COMMUNICATION WITH COGNITIVELY-IMPAIRED CLIENTS
Abstract:
People with cognitive impairment struggle with poor intellectual functioning and have difficulty communicating and understanding what others are saying to them. Confusion sets in and they can become disoriented to person, place, situation, and time. While each person is unique, those who are cognitively impaired lack organized thought processes and the ability to establish progressive personal goals. Working with a client who has a significant degree of cognitive impairment can be difficult. When caring for someone who is confused, afraid, uncooperative, and aggressive, it is important for health care professionals to recognize the client is doing the best that they can at that given moment.
Learning Objectives:
Identify two possible causes of cognitive impairment.
Recognize aspects of non-verbal and verbal communication.
Identify two key approaches that can be used when working with a patient with cognitive impairment.
Understand why people with cognitive impairment may act aggressively.
Recognize the best approaches for working with someone who is acting aggressively.
Introduction
There are many challenges health care professionals face and one of the most difficult is working with clients who are cognitively impaired. The word cognitively is derived from the word cognition, and the word cognition means of or relating to, conscious thinking. Individuals with cognitive impairment have trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. This is a complex aspect of human health because there is no single condition, illness, or disease that causes cognitive impairment.
Cognitive Impairment: An Overview
Everything people do in their daily lives may seem simple but all of these actions actually require complex intellectual abilities and tasks. The term "complex intellectual tasks" would seem to be limited to describing activities such as mathematics, solving memory problems, and intricate problem solving but even the most basic human daily tasks require significantly higher intellectual ability. In order to go through a day safely and successfully, people have to be able to reason, to think, and to use logic. They need to be able to communicate, use short-term and long-term memory, and learn new tasks. All of those skills, the ability to reason, use logic, communication, short and long-term memory, and the learning of new tasks involve higher intellectual abilities in order to function in a given environment.
People with cognitive impairment have limited higher intellectual functioning. They have difficulty communicating, and difficulty understanding what is said to them. They can, at times, become confused about others around them, and they can be confused about their own identity. They can also be confused about where they are, what day of the week it is, and what year it is.
People who suffer from cognitive impairment often do not have the ability to think clearly and logically, or they may only have the ability to do so in limited circumstances or for brief periods of time. Of course, each person is different in terms of strengths and weaknesses. For example, some people may have no difficulty with short-term or long-term memory problems but have considerable difficulty learning new tasks.
Causes Of Cognitive Impairment
There are many diseases and medical conditions that can result in temporary or permanent cognitive impairment. Although the list of causes is long, the common theme among them is that there has been some damage or compromise to the parts of the brain that control higher intellectual function. Things such as an illness, disease, or accidents that have affected parts of the brain that control the ability to think, concentrate, and reason.
Although many people with cognitive impairment are elderly, being of advanced age does notalways mean that someone has a diminished mental capacity. It should never be assumed that simply because someone is older that being agitated or confused is usual for their age. People with cognitive impairment may have had a stroke, they may be suffering from Alzheimer's disease, or they may have had a head injury. In some instances, the cause is unknown. Regardless of why individuals have a cognitive impairment, coping with this situation can be very difficult. It takes patience and compassion. Above all, health care professionalsmust remember that individuals with cognitive impairment do not have the ability to function and think as others with normal functioning. Normally, people use powers of thought, concentration, memory, logic, and language to cope with their environment. For cognitively impaired people, those skills are absent or damaged. As a result, they cannot understand what they see and hear or how others are communicating. Many times, this will leave them frightened and confused, and more importantly, it leaves them dependent on others.
As mentioned above, there are many possible causes of cognitive impairment. The majority of cases of cognitive impairment, however, are due to a few, relatively common issues. These issues may lead to temporary or permanent impairment.
