The dance of communication: retaining family membership despite severe non-speech dementia

The Relational Care Framework: Promoting Continuity or Maintenance of Selfhood in Person-Centered Care

We argue that contemporary conceptualizations of "persons" have failed to achieve the moral goals of "person-centred care" (PCC, a model of dementia care developed by Tom Kitwood) and that they are detrimental to those receiving care, their families, and practitioners of care. We draw a distinction between personhood and selfhood, pointing out that continuity or maintenance of the latter is what is really at stake in dementia care. We then demonstrate how our conceptualization, which is one that privileges the lived experiences of people with dementia, and understands selfhood as formed relationally in connection with carers and the care environment, best captures Kitwood's original idea. This conceptualization is also flexible enough to be applicable to the practice of caring for people at different stages of their dementia. Application of this conceptualization into PCC will best promote the well-being of people with dementia, while also encouraging respect and dignity in the care environment.

A qualitative systematic review of the role of families in supporting communication in people with dementia

BACKGROUND

Cognitive-communication difficulties are often associated with dementia and can impact a person's ability to participate in meaningful conversations. This can create challenges to families, reflecting the reality that people living with dementia rarely have just one regular conversation partner, but interact with multiple family members. To date, there is limited evidence of the impact of changes in communication patterns in families. A family systems approach, with foundations in psychology, can be used to explore the impact of communication difficulties on multiple different family members, including the person living with dementia and potential coping strategies used by individuals, together with the family as a whole.

METHODS & PROCEDURES

A systematic review of primary qualitative research was conducted to identify and examine research exploring communication and interaction within families living with dementia. Studies were identified through a comprehensive search of major databases and the full-text articles were subject to a quality appraisal. We conducted a thematic analysis on the literature identified to consider the role of families in supporting communication for people with dementia.

OUTCOMES & RESULTS

The searches identified 814 possible articles for screening against the eligibility criteria. Nine articles were included in the final review. Three major themes emerged from the analysis of the included studies: (1) 'identities changing' reflected how interactions within the family systems impacted on identities; (2) 'loss' reflected the grief experienced by families due to changes in communication; and (3) 'developing communication strategies' highlighted strategies and approaches that families affected by dementia may use organically to engage in meaningful interactions and maintain connection. Only one study explicitly used a family systems approach to understand how families manage the changes in interaction resulting from dementia.

CONCLUSIONS & IMPLICATIONS

The findings may usefully inform the clinical practice of speech and language therapists in terms of communication strategies and coping mechanisms that may be advised to facilitate connection in families living with dementia. Further research using a family systems approach to exploring communication in dementia may help to support the implementation of family-centred practice as recommended in policy.

WHAT THIS PAPER ADDS

What is already known on the subject There is increasing recognition of the impact of dementia on whole families and the need for family-centred interventions to enhance quality of life. However, much of the research to date that explores communication within families affected by dementia examines interaction between dyads, largely overlooking the roles and skills of other familial communication partners. To the authors' knowledge, there has been no previous review of the literature using a family systems approach, which has the potential to inform clinical practice of those working in dementia care. What this paper adds to existing knowledge The review examines and understands what is known about the approaches used by families affected by communication changes resulting from dementia to preserve connection. It collates the evidence from qualitative studies examining approaches and strategies used by individual conversation partners, including people with dementia, as well as the family system as a whole, to facilitate meaningful interactions, and proposes recommendations for clinicians working in this field. Furthermore, we consider the potential benefits of using a family systems approach to understand the context of people living with dementia and how this could enhance communication, personhood and well-being. What are the potential or actual clinical implications of this work? This review highlights practical conversation strategies and interactional approaches that may serve to enhance communication and preserve relationships between people with dementia and their family members. Such techniques have the potential to be advised by Speech and Language Therapists working in dementia care as part of tailored, relationship-centred care and support that they provide.

Supporting identity and relationships amongst people with dementia through the use of technology: a qualitative interview study

Meaningful activities in dementia care can promote the co-construction of narrative identity in caregiving relationships, helping to preserve the sense of self in people with dementia.

Purpose: Informed by symbolic interactionism and Deweyan transactionalism, the aim of this study was to develop a transactional model of how narrative identity and relationships are promoted through the use of a new technological solution, SENSE-GARDEN, that uses digital technologies and multisensory stimuli to facilitate individualized, meaningful activities.

Method: We conducted a qualitative interview study to explore the experiences of people with moderate to advanced dementia and their caregivers in Norway and Portugal. After using SENSE-GARDEN for 12–16 weeks, 20 participants (7 persons with dementia and 13 caregivers) were interviewed. The interviews were analysed using reflexive thematic analysis.

