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Adaptive interaction: A new approach to communication

  • University of Toronto & KITE Research Institute University Health Network
24 Journal of Dementia Care May/June 2011 [Vol 19 No 3]
Maggie Ellis and Arlene
Astell describe the
development of
Adaptive Interaction as
an approach to
communication with
people with advanced
dementia, and their
success in teaching this
approach to care home
Maggie Ellis (right) is a research
fellow and Arlene Astell (left) is
a senior lecturer, School of
Psychology, University of St
Andrews, Scotland
Adaptive Interaction: a new
approach to communication
Many people in nursing homes have
advanced dementia. Their decline
has progressed to the point where
they can no longer walk or talk, and their
social world is often limited to interactions
that take place during the provision of
routine care.
This article describes our work
developing Adaptive Interaction (AI), a non-
verbal technique for interacting with those
with advanced dementia using communica-
tion behaviours like sounds and gestures
that are familiar to them. We go on to
describe how we taught the approach to a
small number of care home staff.
In the absence of speech, communication
between family or formal caregivers and
people with dementia becomes very
difficult. Faced with a person who cannot
speak, caregivers have to decide how to
communicate, how to judge whether and
what the person can comprehend, and even
if there is any point in trying to
communicate at all.
However, loss of speech does not
necessarily equate to loss of ability or desire
to communicate (Ellis & Astell 2004). We
previously demonstrated that people
without speech still want to interact with
others (Astell & Ellis 2006), which should
reassure dementia caregivers that they can
still communicate with those in their care.
It is a question of finding an alternative way
of communicating.
In this regard, Kitwood (1997) argued
that when ‘sophisticated’ means of commu-
nication, like speech, fall away, more basic
and deeply learned communication
methods may be necessary. Fundamental
communication skills, such as facial
expressions, eye gaze, gestures, sounds, and
laughter emerge early in life as precursors
to speech. Once speech develops, these
behaviours tend to support verbal interac-
tions, but they can also be used
independently to open up communication
for people who cannot speak.
Intensive Interaction
Intensive Interaction (II) is a method of
interacting with people with severe speech
problems developed in the 1980s, based on
Geraint Ephraim’s work on the fundamen-
tals of communication (Ephraim 1986). In
II, the behaviour of people with verbal
deficits is viewed as intentionally commu-
nicative, and their communication partner
attempts to learn and respond to it (Hewett
1996). Accordingly, Caldwell (2005)
described II as a technique for ‘learning the
language’ of non-verbal people.
Intensive Interaction involves the
caregiver becoming familiar with the person
they want to communicate with and their
non-verbal behaviours, such as sounds or
movements. The caregiver then picks up
one of these behaviours and uses it to start
a ‘dialogue’ with the person.
By responding in ways familiar and
meaningful to a person without speech, ie
initially imitating and then developing non-
verbal communication into a shared
‘language’, it is possible to build and sustain
close relationships (Caldwell 2005). This is
as desirable and important for those who
lose the ability to talk through progressive
dementia, as for any other group of non-
verbal communicators.
Testing the approach
To investigate the potential of II, we
conducted a single case study (Ellis & Astell
2008). We worked with Edie, an 81-year-old
lady with advanced dementia, who had lived
in a nursing home for five years. Edie could
not speak and was no longer mobile. The
study involved spending time in the care
home in order to determine (i) the type of
communication that occurred between
caregivers and Edie, (ii) the frequency of
communication during any given day, and
(iii) Edie’s repertoire of non-verbal commu-
nication skills.
Our observations revealed that Edie spent
most of her time alone in her room, with
caregivers going in only for brief periods to
carry out specific care tasks, such as
providing meals. Any communication that
took place was short and consisted mainly
of questions to which Edie was unable to
respond, such as: “Have you seen the
weather today?” or “Did you eat your
From these findings, we constructed what
we termed a ‘standard interaction’,
comprising a set of questions, such as the
ones above. The first author (ME) spent 10
minutes with Edie, working through the
questions and allowing 30 seconds after
each for Edie to respond. This made it
possible to gain an impression of her
communication behaviour in response to
May/June 2011 [Vol 19 No 3] Journal of Dementia Care 25
speech. Subsequently, ME spent another 10
minutes with Edie, using the principles of II
in an attempt to learn Edie’s language.
