The Dynamics of Dementia Communication

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LIST OF FIGURES

1.1 Thematic structure of the book.   7

1.2 Diagnosing types of dementia.   10
3.1 Subtypes of human memory.   34
3.2 Contribution of memory to credibility and self-​confidence.   49
5.1 Illustrative map of how communicative opportunities for a
person living with a dementia (PLwD) can vary by context
and interlocutor.   84
5.2 Deceptive Appearance.  91
5.3 Compensatory requirements in jointly managing
emotionally demanding situations.   106
6.1 Approaches to communication in care mapped for
orientation.  122
7.1 The core structure of the Communicative Impact model.  141
7.2 How the Communicative Demand Management System
operates.  142
7.3 The hearer’s role in achieving Communicative Impact.   144
7.4 How the Context component operates.  146
7.5 Shared knowledge as a core component of context.   149
7.6 How the Resources component operates.   150
7.7 How the Processing component operates.   152
8.1 The modification of context through communication.   174
8.2 The impact of dementia on contextual knowledge.   175
9.1 Potential consequences of disruptions to contextual
knowledge.  186
9.2 The subtle meanings of ‘we.’   190
9.3 Problems and solutions 1: Message production by person
living with a dementia.   193
xi

9.4 Problems and solutions 2: Message comprehension by

person living with a dementia.   194
9.5 Problems and solutions 3: Message comprehension by
neurotypical interlocutor.   195
10.1 The carers’ paradox.   217
10.2 Illustration of distraction technique.   228

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10.3 SPECAL memory as a photograph with the facts of the event
(a) and without them (b).   231
10.4 Subelements of degree and kind, within overall cognition.   241
10.5 Multilevel degree-​kind continua (mid/​late stage
of dementia).   242
11.1 Route map for carers’ interventions (as hearer).   262
11.2 Route map for carers’ interventions (as speaker).   265

[ xii ] List of Figures

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L I S T O F TA B L E S

4.1 Comparison between normal ageing and dementia

symptoms  69
6.1 Summary of some approaches to dementia care, with particular
reference to communication support   108
6.2 Six senses for relationship-​centred care   119
7.1 Examples of decision processes in assessing the context   148
9.1 Pragmatic ambiguities   203
10.1 Summary of Kirtley and Williamson’s ‘truth–​lies axis’   221
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LIST OF BOXES

5.1 Dementia statements 93

5.2 Key statements about good dementia care   94
5.3 Expressions of malignant social psychology   100
6.1 Definition of person-​centred dementia care   115
6.2 Twelve practices of positive interaction   116
8.1 Deliberate mismatches between levels of intention   169
10.1 A (draft) manifesto for achieving caring care using the
degree–​kind model   243
11.1 Ten conditions for effective interaction with a person living
with a dementia   260
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FOREWORD

SHOULD YOU READ THIS BOOK?

Anyone flicking through these pages is probably thinking, What exactly is this
book about? and Is it relevant to my interests and needs? We are busy people, and
ploughing through a large volume to find out whether it was worth reading
is not a luxury most of us have. So, there follows an attempt to capture the
essence of the book in a way that should help potential readers decide if they
should read the rest. Of course, the ideas cannot be fully encapsulated in a
short summary (which is my way of saying that you haven’t read the book
until you’ve read it). All the same, the summary that follows does lay out the
logic of the case I’m making, and why. I hope it’s useful.

