Conversations with Care Homes

Conversations with Care Homes

Conversations with care homes a series by My Home Life England 

‘Conversations with Care Homes’ is a series by My Home Life England (MHLE). In Episode 7 we focus on how best to support care home residents living with dementia during COVID-19. The pandemic has posed additional challenges for those living with dementia – for example the disruption of familiar routine, the need to socially distance and wash hands more regularly, and the impact of staff wearing more PPE. We share stories, tips, methods and signposting for how best to support residents living with dementia at this difficult time.

You can see more Videos from My Home Life here >>

A message from My Home life to the care home community:

You are doing an incredible job in challenging circumstances. You continue to make such a positive difference to people’s lives – thank you. We see you, we appreciate everything that you are doing, and we want you to know that My Home Life England is always here for you. Keep up your fantastic work and please do get in touch if you are able, we’d love to hear from you.

Please get in touch! If you have any stories to share, please contact us at mhl@city.ac.uk or call 02070405776 For more information about My Home Life England, please visit our website or find us on Twitter & Facebook – @myhomelifeuk

About My Home Life 

My Home Life was founded in 2006, by National Care Forum in partnership with Help the Aged (now Age UK) and City, University of London.

It is a social movement for quality improvement in care homes that has spread nationally and internationally.

The success of My Home Life lies in our four evidence-informed guiding principles: Developing best practice together, Focusing on relationships, Being appreciative, and Having caring conversations.

“A diagnosis of dementia for a person is also a diagnosis for the whole family.”– Four letters that make communicating with a person with dementia more real.>>

Face Masks and Dementia Care

What is the person saying?

By Sarah Reed 

How facemasks affect how we communicate.  The importance of emotional perception, expression and reciprocity in non-verbal communication is bound to impact the outcome of any doctor/patient or carer/cared-for interactions. 

Studies have demonstrated the impact of doctors’ and carers’ empathy and person-centred care on the enablement and health outcomes for the person in receipt of care with both chronic and acute conditions. In a large randomised controlled trial in 2014, it was found that the “wearing of facemasks by doctors had little effect on patient enablement and satisfaction but had a significant and negative effect on patients’ perceptions of the doctors’ empathy”.

We must hope that eventually, mask makers will recognise that clear panel masks are really the only ones worth using and start manufacturing them. However, in the meantime, the following tips are good for all our interactions with anyone at any time whether they have dementia or not, but are especially important now with the additional social distancing that masks create.

In communication, most of us rely on language – often at the expense of many other types of communication. However, nonverbal communication is just as important as the words we use. During these times of the Covid-19 pandemic, the use of facemasks has become ubiquitous and they present serious communication difficulties which should not be under-estimated, for the wearer and the person they are talking to, alike. 

Lockdown is one thing, but facemasks are prisons that limit the range of our actions and words.

In covering our facial expressions, face masks hide our emotions. For example, pleasure, sadness, frustration, annoyance and fear are all emotions that we show on our faces without ever having to say a word. And unspoken communications tend to be the same across most cultures. Given the increasing use of facemasks, this means of communication is becoming increasingly challenging.

Non-verbal communication is often the most effective element of communication when connecting with a person who has limited or impaired cognition or is living with dementia. People with dementia increasingly lose their ability to communicate verbally, but their body and para-linguistic interpretive skills are retained longer in most conditions and may even be retained right to the end of their life. They are usually able to interpret facial signals correctly and can be skilled interpreters, understanding when we are relaxed or stressed or conveying other subtle messages, making sense of things from the sound and inflection of our voice, our speed of speech, our posture and the way we move around. We know that when people have difficulty understanding, they will fill in the gaps by reading our facial expressions, the sound of our voice and body movements and posture.

Carers who are more alert to nonverbal cues are often well-practiced at reinforcing the other person’s perception of their sincerity, compassion, appreciation, dedication and competence. This improves their relationships with those they care for as well as their colleagues and also increases their ability to provide meaningful care.

Nonverbal communication provides unique opportunities to connect, so it is important to pay greater attention to our nonverbal communication in this time of social distancing and masked faces.

The following tips can impact and improve interactions with older people while wearing masks. Being focused on the challenge of this is key to success.