The application of II revealed that Edie
had a rich communication repertoire, which
comprised sound, movement, directed eye
gaze, and facial expressions (Ellis & Astell
2008). She was also able to take turns,
initiate the communication, and imitate her
communication partner, signalling her
willingness to communicate and interact
with another person through her behaviour.
Over a 10-minute session, Edie and ME
engaged in a non-verbal ‘dialogue’ that saw
them both smiling, laughing, and
exchanging head rubs.
The findings of this single case study
suggested that II has potential for opening
up communication channels between
caregivers and people who have lost speech
through progressive dementia. However,
since the latter tend to have severe memory
problems, no assumption can be made
about them remembering and building up
a repertoire of non-verbal communication
from session to session. Therefore, each
encounter must be approached as unique,
with the communication partner prepared
to start afresh, responding and adapting to
the person’s non-verbal behaviour. We
therefore named this slightly different
approach ‘Adaptive Interaction’ (AI).
Adaptive Interaction:
a multiple case study
Following the positive results of the work
described above, we conducted further
work using AI with Edie and four other
residents with advanced dementia from the
same nursing home.
The five older people were 80 to 88 years
of age, and had been resident for at least
three years. One was independently mobile,
one spent most of the day in her wheelchair,
and three were mostly bed-bound.
As with Edie, before trying AI, we spent
time in the care home becoming familiar
with the group’s daily routines. Specifically,
we were interested in the type of communi-
cation that took place between the residents
and their caregivers, and the frequency of
communication during any given day.
We then spent several days working with
the residents, either asking questions like
those we saw care staff use – “Have you had
your lunch?” and “Have you seen the
weather?” (Standard Interaction) – or using
AI. We looked at how the residents
responded to the two types of interactions,
to see if the Adaptive one had any impact on
their communication. The outcomes are
summarised below.
Mary, aged 88, was the eldest and the only
independently mobile participant in the
study. She had some speech, but this was
limited to only a few recognisable words.
Yet, during AI, Mary sang and showed a
surprised facial expression, neither of which
she did during Standard Interactions.
Maggie was 87 and, like Mary, used only a
small number of identifiable words.
However, during AI, she touched her
communication partner’s face and drew her
attention to sounds outside the room. She
did not engage in either of these behaviours
during Standard Interactions.
Gil, an 80-year-old bed-bound man, could
make some speech-like sounds and move
his hand to point. He made more speech
sounds and pointed more often in AI than
in Standard Interactions.
Gerty was 84 and confined to bed. She
had no speech and typically made very few
other sounds. During AI, Gerty looked at
the communication partner intently, made
speech sounds, poked out her tongue and
Lastly Edie, with whom we had already
tried AI (Ellis & Astell 2008). She did not
use any speech but regularly made a high-
pitched sound. Adaptive Interaction
revealed a much wider range of commu-
nicative behaviours in Edie. For example,
she rubbed her head against the bed and
the communication partner’s head and
hand. She also showed a surprised
expression, smiled and laughed.
This study, and our initial work with Edie,
showed that we could apply AI to other
people with advanced dementia. Although
there was variability among residents, the
use of this approach revealed that each
person had a repertoire of non-verbal
behaviours, including eye gaze, movements,
sounds, and facial expressions. They also
engaged in turn-taking, imitation of the
communication partner, and initiating
Based on these findings, we concluded
that Adaptive Interaction definitely has
potential in the difficult task of communi-
cating with people whose dementia has
progressed to a point where they can no
longer communicate through speech.