SUMMARY OF THE MAIN IDEAS IN THE BOOK

It is well recognized that when people are living with a dementia, effective
communication can be a challenge for both them and those they interact with.
Despite a plethora of good advice, it can be surprisingly hard to sustain con-
structive communicative behaviours and to integrate them successfully into
routine daily care and interaction.
This book asks why that is. What is it about communication, as a human so-
cial and cognitive practice, that makes it so difficult to manage the disruptions
caused by dementia? Why is it so common to feel awkward, confused, or irri-
tated when talking with a person living with a dementia? Why is the experi-
ence of living with a dementia so personally and socially devastating? What
approaches to communication would work best, and why?
xvi

To answer these questions, the book integrates information from a wide

range of different sources, disciplines, and perspectives. Only in this way can
we hope to understand how communication is shaped by the biological, social,
and emotional factors associated with the dementia experience.
Part 1 explores how various dementia-​causing diseases affect the linguistic,
pragmatic (reasoning), and memory systems (­chapters 1 to 3); how social
perceptions and practices easily exacerbate the underlying biological problems

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(­chapter 4); what people living with a dementia report the experience as being
like (­chapter 5); and how various approaches to dementia care address the
challenges of communication (­chapter 6).
Part 2 shifts away from dementia entirely, to consider the other major
factor relevant to answering the questions posed by the book: how communi-
cation works. Why do we communicate? What shapes how we communicate?
The Communicative Impact model of communication is introduced (­chapter 7)
and then theoretically justified (­chapter 8). In a nutshell, the argument in
part 2 is that all communication (including nonverbal and small talk) is driven
by our desire to make beneficial changes to our experiential world by getting
the hearer to do, say, think, or feel something. Success in this attempt is
termed Communicative Impact.
Part 3 applies the model from part 2 to the range of considerations
explored in part 1. First, the model enables us to see how and why com-
munication is undermined and reshaped by the various biological, social,
and emotional factors that underlie the dementia experience (­chapter 9).
Next, the model is used to shed light on how people living with a dementia
are fundamentally perceived and, as a result, treated. Particular attention
is given to the acceptability of (well-​intentioned) deception (­chapter 10).
Finally, ­chapter 11 asks what needs to change if communication and well-​
being are to be optimized for people living with a dementia. Proposals for
advanced skills in communication with a person living with a dementia are
presented and explained in terms of the observations made in the book.
These recommendations help anchor the ubiquitous dos and don’ts in a
deeper understanding of why interaction is difficult, in pursuit of truly
person-​and relationship-​centred care.
Thus, topics explored and developed in the course of the book include:

• how the fundamental drive to survive shapes our response to challenging

communicative situations;
• how misunderstandings arise between people living with a dementia and
their interlocutors (those they interact with) and why they are difficult to
resolve;
• what role memory deficits play in changing the dynamics of communication;

[ xviii ] Foreword
xi

• why intensively supporting someone living with a dementia can be so

stressful;
• how social attitudes, expectations, and ambient conditions can undermine
the communicative capabilities of a person living with a dementia;
• why well-​intentioned initiatives for improving dementia communication
can go wrong;
• why the acceptability, or not, of deceiving people living with a dementia is

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more complicated than it seems;
• what we can collectively do to enhance people’s resilience against dementia
symptoms; and
• what people living with a dementia need from their interlocutors, if
everyone’s well-​being is to be promoted and protected.

Key new ideas include:

1. Resisting the inherent challenges of the dementia experience depends

on a person’s levels of social reserve and emotional reserve. These new
concepts, which mirror brain reserve and cognitive reserve, are introduced in
­chapters 4 and 5.
2. Communication in the dementia context is complicated by participants’
efforts to address and fix the problems. These fixes can generate awkward
pragmatic gaps: situations of ambiguity about the level of intervention
being made to protect the integrity of what is being said. Unless resolved,
these gaps leave the participants unsure what they should do or say and can
engender high levels of stress that then themselves have to be dealt with
(­chapter 9).
3. Tensions in the carer between empathy and self-​protective distancing can
lead to the carers’ paradox (­chapter 10). These tensions interface with the
carer’s observations and beliefs about the extent of a person’s cognitive,
physical, emotional, and sensory impairment, to shape whether the person
living with the dementia is perceived and treated as different only in degree
from everyone else or fundamentally different in kind. Both perceptions
have their place but need to be carefully managed (­chapter 10).

