Language-Based Strategies that Support Person-Centered Communication in Formal Home Care Interactions with Persons Living with Dementia

Applications of study findings

• Language-based strategies that support multiple goals related to effective communication and personhood can be integrated into communication training and education for caregivers.

Introduction

Dementia is as a chronic, progressive major neurocognitive disorder that affects cognitive functioning and memory processes (5th ed.; DSM-5; American PsychiatricAssociation, 2013). Language functions deteriorate over time resulting in speech, language, and comprehension difficulties, including a possible decline in naming abilities, fluency issues, loss of creative language use, and difficulty understanding rapid or complex speech (Eggenberger et al., 2013; Santo Pietro & Ostuni, 2003).

Ensuring effective communication can be challenging for formal caregivers who enter an interaction without a nuanced understanding of the communication abilities of the person living with dementia. The Communication Predicament of Aging Model highlights that a reliance on age-associated stereotypes can result in communication behaviors that are detrimental to the well-being of older adults (Ryan et al., 1986). However, when communication opportunities are harnessed appropriately, the person living with dementia can partake in a reciprocal interaction that promotes meaningful expression (Acton et al., 2007; Morris et al., 2020). Accordingly, the Communication Enhancement Model stipulates that older adults can be supported when caregivers employ communication modifications rooted in a consideration of the person living with dementia, their communicative intentions, and the environment (Ryan et al., 1995).

Personal support workers (PSWs) provide the bulk of formal dementia care in long-term care and home care settings (Home Care Ontario, 2018). Older adults overwhelmingly want to age at home. For instance, 93% of Home Care Ontario survey respondents indicated their desire to stay at home with none identifying long-term care in their future housing plans (Home Care Ontario, 2020). Thus, it is essential that the home care workforce is skilled and trained effectively to meet the growing demands. Currently, there is inadequate dementia-specific and communication-related training in PSW formal education and training (Savundranayagam et al., 2020). Communication interactions can consequently become task-focused, directive, and patronizing (Vasse et al., 2010). Formal caregivers recognize the need for dementia-specific caregiver training (Breen et al., 2021; Flöjt et al., 2014; Morgan et al., 2016; Savundranayagam et al., 2021). Equipping PSWs with evidence-based communication practices that complement the communication abilities of the person living with dementia while accommodating for their communication challenges is necessary. A person-centered and language-based approach to communication can be the pathway to improved care and caregiver-client relationships.

The person-centered care approach was established by Tom Kitwood’s work highlighting the impact of interpersonal relationships on the behaviors associated with dementia (Downs & Collins, 2015; Kitwood, 1997; Savundranayagam & Moore-Nielsen, 2015). Its benefits are especially evident when communication is used as the mechanism to provide person-centered care (Young et al., 2011). Person-centered caregivers respond to individual needs, amplify abilities, and recognize their client as a unique individual, first and foremost (Downs & Collins, 2015; Kitwood, 1997; Savundranayagam & Moore-Nielsen, 2015).

Interactions that are essential to good dementia care and meet clients’ specific psychological needs are termed as “positive person work” (Kitwood, 1997). Indicators of positive person work most relevant to conversational interactions during care are recognition, negotiation, validation, and facilitation (Savundranayagam et al., 2007; Savundranayagam & Moore-Nielsen, 2015). Recognition includes acknowledging the person living with dementia as an individual, including calling them by name and integrating their life story into conversation. Negotiation includes communication that consults on needs, desires, and preferences. Validation includes communication that is feelings-oriented and affirms the person living with dementia. Facilitation includes communication used to initiate and sustain interactions. Missed opportunities for Person-centered communication (PCC) occur where one of the above indicators could have been used to support the client’s personhood, but were absent (Savundranayagam, 2014; Savundranayagam et al., 2007). A missed opportunity alternative occurs when a caregiver uses a non-person-centered alternative during an opportunity to be person-centered. A missed opportunity omission is when a nonresponse or minimal response, such as failing to greet the client or allowing enough time to respond, occurred in place of a person-centered response.