Permanent causes of cognitive impairment can include:
Alzheimer's disease
Brain tumor
Cerebrovascular accident (CVA), which is commonly called a stroke. A stroke is caused by bleeding in the brain or by a clot that lodges in a blood vessel in the brain. In either case, there can be permanent damage to the brain.
Chronic drug use, chronic use of alcohol, amphetamine, or other illicit substances
Traumatic brain injury
Temporary causes of cognitive impairment include:
Dehydration
Fever
Intoxication with alcohol or drugs
Hypoglycemia (a.k.a., low blood sugar)
Hypotension
Hypoxia (low oxygen content in the blood)
Infections
Medication side effects
Transient ischemic attack (TIA), which is similar to a stroke but the damage is not permanent.
10.Withdrawal from alcohol or drugs
The permanent causes of a cognitive impairment listed above cause death to the brain cells by several different mechanisms. If blood flow is completely blocked to the brain it will be without oxygen, if there is traumatic damage to the brain, or they cause damage to the brain by interfering with the normal metabolism of the brain.
Many of the temporary causes of cognitive impairment disrupt the higher intellectual abilities because they interfere with the metabolism of the brain. The brain needs oxygen and food (glucose) to operate, and the brain and the central nervous system are extremely sensitive to a lack of oxygen or glucose. Without adequate supplies of these nutrients, some level of cognitive impairment will be seen. Elderly people are especially at risk because they may have frail health and pre-existing medical conditions and without glucose and oxygen cognitive abilities will suffer.
It is important to remember that although cognitive impairment is more common in the elderly, this is simply because many of the causes of cognitive impairment such as Alzheimer's disease, stroke, and TIA are more often seen in the elderly population. Getting older does not mean that mental function will also decline to a point that the elderly person cannot competently perform activities of daily living.
Example: An 89-year-old client who has a fever of 104.3°F also has an increased heart rate due to the fever. The patient’s heart rate increases as body temperature goes up. If the patient has a high fever with a rapid heart rate, and the heart is too weak to tolerate the faster pulse or pump an adequate blood supply with each heartbeat, the brain will not get the blood containing glucose and oxygen it needs and the patient will become confused.
It should never be assumed that a sudden decrease in someone's mental abilities is acceptable just because that person seems to be of an age where mental abilities are assumed to decline. The decrease in mental acuity may be from a simple, easily treatable cause or it may indicate that a serious medical condition has developed or is developing and needs immediate attention.
Cognitive Impairment Case Example
This scenario involves a health care professional who returns home after a long day of work. The health care professional is due to work tomorrow at 7:00 a.m., so the alarm is set for 6:00 a.m. Imagine that you are the health care professional in this scenario.
You are awakened from a deep sleep because someone has just turned on the lights, and there are two women standing in the bedroom that you have never seen before. You have no idea who they are and before having a chance to become oriented to the situation, one of them yanks the covers off the bed and the other one is trying to remove your pajamas.
They are saying something about how it is time to get up and get washed, but it is difficult to understand what they are saying. The only thing that matters at the moment is that you were sleeping and now two strangers are trying to undress you. Suddenly, a third person comes into the room. That person, without a word, pulls up one sleeve of your pajama top and sticks a needle into your arm, and then tries to push some pills into your mouth. Then, they all team up and try to pull you out of bed. They are not necessarily being rough, but it is obvious that they are in a hurry.
How would you react if someone you did not recognize woke you up from a deep sleep, tried to take your clothes off, stuck a needle into your arm, was pushing pills into your mouth while trying to yank you out of bed? To make it worse, all while speaking what was essentially a foreign language. It is safe to say that you would be very frightened and confused. It would not be unreasonable for you to resist and you might even try and defend yourself as best you could.
This illustration may seem extreme but it is not an unusual occurrence. Anyone who has worked with individuals who suffer from cognitive impairment will recognize this scenario as very common. A patient who has a significant degree of cognitive impairment will be unable to understand what is happening and the confusion and difficulty in communicating with these individuals can be quite frustrating for the patient and the people caring for the patient.