The book makes a contribution to our understanding of a highly complex

set of experiences that often engender deep fear, not least because dementia
appears to deprive a person of his or her core identity (­chapters 3 to 5) and
agency (­chapters 7 to 10). But there is much to be positive about. By under-
standing what drives us to communicate in certain ways, we are better placed
to develop new and better strategies for meeting our own needs without
sacrificing those of the person we most want to support (­chapter 11).

Foreword [ xix ]
x

WHO IS THE BOOK FOR?

This book is for everyone interested in why communication is difficult when

one of the participants is living with a dementia, including neurologists,
geneticists, gerontologists, general practitioners, speech and language
therapists, psychologists, sociologists, linguists, philosophers, professional
carers, those whose work sometimes involves dementia interaction (e.g.,

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clergy, paramedics, solicitors), family members, friends, neighbours, and
people who themselves live with a dementia. I have tried to assemble a package
of information and ideas that most potential readers can use to augment their
own existing knowledge with new insights. Readers from most domains will
quite likely find that my knowledge of their specialism or area of experience
ends before their own does, but I hope this is compensated for by the many
other domains of coverage beyond what they already know.
The book is a pragmatist’s attempt to bring together two very different
narratives of dementia: the positivistic scientific view of what dementia is and
how it can be identified and treated, and the interpretivist view of how society
constructs the options available for undertaking those tasks. It uses scientific
evidence to shed light on social questions, but also challenges scientists and
clinicians to question the many hidden assumptions that can shape their in-
terpretation of what is happening and what is possible. Meanwhile, by aligning
that scientific evidence with a theory of communication, it seeks to enlighten,
and gently challenge, professional and family carers who are looking for better
approaches in their daily struggle to communicate satisfactorily with people
living with a dementia.
Those looking for a description of what communication is like in the de-
mentia context will only need to read part 1. But for those interested in the
content of part 3, regarding how people living with a dementia are perceived,
whether it is acceptable to deceive them, and what approaches to communi-
cation are most likely to be effective, part 2 (or at least c­ hapter 7 and §8.2.1,
§8.5.2 and §8.6.1) is essential prereading, because part 3 interprets current
practices through the lens of the model described there.

HOW THE BOOK CAME ABOUT

It has been a major intellectual journey to equip myself to write a book of

this scope about communication in the dementia context, even though
the transition from my previous work on formulaic language was, in many
respects, a direct and obvious one. After Formulaic Language and the Lexicon
was published in 2002, a researcher into Alzheimer’s made me aware of
the relevance of my ideas to the patterns of repetition observed there. My

[ xx ] Foreword
xxi

subsequent engagement with the discourse of dementia introduced me to

a new way of thinking about communication that is consistent with, but
has also challenged and extended, my previous work. Most markedly, as
I identified formulaicity within the language of people living with a dementia,
I was struck by the tendency for the language of their interlocutors also to
be rather formulaic. Superficially, it is easy to see why that might be: there
is a limit to the number of ways you can respond if a person living with a