Adaptive Interaction:
a feasibility study
Our next step was to explore the challenges
of introducing AI into dementia care
settings. We describe here our first attempt
at teaching a small group of caregivers in a
nursing home specialising in dementia the
basics of AI, in order to give them the ability
and confidence to start using this novel
To introduce the project, we organised an
open evening for staff and residents’
families. The main purpose of the event was
to introduce the principles of AI, which we
did by illustrating the cases previously
described in this article. We also wanted to
find out from staff and families what they
perceived to be the barriers to communica-
tion in advanced dementia. Additionally, we
wished to invite people to participate in the
project. We were looking for staff members
as well as residents with advanced dementia
whose families were able to provide proxy
consent for them to participate.
We received responses from seven
families, who were keen for their relatives
to take part in the project. Four staff
members initially agreed to participate.
However, one of these was unable to attend
all the planned sessions, so we used data
from three: one nurse, one nursing
assistant, and one activities coordinator.
Each staff member was asked to pair up with
one of the residents with advanced
dementia and to work with them over the
duration of the project. This took place over
a six-week period. Staff participants
attended one teaching session a week
during the first four weeks, and a follow-up
session in week six. The teaching sessions
comprised a mixture of theory, demonstra-
tions, and practical skills. These were
supported by between-session activities that
staff participants practised with their
residents and reported back on at the next
meeting. This enabled them to gain direct
hands-on experience of using AI, and to
address concerns about how to use it.
The project aimed to answer two
questions: “Can we teach care staff the basic
principles of AI?” and “Can we overcome the
barriers that could prevent care staff from
using these principles?”
To address the first question, we devised
the teaching sessions to provide staff partic-
ipants with insight and understanding of AI.
We included information about the funda-
mentals of communication, the
development of communication in humans,
and the use of verbal and non-verbal
communication. We also covered the basic
Despite being unable to speak, Edie was
able to communicate in a range of other
ways using sounds, movement, her eyes
and facial expressions
26 Journal of Dementia Care May/June 2011 [Vol 19 No 3]
principles of Intensive Interaction (from
which we developed AI), and the role of
imitation in initiating and supporting
communication. This was recognised as a
particularly delicate issue, which has to be
properly introduced and explained to avoid
the possibility of it being used insensitively
or inappropriately.
In addressing the second question, we
recognised that one barrier to the imple-
mentation of AI was staff resistance to the
idea of engaging in non-verbal communica-
tion. One indicator of this was the small
number of caregivers who had volunteered
to participate in the project. However, we
were aware that this was partly due to the
self-consciousness of communicating
through sounds and movements. We also
recognised people’s natural fear of failure,
especially when we were asking them to
come back and share their experience,
including lack of progress, from week to
week. Furthermore, we knew that staff
participants were unsure as to what, if
anything, residents with advanced dementia
could understand and, consequently, how
they would know if their attempts to
communicate were effective. For this
reason, using our previous cases as
examples, we worked with them to explore
the sorts of things they might see in their
residents that could be taken as indicators
of communication behaviour.
We then set out to tackle, through a
careful mix of practical training and
support, the obstacles we had identified, to
enable staff participants to put into practice
the principles of AI.
The follow-up session in week six was
used to gain feedback from staff on both the
teaching and their progress following the
end of the four weeks of formal instruction.
As for the teaching, all staff participants said
they had enjoyed the course and wished
that it had been longer. Regarding the
techniques we had used, one said: “You
watch training videos that put you to sleep
but this one does actually mean something.”
They also felt better equipped to identify
communication behaviours in people with
advanced dementia, and to respond appro-
priately to them. For example, one of the
participants said: “I think it’s worked really
well. You do it without realising you’re
actually doing it.”
At the end of the project we organised a
second open evening to present our
findings to staff and residents’ families at the
nursing home. One important outcome was
a request for us to teach staff members who
had previously refused to participate. Addi-
tionally, the wife of a resident who had
joined the project, once she had seen the
results, asked that we show what was
achieved with her husband, pointing out
that it was the first time he had smiled in
Overall, the findings from this short
feasibility study were very encouraging.
They demonstrated, not only that we can
teach care staff the use of Adaptive
Interaction with residents with advanced
dementia, but also that we can overcome
the barriers that may prevent staff from
implementing this novel communication
People with dementia lose the ability to talk
in the advanced stage of the disease.
