As dementia progresses, the way a person communicates gradually changes. Difficulties begin to appear, subtle at first, but increasing as the disease advances.
On the one hand, language alterations occur:
Verbal expression becomes affected, with difficulty finding words. Often, faced with these limitations, the person substitutes the word they are looking for with synonyms, similar words, general words that encompass an entire category, or even a descriptive phrase. For example: shirt: t-shirt – that – clothes – that white thing I wore yesterday. We can try to help the person find the word, or express themselves, through semantic or phonetic cues, asking them to express themselves through examples, pointing with their finger, or by saying the word ourselves without systematically correcting their mistakes to avoid generating more frustration and insecurity.
There is also a reduction in spontaneous language. The person’s speech becomes simplified, reducing the quantity and variety of words, limiting the use of connectors, prepositions and adjectives. In this situation, it is important to know how to listen, show empathy, pay attention both to the verbal message and the context and non-verbal signals accompanying it, making an effort to understand what the person is expressing.
There is also a loss of fluency, with more pauses in speech due to greater difficulties in grammatical organization and verbal production. If our relative loses track while speaking, or stops in the middle of a sentence, we should give them time to finish. We can help by repeating the last two or three words they said or changing the subject if they cannot resume the thread of the sentence, thus helping them maintain their dignity and self-esteem.
Speech without content may also appear, meaning that they often use set phrases without conveying any useful information. In this case, what matters is not the discourse itself, but ensuring the person feels listened to, accompanied and valued.
At the same time, comprehension is affected:
At first, there is difficulty processing complex ideas or long subordinate sentences, abstract language, double meanings or irony. This often leads to misunderstandings. In the final stages of the disease, there is a loss of the ability to understand the meaning of words.
To facilitate understanding, we should speak clearly and simply, slowly and with a calm tone of voice. Emphasize the key words of the messages we want to convey. Adapt the complexity of the information we provide to the person’s abilities, simplify speech, use short sentences, and give instructions one at a time. Avoid pronouns, unusual expressions or abstract concepts. Avoid excessive information or over-explaining. Ask only one question at a time. Use closed questions, limiting response options to two alternatives, or yes-or-no questions when dementia has progressed further.
In more advanced stages, language abilities become extremely limited, leading to the progressive disappearance of language. In this sense, we must remember that communication is not based solely on words, and now the quality of contact will be more important than its content. Therefore, non-verbal language becomes especially relevant. We must convey affection, respect and reassurance through tone of voice, facial expression, eye contact, smiling, showing interest and avoiding signs of impatience.
At the same time, other cognitive changes also affect communication:
There may be a slowing in information processing. The person has a different pace and, to facilitate communication, we must take this into account and give them time to respond without interrupting, with patience, encouraging their effort by showing interest, maintaining eye contact and reinforcing attempts to communicate despite the difficulties that arise. Minimize mistakes so they do not feel judged or frustrated.
Difficulty maintaining attention and concentration also appears. In this context, to facilitate communication it is important to choose the most appropriate place or moment, avoiding interference, interruptions or noisy environments. In other words, an environment without distractions that could hinder concentration. A one-on-one conversation will be much easier than when there are many interlocutors and therefore many more stimuli.
Memory impairment also affects communication, causing difficulty finding words, limiting conversation topics, making the person unable to remember events and causing them to lose track during conversations with unfinished sentences and sudden topic changes. Speech becomes very repetitive. To minimize this challenge, we should reduce working memory demands, avoiding questions that require retrieving information from memory, that is, speaking about the present or what they still remember. Avoid uncomfortable questions such as “don’t you remember?”. Repeat information as many times as necessary using short and clear messages. It is important to remain calm in response to repetitive questions and answer as if it were the first time, using simple responses.
Dementia also affects reasoning abilities. The person loses the ability to structure speech, plan what they want to say and organize concepts in a logical sequence. They also lose the ability to think abstractly. Keeping this in mind, we should make an effort to understand what they want to express while also simplifying our own speech. Use closed questions, limiting the number of response options to facilitate decision-making. For example: “Do you want fish or meat?” instead of “What do you want for dinner?”. When communication abilities become even more limited, we can simplify further using yes-or-no questions. For example: “Do you want a banana?” (while showing the banana). This allows the person to continue making decisions despite their limitations.
In addition, behavioral changes also affect interpersonal relationships:
Apathy limits the person’s willingness to communicate. The person stops initiating conversations and only speaks when asked direct questions, responding briefly. Feelings of frustration due to the inability, or the great effort required to understand and be understood, often generate insecurity and a tendency toward isolation. In this context, we can facilitate communication by seeking topics that interest and motivate the person. Talking about past experiences often helps. It is also important to include the person in conversations and not speak as if they were not present. We can do this by asking for their opinion, allowing the person to maintain a sense of autonomy, choice, independence and control over the situation. At the same time, we should make an effort to understand what the person means and avoid constantly correcting them when confusion arises. Validate the person’s emotions and establish an emotional connection. The content does not need to be current or factual; what matters most is that the person feels listened to.
Excessive information, as well as awareness of communication difficulties, generates anxiety and frustration. We communicate better when relaxed, so it is helpful to simplify speech, show interest without pressuring, correcting or judging. Respect the person’s pace and avoid rushing. In addition, people with dementia are highly sensitive to the emotional states of those around them and may detect if we are impatient, worried or distressed.
Finally, the person may also experience delusional ideas, mistrust or aggressiveness.
They may appear confused or suspicious toward the main caregiver and may even become aggressive, often as a result of misinterpreting reality. In these situations, we should avoid arguing, confronting or trying to use logic. The goal is not to convince the person that they are wrong, but to reduce distress and restore functionality. It is necessary to remain calm, maintain a relaxed posture and a gentle tone of voice without denying what the person is experiencing, since for them it is real. At the same time, avoid confirming the false belief. We must validate the emotion, not the belief, for example: “I understand that you are worried” or “I understand that you feel bad”, showing affection and offering help: “let’s check it together.” In other words, contain the emotion and provide reassurance: “I do not see it the same way, but I can tell you are worried and I want to help you. I am with you, let’s see what is happening.” Try redirecting their attention to something that may provide comfort or wellbeing. Avoid imperative language or giving orders. Use polite expressions such as “please”, “could we?”, “what do you think if…?”. Use positive language (saying what can be done, not what cannot). Treat the person as the adult they are, deserving of respect without complex explanations that could generate more confusion.
To conclude, if we want to maintain good communication, we must learn new ways of interacting that allow us to continue building meaningful connections. We must adapt our communication style with great empathy, understanding that dementia does not eliminate the ability to communicate, but rather transforms it. What changes is the way the person expresses, connects and conveys what they need or feel.