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dementia says the same thing to you over and over again. Similarly, daily
routines of care are likely to engender a set of expressions that fit the circum-
stance. Such expressions might indeed help a person living with a dementia,
because they signal something familiar in a potentially bewildering world.
But my existing models of how formulaic language supports communication
pointed to a much more profound explanation as well, and I have built on
that in developing the Communicative Impact model.
I first flagged the dementia research agenda in Formulaic Language: Pushing
the Boundaries (Wray, 2008a), but at that point I still knew far too little to offer
more than a few hints about the complexity of the link between formulaicity
and dementia communication. Since then, through a series of journal arti-
cles and book chapters, I have systematically explored the nature of the cog-
nitive and social challenges arising from dementia, with particular attention
to Alzheimer’s disease, and to the approaches that others have developed for
improving the quality of communication as a core component of care. The
roles of formulaic language in communication under pressure are gradually re-
vealed across the book: it is a major mechanism by which balance is sustained
between the cognitive burdens and the social expectations of communication.
Over the 10 or so years since I began work on this topic in earnest, I have
tried out various ideas on long-​suffering colleagues within and beyond my in-
stitution and have had many very valuable comments and suggestions in re-
turn, along with various types of practical support.
I would particularly like to thank the following for their contributions
(and if I have omitted anyone, I sincerely apologize): Tom Bartlett, Andreas
Buerki, Vineeta Chand, Samantha Collins, Boyd Davis, Rosie Dymond, Anders
Ekstrand, Zoë Elkins, Tess Fitzpatrick, Cindy Gallois, Penny Garner, Jackie
Guendouzi, Catherine Hall, Mike Handford, Chris Heffer, Danielle Jones,
Katy Jones, Vicky Jones (and Merlin), Wendy Lewis, Lindsay Lindley, Camilla
Lindholm, Danuta Lipinska, Phil McEvoy, Margaret Maclagan, Lisa Mikesell,
Lydia Morris, Nicole Müller, Maria Nicol, Bilge Ozgun, Charlotta Plejert, Vai
Ramanathan, Rhian Rattray, David Schönthal, John Schumann, Damian
Walford Davies, Jon Webber, Janet Wiles, and Naomi Wray.
On the practical side, writing the book was made possible by more than
one iteration of departmental research leave and also a University Research
Leave Fellowship, all granted by Cardiff University. I’d also like to extend a

Foreword [ xxi ]
xxi

special thank you to Sankari Balasubramanian, the OUP production editor at

Newgen, who fielded my many queries and requests with grace and patience.
Moral and intellectual support over this long process was, as always, in gen-
erous supply from my husband, Mike Wallace. In fact, many of the key ideas
in the book emerged from conversations with Mike. Meanwhile my musician
friends, particularly Tim Tozer, Phil May, and Pam Smith, kept me sane by
distracting me with songs.

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Alison Wray, Cardiff University, 2019

[ xxii ] Foreword
3

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CHAPTER 1

The Challenges of Communication

in the Dementia Context

1.1 WHY IS IT DIFFICULT TO SUSTAIN EFFECTIVE

COMMUNICATION PRACTICES IN DEMENTIA INTERACTION?

In her 2015 editorial for the Psychiatric Bulletin, Campling (2015) asks, “Why
do seemingly caring staff behave unkindly?” (p. 1). She notes that “health-
care organisations and the healthcare workers within them are capable of ne-
glectful and abusive behaviour that can justifiably be described as cruel” (p. 1).
What she observes with regard to care generally is particularly true for de-
mentia care. Significantly, she claims that in many ways, nothing has changed
since the 1950s (p. 2).
Yet in the intervening decades, much has been learned about how to pro-
vide good-​quality care. While specific methods and approaches may come and
go, some core underpinning principles—​respect for personhood, empathy,
quality engagement, identity, and sense of purpose and worth—​have become
well established, are consistently focal, and are recognized as vital for the well-​
being of not only people living with a dementia but also those caring for them.
The humane approach developed by Kitwood (1997) is frequently cited and
has been progressively built on (e.g., Brooker, 2007; Campling, 2015; James,
2008; Nolan, Davies, Brown, Keady, & Nolan, 2004; Sheard, 2011, 2015,
2016), though it is not without its critics (see Dewing, 2008, for a review).
We have to wonder why, then, it is so difficult to transform care practices
for the better across the board, and successfully sustain them. Explanations
include the financial constraints that turn dementia care into an unattrac-
tively underpaid job with too few staff to fulfil more than the mechanical
basics; the distasteful demands of hands-​on intimate bodily care; the physical
and mental challenges of managing people with disturbed, sometimes abusive

