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Communicating with Alzheimer's by Susan Kohler

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Dr Carol Francis

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Any form of dementia, including Alzheimers, causes the sufferer to loose memories and the ability to connect with loved ones. The stress and disappointing sadness that family members, friends and caregivers experience when dementia takes over often interferes with the emotionally satisfying experience of connecting, through communication, touch or shared experiences. Susan Kohler, a Speech Pathologist, has discovered a way to help family and friends of dementia sufferers reconnect with their loved one in ways that are touching, moving, satisfying and amazing. This hour interview provides listeners with a 9 step roadmap toward reconnecting with Alzheimer sufferers who are loosing their way, their loves and their Selves. Call ahead with questions to Dr. Francis at 310-543-1824; review the book How To Communicate With Alzheimer's by Susan Kohler at BookEnergy.weebly.com or contact Dr. Francis at drcarolfrancis.com or MakeLifeHappenNow@gmail.com. Or contact Susan Kohler at SusanKohler@grpublishing.com


0:00 Narrator

Blog Talk Radio.


welcome to Make Life Happen. This is Dr. Carol Francis from the Los Angeles area. I have a special treat for those of you who have family members or friends that have some sort of dementia or Alzheimer's that has made it so that you cannot communicate or relate to them the way you used to be able to. And yet, I don't want you to despair because there are ways to have a very intimate, close, warm, friendly, happy relationship with individuals suffering from Alzheimer's and dementia. Even though know I know all the other complications definitely are going to press upon your time and energy and frustration. And so as a consequence, Susan Kohler. Hello Susan.

0:45 Susan Kohler

Good morning. How are you?


Thank you. She has written a book called, How to Communicate with Alzheimer's. And one thing I appreciate in getting to know Susan is she has such a heart and has, out of her passion for the elderly in the family that help individuals with Alzheimer's and dementia, decided that she must be able to communicate how people can communicate and connect with those suffering from dementia. And she's created this wonderful usable handbook I'm going to call it, but actually it's a book. But it's like walking with a work book next you to encourage you with very doable techniques and strategies so that you can have a relationship; a different type of relationship with your friend or your family. So Susan, I'm going to let you take so much of this program over because you have such a passion for this topic. Introduce yourself and then let's get going helping these people with this information.

1:40 Susan Kohler

Well, thank you. It's just really such a pleasure to be able to talk with you about these issues, Carol. I can't tell you how much I appreciate the opportunity. My background is a dual background. I actually am a licensed speech and language pathologist, and I do work with the elderly. I was one of those people who got out of school and for some reason took the road less traveled from my peers, and really was drawn to our senior citizens. And once I started working with them, particularly those people that had dementia I really saw that there's such a created helplessness and a distance that happens between them and the rest of our society, created by their difficulty in communicating with us. Difficulty in getting their thoughts known to us, difficulty in expressing to initiate a need, or just to have a good interaction with someone. And slowly it started to turn around where I saw that it was us who would approach them and do the facilitating to get them to come forward and to communicate and what I call, connect with us.

2:54 Susan Kohler

So one of the things that I really want to emphasize here this morning with you is that I want us to really look at what we do in making a connection with our loved one, with someone that we're coming in contact with who has some kind of dementia process going on because it affects their ability to have interaction with us, to engage with us. And then they become isolated, and then their skills will decline faster, there's more difficulty in reaching out to them. They're going to have that sense of helplessness and dependency and depression that will come because they're not having the interaction with others.


said. And so this isn't just about having an option to still continue a relationship with this person. This is also recognizing that you as a caregiver, in whatever capacity, you can keep them more actively alive, their brain more actively present just by using a lot of these strategies and techniques. That is a beautiful, additional asset to what you're suggesting. I hadn't thought of that when I was reading your book. Thank you. Well, now--

4:04 Susan Kohler

Oh, yeah. But if I may say, it's so important to look at it that way. Is to start with the basic, the foundation. Is to create a connection. Because once you're connected by using good communication techniques then you start to have that person be attentive to you in a way that helps them interact or cooperate or do some of the things you're going to have to do in terms of their daily care with them.


Now let's get everybody kind of grounded on the same topic of dementia and Alzheimer's as well. We all think we kind of know what it is. Your book delineates three different stages where you can begin to recognize the beginning signs of things beginning to happen on to very severe presence of Alzheimer's and dementia. Can you walk us through those steps?

