Introduction

The cognitive losses caused by Alzheimer's disease and the other dementing illnesses can cause emotional upheavals for the victims. Whether health care professionals or family, caregivers struggle each day to provide effective emotional support to victims dealing with monumental changes and dwindling verbal skills. Psychiatrists and psychiatric clinical nurse specialists are often asked to assist staff of long term care facilities alleviate the suffering and disruptive behaviors of demented residents. Their recommendations are often limited to adjusting medication regimes and perhaps suggesting some behavioral strategies for the staff to use when interacting with the residents.

Fortunately, either or both of these can be very helpful. Over recent years, the arsenal of psychotropic medications has grown dramatically and strategies for behavior management have been improved. But what about the therapeutic relationship based on dialogue between a clinician and health care professional which is an essential component of most other mental health care plans? Due to progressive cognitive and verbal losses, interventions have been primarily limited to caregiver affect, touch, validation, and redirection rather than verbal dialogue. This study attempted to determine if therapeutic relationships could be established for residents in the later stages of Alzheimer's disease.

Method

This study report was part of a larger study examining communication in the later stages of Alzheimer's disease. Forty-two nursing home residents were included in the study. Each was determined to be in the middle or later stages of the disease based on Mini-Mental State Exam (MMSE) scores. One-to-one sessions with an advanced practice nurse were provided three times a week for sixteen weeks. Sessions in the first, eighth, and sixteenth weeks were tape recorded and transcribed. Content of the transcribed conversations was reviewed to identify the stage of relationship development represented.

The stages were based on Peplau's framework. Stage I - Orientation; Stage II - Working/Identification; Stage III - Working/exploitation; and Stage IV - Resolution. In the first stage, the purpose of the interaction and the patient's trust are established. In the second, the patient reveals emotional response to the clinician and the interaction. In the third, the patient begins to use relationship as might be done by confiding or sharing a feeling. In the final stage, the termination of the relationship is anticipated. As with all descriptions of progressive change, there is usually not a clear demarcation between the stages.

Results

All of the participants developed a familiarity and comfort with the clinicians over the study period. Seven patients were unable to progress in their relationships with the clinicians. All seven had severely impaired speech. For those who retained the ability to speak expressively, if not always using the correct words or grammar, expressed more feelings to their clinicians after several weeks of interacting. Common feelings were confusion, anxiety, and low self-esteem.

Comment

Readers who have provided direct care to demented elders will not be surprised by the ability of the residents to become familiar with the clinicians. In all but the final stage of Alzheimer's, victims do come to recognize caregivers who interact with them consistently. By this, of course, the caregiver becomes 'familiar' even if the patient cannot name or describe the relationship with the caregiver.

It has been appreciated for many years, that whether in a private home or an institutional setting, it is worth trying to limit the number of direct caregivers of demented patients so that relationships can develop. This research takes us further. It reveals that when a therapeutic relationship is established, patients with Alzheimer's disease can still express feelings and concerns.