Clarify, Condense, Collaborate: Communicating With the Cognitively Challenged Patient

Doctor-patient communication that is patient centered is characterized by active listening and engagement—the physician solicits the patient’s perspectives and feelings so as to enhance the formation of a therapeutic partnership in addressing health challenges. Positive rapport building, facilitation and patient activation, and emotional rapport building are all considered patient-centered communication techniques that may improve open dialogue and collaboration in understanding and treating an individual’s maladies (1). Optimizing communication is central to a patient’s feelings of satisfaction with care. Highly effective communication improves adherence to a jointly constructed treatment plan (2). However, there are many obstacles to actualizing patient-centered communication. Busy patient-care schedules, medical documentation requirements, and productivity metrics may all pose challenges to developing the type of doctor-patient communication in which the patient truly feels heard and understood. This communication may be even more difficult in the case of the cognitively challenged patient. There is evidence that primary care physicians tend to ask very few open-ended questions of and spend less time with older and sicker patients—patients who may require more active listening to truly understand their health complaints (3).

Optimizing communication and ensuring a joint understanding of treatment recommendations and plans can be particularly complex with patients presenting with memory and cognitive challenges. Sugarman and colleagues (4) examined the interaction between patients and physicians when the patients had a mild dementing illness. The study documented that during informed consent communications, the physician primarily spoke to and looked at the patient’s companion rather than at the patient. Communication dynamics may be complicated by the patient’s cognitive impairment as well as by the presence of a companion (4, 5). Cognitively limited and literacy-limited patients present unique challenges to effective communication—and those challenges may be inherent in the patient, may reside with the physician, or may be related to context (1, 5).

Challenges to Effective Communication

The Patient.

Communication requires special modifications for patients who present with memory, cognitive, or health-literacy challenges. These patients are much less likely to accurately recall what was discussed and agreed upon in a session. Usual methods of obtaining informed consent for medication or other procedures are also frequently inadequate for such patients (4–7). The initial portion of each visit should include an assessment of the patient’s understanding. The Mini-Mental Status Examination is one tool with which to regularly assess cognitive functioning. However, another (or additional) method of building rapport and learning about patients while assessing their level of understanding involves chatting—about what they have done recently that they enjoyed, foods they’ve eaten, and strengths-based as well as symptom-based inquiry. The patient’s use of vocabulary, clarity of recall, and methods of communicating can all be diagnostic. Observing these also allows the physician to match his or her communication pattern to that of the patient and to avoid talking “down to” the patient, which may leave the patient feeling patronized, or, alternatively, using excessive jargon, which may leave the patient feeling mystified (5, 7). Don’t forget to note any medical or sensory issues that may interfere with communication—such as hearing or vision loss, chronic pain, and fatigue—and the resultant expressions of annoyance that may accompany them.

The Physician.

As psychiatrists, we emphasize skills in forming a therapeutic rapport with patients and in maintaining sensitivity to race, religion, culture, gender, and gender identity. However, we are not immune to manifesting implicit bias toward and subtle stereotyping of our patients. One frequent stereotype involves assuming that individuals with cognitive and memory challenges have very limited ability to participate in decision making around their care. In fact, individuals with intellectual disabilities, cognitive impairments, and dementing processes have much better health outcomes if they are as involved as they are capable of being in decisions about their treatments (5–7). Individuals with memory challenges are often challenging patients in many other ways—they may have chronic irritability, take longer for their appointments (thus, potentially leading to a wait for subsequent patients), and typically require the physician’s collaboration with spouses, caretakers, and other service agencies—all of which may be time-consuming (5). Note your own emotional reactions to these patients. These reactions may help you to understand what life must be like for your patient.

The Context.

Patients presenting with memory and cognitive challenges also highlight the potential obstacles to communication related to context. First, there are the features of the office setting itself—lighting, background noise, the efficiency of the intake process, the degree to which the building accommodates disabilities and is easy to find and negotiate—all of these are relevant to optimizing treatment of individuals with cognitive challenges. Adults with cognitive challenges (unless a guardian ad litem was appointed by a judge) have the right to determine who is informed about their medical condition and treatment. Determining which services are involved and getting consent to communicate about those is one challenge. Once consent is given, collaborating effectively with the patient when a caregiver may express another point of view is also a challenge. Listening to both patient and caregiver and helping the two communicate optimally with each other is another undertaking. Monitoring treatment adherence is yet another challenge. Lack of reliable transportation may also hinder optimal follow-up care. With cognitively impaired or cognitively limited patients, one needs to be cognizant of the office structure, the multiple service providers, and the needs of the caregivers, in addition to one’s primary responsibility to the patient—all of which take practice and potentially involve learning new levels of assessment and gaining new areas of expertise.

Clinical Vignette.

Mr. Madison sat stiffly in the waiting room, staring unblinkingly ahead, his fingers shifting rhythmically in the classical “pill-rolling” movement. His wife sat next to him. She combed his hair, straightened his shirt collar, and then reached out and took his hand in hers. He looked over at her with a hint of a smile before his face returned to its previously dazed appearance. Dr. Rau observed them in the waiting room fleetingly. He unknowingly glanced down at his watch—he suspected this would take a while. He turned back toward his office, took a “deep cleansing breath,” and prepared to greet the couple as the receptionist called them to his office.