4:52 Susan Kohler

Sure, I can talk a little bit about what we generally classify into three stages. And where we see the kind of thought process or the communication abilities break down. They tend to be kind of grouped into three particular stages. The first being where we see-- it's very subtle-- but we see changes in memory, particularly for recent events. And if I may say, one of the reasons for that, it's the ability to selectively and carefully attend-- focus our attention on new information coming in. We start as we get a little older to lose that strength, but when someone has a dementia process happening they really begin to have difficulty with that. That's why the short-term memory is so much more impaired as the disease progresses as opposed to some long-term events that people can call upon. So with that difficulty in short-term memory you're going to see difficulty in concentrating, and you're also going to see perhaps, some subtle changes in a personality, and you'll start to see some word finding problems. Where they may start to search a little more. Now we all do this, but--


6:17 Susan Kohler

--we're going to see this-- yes, exactly. But you're going to see someone who may start to have some difficulty, really struggle to search and find those words and that ability then to make themselves understood starts to become a little more difficult. And then, just in general, you're going to start see a slowness in processing information. And that has a little bit to do with that attention I talked about. That ability to really selectively attend and bring that information just doesn't happen right away. It's a slower process; slower to warm up, slower to happen.

6:54 Susan Kohler

Now because these changes are subtle we don't always know why they're happening, but it's very important to notice if you notice a change in a loved one with these things happening. And one of the things to always begin to do is start to watch how they behave with you, how they interact with you. And that begins to show you maybe some of these subtle changes. You always want to bring in your physician, your primary physician in on any kind of changes you see so that they can start to look at what might be happening with them medically or even nutritionally. Things change as we get older and so there may or may not be a disease process going on, it could be because of something else. So that's the first stage. And the first stage can last a long time.

7:42 Susan Kohler

It's one of the difficulties about that initial stage, is that it happens over a longer period. It's subtle and it's moving slowly in someone. So if you start to think about how you're communicating with someone right away, noticing somebody subtle changes, you're going to really start to understand that ability to connect and engage and keep things stimulated if this is a disease process of one of the dementias happening, how you can work with it as we move it to the next stage. So I'll begin to talk about then a little bit more about stage two, OK?


Can I make a quick comment here? I've done a program with medical individuals on menopause and others with women who are pregnant and the hormonal changes throughout the month. And it's so interesting because when I read stage one I said, oh my goodness, this is the woman vexed with thyroid condition, pregnancy, too many chores and children, and also menopause. And so I want say that these signs are, like you say, evident in so many individuals. Not to jump the gun. However, not also to become passive or two humorous about it. Taking stock on this because if it's reached-- if medically this stage is tended to with nutrition, medication, and becomes the baseline for further development in terms of whatever MRIs can be given, then this can become very useful in the ultimate treatment of it. So thanks for including that stage one. I want our listeners to think about that on many, many different levels. Stage two, you narrow down the situation a lot. So please proceed.

9:25 Susan Kohler

Right. Exactly. In stage two what happens is the communication problems definitely become more frequent. There's more severe loss in memory and thinking. This becomes a little more obvious, the noticeable change where these problems start to become exposed in communicating in say, new or unfamiliar settings. One of the strengths which I know we want to talk about later in someone who has dementia is that one of their strengths is in, what is familiar with them. That gives them security and that they know. So when you're watching something or someone in a new setting or unfamiliar setting it's almost as if now they're going to be working without a net. They're not going to have all the familiar things around them to respond with. New settings are going to become very much-- it's really going to show you if there's some issues going on. Some of the things that we'll see is understanding things auditorily. They may have difficulty processing that information and so they're not getting messages correctly. They're going to have more trouble expressing and particularly completing their thoughts. They'll use more repetitious statements, more repetitious questions, and they'll have a decreased ability to keep engaged with you, to keep a conversation going. These become more evident as we get to stage two.

10:52 Susan Kohler

You may find some difficulty even in pronouncing words. As they try to organize their thoughts and put them into their expression they may mispronounce more. We also see decreased memory for the meaning of words, and so there's sometimes some unusual substitutions. You know, I don't know if you've ever experienced this with someone you may know that has dementia where there's a group of words that come out of a particular class and they may pick the wrong word out of that class. We call that a class error. They want to pick up the cup and they look at that and they say I need-- instead of saying cup, they might say I need that plate thing there. You know, so they're searching for that word in the right group, but they don't get the right one. And then what happens on the long-term memories is they might get a little fragmented and out of sequence as they try to collect and pull those things together. And this is what's happening in stage two. Things obviously more apparent.


you know neurologically what the damage level is at this point? And how it's measured? Or no, is that getting into a totally different field?

