")

. Speak clearly, slowly (- 120 words per min : 2 words/s) at aslightly low pitch and at a slightly louder volume

. Calm, soothing speech captures and maintahs attention

. Make intonation pattems obvious; clearly signal question, declara-tive, or imperative

NONVERBAL

. Use calm facial expressions, body movements and posture; becom-ing angry or overexcited may alarm and confuse patlents

. Use slow and deliberate movements; quick ones can appear threat-enlng

. Get patients' attention first before talking (e.g., call out their name,crouch for wheelchair bound patients)

. Consider proremics (i.e., physical distance)Get close (but not too close!); closeness can minimize distractionsand heh: focus attention

. Touch lightly on hand to (re)gain attention and to reassure; do nottouch patients until your presence is known

. You do not always have to talk to communicate; {or example,gesfures, touch, and facial expressions can communicate reassur-ance and help minimize an-riety and fear

. Open posture invites interaction (e.g., arms behind back ratherthal arrns, wfists, or legs crossed)

. Eye contact should be maintained, but be aware of cultural andgender differences

. Watch body language that signals restlessness, lack of commitmentor rejection during interaction (e.9., crossed arms, ftowns, pooreye contact, clock watching, turning away, hurry-up postures suchas {oot tapping, sighing, etc.)

SENSORY

. Test vision and headng

. Avoid competing background noise (i.e., sights, sounds, smel1s);such stimuli may be too confusing

. Use other senses to facilitate talking and understanding (e.g.,

thembody

ORANGE & RYAN

pictures of family, relatives, vacations, pets; familiar music, vid-eos, etc.)

. Speak slightly louder than normal and at a lower pitch to accom-modate hearing problems; if too loud, voice is distorted

ENVIRONMENTS (PHYSICAL AND PSYCHOSOCIAL)

. Limit conversations to a small number of familiar people

. Make lighting optimal; avoid competing messages iuch as blaringnoise from radio, television, nursing statiory streeN or loud-speaker svstem

. Use contiasting primary colors (i.e., not pastel shades) including)arge black and white lettering

. Private and quiet locations enhance communication and minimizedistractions because of backqrourd noise

. Provide opportrmities for pitients to communicate with noncogm-tively impaired individuals, staff, relatives, and friends throughsocial programs and outings

. Promote patients as active interactants rather than passive recipi-ents durinq communication

. Beware th;t fatigue may make communication more difficult andless rewarding

MEDICATIONS

. Several classes of medications are well known to interfere withspeech, language, and cognition in patients with dementia:Sedatives, antidepressants, anxiolytics, antipsychotics, anticoagu-Iants, antihypertensives, narcotic based arralgesicsConsult wiili colleagues (e.g., other physiciins and pharmacists)and well recognized, published scientific literature to establisheffects of medications on speectr, language, and cognition

CONVERSATION

. Communicating takes time; if you do not have the time, youshould not atte-mpt to hold a conversation

. Focus on information exchange rather than patients' accurate useof words

. Introduce yourself at each new contact and call patients by theirfull name (title and last name Mr. Smith-or previously agreedon first name)

. Learn ald use patients' personal history to make conversationmeaningful and relevant

. Explain what you are doing as you are doing it (e.g., aspects ofvour examlnalron )

. Use statements that maintain and extend the topic of conversa-tion (e.g., "That sounds very interesting. Tell me more about

' ,). Tell patients when you are changing the topic (e.9., "Now let's

talk about "); however, do not change the topic too

ALZHEIMER'S DISEASE AND OT}IER DEMENTIAS

means?") or provide a possible under-

often or too quickly, it may confuse patients. Do not interrupt patients; it is confusing and may cause them to

forget what they want to say. Tell patients exactly what you misunderstood (e.g., "I don't under-

stand whatstanding (e.g., "Do you mean -?")

. If after repeated attempts you are rmable to understand whatpatients are saying or they do not understand what you aresaying, acknowledge the problem and change the topic _. Use unambiguous lalguage, and nonverbal and speech cues tosignal that it is the patient's turn to talk (e.g., "Now it's your tumto talk." or "\{hat do have to sav about -?")

EDUCATION

. The years and location (i.e., foreign country) of formal educationand general knowledge levels may influence how language isused and what is understood (e.g., Iamiliarity with technical termi-nology)

. Provide wdtten material that is suitable for the patienfs Ievel ofeducation

EMOTIONS

. Acknowledge patients' emotions (e.g., isolatioo fear, and loneli-ness; "I understand vou feel frustrated. I would feel frustratedtoo if -"i especially related to impaired or reducedfreouencv of communication

. Emfatheiic tone of voice and responses signal that you under-stand patients' feelings of loneliness, arxiety, helplessness, etc.