1. Pause and be mindful. Be self-aware

If things are busy and stressful, try not to let that be reflective in your voice. Make sure there is enough time for any interaction. Taking a moment or two for yourself immediately before an encounter can make a big difference to the experience. Creating a mental ritual to focus your attention before seeing someone, can help. For example, reflecting on the many varieties of communication that older people and their carers encounter in care settings, such as expert-layperson, healthy-sick, independent-dependent, cognitively healthy–cognitively impaired, young-old and family and so on, might be an option.

2. Be Calm. Smile inside – and outside

Show absolute respect. It is essential to approach the person from the front. This will help them to process who you are and what you are saying. Respect the person’s personal space and make sure you speak to them on the same eye level.

Good eye contact is most important. Use your eyes and eyebrows. Let your eyebrows tell the story. Remember to smile! The person may not be able to see your mouth, but they will be able to read the emotion in your eyes which will allow them to feel more comfortable and in control. They are very likely to be able to detect your body language, so remember that any sudden movements can cause distress and make it harder to communicate.

Be straightforward and try to stay calm. Project a positive, calm attitude and avoid any body language that shows frustration, anger or impatience. Try not to interrupt them and give them your full attention. Be flexible and patient.


Don’t just rely on giving information verbally. Using images, gestures, even written words, phone translation/text apps can be helpful. If the person is still able to read, it may be useful to leave any written version of verbal information that you use with them, so that they can refer to it later.

3. Speak clearly

Avoid noisy environments that might overwhelm with additional stimulus. It is useful to remember that 11 million people in the UK have hearing problems or are deaf. There are a number of hearing apps available on the market which can help. Firstly, create a safe space. and maintain your social distancing with a clear path. Ensure that any physical barriers that could block your view or further challenge your voice being heard behind the mask are removed.
Observe first, even if briefly.

Remember to smile! Always ensure that the older person is wearing their glasses or hearing aids. Your tone of voice includes your speed, tempo and pitch which can be as impactful as the words you are speaking.

Slowly communicate one point at a time. Use short, simple sentences and underline your words with appropriate gestures. Make your statement or ask your question and then pause. Keep your voice even, gentle in tone, and moderate your speed of speech. Go slow!

Lip-reading cues that many with hearing disabilities use to compensate will be absent, so make sure you articulate your words clearly without sounding forced, which may be taken as condescension.

Consonants matter! Speak louder if necessary but without raising your voice or its tone, because this might be perceived as aggression. Using NLP (Neuro Linguistic Programming) techniques of mirroring and matching the person’s gestures, vocal tone or mood can be re-assuring for them and help them feel better understood.

The messages we convey might be harder to interpret so we need to develop new habits, ensuring that we underline everything we say with gestures and pantomime. Going slowly with the person will make connection easier.

4. Remember to listen well

Listening is a vital part of communication as well. Making space to listen is very important in any encounter. However, in one randomised trial in 2010 it was found that “64% of the nurse participants had a weak knowledge of verbal communication skills and only 36% had relative knowledge about listening and speaking skills. This is while verbal communication skills are considered as the foundations of communication in everyday life”. your view or further challenge your voice being heard behind the mask are removed.

Observe first, even if briefly.

Remember to smile! Always ensure that the older person is wearing their glasses or hearing aids. Your tone of voice includes your speed, tempo and pitch which can be as impactful as the words you are speaking

5. Remember that our bodies speak as well

It is vital that we think about the ways in which we typically communicate, such as gestures and tone we use when we are not inhibited by distance and PPE. Once we become more aware of our characteristic gestures and body language, it is easier to align our nonverbal signalling with our spoken message.

Body language is vital to deliver meaning well and communicate effectively. Together, hand gestures and posture are very important. Our non-verbal cues should send message of kindness and empathy. Try to relax your shoulders. Remember to avoid crossing your arms in front of your body and keep your hands off your hips and out of your pockets.

It is always helpful to nod and add ‘mm’ and ‘yes’ when appropriate, as it acknowledges that you are listening and understanding.