12:00 Susan Kohler

I do know a little bit about-- not being a physician, my emphasis obviously in the communication techniques. When we have this breakdown in pathways, as the mental condition is impeded-- the ability to function, the brain telling the body what to do-- it's hard to say how much damage or how much difficulty is occurring because people are so different. People we've known through now studies that keep themselves very active, particularly people who read a lot, who are very mentally-- try to keep themselves in a nice challenged way, keep engaged, keep active, could have the same amount of damage as someone who may present more problems or more manifesting issues. And that second person may not have been so mentally active or physically active or, like you said, keep up with good nutrition, keep up with good regular check-ups with their physician. They could have the same amount of damage, but still be able to function in different ways. So it's difficult to say.


once again, passivity produces atrophy predominantly as opposed to--

13:09 Susan Kohler



13:11 Susan Kohler

Right. We talk a lot about people who have these particular issues is, really find activities that may challenge and help them use their brain. I mean that's very simply put, and as we talk about these communication techniques we can find that sometimes it's difficult to do and we have to find ways to do it. But we can help stimulate a lot of these processes to stay as active as possible.


13:38 Susan Kohler

You know, particularly in the second stage it's an opportunity to really get in there and look at how we can keep communication open, keep connecting open, keep activities open, and keep their daily activities vital and alive and active.


a sideline here, I know that a lot of families, once they realize that their loved ones are going into a state of dementia or severe medical complications, they say, I want to move my relative close to me so I can have them. And while that is so important and there's so many difficult decisions associated to that, at the same time it does move them out of their familiar path and wouldn't it nice if everybody could catch individuals at the beginning of stage two when they move the individual and develop a lot of familiarity with the new, safe environment prior to dipping into stage three?

14:33 Susan Kohler

That's excellent. That is such a great notion because while we don't always think of someone with dementia as being able to necessarily learn something, we can condition them. You know, we can help create, like you say, familiarity, create routine, create consistency. Now if we have this in our plan to say choose to bring someone closer or into an environment where we can be closer physically to them and say, visit more often, I think we need to look ahead and say, how can I do this and help this person with this adjustment so that things can become familiar and routine for them as easily and as much as they can appreciate that and respond in a positive way? We are so vital to create those positive experiences. And like you say, if we do it in the earlier stages we have an opportunity to really make those connections and they begin to respond to that. They clearly do.


thing about stage two before we move on to stage three is an interesting development that was outlined in Time magazine a few months ago. Was a notion that the best medication, so to speak, against dementia or Alzheimer's is exercise. Which [INAUDIBLE] tells us your sense to keep active. That the exercise proved to fight more dementia than almost any other form of medication.

16:02 Susan Kohler

Absolutely. I really think that there's always a place for medication. It can be supportive and it can be monitored correctly and see if it is helping. But really, honestly, we have so much at our disposal in terms of shaping behaviors and keeping people active. It's really something we should look into and the idea of being physically active-- I know I've had my own experience with my case load. I've had patients I've worked with who actually couldn't physically do too much and so I created some-- put on some music and did kind of like a chair dancing where they could do some physical things even sitting down. And use music from their generation, like some big band music. And people loved it, and they just watch you and follow you and move and get physical and active. It just brings so much energy up and I'm sure it's lighting lots of parts of the brain because they're watching, they're visual, they're concentrating, they're moving. Something as simple as that can be--


So now we move on to the transit to stage three-- much more difficult stage to go through.

17:14 Susan Kohler

Right. And I know that it is difficult and yet, again, if we think about how we want to engage and connect someone, even in stage three, you can find and feel that there is a connection there. And particularly if you've been lucky enough to work on some good engaging techniques through the earlier stages, you'll start to read that person even on a nonverbal level and know that they're there, that they're connecting to you. And when they are, my caregivers who I work with tell me, I can tell by their eyes when they're engaged. I can tell. And I watch for that and when I see it I reinforce it right away, and it's just very pleasing for both of us because in that third stage, obviously, we have the most impaired of what I teach in terms of techniques, we have the most impaired communication. The facial expression is very limited and it looks very flat, but yet, inside there is something happening.

18:21 Susan Kohler

And again, people tell me they see that in their eyes, that there is a connection there. If we get any verbal expression at all it's very empty, it's imprecise, it can often be unintelligible. There may be a few social words like thank you, how nice, hello. And I think it's so good to try to engage and have people give them an appropriate meaningful response to say that. To approach them and talk to them and just be able to look at them, and when they do give you one of those few words, repeat it so it's reinforced that you got what they wanted to say. It is so difficult to explain a little bit of how that's going to go because each person's course is going to be a little different, but they still will sense familiarity. There still will be that companionship that they'll be able to definitely feel that connection. And I definitely hear that from my caregivers. They truly tell me that that is there, even in that final stage.


