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Communication with the Cognitively Impaired

October 4, 2014

 

WHAT IS A COGNITIVE IMPAIRMENT?

A cognitive impairment is any deficit in mental functioning that makes it difficult for the impaired person to send, receive, or interpret messages or communications. The patient may be unable to think, speak, understand, or remember. This kind of deficit can be temporary and last for moments to days or months or it may be permanent.

CAUSES OF COGNITIVE IMPAIRMENT

It is important to note that cognitive impairment is NOT a normal part of aging although it is more common in the aged. There are many, many diseases and medical conditions that can result in cognitive impairment. However, the common theme is that there has been some damage or compromise, either permanent or temporary, to the parts of the brain that control the higher intellectual functions. Although there are many, many possible causes of cognitive impairment, the majority of cases of cognitive impairment are due to a few, relatively common issues. Older adults who are hospitalized are at high risk for cognitive impairment during their hospital stays which is exacerbated by unfamiliar surroundings. The cause of the impairment can vary from individual to individual and be a result of stroke, dementia, or other physical problems within the brain. It can also be the result of medications that cause the client to be drowsy, sleepy, or less alert than normal.

Permanent Causes of Cognitive Impairment 

  • Alzheimer’s disease
  • Parkinson disease
  • Brain tumor
  • Cerebrovascular accident: A cerebrovascular accident (CVA) is commonly called a stroke. A stroke is cause by bleeding in the brain or by a clot that lodges in a blood vessel in the brain. In either case, there can be permanent damage to the brain.
  • Chronic drug abuse, e.g., chronic use of alcohol, amphetamine, or other illicit substances.
  • Traumatic brain injury
  • HIV associated dementia
  • Mental Retardation

 

Temporary Causes of Cognitive Impairment 

  • Dehydration
  • Fever
  • Intoxication with alcohol or drugs
  • Hypoglycemia (a.k.a. low blood sugar)
  • Hypotension
  • Hypoxia (Low oxygen content in the blood)
  • Infections
  • Medication side effects
  • ICU deliriums
  • Transient ischemic attack: A transient ischemic attack (TIA) is similar to a stroke but the damage is not permanent.
  • Withdrawal from alcohol or drugs

 

The permanent causes of cognitive impairment cause death to the brain cells by several different mechanisms. They completely block blood flow to the brain; there is traumatic damage to the brain; or they cause damage to the brain by interfering with normal metabolism of the brain. Many of the temporary causes of cognitive impairment disrupt the higher intellectual abilities because they interfere with the metabolism of the brain. The brain needs oxygen and food – the food being glucose, or blood sugar – to operate, and the brain and the central nervous system are extremely sensitive to a lack of oxygen or glucose. Without adequate supplies of these nutrients, some level of cognitive impairment will be seen. Elderly people are especially at risk because may have frail health and pre-existing medical conditions and without glucose and oxygen cognitive abilities will suffer.

Communication breakdown between caregivers and cognitive impaired patient can cause a lot of frustrations to both the patient and the Nurse Assistant. As a Nurse Assistant, it is imperative to identify and recognize patients who are cognitively impaired and learn how to communicate effectively with them in order to meet their needs.

Communication is simply the sending of a message from one person to another. Effective communication is a two way information sharing process which involves one party sending a message that is easily understood by the receiving party. So one may infer from this statement that in order for communication to be present, there has to be a message sent and that message must be understood; this can present a challenge for both the patient (who may have a cognitive deficit) and the care giver who is trying to care for the patient. We communicate with patients multiple times a day every day that we care for them. It is vitally important that we be able to convey our messages to them and that they are able to understand the messages that we are trying to deliver to them even though they may have difficulties with their cognitive abilities.

Types of Communication
Communication can be:

  • Written,
  • Oral or verbal
  • Body language or non verbal

 

Body language is the nonverbal sending of messages. This form of communication may be conscious or unconscious. Patients who have tightly knitted brows, gritted teeth and a sorrowful expression may be sending you the non-verbal message that they are in pain. Patients who grunt, or hit tables and chairs may be trying to gain your attention. Non-verbal communication may or may not be congruent. In other words, the signals that a person’s body is sending may or may not agree with what they are saying.

A skilled nurse assistant will always assess both the verbal and non-verbal communication of a client. Nurse Assistants who care for patients send messages through body language as well. Nurse Assistants who sits at the patient’s eye level with arms at sides conveys that they are prepared and ready to listen to the patient. Just because our patient has cognitive impairments or deficits does not excuse us from trying to attempt to communicate with them. Through attempts at communication we look after not only their physical needs, but also their psychosocial, spiritual, and emotional needs as well. The challenge is upon us as the caregiver to find ways of communicating our message to the cognitively impaired client and having it understood. Communication is not one sided. Communication implies the exchange of messages between two or more persons; therefore we must be able to understand the messages that our patients are trying to send to us even though they are not able to speak. We must take the time and make the effort to be a good receiver of the messages that our patients need for us to understand.