The Dynamics of Dementia Communication. Alison Wray, Oxford University Press (2020). © Oxford University Press.
DOI: 10.1093/oso/9780190917807.001.0001
4

or violent behaviours; the emotional strains of the daily reminders of human

frailty and mortality; and the sense of failure and guilt associated with not
being able to do more for people in need and distress.
As we shall see in ­chapter 4, problems arise if society constructs dementia
as a frightening and hopeless condition, and if the medicalization of ageing
defines people living with a dementia as static objects for pharmaceutical
treatment rather than living beings in need of special humane care. Again, we

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know about these problems, and there is plenty of evidence that researchers
and practitioners understand how to bridge the gap between what is needed
and what is currently typical. So why is it so difficult to put such measures into
consistent practice?
There must be something else, something that impedes the prolonged suc-
cess of insightful interventions and imaginative new initiatives. But what is
it? Is it just the inertia characterizing institutions that have hunkered down to
cope day by day? After all, how many new ideas can an organization cope with
“on top of an already toppling tower of initiatives” (Campling, 2015, p. 1)?
Is it entrenched beliefs about what is most important to prioritize, when
choices must be made? McLean (2007), in her in-​depth study of two de-
mentia nursing care facilities in the United States, found that a commitment
to a high level of person-​centred care came at the expense of the routines
and regulations imposed by the standards authorities, leaving the facility vul-
nerable to inspectors’ clipboard judgements (see §10.1.2). Is it the way that
regulating best practice into something sustainable transforms it into a pale
imitation of the original idea (Brooker, 2007, p. 11)? Does the regulation-​
bound approach of “risk aversion, sanction avoidance, and profit” (McLean,
2007, p. 235) deter the kinds of people we need in care and attract those we
don’t (McLean, 2007, p. 184)? Are all these factors parts of the cause of poor
care, or are they symptoms of something else? If the latter, what more fun-
damental challenge might account for the intractability of current practices,
despite the well-​thought-​through visions for a better approach to care?
This book argues that the core problem is communication. This might not
seem at first glance a particularly original claim. According to the Alzheimer’s
Society (2007, p. 4), “care staff perceive communication problems as one of
the biggest challenges in providing good dementia care.” Not only have the
specific challenges of communicating with people living with a dementia been
well explored, but also the majority of the initiatives for improving dementia
care include attention to communication.
However, this book is about a lot more than just what we say to each other
and how we listen to each other. To understand the capacity for communica-
tion to support or undermine our best attempts to engage in a kind and con-
structive manner with people living with a dementia, we have to dig deeply
into the way our surface actions are motivated. Only then can we hope to un-
derstand why a carer1 may sincerely mean to do one thing and yet end up

[4] Part 1. Contexts Shaping Communication

5

doing something else. The theoretical model developed in this book sheds
light on why our communicative actions can leave us with negative feelings
and how those feelings then shape our next actions. It demonstrates how the
memory impairments associated with dementia impact on communication at
a much deeper level than just the loss of informational content. It explores the
awkward pragmatic gaps2 that open up when interlocutors3 are not sure what
the other person knows and, thus, what they should say or do next.