Results: Three themes were generated: openness, learning, and connection. Findings suggest that SENSE-GARDEN can stimulate emotional experiences, preserve narrative identity, and foster interpersonal relationships. These findings are illustrated through a transactional model.

Conclusion: This study highlights the complex multitude of factors affecting person-environment interactions in which narrative identity and relationships are constructed. To better understand these factors, future work should adopt a holistic approach to studying new methods of creating meaningful activities in dementia care.

Making a difference: Students' experiences with a dementia care program

As the number of elderly citizens in general and the number of persons with dementia in particular rises, the importance of educating geriatric health care professionals increases. Recruitment is, however, impaired by negative stereotypes and insecurity. Previous research has shown that contact with the field of dementia care is important for students' motivation for choosing this career path. This paper presents an extracurricular psychomotor intervention program in which students through eight visits to elderly persons with dementia carry out an intervention involving direct individual contact. Eight psychomotor therapy students participated in follow-up focus group interviews. The purpose was to explore the motivational dynamics that make these experiences meaningful to students. Qualitative analysis of the students' self-assessed outcomes revealed three themes: The relational encounter, Discovering the person, and Making a difference. In combination these themes show important nuances to existing literature on student career dreams by pointing to the benefits of attending to the moment to moment changes in the care situation.

Dance for People with Alzheimer's Disease: A Systematic Review

BACKGROUND

In recent years, several reviews have addressed the effectiveness of dance therapy in dementia, healthy older adults, or the elderly in general. However, reviews regarding the effect of this therapy exclusively on patients diagnosed with Alzheimer's disease have not been found.

OBJECTIVE

The purpose of this study is to review the available literature describing clinical trials which explore the effects of dancing on psychological and physical outcomes, functionality, cognitive function, and quality of life in patients diagnosed with Alzheimer's disease. In addition, this review aims to assess the quality of studies that perform dance therapy interventions in these patients.

METHODS

This study is a systematic review of randomized and non-randomized clinical trials regarding the effect of intervention including a dancing activity in people diagnosed with Alzheimer's disease.

RESULTS

In total, the evidence for this review rests on 12 studies with a total of 349 participants. The findings of this mini-review confirm the positive effect of dance therapy on physical and cognitive function, functionality, psychological outcomes, and quality of life in people with Alzheimer's disease.

CONCLUSION

Most of the studies implementing dance as part of the therapeutic treatment has shown to improve or slow the worsening in the quality of life of patients with Alzheimer's disease and their caregivers. Future research focused on these patients should use a more exhaustive methodology and make a more detailed description of these kind of interventions.

"I Would Like to Be Heard." Communicating With Singaporean Chinese Patients With Dementia: A Focused Ethnography Study

INTRODUCTION

Although first-generation Singaporean Chinese were mainly immigrants from Mainland China, the communication patterns of Singaporean Chinese in the present-day context differs from Mainland Chinese. This difference could be attributed to the subculture but is not conclusive. This study aimed to explore the experiences of nursing staff communicating with Singaporean Chinese with dementia in Singapore.

METHOD

A focused ethnographic study was conducted in a long-term care setting for people with dementia, where data were obtained using nonparticipant observations and semistructured interviews. Data analyses were conducted using Braun and Clarke's thematic analysis.

RESULTS

Nineteen nursing staff were interviewed. The central theme of "embracing diversity and accepting differences" was supported by three subthemes: acknowledging cultural differences, understanding the patients, and overcoming communicative challenges.

CONCLUSIONS

This study highlighted the need for nurses to understand cultural characteristics among Singaporean Chinese with dementia especially on emotional expressions when they are not understood by others.

Moderate dementia: relational social engagement (RSE) during family visits

OBJECTIVE

This qualitative study seeks evidence of retained social awareness in individuals with moderate dementia residing in care-homes, when engaged in interactive family visits.

METHOD

Speech/non-speech data collected from 10/15-minute video-recorded family interactions of five family groups (12 individuals; 2 sessions per family group) were coded using thematic analysis.

RESULTS

Interactional patterns embedded in familiar bonds provided the context for the superordinate theme: relational social engagement (RSE). This overarched two subthemes: in-step and out-of-step; highlighting that RSE, can occur as a result of both positive and negative familial communication patterns. When familial communication was in-step, despite changed communication pathways, the resident's attempts at social engagement appeared open, relaxed, and responsive. A sense of trust, and familiarity appeared to facilitate reciprocal understanding and the striving of resident family members to retain family group membership. When familial communication was out-of-step, active attempts at reciprocity or open engagement from visiting family members were not observed. At such times, communication became discordant, and frustrated in their efforts to remain an integral part of the family group, the resident appeared disinterested or guarded often retorting with annoyance at visiting family members.

