Communicating with Patients with Dementia – Strategies for Students

Communicating with Patients with Dementia – Strategies for Students

By: Cheyenne Hilton Brown, SPT

 

Background

One factor that has always fueled my interest in geriatrics is the complexity of each patient.  Dementia is a common condition that adds to the complexity of caring for the geriatric population and is one with which I have had both personal and clinical experience.  Ever since I can remember my grandmother has had dementia, so growing up my family and myself have had to learn how to best communicate with her and how to respond when she is agitated.  We have also seen both successes and failures in how the health professionals involved in her care have approached, or conversely not even considered, her dementia during their interactions with her.  I have encountered patients like my grandmother throughout my clinical rotations and have been appreciative of my personal experiences with dementia and guidance from clinical instructors to help me best communicate with them.  However, I realized that for students it can be challenging to know how to interact with a patient going through so many cognitive changes, especially if they are going into a rotation without any prior experience with dementia.  Therefore, with this project, I wanted to delve further into the literature to find guidance for students to be able to best communicate with patients and get the most out of their care.

Overview and Purpose

Dementia is estimated to affect about 14% of those 71 years of age and older, and the cognitive and behavioral changes associated with it can be complex and difficult to navigate.¹  There are multiple types of dementia that each have their different presentations, with possible changes including memory loss, decreased language skills, hallucinations, personality changes, and impaired executive function.  A patient can suffer from more than one type at a time, further complicating the patient’s presentation.²  Regarding caring for patients with dementia, physical therapy students have reported being less confident in their abilities compared to nursing students.³  Education in communication strategies has been shown to be beneficial for patients with dementia, healthcare staff, and healthcare students, reducing the frequency of depression and disruptive behaviors of patients, decreasing staff strain and turnover rates in nursing facilities, and increasing students’ knowledge and confidence with dementia patients.^3–5

This capstone compiled communication strategies found effective in the literature into a resource for students.  Second-year students are the target audience since their spring coursework includes academic content covering dementia (in the PHYT 736-Physical Therapy for Older Adults course and the dementia segment of the PHYT 785-Neuromuscular II PT Intervention course), making this resource an appropriate supplement at that point in the DPT program.  At the suggestion of Dr. Giuliani, as part of this project I explored which course the resource should be included with by surveying current students regarding which they feel is most appropriate.

Statement of Need

As referenced above, physical therapy students feel less confident interacting with this population than their peers of other disciplines, demonstrating a need for education of communication strategies with dementia in mind.  With second-year students about to go on two clinical rotations after their short spring semester, this resource would be particularly useful for those going to geriatric-focused sites, such as a skilled nursing facility or a home health company.  With the rise in the older adult population, students going to any setting, both for their rotations and in the course of their careers, are likely to have patients who are older adults, and therefore may experience the barrier that dementia can be to successfully helping a patient.  I discussed my project with the instructors of both courses the resource could appropriately accompany, Drs.  Karen McCulloch and Carol Giuliani, who both agreed that there is a place for the resource in the curriculum.

Products

To prepare for the creation of my educational resource, I created an annotated bibliography that summarizes relevant evidence, how it would contribute to the resource, and key concepts that would lead to the development of the strategies described in the resource.

For my primary product, I chose to create my educational resource in the form of a website that would be easily accessible to students through a link (https://dptanddementia.web.unc.edu/) rather than a downloaded file.  This website describes the communication strategies formed from my literature review, as well as video examples for students to see the techniques in use.

I also created a pre- and post-quiz to include on the website for students to test their knowledge and allow me to gather feedback.   The included document shows how the quizzes appeared to current students when viewing the site during the development of the capstone, thus they included questions to gather general feedback from the audience about the quality and utility of the resource, as well as the question regarding which course the students feel the resource would most appropriately accompany in the future as mentioned above.  Since these feedback questions were for the evaluation component of the project and will not be as relevant when viewed by future students, the quizzes currently seen on the website only contain questions for future students to test themselves on content-related knowledge.

