Approximately 55 million people are living with dementia worldwide (World Health Organization, 2021). However, incidence is likely underreported due to diagnostic delays (Bradford et al, 2009). Many people with dementia experience dysphasia or aphasia, leading to lost or inhibited expression and comprehension. This significantly limits communication, which is comprised of transmission, perception and reception of information (Bach and Grant, 2014).
How important is communication?
Ineffective communication leads to poor patient outcomes and experiences (Fong et al, 2010; Lang, 2012). Communication difficulties make gaining informed consent more challenging, delaying initiation of assessment and treatment (Care Quality Commission, 2011). These difficulties can also lead to incomplete patient history and subsequent inaccurate diagnoses, as well as inappropriate patient management (Institute for Healthcare Communication, 2011; Woodward, 2013). This may compromise patients' physical outcomes. Furthermore, clinicians may communicate less with patients who are cognitively impaired because it is more challenging (Miller, 2002; Jootun and McGhee, 2011), leading to social isolation in clinical settings. Social isolation affects mental and physical health and is associated with an increased incidence of depression, as well as higher mortality rates (Holt-Lunstad et al, 2010).
Literature and guidelines
Literature and guidelines suggest facilitating understanding by using repetition, closed questions and slowed, simplified, speech (Caroline, 2014; Association of Ambulance Chief Executives, 2016). However, the Department of Health and Social Care (2009) notes that recognising wide-ranging manifestations of dementia is imperative: dementia affects every person differently. This brings into question whether generalised guidelines are sufficient—particularly for clinicians, who have to discuss important and complex information.
Guidelines are understandable and implementable, with research suggesting that caregivers use them frequently (Wilson et al, 2012). However, they are only somewhat based on current evidence: the majority of corroborating research is premillennial. Recent research suggests that simple sentences and closed questions facilitate understanding but shows no benefits from slowing speech (Wilson et al, 2012; Savundranayagam and Moore-Nielsen, 2015). Furthermore, the techniques are only evidenced to be of use in increasing completion of practical tasks. If transferable to clinical settings, practitioners may employ them to empower patients, enabling them to assist with elements of the assessment process. However, open questions are required to initiate these tasks (Savundranayagam and Moore-Nielsen, 2015). Of concern, some research suggests that patients with dementia can automatically answer ‘yes’ to closed questions, as part of a default response mechanism (Weirather, 2010). This poses a legal and ethical dilemma as the use of closed questions may lead practitioners to falsely believe that they have gained valid consent.
Use of ‘elderspeak’
The guidance includes elements of ‘elderspeak’—a simplified form of language. In practice, many use elderspeak in an effort to appear compassionate and to improve understanding when, in reality, patients describe those who use elderspeak as paternalistic and unprofessional (Lombardi et al, 2014; Grimme et al, 2015). Elderspeak infantilises patients, often leading to withdrawal from care and potentially challenging behaviours (Herman and Williams, 2009; Williams et al, 2009), which may hinder assessment and treatment.
However, most research evaluates the use of elderspeak in general rather than the individual components that guidelines suggest practitioners use. Due to the overlap, it may be prudent for clinicians to maintain awareness of communication principles and modify these based on patients' verbal and non-verbal cues, focusing on patients' cognitive abilities, rather than deficits.
Assessing proficiency
The Health and Care Professions Council (2014) and the National Institute for Health and Care Excellence (2012) highlight that professionals should be competent in communication. However, conflicting evidence suggests that more research is required to clarify what proficiency entails.