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For all that many approaches to communication in care are termed theories
by their proponents, dementia care is a largely atheoretical domain. There are
certainly coherent frameworks for methods that draw on observation and on
cognitive or social science, but their job is to present a way of doing things
rather than to explain in much depth why it might work. What we generally
see are assertions that it does, and should, work, and although, for the most
part, there is little to object to in the illustrative narratives of how someone’s
experience has improved, we learn relatively little about how a given approach
to communication is interfacing with and modifying the cognitive and social
mechanisms underlying carer–​client interaction.
In practical terms, with one or two potential exceptions, which will be
discussed in detail later, a provider of care, whether an individual or institu-
tion, can pretty well choose any thought-​through and evidenced approach to
communicating with a person living with a dementia, give it a try, and prob-
ably find that, so long as it is carried out in the spirit of its inception, it works
quite well. However, adhering to that spirit is not necessarily easy to achieve.
The problem is that, without a theoretical foundation, it can be hard to recog-
nize which elements of an approach can legitimately be changed or omitted
without detriment. This matters, because it means that any approach created
by a small team of enthusiasts is likely to be difficult, in practice, to roll out
into wider usage. Unless very extensive training and accreditation is set up,
there is a significant risk that the approach becomes a caricature of itself, as
the designers of Reality Orientation, for instance, claim happened to their
method (see §6.3).
It is often left to individual carers or care managers to pick up what they
can of an approach from books, professional journals, online videos, or short
conference or training inputs and try to apply it themselves and/​or introduce
it to others. In such circumstances, unless there is careful oversight from
those who developed the method, ideas can easily be misconstrued, elements
omitted, and changes made. Ideas can become distorted, particularly when
they have to be applied to cases and contexts that happen not to have been
mentioned in the training. Seeing these distortions, the originators of an
approach can get protective of their method, arguing that (a) only they or
their close team should ever run training and (b) their approach cannot be
hybridized with others. This, however, then counts against them in a wider
context of inclusivity and plurality. Carers want the scope to try different

C h a p t e r 1 .  T h e C h a l l e n g e s of De m e n t i a C o m m u n i c at i o n [5]
6

approaches and mix and match till they identify their own best way. Indeed,
we find that the majority of the main ‘branded’ approaches have themselves
borrowed heavily from what went before.

1.2 OVERVIEW OF THE BOOK

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This book introduces a theoretical model of communication as a means
of interpreting the relationship between the manifestations of dementia-​
causing diseases and the daily lived experiences of those affected by dementia.
Is such theorizing necessary? Would it not be enough to lay out what is known
and what approaches to supporting communication have been found to
work? I argue that it is not. Theory makes it easier to identify patterns and,
by explaining them, to predict alternative outcomes arising from changes to
practices. For as long as communication in the dementia context remains dif-
ficult, new insights must be of some use.
A model does not have to be perfectly ‘correct’ in order to be useful, though
of course the intention is to give it as much explanatory adequacy as possible.
A model provides something to ‘push against’, so that we can ask: Insofar as
we understand communication to work like that, how effective would we expect this
particular approach to be? If the model cannot explain the effectiveness of an
approach, then the model needs to be changed. But where it can shed light
on the independently recognized limitations of an approach, it may point
the way to how perhaps rather small changes could improve the approach’s
performance.
The Communicative Impact model described in c­hapter 7 is, for these
reasons, the fulcrum for the book as a whole. It is introduced in part 2 so that
part 1 can first lay out in some detail what issues and challenges it addresses.
Importantly, the model is not specific to the dementia context and, for this
reason, part 2 does not mention dementia all that much. The model interfaces
with dementia in c­ hapter 9. The deployment of a generic model of communi-
cation is significant. The problems associated with dementia interaction are
shown to be natural responses to new challenges within the general system that
humans develop across their lifetime as their means of communicating with
others every day. Both people living with a dementia and their interlocutors
are shown often to be operating in an entirely rational and necessary manner
when they generate the communicative behaviour that, superficially, appears
dysfunctional.
It is from that recognition that new ways forward are possible. The core
message developed through the book and forming the focus of the final
chapters is that interaction with people living with a dementia can be more
successful if we are aware of what they are trying to do and of how our cogni-
tive and emotional drivers tend to program us to respond to each other. That

[6] Part 1. Contexts Shaping Communication

7

knowledge enables the making of different choices, choices that can open the
door to a new interactional space within which people living with a dementia
can communicate more effectively and relate better to those around them.
The book is structured around a series of questions (Fig. 1.1), each of which
occurs as the heading of the first section of its chapter. The answers to the
questions posed in c­ hapters 2 to 8 progressively contribute to answering the
questions posed in c­ hapters 1, 9, 10, and 11. In this way, the account begins

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with the mystery of why it is so difficult to sustain effective communication in
the dementia context, proceeds to offer answers, and ends with some theoret-
ically grounded proposals for the future.
Part 1 is dedicated to understanding the nature of dementia and de-
mentia communication. In the remainder of this chapter some key concepts
and theoretical orientations are laid out. Chapter 2 explores the direct im-
pact on language of the neuropathologies associated with different types

Pt 1: The pressures on communication in the dementia context

THE CHALLENGE
Chap 1. Why is it difficult to sustain effective communication practices in dementia interaction?