Evaluation

The website was shared with current second and third year students.  Of those that completed the pre- and post-quizzes, the average quiz score on knowledge questions increased 11% from the pre-quiz to post-quiz.  Their pre-quiz feedback indicated that lack of knowledge of specific communication strategies with patients with dementia and lack of knowledge about how to handle problem behaviors were the primary factors they felt limited them from effectively communicating with patients with dementia.  In the post-quiz feedback, responders felt like the resource helped them improve in both of these areas.  Pre-quiz feedback demonstrated that no students felt “completely confident in communicating with people with dementia independently in a professional, physical therapy setting”, with most indicating they only felt confident in a casual setting or with the assistance of another person.  This did not change significantly in the post-quiz responses.  All responders indicated that the resource was extremely informative and that they will likely reference it again.  The majority of responders indicated that the resource should supplement the PHYT 736-Physical Therapy for Older Adults course.

It should be noted that participation in the quizzes was low with only 5 responders at the time this was posted, and therefore results regarding improvement after reviewing the resource, perceived utility of the resource, and other results should be interpreted carefully.

Self-reflection

Overall, I am very pleased with the product I created and feel that I met my personal goals to increase my own competence in communicating with patients with dementia and to gain efficiency in compiling evidence and sharing my findings with peers.  Communication is a very abstract concept compared to the physical outcomes we often measure, so this project challenged my literature review skills to find concrete, evidence-based strategies to help students develop such a non-concrete skill.  It also helped me cultivate a greater appreciation for the role a soft skill like communication has in our overall “clinical toolbox”.

The feedback I received was positive in indicating that students found my resource informative and useful, but I was disappointed in the overall lack of responses I received to the quizzes.  As I reflected on what I could have done differently to change this, the main thing I arrived at was to have made the presence of the quizzes clearer on the Welcome page of the site, such as mentioning them earlier in the introduction in case people reviewed the website but somehow missed the quizzes.  I also recognize that personal factors could have played a role, such as my reserved nature to not be “pushy” with asking for feedback and the fact that I am not local to draw attention to my resource via a presentation.  With the timing of this resource’s completion, students may also be busy during their current rotations and classes, so messages about a resource to explore may be low priority when it is not currently relevant to their coursework.  When the resource is included with a course, I hope that this will be a better platform for future students to take advantage of this resource and learn about how to communicate with their future patients with dementia.

Acknowledgements

I deeply appreciate the help of my capstone advisor Dr. Karen McCulloch, as her early and continued guidance solidified my vision for this project and provided ideas for crafting my resource to best benefit students.  I would also like to thank Dr. Carol Giuliani for letting me bounce ideas off of her early on and offering her solution for deciding which course the resource would best accompany.

I am so grateful to my committee members, Janet Elder, PT and Elizabeth Huber, DPT.  As my CI during my acute care rotation, Janet and I experienced communication barriers of various types with our patients, and she has instructed many UNC students during her career.  She was able to provide clinically relevant advice that is appropriate for the student audience.  As my “big buddy”, Elizabeth has been a source of support throughout my time in PT school.  Her experience in geriatric settings and as a recent graduate of our DPT program helped provide a student perspective for use of the resource and helpful information to include.

Lastly, though not directly involved in the development of my project, I would like to acknowledge my mom as an inspiration behind it.  Through an often tough 20 years of being a caregiver for my grandmother, my mom learned many of these communication strategies the hard way.  Her example has demonstrated to me the importance of effective communication for your own wellbeing as well as that of the person with dementia for whom you are caring/treating.

 

References

1. Alzheimer’s Association. 2016 Alzheimer’s disease facts and figures. Alzheimers Dement 2016;12(4):459-509. doi:10.1016/j.jalz.2016.03.001.
2. Grossman H, Bergmann C, Parker S. Demenita: A Brief Review. Mt Sinai J Med 2006;73(7):985-992.
3. Wood JH, Alushi L, Hammond JA. Communication and respect for people with dementia: student learning (CARDS) – the development and evaluation of a pilot of an education intervention for pre-qualifying healthcare students. Int Psychogeriatr 2016;28(4):647-656. doi:10.1017/S104161021500188X.
4. McCallion P, Toseland RW, Lacey D, Banks S. Educating nursing assistants to communicate more effectively with nursing home residents with dementia. Gerontologist 1999;39(5):546-558. doi:10.1093/geront/39.5.546.
5. Liddle J, Smith-Conway ER, Baker R, et al. Memory and communication support strategies in dementia: effect of a training program for informal caregivers. Int Psychogeriatr 2012;24(12):1927-1942. doi:10.1017/S1041610212001366.

Image Source:

Hyatt M. What Do You Wish You Knew Then That You Know Now? https://michaelhyatt.com/what-do-you-wish-you-knew-then-that-you-know-now/. Published August 13, 2012. Accessed March 21, 2018.