As dementia progresses, communication deteriorates and it becomes increasingly difficult to ensure that the person’s views are heard.
This study involved 31 people who were each interviewed about their well-being using both Talking Mats – a system of simple picture symbols – and usual communication methods.
The researchers compared the effectiveness of each method and found that:
- Talking Mats improved the ability of people at all stages of dementia to communicate, compared to usual communication methods;
- this tool also reduced repetitive behaviour and helped to keep participants engaged in conversation.
The deterioration of communication between people with dementia and their carers is one of the most distressing aspects of the illness. This project aimed to establish whether Talking Mats (www.talkingmats.com), a low-tech communication framework, help people with dementia to communicate, and to examine how effective they are for people at different stages of dementia.
- Conversations using Talking Mats were more effective for people with dementia than both unstructured (ordinary) or structured conversations. Improvements were evident in the participants' understanding, engagement, and ability to keep on track and make their views understood.
- Talking Mats enhanced the reliability of information provided by people with dementia.
- The amount of time spent 'on-task' – e.g. making eye contact and engaging actively in conversation – increased when using Talking Mats, and participants were less frequently distracted.
- Talking Mats reduced instances of repetitive behaviour, such as repeating words, phrases, ideas or actions.
- Conversations using Talking Mats lasted longer than ordinary conversations.
- People with early and middle-stage dementia could use Talking Mats effectively. People with late-stage dementia showed improvements when communicating with Talking Mats, but not everyone with late-stage dementia could use Talking Mats effectively.
- The researchers conclude that Talking Mats can be used by many people at all stages of dementia and that the framework improves their ability to communicate. Talking Mats may therefore play an important role in improving the quality of care by helping family and staff to engage with people with dementia and help them express their views about a range of topics.
The communication difficulties often experienced by people with dementia mean that a wide range of staff in different settings, as well as family and friends, may wish to find ways to communicate more effectively with people with dementia.
'Talking Mats' is a low-technology communication framework that was developed at the University of Stirling to help people with communication difficulties to express their views. It uses a simple system of picture symbols and a textured mat that allow people to indicate their feelings about various options within a topic by placing the relevant image below a visual scale.
The project compared how well people at different stages of dementia could express their views about four aspects of their well-being (activities, people, environment and self) in three types of conversation:
- an unstructured (ordinary) conversation where the researcher simply asked the participant to tell her about each topic;
- a structured conversation where each topic was subdivided into a number of options that were discussed in turn, in random order;
- a conversation using Talking Mats, which was similar to the structured conversation interview, but here, the topics and options were converted into visual symbols.
Figure 1: an example of a Talking Mat
The main finding was that people with dementia show improvements in the effectiveness of their communication when using Talking Mats compared to both unstructured and structured conversations. This is particularly significant in those with moderate and late-stage dementia.
The indicators used to measure communication effectiveness include:
- the extent to which the person with dementia understands the topic being discussed;
- the degree of engagement between the person with dementia and the communication partner;
- the extent to which the person with dementia remains on track;
- the extent to which the communication partner understands the person with dementia.
Reliability of information
Although many of the participants were able to understand what the researcher was asking them, and the researcher was often able to understand their views, it was less clear how closely these views represented the reality of the participant's day-to-day life. To address this question, a member of staff who knew the participant well was asked to complete a questionnaire that covered many of the subjects discussed during the interviews. The project examined how closely the views expressed using Talking Mats and structured conversation represented the reality of the participant's day-to-day life. The results found that people with dementia produced more reliable information when using Talking Mats than when being interviewed in a structured conversation, especially people with moderate and late-stage dementia.
A commonly observed phenomenon in dementia is that people will repeat previously used words, phrases and ideas that no longer appear relevant to the topic of discussion. This is known as perseveration. Many participants also made repeated (apparently inappropriate) references to events and people in their childhoods, and some exhibited other forms of perseverative behaviour.
The project found that participants in all three groups exhibited less perseverative behaviour when being interviewed using Talking Mats than when being interviewed in both a structured and an unstructured conversation. This suggests that people with dementia can focus their attention to a greater extent and become more involved in an interaction when they are using Talking Mats.
The project also examined the proportion of time each participant spent engaged in 'on-task' and 'off-task' behaviours when talking about the 'activities' topic. 'On-task' behaviours included eye contact and active engagement with the conversation process – 'off-task' behaviours included being verbally off topic and distracted, due either to internal factors (e.g. discomfort) or external factors (e.g. noise). The project found that using Talking Mats increased the amount of time that people with dementia (particularly those in the later stages of the illness) remained 'on-task'.