However, in conversation, they engage in
communication behaviours, such as sounds
and gestures, which indicate desire and
ability to interact. Adaptive Interaction
encourages dementia caregivers to learn
these behaviours, and to use them for
communicating with the person in their
Our work so far shows that, in the nursing
home setting, Adaptive Interaction
effectively supports and facilitates the
communication between care staff and
dementia residents with no speech ability.
We also found that AI can be taught success-
fully, giving caregivers the skills to start
using it with confidence. As such, we are
currently developing a training pack, which
we hope will be of interest to the care
industry and the wider community.
Astell AJ, Ellis MP (2006) The social function of
imitation in severe dementia. Infant and Child
Development 15, 311-319.
Caldwell P (2005) Finding You Finding Me: Using
Intensive Interaction to get in touch with people
whose severe learning disabilities are combined
with autistic spectrum disorder. London: Jessica
Kingsley Publishers.
Ellis MP, Astell AJ (2008) Promoting communica-
tion with people with severe dementia. S. Zeedyk
(Ed) Techniques for promoting social
engagement in individuals with communicative
impairments. London: Jessica Kingsley
Ellis MP, Astell AJ (2004) The urge to
communicate in severe dementia. Brain and
Language 91(1) 52-52.
Ephraim G (1986) A brief introduction to
augmented mothering. Clinical Paper, Learsden
Hospital, unpublished.
Hewett D (1996) How to do Intensive
Interaction. In Collis M, Lacey P 1996 (Eds.)
Interactive Approaches to Teaching: A
Framework for INSET. London: David Fulton.
Kitwood T (1997) Dementia reconsidered: The
person comes first. Maidenhead: Open University
May/June 2011 [Vol 19 No 3] Journal of Dementia Care 27
How can we improve care in gen-
Recently, dementia has become a hot
topic in the world of the acute
general hospital. After years of
rumblings about poor quality care, the
publication of the National Dementia
Strategy (2009) and the subsequent (quite
damning) Counting the cost report (2009)
crystalised a conviction that something
needs to be done to improve care for
people with dementia in the general
hospital setting. Several strategic health
authorities have also attached CQUIN
(Commissioning for Quality and
Innovation) money to improving dementia
care, and this has helped to focus attention
on the issue.
At the Royal Free Hospital in north
London, we have undertaken to deliver the
National Dementia Strategy (2009) as part of
a wider service improvement plan for older
people in the trust. As we began this journey,
we realised that we had a choice: deliver the
basics (say ‘name a champion’ or training) or
find a way to change the organisation at a
fundamental level. To do this, we needed the
support of the Trust’s board, funding, and
the backing of senior staff. We needed them
to agree that caring well for people with
dementia is everyone’s responsibility.
I am the lead nurse for dementia. I work
alongside the Trust’s Dementia Lead (Dr Dan
Lee, the lead geriatrician), the speech and
language lead and various interested parties
to improve the care that people with
dementia receive while at the Royal Free
Hospital. We have received very strong
support from the senior management of the
hospital and this has made it easier to get
things done.
Alongside this, we have set up an Older
Person’s Board and one of its functions is to
oversee the quality of care for patients with
dementia. The board first met in October
2010. Its membership includes clinicians
from across the trust and specialities as well
as representatives from service users and care
homes. This means
that the Trust
Dementia Lead has
executive support as
well as the ear of
senior clinicians from
different specialities.
We feel that this will
ensure that the changes are sustained and
that standards will not be allowed to drift
after the initial flurry of activity and
We were granted a small budget to pay for
staff to cover those attending training, as well
as some equipment and resources. This has
enabled us to push hard to get staff released
from clinical areas for training and also given
us the chance to offer some creative
approaches to improving patient care.