Working with a patient who has a significant degree of cognitive impairment can often be very difficult. What is considered to be normal patterns of communication are not possible. However, it is important to realize that these interactions are a two-way street; the situation is difficult for the patient, as well. When caring for someone who is confused, uncooperative, perhaps even aggressive because they do not have the ability to understand what is being said or done around them, it is absolutely natural to feel frustrated. But it should be remembered that the patient is doing the best they can and theirfeelings of confusion and fear are probably just as intense as your feelings of frustration.
Someone with a significant degree of cognitive impairment may not know why they cannot understand the world around them. This person often does understand on some level that there is impairment. The person can sense that the ability to cope is limited and as a result, fear and uncertainty are natural feelings when interacting with others. Persons with cognitive impairment feel a bit defenseless, and they are to a certain degree. They are impaired, they sense that they are impaired, and that increases their anxiety level.
Caring For Patients With Cognitive Impairment
Fortunately, with the proper attitude and some simple techniques, working with individuals who have cognitive impairment does not have to be painful for the caregiver or for them. Some basic tools that can help health care professionals when working with a cognitively impaired individual are discussed here.
Patience
Those caring for cognitively impaired individuals will need a lot of patience. The natural instinct when interacting with another adult is to assume that they are at the same level of emotional and intellectual ability as the average person. This is not true of those with cognitive impairment.
This is a simple idea to understand, but many people have difficulty remembering this. It may help to consider what it was like interacting with a small child. A child would not be expected to act like an adult or expected to understand complex ideas or new and unusual situations. Knowing all of this, adjustments are made in how one would communicate and treat the child, and the responsibility for making these adjustments would fall on the adult. When working with a patient who has cognitive impairment, in one sense, the health care professional or caregiver is acting as the adult in the relationship. Patience would be needed and expected.
The above example is not intended to compare an adult to a child or to be demeaning. It is simply used to stress the point that expectations must be realistic. The health care professional may be working with clients who have a significant disadvantage in terms of their mental abilities.
Non-verbal Communication
Most individuals think of communication as what is expressed or the words used but there is quite a bit of communication that is non-verbal, such as the tone of a person’s voice, the loudness or softness of speech, the speed at which a person talks, the way a person stands, and where a person stands when speaking to someone else. These are forms of non-verbal communication.
People with cognitive impairment may have lost the ability on an intellectual level to understand everything others are saying but their other senses are completely intact. They will often respond to how others speak to them rather than what they are saying, so it is often best for those speaking to a cognitively impaired person to stand where the person can easily see and make eye contact with the cognitively impaired person.
Health care professionals should avoid touching the cognitively impaired person until they are sure that they do not feel threatened by physical contact. They should neverpull or yank on someone if they want that person to move, change positions, or stand up. When first approaching someone, it’s important to try and do so slowly and to not rush at them.
Verbal Communication
The ability of an impaired person to communicate verbally can vary greatly and rapidly change. Throughout interacting with a patient, the health care professional may have to adjust their communication approach while observing changes in the patient’s behaviors, reactions, and cognitive abilities.
Some general tools and approaches will help. It helps to keep communication simple and direct. The health care professional should be gentle and take time when communicating with these patients, speaking slowly and clearly. Language should be kept at a basic level. This does not mean those caring for people with a cognitive impairment should be "talking down" to them but, rather, should give them the time they need to process what is being said. It’s important to try to remember that it may take them far longer than one could imagine to completely grasp the meaning of what others are saying. Repetition and reinforcement will also help cognitively impaired patients to remember.
When dealing with the cognitively impaired person, it’s also important to not speak quickly and to make sure that simple terms and words are being used. The health care professional should not be afraid to repeat what they have said, and should not be surprised or frustrated when having to repeat statements several times to the patient.
The health care professional caring for the cognitively impaired patient should not forget that although the patient may remember something that was said earlier in the day or week, these patients may forget something that was said to them just an hour or a few minutes before.
