3.4 Effective communication

3.4.1. Introduction

Communication is a process through which individuals create relationships with each other. In the communicative process there are several elements that we have to take always into account:

• Sender or speaker: person who transmits something to the others.
• Receiver: the person who receives and interprets the information or message.
• Message: the information the speaker sends to the receiver.
• Channel: the element that is used to stablish a connection between the speaker and the receiver.
• Context: group of factors and circumstances in which the message is produced.

We have to repair in all these elements if we want to achieve an effective communication, whether we are senders or receivers. We have to adapt our message and communication channel so that it is accessible to the receiver. Equally, we have to look for a favourable context and channel as receivers to facilitate the transmission of the message to the sender.

3.4.2. Types of communication

Verbal communication

Verbal communication is the ability that humans have to communicate using the language, both written and spoken language. The instrument of the oral or spoken communication is the speech and it is supported by elements such as the tones of voice, laughter or silences among others. On the other hand, the main instrument of the written communication is writing, on this case supported by for example orthographic resources.

Non-verbal communication

Non-verbal communication is the exchange of messages without using words. There are 3 areas of study of non-verbal communications:

• Kinesis: body movements (gestures, postures, etc.)
• Paralinguistic: behaviour expressed in the voice (tone, volume, rhythm, etc.)
• Proxemic: behaviour related to space (distance, looks, etc.)

3.4.3. Communication barriers

Whenever a communicative process is carried out, a huge variety of barriers can interrupt, damage or nullify the communication and cause messages not to reach the receivers. Due to this fact, misunderstandings appear. On the following lines some of the possible barriers are listed:

Semantic barriers

This occur when the language, symbols or vocabulary used are not well understood. In order to get an effective communication, it is necessary to use clear and simple language that is accessible to the receiver.

Physical or environmental barriers

Aggrupation of interreferences that may be present in the environment or surroundings that block the communication. They could be characteristics of the environment (noisy places), physical characteristics of the space (dimensions of a room), the channel we are using (a telephone), etc.

Psychological barriers

Barriers related to emotions of those present at the moment of the communication: prejudices, negative attitudes or others. Sometimes these emotions can condition the effectiveness of communication.

Barriers caused by the sender and the speaker and the receiver

Barriers that may be related to the skills or abilities of the participants (speakers and receivers) as for example: beliefs, lack of communication skills, attention or others.

3.4.4. How does dementia affect communication?

As it is mentioned in the previous units, sometimes people with dementia experience language and communication ability impairment. This fact has a direct impact in communication between individuals.

Changes in production and comprehension abilities differ in their extent and nature depending on the type of dementia and the stage of the disease. While the exact progression of the disease is different for each person, there are some steps which are common among different conditions and stages.

Initially, people with dementia often have troubles in finding the right word at the right time (“anomie”) and often makes use of one word for another, basing on phonological similarity (regarding sound) or semantic similarity (regarding meaning). At times, speech appears to be confused and contains false starts (sudden stops or topic shifts). This arises from the difficulty of keeping in mind what the person wants to communicate while his conscious thought elaborates him linguistically. The person may experience increased frustration. Furthermore, the person might have troubles in following fast and complex dialogues between several people, especially if there is background noise. There may also be some difficulties in writing (reduplications and /or omissions of letters, overlapping and/or spacing of letters within of the same word, etc.).

As dementia progresses, speech problems become greater, and language becomes unclear. The difficulties at the pragmatic and semantic level increase considerably. At this stage the vocabulary becomes more and more limited. The person needs more time before speaking and sometimes they repeat the same word over and over again. The person might resort to passe-partout words (“the thing”) or to pronouns (“it”), leaving no lead way for someone else to guess what it is they are trying to communicate, which might cause great frustration in both the person and his caregivers. The person has trouble understanding everyday conversation and following complex orders (e.g. “Before coming to the table, go wash your hands.”), or even simpler ones. Understanding of figurative language (e.g. “I feel blue”) is also compromised as well as understanding of written messages. Even the expressive side of non-verbal communication deteriorates: the gestures that accompany the words are not always congruous, the prosody becomes monotonous or sometimes it does not match the emotional content of the message. However, the decoding of gestures, affective prosody and facial expressions of his interlocutor is still relatively well preserved.

At later stages, people appear to lose the capacity for recognizable speech. The person becomes increasingly laconic and speaks only if stimulated, with often stereotyped answers. The person repeats the sentences she heard or that she has pronounced herself (“echolalia”). Sometimes the person whispers only one or two syllables. Finally, the person might only moan or scream and then become totally mute. Oral comprehension is seriously compromised and writing and reading are no longer possible. Even non-verbal communication is noticeably reduced: there is motor inertia, the face is devoid of expression, and affective, visual contact with the interlocutor is difficult.