The first area that we needed to address was
training. Unless clinicians happen to work
in mental health they are unlikely to receive
any training specific to dementia. Given that
up to 35 per cent of all acute hospital
admissions can have cognitive impairment
at any one time (RCP 2005), this is quite
We also needed to think carefully about
the patient’s journey through a hospital –
who they meet, who looks after them and
how their attitudes and approaches will
affect a person with dementia. If we want to
ensure that we really change the organisa-
tion, we have to start improving the
understanding of all the staff who interact
with patients (for example, the porters,
security teams, transport, reception and
clerks), not just the clinicians.
In response to this, we secured 150
funded training places for nurses (a full day
of training) and a programme of four-hour
training sessions specifically designed for
non-clinical staff (aimed at transport,
security and reception staff in particular)
with funding to cover up to 64 places. In
addition to this, there is a six-month self-
study course under way for healthcare
assistants (HCA) that has been developed by
the Dementia Services Development Centre
at Stirling University and we have funding
to train a further 16 HCAs this year. HCAs
have been offered either this course or a half
day of training. We are now training one of
our HCAs who has completed it to be a
facilitator as well.
We have also trained volunteers, doctors,
hospital chaplains, all nurses and midwives
at induction and student nurses. In the near
future, nurses working in surgery, security
staff and local care home staff will have
training too. Inevitably we have not reached
everyone, but the work has only been under
way since April 2010 and we are confident
that more requests for training will arise as
it gathers momentum.
In total, since April 2010 we have trained
627 members of staff, made up of the
following staff groups:
• nurses: 350
• doctors: 101
• student nurses: 75
• non-clinical staff: 64
• chaplains: 12
• volunteers: 25
Feedback from the study days run so far
has been very positive: 100 per cent of
respondents said that the study day would
affect their practice.
The training content
One of the greatest challenges people with
dementia face is lack of understanding
about their disease and a lack of flexibility
in approach. The focus of all hospital
training should, in my opinion, begin with
Barbara Pointon’s description of institu-
tional care (in Stokes 2008):
Meet the damaging world of control, of
rigid institutional routines, of risk
avoidance, of unhelpful environments, of
eagerness to prescribe or run for the
sedatives, of attributing everything to
Facilities management staff such as domestics, transport, security and clerical staff have
all received training
28 Journal of Dementia Care May/June 2011 [Vol 19 No 3]
dementia, of mechanistic care-giving, of
one size fits all.
All of the training at the Royal Free has
been based on the need to move away from
the description above towards to a more
understanding and flexible workforce. It is
centred on similar themes, whichever group
it is aimed at: personhood, the experience
of the person with dementia, communica-
tion and stress. Clinical staff also receive
sessions on pain, eating and drinking and
ethics. I deliver most of the training with
input from a clinical psychologist, speech
and language therapy, dietetics, chaplaincy
and a consultant geriatrician.
Throughout the training, we emphasise
that there are no easy answers. Research has
shown clearly that hospital is not a good
place for a person with dementia
(Alzheimer’s Society 2009) and while
training can reduce the difficulties, it does
not, in my opinion completely mitigate
them. Patients are still being pulled out of
normal routines, they are still sick and will
still be cared for by strangers who they
might not trust or understand. All we can
ask of hospital staff is that they understand,
keep an open and flexible approach and
have some insight into what will make
things easier. This is the aim of the training.
Supporting the training
To support the training, we have developed
a Dementia Portal on our hospital intranet
as well as guidelines and pathways for
particular areas, such as transport and
security guidelines and a Delirium Action
Plan. An Emergency Department Pathway is
currently under construction as well. The
portal is accessible for any staff working in
the Trust and contains wide ranging
information and advice relating to people
with dementia. It went live at the beginning
of December.
Every section has information in printable
format that can be distributed to other staff
or to relatives and carers. The idea is that
staff can have information available 24
hours a day – so that even at 2am when a
member of staff is struggling they will be
able to find clear, succinct information that
will help them to care for the patient in the
best possible way. We are planning a similar
site for relatives this year that will appear on
our external website.