CONCLUSION

The construct of RSE appears specific to prior meaningful relationships, where optimal social awareness and communication, positive and negative, can occur. Currently, dementia assessment and care does not include RSE during family interactions. Implications are discussed.

Severe dementia: relational social engagement (RSE) during family visits

OBJECTIVE

Few studies have utilised observation to investigate retained awareness when individuals with severe dementia interact with family members. Seeking evidence of retained awareness in those with severe dementia, interactive family visits in care homes were observed and analysed.

METHOD

Five family groups (14 individuals) completed 10/15-minute video recorded family interactions. Speech and non-speech interactions were analysed using Thematic Analysis.

RESULTS

One superordinate theme: Distinctive family bonds; overarched two subthemes, in-step and out-of-step describing positive and negative familial interactions. In-step interactions revealed family groups reciprocating social support, having fun together, and willing to go on the ride together. Out-of-step interactions characterised social frustration, non-reciprocity, and sidelining of members with dementia. Although awareness fluctuated, complex awareness was observed in the speech/non-speech expressions of those with dementia. In response, visitors appeared to treat those expressions and behaviours as understandable. Observed outcomes were out-of-step when visitors sought to retain the familiar and in-step when visitors sought to optimise all communication possibilities.

CONCLUSION

Video recorded family interactions and analysis revealed: (a) awareness was retained in the participants with severe dementia beyond assessed levels; and (b) Relational Social Engagement (RSE) occurred within family groups despite positive or negative interactions. Implications are discussed.

Holding on while letting go: trauma and growth on the pathway of dementia care in families

OBJECTIVES

Limited research explores the medical model of residential care in dementia from the family caregiver's perspectives.

METHOD

This study sought subjective interpretations of nine family caregivers who experienced relinquishing their status as primary caregiver to a medical model, dementia care residential setting. Following semi-structured interviews and transcription data was analysed using interpretative phenomenological analysis.

RESULTS

One superordinate theme, navigating 'system' control, overarched three subordinate themes: connecting/disconnecting, windows closing, and capacity for sensation. Navigating system control reflected participants' experience of circumnavigating a medical system fraught with hierarchical challenges inclusive of a complex maze of contradictions that appeared threatening, yet appeared comforting; authoritarian, yet often humane. For them, care of self, while advocating for a family member with dementia, required vigilance to manoeuvre a system of care that imposed its uninvited authority at will. Connection/disconnection highlights the enduring struggle for inclusivity in caregiving despite the omnipresent trauma of windows closing. Psychological growth came to these participants through an unexpected capacity for sensation which offered a unique lens to communication with the family member with dementia primarily through sensory exchange.

CONCLUSIONS

Models of dementia care and therapeutic interventions could inclusively involve dementia family caregivers who may be experiencing traumatic distress, and associated guilt, stigma, loss, and grief. Co-existing psychological wellbeing, however, is possible when family members are encouraged to transition communication to sensory awareness and exchange as windows close.

Stigma, the medical model and dementia care: Psychological growth in senior health professionals through moral and professional integrity

Minimal research explores the impact of a career in dementia care on senior health professionals. This study sought positive and negative subjective interpretations from seven senior health professionals regarding their experiences in dementia care. Data from semi-structured interviews were analysed using interpretative phenomenological analysis (IPA). One superordinate theme, Honouring stigmatised self, overarched four sub-themes: Systemic stigma, Invalidated, Self-respect and Moral integrity and Growth. Stigma was interpreted as systemically entrenched minimisation of aged care and the aged-care workforce, including poor remuneration and training. Participants experienced peer invalidation particularly when attempting to resolve complex professional and moral challenges in dementia care. These often occurred in the context of efforts to individualise care, constrained within a medical model. Paradoxically, external invalidation motivated a search for redefining ‘self’ and moral integrity. By wisely acknowledging career experience, growthful domains of self-respect, optimism, humility and innovation defined professional practice and personal choices. Implications are discussed.