Happiness can be seen by raised eyebrows, raised cheeks and crow’s feet. Remember to smile! On the other hand, eyebrows pinched together and eyes drooping can indicate sadness and when in a “V” shape can express anger.

The person with cognitive impairment may not recognise you at all in any encounter if you are wearing a facemask, even if they have spent time with you over many months, but we still need to make each connection count. As one wise soul once perceptively observed, “I may not remember what you said, but I will remember how you made me feel.”

Facemasks and perception of empathy

Here is an article from NCBI  – US National Library of Medicine National Institutes of Health. It is regarding a randomised control study that was conducted to explore the effects of doctors wearing facemasks on patients’ perception of doctors’ empathy, patient enablement and patient satisfaction. 

The report can be viewed here and it is titled  ‘Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care’

 

About Sarah Reed

Sarah Reed is the founder and lead at REAL Communication Works.

Sarah lectures in Health departments at Kingston and City Universities. She now works with other highly skilled dementia care learning facilitators to deliver interactive REAL Communication workshops.

She has served on the SUCAB Service User and Carer Advisory Board in the School of Health Sciences at City University since 2017.

She is a Trustee of and thirty-year volunteer co-ordinator and monthly driver for national older people’s charity, Re-Engage (formerly Contact the Elderly). In 2015, she served on NCVO’s Volunteering in Care Homes advisory board. She is a member of the DH Quality Matters board.

More Care for Carers tools >

How does good communication help the person with dementia? (Part Three)

Part Three: Paralanguage

“They won’t remember what you said, but they will remember how you made them feel” 

Carl W. Buechner

When any of us communicate with a person living with dementia, we will both be using non-verbal ways to communicate beyond the words.

These unconscious methods of exchange: body language and paralanguage, may be overt or subtle, but they are always part of the mix. They help to reinforce what the other person — or we are saying and help us to understand one another better.

Can we cross into the world of the person living with dementia, with all its confines and limitations, rather than expecting them to fit into ours?

Our own reactions may inadvertently add to the person’s lack of mental capacity. I have witnessed many conversations between a person with dementia, a caregiver and another, where the caregiver answers on behalf of the person, or completes their sentences for them — all meant kindly, with no intent to harm, but disabling to the person they care for, nonetheless.


For a person with dementia, feelings are often uppermost. In situations in which they feel fearful, anxious, bored, confused, frustrated, in pain or angry, the feelings of isolation and/or helplessness that the person experiences may find different outlets. The words they then use may not relate to the actual conversation, but instead, include those that reflect familiar, well-rehearsed social norms, or those that transmit their fear, dissatisfaction or frustration at the challenges they are facing.


A person might even swear, despite their normal good manners. They may use paralanguage to communicate their feelings, bypassing words altogether, meaning that petulance, physical force, annoyance or anxiety spill over; or conversely, they may retreat into detachment and passivity.

“The single biggest problem in communication is the illusion that it has taken place.” 

George Bernard Shaw

 Caregivers often develop highly nuanced paralanguage skills with those they care for, in order to stay more in tune with them.

When a caregiver enters into the person’s perceptual world with attentive observation, curiosity and empathy, the effect of and feelings about what is happening matter more than the words spoken. Let’s call this “super-awareness”. This deeper engagement makes it easier to identify, understand, respond to and reduce behavioural expression that has been created by negative, uncomfortable feelings.

Those who listen keenly, observe astutely, mirror accurately and understand thoughtfully, can assist in enabling the paralanguage of a person living with dementia, empowering the person to communicate and participate more effectively and make their lives more meaningful as a result.

We need to understand how challenging it can be for a person living with dementia to understand and relate; and how disempowering it is for the person to be judged from a purely cognitive viewpoint.


The heart of good caregiving means being super-aware and being able to “read the person” accurately. To do this well, we need to be present, listen not only with our ears but also with our eyes and nose. Above all perhaps, we need to listen with an openness to hear beyond the words the person is saying. It is only then that we become thoughtful enablers for them, to nourish and enrich their lives.