The portal includes:
• facts about dementia and delirium
• Patient with Dementia Admission Pack –
includes ‘Top tips for ward care’, Abbey Pain
& PAINAD Assessment Scale, referral form
for complementary therapies, and
information on delirium
• FAQs/problems – commonly encountered
problems and suggestions on what to do
• 10 point guides – short guides on
everything from communication to pain
• support information for relatives
• support information for staff
• guidelines for non-clinicians – including
transport, security and volunteers
• full referenced guidelines on pain
management, communication and stress.
Non-clinical interventions
In hospital there is often very little time to
do extra things that make a person feel
cared for, regardless of their physical
condition or the progression of their illness.
If anything like that is on offer, patients with
dementia often miss out because they have
communication difficulties or because staff
might be reluctant to involve them.
However, these patients are often the
people who benefit most from non-clinical
interventions, from company and from
volunteer visits. Research has shown that
programmes of mental stimulation in
hospital are effective in reducing the
incidence of delirium (a condition which
patients with dementia are at high-risk of
developing) (Rubin et al 2006). Anecdotal
evidence suggests that complementary
therapies may calm patients with dementia
when they are agitated.
At the Royal Free, we have an established
complementary therapy service that is
willing to support a wide range of patients.
We have managed to secure funding for the
service to be expanded to offer massage to
patients with dementia in hospital, particu-
larly those who are agitated and unsettled.
The sessions can be as short as five minutes
and focus on areas such as the person’s
hands or feet. We are also offering pre-
operative massage to people with dementia
before surgery in orthopaedics. The service
is also available to support patients with
dementia undergoing planned procedures.
From April to December 2010, we had a
nearly 50 per cent increase in the number
of complementary therapies treatments
given to people with dementia.
We are also working closely with the
hospital volunteer service. They have been
given guidelines on dementia which are
aimed at demystifying behaviours that can
sometimes be frightening or off-putting for
a volunteer. The volunteers have also been
offered a four-hour training course on being
with a person with dementia. Some
volunteers have been trained to help
patients who require non-clinical assistance
with eating. By getting volunteers to work
alongside us, we will be able to ensure that
patients with dementia will benefit from
more extensive pastoral support, which
often staff are unable to offer in the acute
Physical changes
Finally, our plan addresses the hospital’s
physical environment. Hospitals can be
disorientating places for people with
dementia and space is at a premium. While
it would be preferable to plan changes at an
initial design stage, we need to adapt the
environment in established hospitals to suit
people with dementia as best as we can.
We have incorporated relatively small and
cost-effective changes into our service
improvement plan. We aim to make these
changes over a three-year period:
• dementia friendly signage in place on the
elderly care and orthopaedic wards (year 1)
• orientation aids in place (such as large face
clocks and calendars in the wards, and
extend dementia friendly signage to high use
areas such as A&E and medicine (year 2)
• develop quiet areas (rooms where a
person with dementia can be away from the
bustle of the ward/department) and
designated dementia friendly bays – ward
bays in which the colour, the seating, décor
and signage are all aimed at improving the
person with dementia’s well-being (year 3).
We are also developing pictorial menus,
which will give people with dementia a
better chance of choosing their own food,
and a coloured glass scheme. The aim of
this is two-fold: if a patient has a coloured
glass, it will be highlighting the need to
encourage fluids for all the staff, but also,
the colour will make it easier for the person
with dementia to see the glass and
recognise it. The patients on the wards have
been asked to choose from a selection of
glasses and colours and have voted for a
green plastic glass.
Measuring success
We want to measure progress because in the
long term it’s hard to justify the costs of our
change strategy unless we have robust proof
of quality and (ideally) cost improvement. To
monitor this we have been setting up areas
to measure. If we continue to shorten the
difference in length of stay between patients
with and without dementia, the cost saving
will be huge. It also proves that investing in
150 nurses will have received training by 2011
high quality care really can save
We are monitoring
performance by, for example,
comparing the length of stay of
patients with dementia
compared to those without. We
have seen improvement in the
percentage of patients with
dementia staying over 30 days:
this has reduced by 5 per cent
from 2009 to 2010.