Effective language-based strategies are also recommended for communication with persons living with dementia. Verbatim and paraphrased repetitions, using nouns instead of pronouns, right-branching sentences, positive instructions, and allowing time to respond facilitate comprehension. For example, repetitions can lower demands on working memory capacity instead of limiting communicative opportunities by relying solely on simple sentences (Small et al., 1997). Persons living with dementia also often experience challenges with expressive communication (Acton et al., 2007; Dijkstra et al., 2002; O’Brien et al., 2020; Ramanathan, 1997; Savundranayagam & Orange, 2011, 2014; Tappen et al., 1997). Yes/no questions, unfinished sentence prompts, minimal turns, matching comments, and affirmations can improve expression. For example, yes/no questions accommodate difficulties generating additional information, especially during demanding tasks (Ripich et al., 1999; Small & Perry, 2005).

Language-based strategies can also address refusal of care and resolve communication breakdowns. To prompt collaboration, caregivers can announce activity/intent clearly, ask for permission, and use politeness and affirmations (Bourgeois et al., 2003; Medvene & Lann-Wolcott, 2010; O’Brien et al., 2020; Ramanathan, 1997; Santo Pietro & Ostuni, 2003; Savundranayagam & Moore-Nielsen, 2015; Weitzel et al., 2011; Wilson et al., 2012a, 2013). Verification questions and comments, giving more information, and filling in missing information can help resolve issues related to speech production, language structure/processing, cognition, or hearing (Savundranayagam & Moore-Nielsen, 2015; Savundranayagam & Orange, 2014; Wilson et al., 2012b, 2013) . Addressing the person living with dementia by name/title and using greetings is also recommended (Acton et al., 2007; Bourgeois et al., 2003; Kim & Bayles, 2007; Savundranayagam & Moore-Nielsen, 2015; Weitzel et al., 2011; Wilson et al., 2012a, 2013).

Although PCC and language-based strategies are independently effective, there is little knowledge about which language-based strategies support PCC. This study is a timely follow-up to the research by Savundranayagam and Moore-Nielsen (2015) who investigated language-based strategies used by nursing assistants in the United States of America during interactions with persons living with dementia in long-term care. To bridge present gaps in the literature, the purpose of this study is to investigate the overlap between PCC strategies, missed opportunities for PCC, and effective language-based strategies used in a Canadian home care setting with persons living with dementia.

Method

Results

The overlap of language-based strategies with PCC indicators and missed opportunities were analyzed. Figure 1 shows that of 11,347 PSW c-units analyzed, 2578 c-units overlapped with PCC and 433 c-units overlapped with missed opportunities. Language-based strategies overlapped with 39% of all c-units coded as recognition, 95% of all c-units coded as negotiation, 64% of all c-units coded as validation, and 49% of all c-units coded as facilitation.OPEN IN VIEWER

Discussion

Research on communication with persons living with dementia has not explored whether the PCC and language-based frameworks complement each other, with the exception of one study by Savundranayagam and Moore-Nielsen (2015). They examined interactions with persons living with dementia in long-term care to determine whether language-based strategies support PCC. The present study analyzed the overlap between the language-based and person-centered approaches to communication during naturalistic home care interactions with persons living with dementia. This study also extended to assessing language-based strategies that may inadvertently contribute to missed opportunities for PCC.

Our findings highlight the person-centeredness of language-based strategies. More c-units were coded as a language-based strategy overlapping with PCC than PCC alone or a language-based strategy alone. In other words, several language-based strategies support the PCC goals. Yes/no questions, affirmations, and addressing the person by name/title can show recognition of the person living with dementia. Yes/no questions can exhibit negotiation while consulting with the client. Affirmations and positive feedback demonstrate validation. Finally, when used appropriately, yes/no questions and announcements of action/intent support facilitation.