It's sad to watch.

19:39 Susan Kohler

Well, you know, when you reach out and make those connections they feel so satisfying. And I think that even if you're not necessarily a family or professional caregiver, I think we can even look at how we see people day to day or come encounter with older individuals who may be still functioning in some way and may-- in terms of doing a lot of things on their own, but they're going to be out in society and you can tell that they're a little older and frailer. I think if we can all think of using these techniques that we'll talk a little more detail about in a few minutes here about reaching out and trying to make connections with people so that we don't isolate our seniors. And particularly, our seniors who need a little more help and facilitation from us.


On page 28 of your book where you have a title, "Working with the Brain that Remains." That is just such a beautiful phrase. And then in bold you have, "in spite of the deteriorating skills of those with dementia, there are clearly skills that remain somewhat intact even until the later stages." And it's those you want to help us facilitate; those you want us to engage in.

20:57 Susan Kohler

Right. And I think that's important. I think it helps the caregiver. If they can remember and think about, what is the strength of the person that they're working with or the person that they're taking care of or the person in their family. That they can help also keep a successful communication going between the person who has some dementia process because when we look at what's their strengths, they're going to start to be able to respond to us. They're going to feel good about that. They'll have success at engaging with us, and it's going to reduce a little bit of what I call, restlessness sometimes. If you bring in, particularly say, a routine. If you know something about that person that they are say, a morning person. And that they always like doing something around a certain time.

21:56 Susan Kohler

You know, even as simple as they always love that cup of coffee and a piece of toast, well then, maybe they're living out of at a particular facility where they want to serve a huge breakfast and they're trying to make that person eat the huge breakfast. And yet, you know about that person they just ate coffee and they had toast. And you can help share that with that particular facility. You know, this is what this person liked. It creates a security for a person when we use routine.

22:25 Susan Kohler

Another thing that we want to do is create a strong sense of recognition. Recognition is very, very important. It helps with security. It helps a person feel safe when taking instructions. I know that a lot of times if there are too many new people around a person that has dementia, or let's say, or an Alzheimer's in particular, they look around at these new people and they don't know them. They don't know why they're there. They don't know exactly what they're doing. And they feel insecure about that. And when it comes to establishing recognition, it takes time. If you're going to put someone in a new place or you're moving someone closer to you or you're just going to visit on a more regular basis-- someone you already know-- takes a little bit of time to engage recognition. And one of the ways I talk about creating recognition is by using repetition and consistency. So you may have to sit down with someone and use a little bit of small talk. And that small talk might become your routine say. You know, you always visit at a certain time. You always kind of start your conversation the same way. You introduce yourself, even if you are a family member, say your name, say who you are, and maybe you start chatting about the weather right away. That's always your routine. Or maybe you talk about how lovely they look in a particular way that they're dressed. Whatever begins to become kind of your pattern. I really tell people in the book that they need to develop their own sense of style. That they need to use what comes kind of good-- you know, feels good for them and creates a response in the other person. And you can see recognition on someone's face. You know, remember I said, they take a little warmer to attend, kind of to warm up to you. They'll look at you, but then you'll definitely see when they're engaged and they have recognition of you.


it's an ah-ha?

24:26 Susan Kohler

Yes, exactly. There's an ah-la look. Right. And that's what we look for. When you recognize something, it'll really start to create that connection you want. They could look at you initially, and I know sometimes caregivers have told me they walk up and they sit down. They try to work very hard on making a routine and saying certain things a certain way. And that person will look at them and they may call them by the wrong name. But immediately just repeat your own name again. Say yes, I'm so happy to be here. It's Susan. I just came over from-- and you might say where you came from if you are visiting. If you're sitting down with someone that you're living with and taking care of still, you sit down and you say, it's time to have that wonderful morning cup of coffee you and I always share. I'm so looking forward to this, are you? And they'll be able to respond to you.


is beautiful. You know, Susan, something that's kind of embedded in everything that you're saying is that their memory may be lost and that creates the confusion and the fear and a series of other reactions, but you over and over are saying that they have emotional responses of joy, satisfaction, fulfillment. That you can tap into the emotional components of their brain almost more readily than their memory and not to forget that. That in the moment they may not remember you or a whole lot of things, but you can convert isolation, loneliness, fear, worry into joy, happiness, fun, playfulness. That's still where their human spirit is actively available. don't forget that.