It takes everyone time to get used to a new idea. Change is not easy for anyone but for the person with cognitive impairment, even ordinary situations in day-to-day life can represent new ideas and change. While most people can recognize others and situations that they are familiar with, many times for the cognitively impaired person, even people and places they should know well may seem strange and unknown. They are constantly challenged by a world that seems new and different from moment to moment. Imagine how difficult it must be to constantly be "re-introduced" to the world around you.
Flexibility
Perhaps nothing is more important when working with a patient who has cognitive impairment than flexibility.The opposite is also true; nothing is more harmful when working with these patients than being stubborn or rigid. What is meant when using the term flexible? It means simply that an individual will adjust to the demands of a situation. For the health care professional, it means having the ability to adjust plans and to recognize what is or is not important. Getting a task done is far more important than how the task is done.
Health care professionals with inept cognitive shifting skills are fluent in terms of flexibility. Cognitive shifting skills are the brain's ability to adapt your behavior and thoughts to new, changing, or unexpected events. In other words, shifting is the ability to see that what you're doing isn't working and make the appropriate changes to adapt to new situations.
Mental shifting is the main component in cognitive flexibility and is so closely related that they are often referred to as the same concept. However, cognitive flexibility refers to the ability to adapt to a change, while mental shifting is the process that makes it possible to adapt to the change.
Shifting plays an important role in learning and problem-solving. Patients with cognitive impairment lack this skill but if health care professionals working with them possess this type of skill they will have the ability to better connect and engage with these patients. Health care professionals with flexibility choose a strategy and carry it out to adapt to the situation at hand. These health care professionals capture information from the environment and respond to it flexibly and effectively, adjusting their behavior to the changes that the situation requires.
Characteristics of health care professionals with strong cognitive shifting may be the following:
Good mental shifting allows health care professionals to adapt quickly to changes or new situations.
Cognitive flexibility helps health care professionals tolerate changes that may occur when problem-solving or carrying out a task with a cognitively impaired patient. It allows them to create alternative solutions.
Health care professionals with good cognitive shifts are easily able to transition from one activity to another and know how to carry themselves appropriately in amost every situation.
Health care professionals with mental flexibility can capture various dimensions of reality, see from different points of view, and recognize hidden relationships, which allows them to easily find different solutions to the same problem.
Health care professionals with mental flexibility can better tolerate errors and changes, are able to think about a situation from another person's point of view, and are easily able to find compromises.
Priority Setting
Many health care professionals see their job as a series of tasks that need to be accomplished. That is true in one sense, but working with people is very complex. Many times, it is simply not possible to do everything needed or that one desires to do, as well as how and when to do a task. Situations change and people change. When an individual is not able to clearly see what, at any given time, is the most important priority, a job will become very difficult. It’s important to know how to set priorities andhow to adjust them as needed.
Any experienced health care professional will concede that in order to function efficiently, it is important to know what is most important. But it is also necessary to show an ability to recognize when a situation has changed and to understand that a new, more important priority has replaced the previous one.
Setting priorities is important, but so is being able to become flexible and adjust priorities when this is the best thing for the individual you are caring for.
Regular Routines
Because the person with cognitive impairment has difficulty remembering people, places, and situations, they can be helped by establishing reliable routines. If it is possible, the same health care professional should work with the same patients and to try and develop a routine for daily activities that are simple, do not change, and will be easy for the patient to remember. Familiarity is important for patients with cognitive impairment.
The health care professional should be careful to slowlyintroduce change into the patient's daily routine and to try and explain these changes as clearly as possible prior to starting them. After explaining to the patient what needs to be done, the health care professional should make sure to follow through on these stated changes to prevent increased confusion. The patient may surprise others by remembering what was said, for example, “I will be in your room at 9 in the morning to help you get dressed”, and may become disoriented if promises are not kept. It is always best to give an approximate time, such as, “I will be in your room around 9 in the morning to help you get dressed.” This will enable you as the health care professional to follow through accurately with what you stated to the patient.