THE CAUSES
Chap 2. Chap 3. Chap 4. Chap 5.
How do the brain What constraints on How do social attitudes How do constraints on
changes associated with communication are shape how we interact communication shape the
diseases of dementia imposed by memory with people living with experiences of people living with
affect communication? deficits in dementia? a dementia? a dementia and their carers?

THE RESPONSES
Chap 6. How do approaches to care attempt to address challenges in communication?

Pt 2: The potential for communication processes to respond

THE CONCEPTUALIZATION
Chap 7. How do we achieve impact through communication?

Chap 8. How is the Communicative Impact model theoretically justified?

Pt 3: Optimizing communication within the constraints of dementia

THE APPLICATION
Chap 9. Why is dementia so disruptive to communication?

Chap 10. How does the conceptual positioning of people living with a dementia impact on communication?

THE IMPLICATIONS

Chap 11. What are the priorities for improving communication by and with people living with a dementia?

Figure 1.1: Thematic structure of the book.

C h a p t e r 1 .  T h e C h a l l e n g e s of De m e n t i a C o m m u n i c at i o n [7]
8

of dementia. It also reviews the possible causes of resistance to dementia

symptoms when brain pathology is present, associated with brain reserve
and cognitive reserve.
Chapter 3 considers the role of memory loss, asking what it entails in
dementia, and exploring its direct and indirect impact on communication.
Chapter 4 turns to the social factors affecting perceptions of dementia and
the interpretation of symptoms. It introduces the concept of social reserve

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to understand the impact of a wide range of hazards and opportunities
arising from a person’s social resources and our collective social responses
to dementia.
Chapter 5 explores the experiences that people living with a dementia and
their interlocutors have in communicating and introduces emotional reserve
as the inner resource for withstanding the emotional pressures arising from
having dementia or caring for someone with it. Chapter 6 discusses different
approaches to communication in care, unpacking their claimed benefits and
evaluating their fit with each other.
Part 2 (­chapters 7 and 8) introduces and develops the model of Comm­
unicative Impact (CI), which, as already noted, is generic to communication,
not dementia specific. Chapter 7 lays out the model and indicates how it ac-
counts for the generation of utterances that are fit for their communicative
purpose. Chapter 8 argues the case for the proposed underlying motivation
for human communication and reflects on how the CI model relates to other
models and theories.
Part 3 (­chapters 9–​11) examines the implications and potential applications
of the findings so far. Chapter 9 asks how the ‘hard’ and ‘soft’ causes of de-
mentia symptoms described in part 1 impact on the pursuit of CI. To put it
another way, it explores how (a) compromises to cognitive processing and
(b) social stigma, among other things, change the capacity of both people
living with a dementia and their interlocutors to achieve their interactional
goals using language and other communicative tools. It then shows that the
characteristic features of dementia communication are a natural response to
the changes in those parameters and the speaker’s continued drive to pursue
those goals.
Chapter 10 homes in on how people living with a dementia are con­
ceptualized: either as ‘like me’ and thus different only in degree, or ‘not like
me’ and thus different in kind. The impact of these two ways of positioning on
both people living with a dementia and carers is considered, and the accepta-
bility of deceiving people living with a dementia is discussed.
Chapter 11 outlines what is needed if communication by and with people
living with a dementia is to be optimized, and maps out the changes that
interlocutors need to make. The book concludes with a consideration of how
kindness can support the achievement of these outcomes.

[8] Part 1. Contexts Shaping Communication