“Hello, Mr. Madison,” Dr. Rau said, as Mr. Madison shuffled into the office, his wife supporting him at the elbow. “I see you brought a lovely woman with you,” Dr. Rau added, as Mr. and Mrs. Madison took their seats.

Mrs. Madison smiled—“Yes, I’m Mary, his wife,” she told the doctor.

Dr. Rau shook both of their hands. Mr. Madison’s grip was firmer than expected. Dr. Rau pulled his chair up to be closer to him. “Mr. Madison, I’m glad you came to see me today. Before we get started, I just wanted to check on a few things that I ask all of my patients.” Dr. Rau waited until Mr. Madison’s eyes met his.

“Go on,” Mr. Madison barked, unexpectedly.

Dr. Rau then said, “First, I understand that this is your wife, Mary. Some of my new patients want their wives to stay, and some prefer that they not. Which do you prefer?”

“Are you going to talk to me about girly movies?” inquired Mr. Madison, a hint of a gleam in his eyes.

“I wasn’t planning on it,” Dr. Rau replied, somewhat confused.

“Well then, I guess Mary can stay,” Mr. Madison quipped. Mary laughed. Dr. Rau laughed too:

“You are quite the jokester, aren’t you, Mr. Madison?”

“Oh, you have no idea,” interjected Mary. “He’s embarrassed me a lot, this one,” she said in a lovingly teasing way.

“So, you’ve been a prankster pretty much all of your life, Mr. Madison?” Dr. Rau inquired.

“Oh, for Pete’s sake, will you just call me Frank like everyone else?” Mr. Madison blurted.

“Of course. Frank, what else do you like to do?” Dr. Rau inquired, with a hardly noticeable pause to collect himself. “Besides watch girly movies?”

“Yes, what do you like—besides girly movies, Frank?”

“Well, I used to be a welder. Pretty good money in it and I liked the guys. We’d go fishing. Mary and I used to like to go dancing, too. Do you know that we were homecoming king and queen back in the day?”

“That is really something! And you’ve been together all this time?” Dr. Rau queried.

“Ten years, isn’t it hon?” Mr. Madison asked his wife. It wasn’t clear if he was joking or couldn’t recall.

“So when was that, Frank?” asked Dr. Rau.

“1962,” Mr. Madison answered without a pause.

“Wow, how many years has that been?” Dr. Rau asked him.

“Oh, doc, your math is better than mine. Over twenty, though.”

Dr. Rau asked about what brought Frank to see him today. “Mary, of course!” Frank replied. Dr. Rau tried again: “What problem are you having that you came to see a doctor for today?”

“Oh—depression, of course,” Frank snarled. “With this Parkinson’s and all—can’t do anything I like to do. I feel like a bum, with Mary looking after me all day. What if she runs off with a handsome guy like you—then where am I?”

“You’ve been so active and independent all of your life—I can only imagine how hard it has been,” Dr. Rau said, his eyes kind. And just in case Frank was concerned about him he added, “I promise I won’t steal Mary. She is quite a terrific person, though—you are lucky.”

They then discussed collaboration with the neurologist, the primary care physician, and the physical therapist. They discussed sleep and appetite and safety. “Sorry, Frank, but I think it’s time to retire the old hunting rifle,” Dr. Rau pointed out.

“You think I’m gonna shoot myself, doc?” Frank blurted.

“Just want to be sure you don’t, Frank,” said Dr. Rau.

“I have to admit—I did think of it. You know, doc, you’re pretty good,” answered Frank.

“Thanks,” Dr. Rau smiled. “You know, Frank, I think you’re pretty good, too.”

They then set up a safety plan, and Dr. Rau initiated the informed consent process about possible antidepressant medication. Frank’s case manager was asked to help set up visiting nurse services, psychotherapy, and a community group activity plan for Frank and to arrange a time for his treaters to discuss his case. A next appointment was set for two weeks later to decide if medications would be initiated. Frank and Mary were given a concise summary of the diagnosis (depression), the treatment recommendations, the safety plan, and information about the antidepressant medication that was being considered.

Tips for Enhancing Engagement With a Patient Who Has Cognitive Challenges.

Individuals with limitations of memory, executive functioning, or cognitive functioning offer a number of special challenges, as well as opportunities, for effective communication. Assessment of understanding, judgment, and mental status may be more complicated for such individuals. For example, as noted in the vignette of Mr. Madison, such individuals may become facile at hiding their disabilities through jokes, changing the subject, or avoidance. Some individuals may be particularly compliant, thus making it difficult to ascertain whether they are in agreement with a mutually constructed treatment plan or are just passively accepting a plan that they will likely not follow. Other patients, particularly those with deteriorating dementia, may be difficult—demonstrating irritability, disinhibition, and suspiciousness, which can be barriers to optimal communication. These individuals may challenge our health and mental health systems, as they often require particularly well-coordinated care and clarity of treatment recommendations from multiple caregivers in disparate disciplines. The potential for miscommunication and for leaving the patient out of the loop in terms of services and treatment planning is an ever-present danger. And finally, there may be patients to whom we have a personal reaction—they may evoke unrecognized stereotypes and subtle annoyance in us that may lead to lack of patience or an unintended condescending manner on our part (5–7).

Establishing a collaborative partnership in which the physician and patient work together is particularly important to optimizing outcome. Below are practical tips for improving effective communication with your patients with memory challenges (8).