How to communicate well with someone living with dementia (Part Two)

Photo by Nick Fewings on Unsplash

 

Part Two: Words aren’t everything

The Language of Dementia

Unfortunately, speech and language deterioration is almost inevitable for a person living with dementia. The reasons are multifarious — among others, the person’s natural language and vocabulary are increasingly challenged by reduced mental capacity. Reduced brain-processing power means that they may struggle to understand what is being said to them. Loss of short-term memory makes it harder for them to orientate themselves in a narrative, or in conversation. They may be unable to respond at we would consider to be a ‘normal’ speed. They might return to using another language learnt in their childhood.

But words aren’t everything

We can communicate better with a person living with dementia by using overt and subtle, non-verbal language that conveys meaning beyond the words — especially if it mirrors theirs. Mirroring non-verbal cues helps to give clarity to our engagement, making it easier for us to understand one another.

Over the years, I’ve heard a number of stories of people living with dementia who have become newly attached, or antagonistic to another person because the person reminds them of a family member or friend they once liked or someone they disliked. It is often something in the tone of the person’s voice that has created this attraction or repulsion.

And it is not just what we say, but how we say it — our tone of voice.

Tone of voice matters, because it helps us to express the feelings behind the words we use, and may reflect among other things, our social culture, where we come from, our age, social status, education and command of language, our sense of ourselves, our attitudes, our state of health and our current mood. The timbre of our voice may help or hinder our connection with someone, even if we may be hardly, if ever, conscious of it.

Over the years, I’ve heard a number of stories of people living with dementia who have become newly attached, or antagonistic to another person because the person reminds them of a family member or friend they once liked or someone they disliked. It is often something in the tone of the person’s voice that has created this attraction or repulsion.

What are the ingredients that make up tone of voice?

These include natural vocal musicality, pitch, depth and intensity, the clarity and sound of our words, the accentuation we use, the speed at which we speak and more generally, the personality and outlook we convey by these means.

Even the simplest of questions, such as “How are you today, John?” may be imbued with a range of meanings depending on the tone of voice used, from genuine authenticity to patronisation, from positivity or cheeriness, to sadness or negativity. How many underlying meanings are you able to convey, just by changing your tone of voice and accentuation in the sample question?

Being more aware of how we sound can help improve our relationships with everyone

How to communicate well with someone living with dementia (Part One)

Photo by Harli Marten on Unsplash

 

Part One: Beyond the words

“Nonverbal communication forms a social language that is in many ways richer and more fundamental than our words.” 

 

Leonard Mlodinow

Body and paralanguage always speak louder than the words we use.

When we are alert to these, communication can be more effective, helping us to better understand the main — and also the underlying messages being conveyed.

When talking with a person living with dementia, they are particularly important to understand, for a few reasons. Firstly, the person’s reliance on non-verbal communication may accelerate as their natural language skills become increasingly compromised by the condition. Secondly, their sense of self alters subtly over time. Thirdly, the speed at which the person is able to process and absorb information is reduced. Finally, emotional feelings may rise to the surface (sometimes quite unexpectedly) in situations that challenge them in some way. All these facors contribute to how the person is able to hear, listen and respond.

Approximately 60% of our interactions use non-verbal communication.

These include proxemics (the space between us), kinesics (our body and head movements), hand gestures and posture. Facial expression and eye contact are key, of course. Perhaps crucially, a person’s tone of voice, intonation, pitch and speed of speaking, hesitation noises, gestures and facial expressions, make a significant difference to how we perceive both them and their message. We rely more heavily on this paralanguage to make sense of the world and our experiences than we might realise, or like to admit.

For any person, a diagnosis of dementia can feel like the beginning of the end.

Hardly surprising perhaps, given the prevailing, dismal medical model with which dementia is often viewed: as a journey of emptiness and inexorable physical and mental decline.

This depersonalised stereotyping over-simplifies the experience, presenting a one-dimensional view of personhood, overly dominated by cognition and short-term memory loss. Of course, as the disease progresses, the person’s thoughts and words inevitably become more tangled and confused.

However, a broader (and more humane) definition recognises that a person is far more than their thoughts alone and that together with their many long-term memories and experiences, the essence of the person remains, despite changes to the brain.

To keep well-connected to a person living with the condition, we need to become increasingly attentive to their non-verbal clues — as well as our own. We need to try to be more aware of what we are both communicating, beyond the words.