3.4.5. Some tips to improve communication with people with dementia

Here are some tips which might be useful to develop person – centered (Kitwood 1997) strategies of communication:

• Gain attention.
  As people with dementia usually have difficulties in performing two activities simultaneously, it is very important that the person can devote himself exclusively to the act of communicating without having to perform other tasks including routine tasks such as eating, washing or dressing. This also applies to the interlocutor. If he carries out other activities while talking to the patient or listening, he will surely end up distracting the person with dementia. Make sure you have the person’s attention before speaking. Get close enough so that the person can see your facial expressions and any gestures you may use. Making eye contact helps focus attention and try to keep at little distance (this is also to facilitate the reading of the lips and the identification of facial expressions). As some people have problems recognizing family and friends, you might want to introduce yourself and remind them who you are. Ensure the person is comfortable (not in pain, tired, hungry, too hot or cold, wanting to go to the toilet) before attempting an important conversation.
• Limit distractions.
  Choose a quiet and well-lit environment to speak and signal your arrival through another sensory channel (e.g., saying your name, talking, making noise, touching your hands or shoulders). Reduce distractions like TV, radio, or other people talking in the background and choose places free of other noises in order to avoid confusion, anxiety or irritation for the person, thus facilitating concentration.
• Be aware of your tone and body language.
  When communicating with a person with dementia, how you say something is often more important than what you say. Make sure your body position is relaxed and that your facial expression and stance are coherent with what your words are saying. Speak in a relaxed tone of voice. Make sure you are calm; otherwise the person will notice your anxiety and become anxious themselves. Try to avoid sudden movement which might make the person nervous.
• Speak clearly and slowly.
  Speak slowly and clearly, using short sentences. Avoid metaphoric phrases that can be interpreted literally. Short sentences, visual cues or pictures may help the person with dementia understand what he or she is hearing.
• Use gesture or body movements
  such as pointing or demonstrating an action to help the person understand what you are saying. Of course, this should be done tactfully so the person does not feel you are treating them as a child.
• Be patient.
  Avoid interrupting people with dementia; they may lose their train of thought. Allow them to interrupt you, or they may forget what they want to say. The person may need more time to process the information and respond a question, so be patient and provide reassurance. If they are having trouble communicating, tell them that it’s fine and encourage them to keep trying to put their thoughts into words. If they sense you are impatient or agitated, they may feel stressed or frustrated.
• Be respectful.
  Use the person’s name when addressing her to help her retain a sense of identity. Avoid using childish or “elder” talk or any demeaning language. Do not talk about the person as if she isn’t present. They may still understand what is being said even though they have lost the ability to form the words that are in their mind. Respect the moments where the person doesn’t want to speak.
• Try to be reassuring and encouraging.
  Instead of criticizing and correcting, ignore failures and remember to be supportive, positive and encouraging. If appropriate, explain in understandable terms what is happening and offer reassurance such as, “I’m going to wash your arm now. You’re doing great!”
• Suggesting lost words
  may help and some people appreciate the assistance. For others, however, it is frustrating if you finish sentences for them and get it wrong. Don’t be personally offended if the person who has dementia becomes paranoid or accusatory. Ignore offensive language and try to redirect attention if the person with dementia begins using bad language.
• Remember that this IS his or her reality.
  With the progression of the disease, a person’s perception of reality can become confused, it is important to remember that this IS his or her reality. Accordingly, you should avoid contradicting the person you are caring for or shouldn’t try to convince her that her perception of reality is not correct. This will cause just frustration. Research shows that breakdown in the conversation does not just disrupt meaning but also threatens to expose a lack of competence on the part of the person with dementia which has the broader effect of placing the individual’s sense of dignity or positive self-image at stake (Goffman 1967; Hamilton 1994).
• Listen carefully.
  Listen carefully to what the person is saying and observe both verbal and non-verbal communication. Some research showed that an attentive role of the listener – which includes the use of words signaling attention (‘mmm’, ‘yeah’) or news‐marks (‘you don’t say!’) plays a beneficial effect on the communicative competence of the person with dementia (Hydén et al. 2012). If you find it difficult to understand the person, call upon their past experience and what you know about them. If you don’t understand what is said, avoid making assumptions. Check back with them to see if you have understood what they mean. Watch for behavior changes, body language and non-verbal signs that may be used to express a feeling or indicate physical discomfort, in which case you may wish to contact the person’s family doctor.