Verbal and Non-Verbal Communication: Example 1
As a health care professional, you are caring for a patient who is being treated by the physical therapy department because she is recovering from a broken hip. You need to help the client perform a range of motion exercises. These typically take about 10 minutes to perform, there are five separate exercises, and three of them are a bit complicated. You are familiar with the exercises, you have helped other clients do them but this is the first day you have worked with this patient. The first three exercises go smoothly, but the fourth is more complicated. This one requires you to place your hands under the client's heel and on the sole of the foot.
The patient must lift her leg from the hip, bend the knee down, and then push against your hand while flexing the leg at the hip and knee. But every time you ask the patient to push against your hand she pulls back instead, and at times she straightens her leg instead of bending at the knee. The patient has a degree of cognitive impairment because she suffered a stroke, and the simple instructions you are giving her (which seem simple to you) are not working. "Bend at the knee and hip, now push, push against my hand." The patient cannot seem to understand these simple instructions.
The wrong and unproductive way to handle the situation would be to become impatient. A feeling of impatience would be perfectly normal, and impatience does not imply being rude or discourteous. People who feel impatient may express this by repeating the same instructions in the same way, speaking a little louder and a bit more slowly, and eventually becoming exasperated and frustrated. This approach is rigid and is unlikely to be successful. If the patient cannot understand the instructions for the exercise, giving the instructions over and over again while speaking more loudly and a bit more slowly is not likely to work.
A more productive and appropriate way to make this experience better for the patient and for you, or at least a better way would be to see if simplifying the instructions would be helpful. Breaking the instructions down into small steps in order to give the patient time and you can use non-verbal communication. Instead of saying "Bend at the knee and hip, now push, push against my hand", take the patient's leg and bend it at the hip and while doing so say "Bend at the hip." Repeat this several times, and after each attempt wait a bit to give the patient time to absorb the information, ask her if she understands, ask her to perform the action a couple of times. If the patient understands and is able to perform the first step it is then time to try and add the next step. Doing it this way uses simple, short verbal communication and non-verbal communication, and small discrete steps instead of a long chain of tasks. This should help the patient by making the process shorter and more manageable. The health care professional just utilized their cognitive shifting skills by discovering a different way to assist the patient.
Regular Routines: Example 2
Patients who have cognitive impairment have difficulty learning new tasks and adjusting to change. Unfortunately, the routines of many healthcare facilities are often disrupted and unpredictable. As the health care professional, suppose you have established a routine for one of your patient's meals and it seems to be successful. His meals are served at the same time every day and he always eats alone. However, on this day not only is the meal 10 minutes late, but because of new admissions to the unit, the patient has to take his meal in a different area and eat alongside several other people. It is clear that these changes have upset him, he is confused, and you are worried that he will become agitated.
The inappropriate way to handle this situation would be to fail to recognize how upsetting this change is for this patient who has cognitive impairment (he has suffered a traumatic brain injury), and this would be easy to do. You may rationalize this situation by thinking, after all, 10 minutes is not a long time, and what is so difficult about sitting next to someone else during a meal? So, you tell the patient that the meal was late but that won't happen again and that the seating and eating arrangement is temporary; he will be able to resume his normal routine tomorrow. However, that attitude assumes that the patient can easily adapt to and understand changes in the environment and routine, and he is clearly indicating that he can't. Secondly, this attitude also suggests to the patient that his feelings are unrealistic and unimportant. Finally, you voiced that it won’t happen again and the situation is only temporary. You also promised something you are uncertain of and do not have control over.