We are collecting a range of
other statistics, for example:
(i) The percentage of carers
who rated care as very
good/excellent – this is being
collected as part of the wider
post admission follow-up ques-
tionnaire which is done by
telephone for 10 patients who
have been discharged the
previous month.
(ii) Well-being Audit from Notes: This has
been underway since late 2010 and involves
auditing 10 randomly selected sets of notes
per month to identify and score markers of
well being for patients with dementia. These
are: level of weight loss during admission,
development of dehydration during
admission, use of sedation during
admission, and discharge destination. The
audit is very useful and early indicators
suggests that patients’ well-being has been
significantly better in areas where greater
numbers of staff had undertaken training,
but this needs to be monitored for a longer
period of time.
Our plans
Other projects we are working on include:
• implementing a shortened version of the
This is me document from the Alzheimer’s
Society (2009)
• a pilot for a delirium recognition and
treatment programme
• using Talking Mats to help when
discussing decisions about artificial
nutrition and hydration, and for satisfaction
• running quarterly multi-disciplinary ethics
workshops exploring ethical dilemmas in
hospital care of people with dementia.
• research into the efficacy of complemen-
tary therapy in dementia.
We also intend to:
• increase the number of HCAs on the six-
month course
• increase service user involvement – I and
our Patient Experience Manager have
started visiting a group of day centres and
care homes each month to talk to service
users about what they want to improve,
their experiences and also if they are happy
with our plans
We have begun collaborating with neigh-
bouring hospitals, the University College
London Hospital, North Middlesex and the
Whittington. Together, we plan to launch
our acute hospital dementia declaration this
summer, as well as share our training from
September. This will ensure that we start
developing a sector-wide standard of care
rather than geographical variations in
There are lots of different ways to approach
delivery of the National Dementia Strategy
in the acute setting and every
way is good, in as much as it is
an improvement on what has
gone before. However, I think
that we all have a window of
opportunity to do something
exceptional with dementia care
in hospitals.
We need to share our work
and try to develop sector-wide
consensus on core issues such
as values and standards. In an
ideal world, a person with
dementia should be able to
attend any hospital in a given
area and receive at least a
minimum standard of care that
addresses their needs appropri-
We have just started on our
journey to make our trust and
our sector dementia friendly
for hospital users. To achieve
this will be a big task requiring significant
culture change for the organisation.
However, our approach is underpinned by a
strong conviction that it is the right way to
go – we believe that we can change attitudes
and approaches at a core level in a way that
will embed excellent care of people with
dementia into everyday practice. Not only
does this mean that we are changing at a
practical level, we are also sending a
message to our community about our
commitment to make things better for a
group of patients who are vulnerable, in
need and deserve our attention at last.
Alzheimer’s Society (2009) Counting the cost:
caring for patients with dementia on hospital
wards. Alzheimer’s Society, London.
Alzheimer’s Society (2009) This is me.
Alzheimer’s Society, London.
Department of Health (2009) Living well with
dementia: a National Dementia Strategy.
Department of Health, London.
Royal College of Psychiatrists (2005) Who cares
wins: improving the outcome for older people
admitted to the general hospital. Royal College
of Psychiatrists, London.
Rubin FH, Williams JT, Lescisin DA, Mook WJ,
Hassan S, Inouye SK (2006) Replicating the
hospital elder life program in a community
hospital and demonstrating effectiveness using
quality improvement methodology. The Journal
of the American Geriatrics Society 54 (6)
Stokes G (2008) And still the music plays.
Hawker Publications, London.
