Consulting a person who has significant diminished capacity can be very difficult for both the consultant and the individual. In Part One of this article, we explored a case in which a client with moderately severe dementia gave one answer to a simple question posed by a family member in the morning and the opposite answer to another family member that same afternoon, sparking heated conflict among the siblings. This is not inconsistency or deception; it is the clinical presentation of significant cognitive impairment.
Having a successful discussion or consultation is anchored in effective communication. And at its core, communication depends on the sender, the receiver, and the environment. Consulting with a person with significant diminished capacity can be difficult for both the consultant and the person being consulted. Information about the person’s diagnosis, the stage of their disease, and testing, such as MoCA scores, can help determine the approach and support communication.
Medical descriptions for various dementia diagnoses and the clinical stage of the disease can be very confusing. For example, “mild cognitive impairment (MCI) is very different from “moderately severe cognitive decline” due to Alzheimer’s disease. A lay person may think “moderate” doesn’t sound too bad; however, there can be significant difficulty in communicating with someone who is diagnosed with “moderately severe cognitive impairment.”
One of the many explanatory tools to assist clinicians and caregivers with staging and understanding the progression of Alzheimer’s disease is the Global Deterioration Scale (GDS). [1] Using this scale, “moderately severe cognitive impairment” is described as a situation where the person with Alzheimer’s disease can no longer manage on their own in the community without significant help and supervision. For example, they are unable to adequately shop for and prepare nutritious meals; they are vulnerable to predatory behaviours such as scams; they are not always oriented to time and place and may choose clothing inappropriate to weather conditions; and they have difficulty paying bills and managing their finances without assistance.
During the diagnosis of their disease, the person may have been tested for cognitive impairment using the Montreal Cognitive Assessment (MoCA) tool. The MoCA score gives insight into the person’s ability to understand and communicate their wishes. In use since 2005, the MoCA test assesses six domain specific areas of cognitive impairment – memory, executive function, attention, language, visuospatial and orientation.[2] Understanding the type of cognitive impairment can guide how you communicate and if there are trend lines in MoCA scores, it will assist in determining how quickly the impairment is progressing.
Given the diagnostic information, staging, and testing information described above, the consultant can gain an overview of what to expect.
Preparing and Conducting an Effective Consultation
How can we prepare and conduct an effective consultation with a person who has moderately severe cognitive impairment due to Alzheimer’s disease?
The Environment
- A calm, distraction-free environment will help the person focus on your conversation. Hearing aids or visual aids may be needed.
- Meet in a room where the person is comfortable, the temperature is comfortable, and there are beverages available if they wish to have some water or tea.
- Depending on your reason for the consultation, the person may wish to have a support person accompany them. It may be a family member or a professional caregiver who can support them during the conversation, take notes, or help them ask questions.
Consulting the Person
- Before you meet with the client, find out some things about the person – what do they like, what don’t they like, what is the best time of day for them? For example, if a person rises late most days and is not at their best until early afternoon, then pick that time for a consultation after they have had their lunch.
- Choose seating where you can make direct eye contact with the person.
- Speak clearly and give a few options at a time if you are asking for their opinion.
- Connect with the person instead of correcting their mistakes. Encourage them to discuss their thoughts.
- Be patient. People with cognitive impairment often have to marshal their thoughts before they can express their views.
- If the person seems overwhelmed, stop. Discuss something different that the person might like, then try again.
- Respond to the person’s moods. If they are becoming agitated, stop. It may be necessary to come back another day. [3]
While these insights may seem straightforward, they are often not utilized. Effective consultation with a person who has significant cognitive impairment can be challenging. As advisors and consultants, it is prudent to remember that Alzheimer’s disease and various other dementias are progressive neurodegenerative diseases that change over time. Even with these changes, it is important to consult with the person and to try to find the “islands of good cognition” in the sea of cognitive impairment and lack of insight.
[1] https://www.alzinfo.org/understand-alzheimers/clinical-stages-of-alzheimers/
[2] Wood JL, Weintraub S, Coventry C, Xu J, Zhang H, Rogalski E, Mesulam MM, Gefen T. Montreal Cognitive Assessment (MoCA) Performance and Domain-Specific Index Scores in Amnestic Versus Aphasic Dementia. J Int Neuropsychol Soc. 2020 Oct;26(9):927-931. doi: 10.1017/S135561772000048X. Epub 2020 May 19. PMID: 32423505; PMCID: PMC7554137.
[3] https://alzheimer.ca/en/help-information/i-have-friend-or-family-member-who-lives-dementia/communicating-people-living