A more appropriate way to handle the situation would be to recognize that all of these changes in the routine have made the patient very upset, and his feelings are normal and should be respected. So your communication, verbal and non-verbal, should focus on providing reassurance, comfort, and support. Direct the patient's attention to the parts of the environment that are part of the regular routine. Talk to him about the food, about what you and he have done together so far that day, and what is planned for after lunch. Distraction can be a very useful technique for helping calm someone who is upset, and in this situation, the distraction will hopefully remind the patient less of how his routine has been disrupted and more of how much of it has been maintained. Encourage him to talk and express his concerns, and be flexible. You may have duties, but try to rearrange your schedule so that you can spend enough time with the patient in order for him to feel safe.
Priority Setting: Example 3
Imagine that you are the health care professional assigned to assist a patient in the morning with getting out of bed, toileting, and getting dressed. You are very busy and you have a lot of other things you need to do for other patients, as well. But the patient you are working with is resisting all of your efforts. He doesn't want to get up, and he does not want to get dressed. You cannot understand why and he cannot tell you.
Some people may try to physically lift the patient out of bed and begin to undress him. This is not an appropriate way to handle this situation and you should not try to force the issue. You may be inclined to raise your voice slightly, speak firmly but politely, and tell the patient that he has to get up and get dressed now. This would be a normal reaction to the situation; after all, you think, this task does need to be accomplished and you do have a lot of other people to care for. However, if you attempt to force the patient he will more than likely begin to get agitated and become more confused.
The appropriate way to proceed would be to stop and assess the situation. You need to determine what the most important priority is, and what the best way to accomplish that goal is. Perhaps in this situation, you have more time than you think. You might be able to sit quietly with this patient for a bit and give him a few minutes in which to adjust. The patient may have just woken up, may not feel well, or maybe confused or disoriented. Gently inquire why he does not want to get up and get dressed and give him time to answer. He may not be able to express his thoughts immediately but within a few minutes, the reason might be clear.
Perhaps you can accomplish the task in steps; this will also give the patient time to adjust. Maybe he needs to sit on the side of the bed and orient himself to the room and you. If he doesn’t feel well he may need time to articulate this to you. Patience is important and the ability to pause and remember this patient has his own reasons for his reactions. Also, you might be able to move to another task with another patient. It may not be important that the patient get dressed right at that time you had planned. When the day is not going as you have planned, you need to pause and reflect. Can you change your priorities to make your day and the patients' day run a bit smoother?
Flexibility: Example 4
Flexibility is closely aligned with patience, priority setting, regular routines, and skillful use of verbal and non-verbal communication. Flexibility could be considered to be the essential ingredient to successfully working with a patient who has cognitive impairment. In Example #1 the health care professional broke out of the standard routine for performing a range of motion exercises and used new patterns of communication. This took critical thinking skills and innovation. In example #2 the health care professional was able to see the situation from the patient's perspective which enabled the health care professional to help him adjust to a change. The use of empathy through truly understanding others’ feelings and their current situation will enable you as the health care professional to engage with that patient on a deeper level. And in example #3 the health care professional was able to see that he had more time than he imagined and was able to think of several different approaches to being present with the patient and assessing the situation.
All of these examples may have implied that the client's cognitive impairmentis a permanent condition. However, when the health care professional is working with a patient who has become agitated, confused, or uncooperative, he/she must always keep two points in mind. First, is this behavior new and unusual? If the answer is yes, then the health care professional should immediately notify a supervisor. The behavior may simply be an extension of a pre-existing problem, but it could also represent that something new is going on. And second, the health care professional should always keep in mind the possibility that this behavior could be due to a medical issue. In example #3 the patient's agitation and confusion could be explained by a pre-existing cognitive impairment, but the patient could also have diabetes and be hypoglycemic and that could be playing a part in the situation. Many times, people who have a condition that is known to cause cognitive impairment, a condition such as a stroke, may also have a medical condition that could also be affecting behavior.