26:14 Susan Kohler

Right. And I think that in looking at the strengths that they would have say with developing routine and recognition, and looking at things that they like to do, that they like to talk about, that you can tell by their face brings joy as you say. Bottom line, Carol, that's why we're here.


26:36 Susan Kohler

We're here to create positive experiences of connecting with one another. And if that is your focus and then using some good techniques to do it, so many other things will start to happen in your own experience with them in your daily caregiving or your daily or regular visits. Or if you're a professional caregiver, in your particular job. You'll see so much happening for both of you-- this enjoyable exchange. And you know, I really think that we need a movement here, we need to look at how we can stay connected with one another and this is a particular group of people that without our help and facilitation, they don't get a chance to have those connecting times like you say. And when we reach that kind of emotional part of the brain, there's spontaneous answers, spontaneous responses. And they're very enjoyable. Very enjoyable.


was sitting in a Whole Foods store eating a meal and watching an elderly man walk into the store and looking at the children; they were decorating pumpkins when the elderly man said-- very elderly man with his walker said-- you know, children are first, aren't they? And he was so pleasant and friendly about it and he was engaging them in this conversation. And I thought sadly to myself, in anticipation of my interview with you that that is such a nice sentiment, but wait a minute? Children aren't necessarily-- of course you've got so much energy there-- they are one among many and the many are the elderly. That house this history, this commitment to their community, their giving to their family. And to just forget about it because it's difficult to access. [UNINTELLIGIBLE]

28:26 Susan Kohler

Absolutely. That's an interesting observation you had there. And how about his particular response to that situation? And yet, in such a gracious way, giving those children that attention. And yet, in a way though it helped him reach out and engage a little bit. This is probably a whole 'nother topic for discussion, but the idea of intergenerational communication is also something I think soon in the future we're going to look at because we have our seniors living longer. And then they live longer with something like dementia, Alzheimer's, and that process that goes on. We still have the fabric of society full of different generations now with families and friends that get together, and the connections can happen across the generations as well. That's an example of that. That reach out, like how do we get our children with our grandparents and our great grandparents now? And make that connection. That's another thing that's really nice about the strengths of a person with dementia, is that things that are familiar again, would be family members.

29:50 Susan Kohler

Other things that are strengths for them become things like music, reciting and singing. It's such a strong connection in every human being and music can be fun for everyone to do. And if there's a particular kind of music that they like or music that is calming to them, or music they just simply like to kind of move to a little bit or sing or try to-- you know, I put some songs in my book in one of the sections in the back to have people like, try to sing a song with them. They'll like it. And if you're both having fun and if you don't think you sing well, isn't that fun?


That's right. Don't be inhibited, there's no time to waste.

30:32 Susan Kohler

Right, exactly. And it's like, if we try it, and we had fun, well OK, we had fun. And no one else has to hear us.


30:41 Susan Kohler

That's the thing I love about some of the things I encourage everybody, just try them. Try these activities. Try the techniques. Try to tap into things that are familiar to them. See what happens. And if it looks like a good thing and it's something that really made a connection, keep that in your little bag, in your little memory bank there if this worked nicely. Or my book actually is layed out with some wide margins. People tell me they put notes in there. They go, oh, they liked this. This worked.


31:12 Susan Kohler

Yeah. Exactly. Exactly. Another thing I do want to bring up about some of the strengths for a person who has dementia is obviously long-term memories. If you have some old photographs and there's things that really make a connection with a person, put them in a little book. I have an activity in the back. I talk about putting like a little memory book together. People really seem to enjoy those and they may be able to give you some nice verbal responses if you prompt them as to certain photographs. And if you put can options underneath then someone who doesn't particularly know that particular family member well or if it's a friend, can also pick up that book and look at some of the photographs and prompt that person to respond about those activities. And then the other part of the memory, the procedural memory, if they had something that they really enjoyed doing say, playing the piano. I always encourage people to try to make those kind of activities available to them. Even if they may not play the song all the way through, but if they can still sit down and start to play something, tap into that. That's something that's familiar and comfortable for them. You know, if you want to have a person still help you set the table, but they can't do the whole table, maybe they can just lay down the plates with your help or put the fork in the right place. There's so many things you can engage in your daily activities that tap into what we call procedural memories. Things that we did in a sequenced way. A task that we did.