Yes/no questions overlapped at a frequency greater than 10% with three of the four PCC indicators: recognition, negotiation, and facilitation. Home care PSWs frequently used yes/no questions to demonstrate recognition of the client’s life story. In contrast, Savundranayagam and Moore Nielson (2015) found that greetings overlapped most frequently with recognition in long-term care interactions between staff and residents with dementia. In comparison to long-term care, where constraints like staffing issues limit one-on-one time between PSW-client dyads (McGilton & Boscart, 2007), numerous home care interactions were enriched with opportunities for conversation. This may have motivated PSWs’ use of questions demonstrating recognition during active conversation about the client’s family, interests, and life events. Yes/no questions can facilitate the comprehension and expression of persons living with dementia (Ripich et al., 1999; Savundranayagam & Lee, 2017; Savundranayagam & Moore-Nielsen, 2015; Small et al., 2003; Small & Perry, 2005; Tappen et al., 1997; Wilson et al., 2012a). Yet, the literature also recommends them for specific purposes, namely, to accommodate communication difficulties, generate necessary additional information, or during collaboration on demanding tasks (Ripich et al., 1999; Small & Perry, 2005). It is notable that these functions seem more task-focused. Caregivers should be encouraged to use other question types, such as open-ended questions, if yes/no questions do not in fact yield further contributions from the person living with dementia. Yes/no questions overlapping with negotiation were posed in the current study to consult with the person living with dementia, rather than assuming their decisions (Kitwood, 1997). However, there is discussion that the use of yes/no questions in such situations should be limited to avoid inhibiting the free expression of persons living with dementia (Small et al., 2003). The present study displayed a similar pattern of frequent overlap between yes/no questions and negotiation as was observed in long-term care (Savundranayagam & Moore-Nielsen, 2015). This could indicate a shared task-focused nature of care across settings or rather the effectiveness of yes/no questions in facilitating successful responses thus prompting continued use. Unlike yes/no questions and choice questions, open-ended questions do not restrict the client’s responses. Contrarily, they may preserve the autonomy of the person living with dementia (Tappen et al., 1997). However, in practice, they overlapped with negotiation at a low frequency. Still, home care PSWs used open-ended questions to consult with persons living with dementia at a frequency more than double that observed in long-term care (Savundranayagam & Moore-Nielsen, 2015). Ultimately, caregivers should find a balance between modifying messages to improve comprehension/expression and providing opportunities for meaningful participation. Yes/no questions, overlapping with facilitation, that intend to learn more about a client are an example of formal caregivers striking this balance. They first prompted a confirmation/denial response to an information-seeking question, which often led to further talk from the client.

A majority of missed opportunities for PCC overlapped with language-based strategies. This indicates that language-based strategies are not always person-centered. Language-based strategies contributing to missed opportunities included announcements of action/intent, positive instructions, and various question types. For example, announcements of action/intent were missed opportunities when the PSW could have consulted with the client prior to announcing a new care activity or next steps. Instead, they prescribed what was going to happen next, failing to take consideration of individual preferences. Although announcements of action/intent can prepare the client for an upcoming activity, they should not hinder autonomy and free expression. Further, PSWs often missed opportunities to be person-centered when providing positive instructions. Positive instructions, which instruct what to do, can encourage collaborative behaviors (Belzil & Vézina, 2015; Bourgeois et al., 2003). However, when used inappropriately they can become overly directive and patronizing. Also, the common inclusion of collective pronouns in positive instructions, as in the previous missed opportunity alternative excerpt, feed into the perception that older adults cannot be independent (Williams et al., 2017). Understanding these pitfalls causing effective and well-intended language-based strategies to produce non-person-centered interactions can encourage caregivers to be mindful communicators.

