5 Strategies to Reduce Refusals in Dementia Care

When a dementia patient is refusing to go into care, it can create significant challenges for both therapists and caregivers. As rehabilitative therapists, it is within our scope of practice and expertise to employ our skills to help caregivers, enhancing the likelihood that patients will receive the care they need. In this article, learn five ways to help ensure that your dementia patients who refuse care receive the essential treatment they need.

How to Encourage Treatment Compliance

If you’ve ever had the opportunity to work with a person with dementia, you’ve probably encountered instances where your assistance or services have been declined. The implications of missing a treatment session might cross your mind: Perhaps your day will be unexpectedly short or your boss will pressure you to go back and try again. However, the more concerning issue is that individuals with dementia who decline therapy services might also be declining medically necessary care. Refusals of care, of any kind, are a problem that warrants our attention and skill as therapists.

Caregivers, paid or unpaid, are often incredibly limited in time and resources. However, speech-language pathologists and other rehab therapists have the educational background, experience, knowledge of neurology, training, materials, and the time to invest in these clients. We have the power to improve their quality of life. It is within our role and our skillset to increase compliance. So how do we, as therapists, do that? Here are five key strategies:

Model Appropriate Communication

Individuals with dementia experience changes in their ability to communicate. Care tasks like showering, toileting, and dressing rely heavily on caregivers requesting attention and then giving verbal and nonverbal instructions to individuals with dementia. Here are a few tips you can employ and also pass along to caregivers:

• Build rapport. It’s important in the initial interaction to be likable. You can approach slowly and from the front, get on their eye level, and introduce yourself.
• Speak simply. We use idiomatic expressions far more often than we realize. When speaking to individuals with dementia, it’s important to say exactly what you mean.
• Decrease use of pronouns. Pronouns such as he, she, it, that, here, and there reference nouns mentioned earlier in a conversation. Using pronouns with someone who experiences memory loss will make following commands more complex if they have forgotten what you are talking about.
• Slow down. Not only should we slow our rate of speech, but we should increase latency, which is the time between your speaking and their response. Placing intentional pauses between ideas can allow for much-needed processing time.

Assume Objections Are Valid

Whenever a person with dementia declines care, they will likely give you a clue as to why. A great example of this is an interaction that occurred with a real patient named Sue. She was agreeable to toileting until she was positioned in front of the toilet. When staff told her to sit, she became stiff as a board. She absolutely refused to sit down!

If we take the position that Sue’s objection is valid, we will have better insight into how we can help her overcome it. When we pause to consider the reasons why someone might not want to sit on a toilet seat, lack of cleanliness could come to mind. Although the seat was sanitary, the staff’s simple act of cleaning it anyway erased Sue’s hesitation and she sat down without resistance. We can use our skills to resolve issues by considering the world through our patients’ unique perspective.

Support Independence

The importance a person places on autonomy doesn’t disappear once they are diagnosed with dementia. Individuals with dementia might be more receptive to care when they’re assisted, rather than having tasks done entirely for them by someone else. Caregivers may notice that a task is becoming a struggle and opt to take it over rather than using cues or varied levels of support. As therapists, maximizing independence is our expertise! We can help improve compliance by allowing individuals with dementia to help themselves in a physically and cognitively appropriate manner.

Prepare the Environment

Changes in the way a person with dementia perceives and interacts with their environment can impact their willingness to comply with care. If a person feels overstimulated and in danger, or if they don’t have the proper equipment needed to physically participate in a task, they might be more likely to refuse care.

If a patient is scared during showering, you might trial a transfer bench and train the caregiver in its use. To increase compliance with dressing for a person who gets frustrated easily, you might train caregivers to lay out all clothing in the order in which the patient will put them on and orient them so that they don’t have to decide which side is the front. As therapists, we have extensive experience in knowing how to adapt a patient’s environment.

Create Context

Disorientation and memory loss are common symptoms experienced by individuals with dementia. This can result in a person not understanding where they are and what time it is with little memory of the last 24 hours. Although we don’t realize it, many of our daily tasks rely on this kind of information. Some days you might shower, not because you feel dirty, but because you know you do it every morning. You might drink water, not because you’re thirsty, but because you realize that you haven’t had anything to drink all day besides coffee.

We can train caregivers to create context by providing multi-sensory stimulation such as guiding patients into the bathroom before asking if they need to use the toilet, talking about cooking before lunch to whet their appetite, or playing relaxing music before bedtime. Employing task analysis and determining where the breakdown occurs can be the key to maximizing compliance.

Using person-centered care methodologies, our therapeutic expertise can serve as a beacon to a caregiver who is overwhelmed and desperate for help. If we aren’t using our full capabilities to help dementia patients refusing to go into care accept the care they so desperately need, who else will? Don’t be afraid to be creative, and don’t underestimate the impact of your skills.