Working With Aggressive Patients
Most people are able to stop, sit back, and assess a new situation. People can generally decide if they like what they see and whether or not it is safe. If a person is not comfortable, they can simply avoid a situation. As experience in the world is gained, this process becomes easier because a person may have encountered similar situations before, and the learning process has become more efficient and comfortable.
Patients with cognitive impairment are not able to stop, sit back, and assess a new situation. Because of their impairment, many situations, even ones they have encountered many times before can seem new. Like most everyone else, this can make them anxious, butunlikemost people, they cannot draw or reflect back on their past experiences to interpret what is happening now in the current situation. They do not have the ability and cannot quickly assess what is happening because of their impairment. Not surprisingly, when someone who has a significant level of cognitive impairment is confronted with a new and unusual situation they feel vulnerable and afraid. Unfortunately, in many cases, this fear leads to aggression and attempts at self-defense.
It can be very difficult to work with and assist someone who is confused, afraid, and aggressive. It is the health care professional’s responsibility to keep that patient safe. The health care professional is also responsible to protect others as well as themself. Working with a patient who is aggressive, afraid, confused, and potentially violent is very difficult but with some common sense and planning these situations can usually be handled safely.
Do Not Indiscriminately Use Force
Using force can most often backfire. Certainly, there are times when a health care professional will need to physically restrain someone. But when and how to do so should be clearly outlined in the policies of the healthcare facility or employer, and the use of physical restraint is usually only allowed if it has been ordered or approved by a physician or a supervisor. So, the health care professional should make sure to become familiar with the rules governing the use of physical restraints before these incidents happen. It is safer and less stressful to be proactive rather than reactive. Physically restraining someone is the last resort. It can be dangerous for health care professionals and the patient.
Remember that much of your communication to the patient involves body language. Standing over the patient rather than placing yourself at their eye level, crossing your arms over your chest represents you are close to what they have to say, and planting your feet in an aggressive position could be interpreted as getting ready for attack. Any of these postures can be interpreted as a threat by an already agitated patient and certainly do not allow for resolution of the situation.
If a health care professional does have to restrain a patient due to safety it should be done in the safest manner. Secondly, only restrain a patient for the shortest duration possible. Restraining someone can cause physical and emotional trauma so as stated above it should always be a last resort. Most importantly, if you do have to restrain a patient for safety ensure the patient is able to breathe easily and you can monitor their airway and level of consciousness.
Stay Calm
It is natural to become excited or nervous when someone is acting aggressively. But many times, allowing that patient to verbalize their anger or frustration lessens the possibility of physical violence. Most people have a natural aversion to harming another person, so give the person who is angry the opportunity to be verbal rather than physical.
Do Not Take It Personally
The patient who is acting aggressively is not doing so because they want to harm another person; the situation is usually not personal. Although the patient is acting dangerously, that person believes they are trying to protect themself from someone or others. The health care professional should avoid giving them any reason to feel threatened. The health care professional should remain rational, calm, and non-threatening while remembering that the situation itself is not rational, so trying to force the patient to "see things sensibly" often will not work.
The health care professional should certainly try and speak calmly and rationally, but a patient who has cognitive impairment and is acting aggressively will be unlikely to be influenced by appeals to reason and common sense.
Summary
Cognitive impairment is defined as a loss of higher intellectual function, the inability to perform complex intellectual tasks. It can be temporary or permanent, and there are many causes. Alzheimer's disease, hypoglycemia, stroke, and traumatic brain injury are some of the more common ones. Cognitive impairment is more common in the elderly, but it should never be considered a normal, inevitable part of aging; it represents a serious pathology.
People who have cognitive impairment have difficulty with many of the higher intellectual functions such as short-term and long-term memory issues, adjusting to changes in routine, learning new tasks, and communication. Working with patients who have a significant degree of cognitive impairment is very challenging. But it does not have to be difficult or frustrating for the health care professional who practices qualities of flexibility, good verbal and non-verbal communication, patience, priority setting, and regular routines.
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