. Respond to the patients' message not their words; words maygive one message (e.g., anger) but the real meaning may be oneof fear or frustration

. Provide opportunities for patients to express anxietles and frustra-tions concerning comrrrurication changes and associated stresses

. Act as the comforter and not the bad guy; soothe rather thanprovoke

. Ignore patients' sudden verbal outbursts; do not respond in anaeitated manner

772 ORANGE & RYAN

STYLE

. Communication is a fundamental aspect of being human; it shapespersonal identity (i.e., Personality ) ind establis[es self-worth anddignity

. Av:oid" saying information in the presence of patients which youdo not want them to know

. Thank patients for talking with you; this expresses apPreciationfor their willingness to communicate

GENDER

. Men and women use different forms of language (e.g., vocabulary,word order, question asking, making statements) when commuru-catins within and between the sexes

. Evidence shows that men generally make statements and askquestions in a direct mar-"i1e.g., "Please close the window." or"-What time is it?"), white women use indirect requests and pro-yide options when asking questions, (e.g, "Is it cold in here?","Do y<iu want the windoiz open or closed?", "Is the time ten pastthree or four?")

. Gender differences in language and communication may createmisunderstandings in inteigender communication and lead to animbalance (asyminetry) in the amount of and satisfaction withcommunication

. Cender issues may be par t icutar ty inJ luent ia l in delermin ing thesuccess and satisfiction of comrrrunication when combined withage differences (i.e., young caregiver versus older person) andethnicity factors

INTRA- AND INTERGENERATIONAL

. Young adults may base their language and comrn-unicatron onnegative perceptions, attitudes, and stereotyPes of all older adults(e.i., "A11 older adults are too talkatiYe so do not start a conversa-t io ; wi th one or you wi l l never be able to get awdy: l t is okdy totalk about older adults in front of them 6ecause'they all haveproblems hearing." )

. Voung clinicians may rely on cohort expedences and use languageforms" that are un{amiliai to older adults, some of whom may be30, 40, or 50 years older than the clinician

CULTURE AND ETHNICITY

. Phvsicians and patients mav be from different cultural and ethnicbaikgrounds thit may creaie (or break down) barriers along lan-guage, religious, cultural and social dimensions

ALZHEIMERS DISEASE AND OTHER DEMENTIAS

. Phvsicians must be sensitive to cultural values that manifest them-selves in the form of different languages, gestures, and manner ofcommunication (e.g., direct and prolonged eye contact may be animpolite aspect of communication, asking direct questions may befrowned upon)

. Us,e family members as sources of information or as translatorsomy wnen necessary

ROLES AND RELATIONSHIPS

. Roles change with aging (i.e., retirement, no longer parent butpossibly grandparent, fewer social responsibilities, influencenumber and type of social activities, and the place of older adultswithin society

. Fewer roles may mean fewer social contacts (or for that mattermore!); communication opportunities may be reduced or enhancedbv chanses in roles

. Support a role of independent communicator for patients throughthe use of language, speech, nonverbal, and conversation strate-gies (e.g., minimize completing sentences when the patient experi-ences difficulty finding the right word, do not speak in front ofpatients as if they are not there, use patients' name rather thanpronours)

. Communication creates and fosters relationships; use communica-tion to maintain and expand integrity of relationship with patientsand to maintain their identitv of self

PERCEPTIONS AND ATTITUDES

. Minimize your:Actions that support dependenceViews of communicative incomDetence of older adults that influ-ences content, structure, and style, and o[ interactionsStereotype views of less competent elders based on physical,speech, language and voice featurcs

. Provide unconditional positive regard; clinician sees person pos-sessins unconditional self-worth

. Elimiiate use of "elderspeak" and patronizing talk (e.g., exagger-ated pitch" shrill tone, loud voice, terms of endearment such as"Sweetie," "Dearie," nicknames, and nonverbal behaviors thatsuggest incompetence, dependency, or lack of respect)

. Work through own views of patients with dementia, recognizingthat feelings of resentmenl angeq, or frustration will be evident inlanguage, speech, and nonverbal behaviors and will have a harm-ful influence on patients

*Adapted fton Orcrlge JB, Molloy DW Lever J, et al: Alzheimer's disease: Physi-

cian-patient cornrnunication. Can Fam Physician 40:1160 1168, 1994; with permrssron.