Patients who have had a stroke may have trouble thinking. Some may know what they want to say, but they just cannot find the word that will send a message to other people. This is called expressive aphasia. They may also have trouble understanding a message from other people or processing messages. This is called receptive aphasia.

HOW TO COMMUNICATE WITH PATIENTS AND RESIDENTS THAT HAVE COGNITIVE PROBLEMS

When communicating with patients that have cognitive impairments you should choose simple language and speak slowly and distinctly; avoid using medical jargon if they don’t understand these words. Words like ambulation, void, or NPO will add to the client’s confusion and frustration when trying to communicate so always remain calm and be reassuring. With the proper attitude and some simple techniques, working with clients who have cognitive impairment doesn’t have to be painful for you or for them. Staying calm and maintaining the same tone of voice can de-escalate a charged situation. When a patient is rashing out in frustrations, don’t take it personally. The patient who is acting aggressively is not doing so to harm you; the situation is not personal. Although the patient is acting dangerously, that person believes that he/she is trying to protect herself/himself from you. Don’t give them another reason to feel threatened so stay calm and try to reassure them using simple words. Here are some basic tools that can help you when you are working with a client who has cognitive impairment.

  •  Patience: You will need a lot of patience. The natural instinct when interacting with another adult is to assume that he/she is at your level of emotional and intellectual ability. This is not true of the patient with cognitive impairment so you need to be patient and explain in simple terms what you want to communicate to your patient.

 

  • Non-verbal communication: Most of us think of communication as what we say or the words we use. But there is quite a bit of our communication that is non-verbal. The tone of your voice, the loudness or softness of your speech, the speed at which you talk, the way you stand, and where you stand when you speak to someone – all of these are forms of non-verbal communication. Patients with cognitive impairment may have lost the ability on an intellectual level to understand everything you are saying. But their other senses are completely intact. They will often respond to how you speak to them rather than what you are saying. So it is often best to stand where the person can easily see you. Make eye contact and avoid touching the person until you are sure he/she won’t feel threatened by physical contact. Never pull or yank on someone if you want that person to move, change positions, stand up, etc. When you first approach someone, try and do so slowly; don’t rush at them.

 

  • Verbal communication: Do not “talk down” to patients who have cognitive impairment. Be gentle and take your time when communicating to these patients. Speak slowly and clearly and keep your communication simple and direct.. Try and keep your language at a basic level using only simple terms. Give them time to process what you are saying, and try and remember that it may take them far longer than you imagine to completely grasp the meaning of what you have said.  For patients with short term memories, repetition and reinforcement will be essential in communication.

 

  • Flexibility: Perhaps nothing is more important when working with a patient who has cognitive impairment than flexibility (And the opposite is also true: nothing is more harmful when working with these patients than being stubborn or rigid). Flexibility simply means that you have to learn to adjust to the demands of the situation. It means that you are able to change your plans. It means that you realize what is/isn’t important, and that you know that getting the task done is far more important than how you do it.

 

  • Priority setting: Many health care professionals see their job as a series of tasks that need to be accomplished. That is true in one sense, but working with people is very complex. Many times it is simply not possible to do everything you need to do and want to do, how and when you want to.  You are not a robot. Situations change and people change. If you are not able to clearly see what at any given time is the most important priority, your job will be very difficult: you must know how to set your priorities and how to change them as needed. Ask any experienced health care professional and he/she will tell you that in order to function efficiently, it is important to know what is most important, but you also need the ability to see that the situation has changed and to understand that a new, more important priority has replaced the previous one. Setting priorities is important, but so is being able to change and adjust your priorities.

 

  • Regular routines: Because the person with cognitive impairment has difficulty remembering people, places, and situations, establishing regular routines is important. If it is possible, ask your charge nurse to assign you the same patients.  This is a great benefit to the patient because of continuity of care. Try and find a routine for daily activities that is simple, does not change, and will be easy to remember for the patient. Be careful to slowly introduce changes into the client’s daily routine, and try and explain these changes as clearly as possible.

 

 

References

Caring for Adults with Cognitive and Memory Impairment. (n.d.). Retrieved October 4, 2014, from https://caregiver.org/caring-adults-cognitive-and-memory-impairment

Gerteis M, Edgman-Levitan S, Daley J, et al. (eds).Through the Client’s Eyes: Understanding and Promoting Client-Centered Care. 1993; San Francisco: Jossey-Bass.

Hall GR. “Alzheimer’s Disease and Chronic Dementing Illnesses”. (1996). University of Iowa Gerontological Nursing Interventions Research Center. http://www.guideline.gov

National Institute of Health. (1997). “Managing the Symptoms of Cognitive Impairment”. http://grants.nih.gov/grants/guide/pa-files/PA-97-050.html

Talking With Patients About Cognitive Problems. (n.d.). Retrieved October 4, 2014, from http://www.nia.nih.gov/health/publication/talking-your-older-patient/talking-patients-about-cognitive-problems