Shame, hope, intimacy and growth: Dementia distress and growth in families from the perspective of senior aged care professionals

Minimal research explores the impact of dementia and a dementia diagnosis on families from the unique vantage of senior health professionals. The participants of this study, eight senior aged care professionals, provided unique interpretative insights into family dynamics and sense-making on the journey with dementia, and their own role in that journey. Both positive and negative perspectives were sought. Data from semi-structured interviews were analysed using Interpretative Phenomenological Analysis (IPA). One superordinate theme, Dementia naiveté; redefined intimacy, overarched Embarrassed shame; Maintaining hope; Redefining a model of intimacy; and Redefined relational intimacy and growth. Within these themes, the participants shed light on hurtful embarrassment and shame experienced by families associated with the diagnostic label given to a loved one. This label was perceived to either trigger separation, hurt and immobility through ignorance, or precipitate a frenzy of naive yet hopeful energy for seeking that elusive cure. The participants saw their role as one of enacting a new way of connecting what was with what could be. Thus, they modelled advocacy, integral care and relational intimacy. Validation came in witnessing a redefining of intimacy in many families who were able to embrace that holistic and empathic approach to the shifting presentation of dementia. Psychological well-being was observed to occur when families embraced growthful domains, e.g. acceptance, hope, relational closeness and altruistic concern for other families. Implications for future care models are discussed.

Estratégias comunicativas de cuidadores de idosos com demência: uma revisão sistemática

RESUMO Objetivo Conduzir uma revisão sistemática de estudos que investigaram estratégias comunicativas utilizadas por cuidadores de idosos com demência, publicados entre 1995 e 2015. Métodos O levantamento de estudos foi feito usando as seguintes palavras-chave “comunicação e cuidador e demência” e “comunicação e cuidador e Alzheimer”, e os termos em inglês “elderspeak and dementia”, “caregiver’s talk and dementia”, “communication and caregiver and dementia” e “communicative and caregiver and Alzheimer”. Desta revisão sistemática, foram excluídos os artigos de intervenção e aqueles que não tinham descrito entre seus objetivos investigar estratégias comunicativas usadas por cuidadores de idosos com demência. Resultados Apenas 22 estudos preencheram os critérios de inclusão. Os estudos revisados mostraram que os cuidadores de idosos com demência utilizam estratégias comunicativas que são ineficazes (por exemplo, comunicação infantilizada; comunicação “controle” e complexa) e eficazes (usar frases simples; dar um comando por vez; realizar perguntas em que a opção de resposta é sim ou não, entre outras). Conclusão É importante avaliar as percepções e avaliações dos cuidadores acerca da eficácia da estratégia utilizada, para que depois sejam ensinadas habilidades de comunicação para cuidadores familiares e cuidadores formais. A comunicação bem-sucedida deve promover a participação dos idosos com demência, contribuindo para manutenção da autonomia e participação tanto dos cuidadores quanto das pessoas acometidas por esse quadro.

General practitioners’ perceptions of the stigma of dementia and the role of reciprocity

A qualitative exploration of the stigma of dementia reported that general practitioners described lack of reciprocity as one way in which people with dementia are perceived within society. This was closely linked to their perception of dementia as a stigma. In this article, we explore whether general practitioners perceive people with dementia as lacking reciprocity and, if so, if this is linked with societal opinions about dementia as a stigma. The implications of both perceptions of people with dementia failing to reciprocate and of stigma for timely diagnosis are explored. Our approach is to follow the thread of reciprocity in the data from our initial study. In this follow-up study, general practitioners’ perceptions of societal views of people with dementia included a perception of a lack of reciprocity specifically linked with; failing to respond to human contact, the absence of an appropriate return on social investment and failing to contribute to, or being a burden on, society. General practitioners reported a link between societal perceptions of lack of reciprocity and stereotypes about advanced dementia, difficulties communicating with people with dementia, and lack of opportunities for people with dementia to reciprocate. General practitioners occupy a key position, they can challenge stereotypes and, with support and targeted training about communicating with people living with dementia, can emphasize the ways in which people with dementia can communicate, thereby enhancing their potential to reciprocate. Such changes have implications for improved care and quality of life through the continued maintenance of social inclusion and perceptions of personhood.

Synthesis of Meaning

A paucity of research explores both negative and positive changes for family members supporting a loved one with dementia, especially when communication by speech and awareness of others diminishes. This qualitative study sought the views of family groups concerning their experiences over the past 10 years supporting a loved one with dementia. A focus group sought negative and positive subjective interpretations of this phenomenon. One superordinate theme: Synthesis of Meaning emerged from the data using interpretative phenomenological analysis. This overarched two subordinate themes: (a) Steps backward—encompassing those times when relatives hovered uncertainly, missed opportunities to engage due to advancing dementia, and felt regret and (b) Steps forward—encompassing moments of unexpected rewards, acceptance, self-forgiveness, and empathic connection with others on a similar journey. This study highlights that although often fraught with distress, positive aspects of the dementia journey are possible and offer opportunity for psychological growth and well-being.