Most aspects of healthcare involve talking - sharing a problem, making assessments, communicating diagnoses, making decisions, gaining agreement and delivering care. Language is used to make relationships, to request, comfort, challenge, negotiate, or resolve problems.

A conversation can be unpredictable, however. We have to respond to unexpected turns 'in the moment', and we cannot necessarily plan what we are going to say in advance. If there is a misunderstanding or we perceive that we have caused offence, we have to repair the damage. We emphasise good communication skills in medical selection and training. Most doctors are good at it.

The difficulties of dementia communication

Unfortunately, our everyday communication skills may not work in dementia. Language is often affected when a person has dementia, including finding the right words and understanding what is said.

Other cognitive impairments also affect communication, including memory, orientation, recognition and planning. In its advanced stages, someone with dementia may be almost mute.

One particularly difficult feature of dementia is behaviours that indicate distress, sometimes called challenging behaviours, or behavioural and psychological symptoms of dementia. These can include aggression, agitation, resisting care, calling out or attempting to leave a ward. Such behaviours can lead to injuries, sedation, restraint, falls, disturbance of sleep, failure to deliver necessary care and difficulties with discharge.

In turn, these can lead to complaints and litigation. General hospital staff have told us that they feel particularly unprepared for managing these sorts of problems. Various laws apply, including the Mental Capacity Act 2005, health and safety law, and the Equality Act 2010, which mandates 'appropriate adjustments' to public services to make them accessible to everyone.

Our research group has been seeking evidence on what communication works best in practice, in the context of acute hospitals, using a research method called conversational analysis. This studies video recordings of real-life conversations, to identify patterns in talk and what reaction it gets. We aimed to identify specific practices that we could teach and use in practice.

Obeying the rules of conversation

When faced with confused or incomprehensible speech, it is easy to assume that a person with dementia has lost all interactional competence. We found that this was not the case. People with dementia orientate to the basic structure or 'rules' of conversation, such as taking turns or answering questions.

When staff do not follow the rules - by interrupting, for example, or by not answering questions - the person with dementia can object. If this occurred, an explanation and apology helped.

Keeping the conversation going

It is normal to 'repair' problems that arise in conversations, such as asking for a clarification. Unfortunately, if talk is very disrupted, as in dementia, doing this results in constantly interrupting, highlighting inadequacies and making the person 'lose face'.

Skilled staff manage this by avoiding direct repair. For example, the conversation can be allowed to continue as if it were understandable by using repetition, picking out what is understandable, or responding to emotional tone rather than the words used.

This keeps the conversation going - and the person with dementia happy - but you may have to get hard information elsewhere, such as from a family member.

Dealing with different realities

Distress frequently arises when an individual with dementia's view of reality is different from that of a staff member - for example, not realising that they are in hospital, in need of care or assuming that they are at a much younger age with domestic or work responsibilities.

Guidelines tend to propose 'honesty', correction or re-orientation, but we found that this was ineffective and was likely to lead to conflict, as was colluding with the false reality.

Instead, skilled staff tried to find an aspect of the situation that they could agree on, such as someone wanting to go home to their father being asked, "Do you miss your dad?" Alternatively, changing the subject or finding a distraction could help, often picking up on the environment (looking out of the window) or a shared activity (such as walking).

Refusing requests for necessary care

We identified particular problems when a person with dementia flatly rejected a request to do a necessary healthcare task. This occurred with surprising frequency, and is unusual in daily conversation, especially in healthcare, when we usually justify a refusal.

We normally play down our authority when making a request, to sound polite and give people the chance to say no, using phrases like, "If it's not too much trouble, I wonder if…?" But this makes it easy to refuse and carries a high cognitive burden in working out the real sense of the request.

We found that people with dementia were more likely to agree if a request was made with a high degree of authority (called 'high entitlement' in conversation analysis). Phrases such as, "We are going to stand up," or, "I need you to stand up," were more effective.

In addition, it helped to make the task sound smaller or easier ("It will be quick"), asking the person to "just try", offering to help or suggesting doing the task together.

Accounting for care

Some aspects of clinical care are uncomfortable or unpleasant and can be resisted if the person does not understand why they are necessary, even if it seems obvious to us. An explanation or 'account' was required, including a running commentary or 'talking through' procedures.

Closing conversations

Endings could be difficult if the person with dementia did not pick up the usual cues that a conversation was finishing, sometimes leading to prolonged and frustrating closings.

Being explicit about the end of an interaction ("I am finished"), describing specific next steps, using supporting actions such as standing up, or using closing idioms ("All done and dusted") helped.

We are commonly taught to end with a request for additional concerns: "Is there anything else?" We found that this invariably caused trouble, was never effective in eliciting issues, and could provoke distress if the intention was not understood.

Conclusion

Everything that we advocate was found to work in everyday practice on NHS wards - we have simply identified and distilled it. What we add is confidence that these strategies work, enabling communication that is less likely to lead to upset or a negative reaction.

We offer a language to enable staff to describe things that they know implicitly, to help them understand and share their expertise, an awareness of a range of different ways to respond in difficult situations, and an explanation of why some practices work better than others.