The overlap analysis with missed opportunities provided support for the effectiveness of other language-based strategies in supporting PCC. Although the language-based strategy, allow time to respond, did not overlap frequently with the PCC indicators, its absence resulted in the association of most question structures with missed opportunities. Caregivers are therefore urged to use pauses, with caution and when appropriate, to allow persons living with dementia time to respond. Some researchers suggest extensive pauses, such as Weitzel and colleagues (2011) who recommend waiting 15–20 seconds after asking a question prior to offering any repetitions. Other researchers, including Christenson and colleagues Christenson et al. (2011), suggest that shorter 5 second pauses suffice. However, it is also conveyed that the dynamic nature of conversing with persons living with dementia depends on the individual, their disease progression, and the context of care (Müller & Guendouzi, 2005; Sabat, 1991; Savundranayagam & Moore-Nielsen, 2015). Pauses must therefore be employed tactfully to avoid threatening conversational continuity, potentially being counterproductive to communicative success (Müller & Guendouzi, 2005; Ramanathan, 1997).

Savundranayagam and Moore-Nielsen (2015) identified minimal diversity in the language-based strategies supporting PCC in long-term care. Similarly, the present study uncovered that only between one and four of the 32 language-based strategies overlapped with at least 10% of utterances coded as each indicator of PCC. There was minimal diversity in home care PSWs’ use of language-based strategies supporting PCC, despite more effective strategies having been identified from the literature. For example, strategies like newsmarks, which promote conversational continuity and demonstrate engagement (Ramanathan, 1997), received evidence-based support in the literature, but in practice were rarely used by home care PSWs. This may have contributed to their minimal overlap with PCC indicators.

Finally, as the proportion of persons living with dementia receiving care at home increases, attention to home care practices should be intensified. PSWs who shared their communication experiences with persons living with dementia emphasized that time constraints and heavy workloads in long-term care hindered meaningful interactions; they preferred home care because of one-on-one interactions and more time allotted for care provision (Kamalraj et al., 2021). Consistent with this finding, home care PSWs in the present study used far more person-centered language than long-term care PSWs (Savundranayagam & Moore-Nielsen, 2015). Also, half of the home care interactions in this dataset were leisure-based involving a great deal of personal conversation. A sub-analysis looking at communication patterns within the routine care and leisure-based interactions demonstrated that PSWs used more PCC during the latter. These interactions were longer in duration and had more contributions from the client living with dementia.

Our findings could be limited by a potentially incomprehensive language-based strategy coding framework. Although best efforts were made to ensure it was representative of present research, language-based strategies that do not yet have evidence-based support were excluded. Although other established coding systems, such as the Roter Interaction Analysis System (RIAS; Roter & Larson, 2002), were available, they did not align with the research objectives of the present study. The RIAS, in particular, was not considered to address the research questions as it is better suited for the analysis of medical interactions and medical dialogue (Roter & Larson, 2002).

The paramount strength of this study is that it contributes important findings to research within the home care setting. This study is the first to examine naturalistic interactions with PSWs and persons living with dementia in a home care setting. A unique perspective was offered on the day-to-day interactions between PSWs and persons living with dementia during various contexts in the home care setting, including routine care and leisure activities. This study also emphasizes that PCC goes beyond using effective language by considering the potential overlap between missed opportunities for PCC and language-based strategies.

Conclusion

Language-based strategies that support PCC can produce a range of outcomes concerning communicative success and level of participation from the person living with dementia. Formal caregivers can thereby avoid reinforcing misconceptions about the needs and abilities of their client. Instead, as demonstrated by the Communication Enhancement Model, these positive communication modifications may enrich the resulting interaction due to the improved confidence and expectations of the person living with dementia to meaningfully contribute to conversation (Orange et al., 1995). Rather than modifying communication behavior based on certain perceptions related to the inabilities of the older adult and/or person living with dementia, such as the need for simplification, the outcomes of this study can provide formal caregivers with effective language-based strategies that support the personhood of their client.

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