Communication in Dementia and Delirium

Authors: Mariam Zaman / Editor: Charlotte Davies, Kate Hudson, Linda Dykes / Codes:  / Published: 29/10/2024

This is a section on communication skills that we have updated and reprinted from our medical student iBook. We look forward to hearing your strategies for providing a best experience to patients with dementia.

I feel it is imperative to know key communication skills to be able to engage and get the best out of a history and examination that would generally be quite difficult to obtain. As medical students we have the luxury of time on our sides, and so we should use this to our advantage, as these histories cannot be rushed and should be comprehensively taken. Things can be easily missed, but also many patients greatly appreciate someone taking time out and sitting and talking to them, and the majority of the time they have the most fascinating stories about their lives and can make your time pass a lot quicker too; you can actually learn a lot also!

A lot of elderly patients presenting to the Emergency Department (ED) are in an acutely confused state due to the environment, or medical causes like infections or sensory problems. Many of the patients presenting will also have dementia and can be adamant about going home which of course is easily understandable as they are confused, feeling unwell, and they are in unfamiliar surroundings. They may also be restrained to a bed, which can be extremely frightening, and healthcare professionals may dismiss this as the patient being awkward, and they may get quite angry towards the patient for behaving in this way, which of course the patient cannot control. Medical students who will frequently see acutely confused elderly patients should try to make them comfortable. During my ED placement I also saw excellent examples of healthcare professionals communicating effectively, taking their time and treating these patients with compassion and dignity, and they got a lot out of a history and examination as a result.

INFOGRAPHIC

Dealing with patients who are acutely confused or have dementia

The key tips I have picked up during my placement on how best to communicate with elderly patients are as follows:

  • Always take your time

This might sound obvious but its so important. As a student you do not need to rush, you dont need to get a history taken in 10 minutes, you can take your time, which means you can make the most out of the learning experience. You will need to ask all the key questions, and rule out all the major red flag symptoms you are worried about, as many patients will not be as forthcoming with all the symptoms they have experienced as they have extremely complex medical problems, and so it is important to take a comprehensive medical history.

  • Check the patient can hear you

One patient I saw during my EM placement was unable to understand what any of the doctors and nurses were saying. He was dismissed as being confused, with the presenting complaint on the clerking booklet being acute confusion likely UTI. The EM consultant who I saw the patient with realised that the patient spoke coherently and logically, it was just that he did not answer the questions he was being asked, and was frightened and shy. She then realised it was due to the fact that he was unable to hear, and so she went ahead and proceeded with writing all her questions down on a piece of paper, which meant she was able to take a completely comprehensive (albeit slightly longer) history. I feel it is massively important to always keep in mind that many patients are mistakenly seen as being confused when in fact they have a visual or hearing impairment, so always assess that they are able to see and hear you before you begin.

Checking the patients have their hearing aids in is essential for their orientation, as well as ongoing communication. Some people find that speaking into the bell end of a stethoscope whilst the patient has it in their ears can also help!

Avoid talking louder or shouting if the patient cant hear or understand. Try to speak in a lower tone, and speak in shorter sentences. A lot of the time the patient can hear what you are saying, they just cant understand what you have said – dont say the same thing louder, rephrase the question in small sentences. Although asking open questions is important, it is often easier to assess the situation and identify red flags using yes/no answers which are sometimes easier for the patient to understand and answer, especially if there is a degree of cognitive impairment or tiredness.

  • Have plenty of patience!

It is extremely difficult to support a patient who is confused and agitated and adamant theyd like to go home. The best way to support these patients is with patience and compassion. Remember they are confused and frightened, they are not purposefully trying to be awkward. Many patients are frustrated and fed up. Whoever treats the patient with care and patience will get the most out of the history and examination. Compassion can look very different according to the patient – it might be that theyre screaming because they need a wee, and taking them to the toilet helps. They might be frightened of the BP cuff – talk to them first. They might be hungry! Ringing a relative to speak to them on the phone might help. A bit of common sense and compassion can go a long way.

  • Establishing rapport

Always sit with the patient at eye level, and never stand over them. Set a positive tone, as being smiley and happy enables a sense of comfort. A small gesture such as holding their hand can make them feel much more comfortable and relaxed and can really help calm the situation. If they are adamant about wanting to go home, talk to them about their home, about what they like doing, what they like eating/cooking, watching on tv, what hobbies they have etc. This can alleviate the situation and it can distract them and allow them to talk about what they like doing. Many patients are confused and generally have reasons why they are worried and adamant about going home, so you should always ask them why they want to go home right away; many will think theyve left the heating on, or their pet has not been fed, or theyve not locked the door – and they might be right.

Addressing their concerns and worries and explaining that the carer/paramedics will have sorted it out for them can sometimes help and calm them down, and it will also demonstrate you have considered their main worries and concerns.

  • Maintain safety

In my local department, all our confused patients should be wearing blue wristbands so people know not to let them out of the department as theyre vulnerable. Ask what the system is where you work.

Reduce risk of falls – make sure theyve got red socks on, or their shoes or slippers on properly. Make sure the call bell is in reach. Lower the bed and bed rails. Make sure they can reach any food that has been provided – and that they shouldnt be on a special diet.

  • Provide appropriate distraction

What distraction you provide needs to be patient specific. A twiddle muff may be appropriate.

  • Appropriately investigate potential causes for their delirium

PINCH ME is a really useful mnemonic that I think should be documented and assessed for every patient with acute confusion.

Youll note a CT head is not routinely indicated in acute confusion. Urine dipsticks should be interpreted with caution. Remember the mortality of delirium is 6% per month – comparable with sepsis and MI.

  • Consider if hospital admission is really safer

Can the patient with confusion be safely supported in their own home – where they know where and what everything is, with familiar people or do they have an acute medical issue needing treatment. The team, including any dementia specialists, may be able to help.

Delirium is VERY important. Weve focussed here on communication, but do look at the other RCEMLearning resources:

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