Length of time
The project demonstrated that a conversation using Talking Mats lasts longer than having either a structured or an unstructured conversation with a person with dementia. This might make Talking Mats less attractive to busy care staff. Nonetheless, it is important to realise that Talking Mats interviews do not necessarily have to be completed in a single sitting. One or more different topics can be easily discussed at subsequent sessions over an extended period of time. Moreover, the instant record provided by Talking Mats is potentially time-saving; care staff no longer have to write up the views of the person with dementia, they can simply put a photocopy or photograph of the completed mats in that person's notes. The fact that staff can be seen to be occupied may give them 'permission' to spend time chatting to people with dementia, getting to know them and interacting with them as individuals.
Stages of dementia
People with early-stage dementia: People with early-stage dementia can usually communicate well using speech in ordinary conversations, but using Talking Mats improved the amount of time that their conversation stayed on track and the extent to which a third party understood their views. Talking Mats helped individuals to organise their thoughts, and to weigh up the pros and cons of their decisions.
People with moderate and late-stage dementia: Significantly, people with moderate and late-stage dementia showed the largest differences between Talking Mats and the unstructured and structured conversations. For these participants, improvements were evident in the four main areas relating to effective communication; understanding the topic of the conversation, engagement with the communication partner, ability to keep the conversation on track and ability to express views to the communication partner.
However, it should be recognised that Talking Mats may not be suitable for everyone. Three people in the project with late-stage dementia were unable to use Talking Mats effectively.
The researchers believe that the main finding of the project – that many people with dementia can use Talking Mats to communicate effectively – means that the framework may be helpful in allowing people with dementia in a variety of situations to express their views about a wide range of topics more easily. For example, Talking Mats could be used to:
- allow people with dementia to choose what they want to do on a day-to-day basis;
- help people with dementia remember what they have said;
- provide a structure for conversation between a person with dementia and their friends/relatives during social visits;
- provide an instant record of what people with dementia have said to put in their notes (see above) or simply to show to their families;
- in addition to being used to augment communication and decision-making, Talking Mats may also simply be enjoyed as an activity allowing people with dementia to occupy their time doing something that is personally meaningful to them.
They also have the potential to:
- help people with dementia to tell family and staff how they feel (e.g. how bad their pain is, how much they enjoy the food);
- provide information for medical and social work staff about the views of people with dementia in relation to health and social issues;
- help people with early (and perhaps moderate)-stage dementia when they face difficult decisions (e.g. giving up driving or moving to different accommodation);
- extend the period during which people with dementia can play an active role in making decisions about their lives.
Department of Health and the Scottish Executive, recommends that all older service users (including people with dementia) should be involved in decision-making about care and treatment options and about key life transitions. Health and social care staff must therefore be able to identify the specific needs and preferences of older people. The demonstration that Talking Mats can allow people with dementia to communicate their opinions suggests that policy-makers and commissioners should consider promoting the use of Talking Mats to help staff consult people with dementia. Talking Mats could help people express their views on various topics including:
- what they want recorded in their personal care plans;
- what they want to do on a day-to-day basis;
- what they think about the services on offer;
- where they would like to see improvements made.
The project found that Talking Mats could be used by many people at all stages of dementia and that it improved their ability to communicate. The research suggests that the Talking Mats framework can provide family and staff with an effective tool to allow many people with dementia to communicate their needs and preferences more easily than through usual conversation. Photographs of the completed mats can provide a permanent record of the views of a person with dementia. This record can subsequently be used to inform care planning, and the development of services and support systems, as well as to ensure that the person with dementia remains in control of their own day-to-day living arrangements for as long as possible.
About the project
The project was carried out over 15 months by Joan Murphy and Cindy M Gray from the University of Stirling. The researchers wanted to hear what people at different stages of dementia felt about their lives, with the central theme of each interview being the person's well-being.
Thirty-one people at three stages of dementia – 10 at early stage, 11 at moderate stage and 10 at late stage – were involved. Their ages ranged from 54 to 90 and they either lived at home, had moved into sheltered housing or were residents in care homes. The participants were questioned about four topics – Activities, People, Environment and Self – in an unstructured conversation, a structured conversation and using Talking Mats.
For details of the consent process and how the reliability of the evidence was checked, please see the full report.