Royal Free Hampstead NHS Trust is a large
acute trust providing a comprehensive range
of secondary acute hospital services for
approximately 750,000 people in the north
central London area. The trust employs
around 5,200 staff and operates from two
main sites and 11 satellite units. Services
include a major accident and emergency
May/June 2011 [Vol 19 No 3] Journal of Dementia Care 29
All we can ask of hospital
staff is that they
understand, keep an open
and flexible approach and
have some insight into what
will make things easier
Student nurses received training on how to care for a person with
dementia in the acute setting
Patients with dementia have access to
complementary therapies while in hospital
... Facial and body gestures offer potential for communicating more specific messages. While integral to regular linguistic expression (Miller, 1990, p. 117), they can also, to an extent, substitute for words (Davis & Maclagan, 2013;ellis & Astell, 2011ellis & Astell, , 2018. Rousseaux, Sève, Vallet, Pasquier, and Mackowiak-Cordoliani (2010) found that people living with Alzheimer's disease had relatively unimpaired abilities for understanding and producing gestures, even when they had difficulties with verbal communication. ...
... A study by Kunz, Scharmann, Hemmeter, Schepelmann, and Lautenbacher (2007) found that PLwDs used facial expressions to signal pain to a greater extent than did control participants. In Adaptive Interaction (ellis & Astell, 2011(ellis & Astell, , 2018, gesture is used to generate a new mode of communication in those no longer able to speak. The carer observes the movements that the person makes, and mirrors them back, giving the person evidence that they can still influence the behaviour of someone else. ...
In multi-ethnic contexts, it is not uncommon to find that dementia carers or their clients are using, as the medium for communication in care, a language in which they are not comfortable and/or are not fluent. In extreme cases, there could be no shared linguistic code at all. This article asks how feasible it is to provide adequate care with inadequate mutual language knowledge. In particular, it challenges the claims of some care-providers that nonverbal communication is a legitimate substitute for linguistic interaction. With reference to two recent models of aspects of communication, the article offers new insights into the necessary parameters for effective interaction. The conclusions have important implications for future decisions in dementia care. Meanwhile, the account extends the boundaries of language awareness by demonstrating the social importance of developing insights into linguistic practices in challenging contexts.
Carrying as Method unpacks the notion of ‘carrying’ as an embodied set of influences that bear upon our research practices and journeys. It is widely recognised that we acquire and carry a body of books as intellectual companionship. It is not however readily acknowledged how we as researchers carry sounds, aesthetics, traumas and obsessions, which stay with us and take time to appear before us, as methodological projects within our grasp. Researchers are carriers embarked on exchanges in a double sense. Firstly, we are embodied and affected by our life trajectories. There is a temporality to our research which is entwined with the very knots of our lives. Secondly, we are carriers through the specific ways in which we activate our research materials and relationships. In this article, the two elements of carrying are underlined as being intimately related.
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We report the case of Jessie, an individual with severe Alzheimer's disease. Over two sessions, we examine Jessie's spontaneous conversation behaviour and urge to communicate using the ‘still face’ paradigm. Spontaneous and deliberate imitation are also examined to identify their importance in social interactions in severe dementia. Although Jessie has difficulty producing meaningful conversation, she retains the urge to communicate and participate in social interactions. These results confirm the importance of imitation in facilitating and maintaining people with communication problems in the social world. Copyright © 2006 John Wiley & Sons, Ltd.
To evaluate a replication of the Hospital Elder Life Program (HELP), a quality-improvement model, in a community hospital without a research infrastructure, using administrative data. A pretest/posttest quality-improvement study. A 500-bed community teaching hospital in western Pennsylvania. Four thousand seven hundred sixty-three hospitalized patients aged 70 and older admitted to one nursing unit over 3.5 years. Application of the HELP multicomponent intervention targeting patients at risk for delirium. A proxy measure for delirium was developed using administrative data to calculate delirium rate and differences in variable costs of care and length of stay for patients before and after the intervention. Similar calculations were used in delirious patients for variable costs and length of stay before and after the intervention. Satisfaction surveys were administered to nursing staff and patient families before and after the intervention. The intervention reduced the absolute rate of delirium according to proxy report 14.4% from baseline, which represented a relative reduction in risk of 35.3% (P=.002). Total costs on this 40-bed nursing unit were reduced $626,261 over 6 months. Satisfaction of nursing staff and families was high in the intervention group. In addition, the intervention showed sustained benefits over time and remains funded by the hospital. HELP can be successfully replicated in a community hospital, yielding clinical and financial benefits.