32:48 Susan Kohler

So those particular strengths you may have to kind of take notes about and look and see, and over time they may seem to deteriorate a little bit. But you can strengthen them pretty well and keep them very much stimulated in terms of making connections and getting good responses. Some of the procedural memories come when we want to get-- if we're taking care of someone, we want to get them ready for the day. We want to use good techniques. We want to use things that are familiar about how they dress, how they groom themselves, how they brush their teeth. All these things are things that we want to keep very familiar in the fashion that they know to do them.


I so much want to make sure we have time for the nine strategies that you have, but on that procedural aspect of it, a lot of the caregivers that I work with are so depressed or frustrated by how much antagonism and opposition they seem to get from the senior because they're just trying to help and the senior is moved or shifted into this antagonism. I know you mentioned that somewhat in your book, but can you elaborate even more than your book about what to do emotionally with your antagonism? What the antagonism may be about and how to move toward connection as opposed to opposition? I know that's probably your last point. Don't argue, but I want to make sure to get that.

34:15 Susan Kohler

You know what? Exactly. You're right. And I phrase that particular strategy to kind of give light to that difficultness when we get that confrontation going and we don't get the cooperation. What I have to remind everybody is they really have to look at that particular situation and see where that opposition started happening. Where that difficulty started happening. Was it happening right off the bat? Was it happening during when you were starting to work with someone to say, get them dressed? Is there in some way, something that changed, and could it have been that we didn't have the engagement, the good cooperation? Where we had the connection. Without the connection you're going to get more difficulty. You're going to get them to be kind of antagonistic with you because what they're not doing at that point is able to process what's going on and feel kind of in control because they're not connected. They're not attending in a way that's going to let them process everything coming in. Is the encounter a little too fast? Am I trying to dress this person too quickly? Do they need to talk to me a little more? Are they distracted and I'm trying to push this on them?

35:41 Susan Kohler

So sometimes, a lot of it is going to be us. If we really start to get good at these techniques, we have to step back and see where did I break down in not using good communication techniques? And then, how did that behavior then start to escalate? And at times, when we can't control those behaviors and they do become difficult, we must begin to again, go back and put that physician in the. Loop Talk about the difficulties we're having right now. Again, we may need to look at nutrition again. We may need to look at a medical work up. You know, we did say at times there may be inappropriate medication. Those are the extremes. But in day to day encounters I think we really need to look at what we're doing in our efforts to communicate, to connect, and watch how our daily activities happen in caregiving.


we move into the nine strategies that you have, I just want to say to the caregivers that are listening that the guilt you experience over becoming highly frustrated with the person you're taking care of is too bad. I'm so sorry that people experience the guilt because you're trying so hard to make a very difficult situation as doable as possible for everyone. And as a caregiver to move into those frustrating, oppositional moments, to give yourself time to pull back and maybe just leave the circumstance is fine. You don't need to keep reengaging the moment. That's no different than trying to get a tire out of mud and all it does is spin around and dig deeper. Just pull back. It's fine. Move away as much as you can. Make sure the situation is as safe as it can be. But don't feel like you have to make the person see your point of view or get the task done in that moment. Sometimes you're just stuck.

37:33 Susan Kohler

You know, exactly. And there is times when things won't go well. And you're exactly right. And you just have to look at the situation and see what you can accept about what you need. Is the situation OK? Are they safe? This isn't exactly how I wanted this to go or this isn't exactly what I wanted them to do, how can I let go of some of my agenda and just let this be right now? And I say the same thing in my book just how nicely that you articulated that, Carol. Just forgive yourself and be ready to just go on and say, OK, now what did I learn from this? You know, this was a difficult time. All right, I'm going to look at this situation. This was a night when the person didn't sleep well or this was a night where-- or this was a morning where we ate too late. Or I was rushed because I got started late or something about the--


the brain chemistry in the patient just shifted so that there's more antagonistic hormones than there are positive hormones and you can't really predict that.

38:42 Susan Kohler

Exactly. And if that's all it is then I just need to accept that and I'm going to try a few-- you know there's always things you can try in terms of the techniques that I advocate. And in a section of the book there's one where you kind of troubleshoot some of those difficult behaviors where it just kind of teachers you to look at the situation, stop, and then come back to a few specific techniques that might help diffuse that situation. And at some point you might try a couple activities that you know may also calm a person down. And again, as things go on and this process becomes at times, more difficult as far as the severity of the dementia you'll find you'll have to adjust some of your techniques and some of your activities that you try to do to help maintain a safe environment while you are caring for someone. So with that in mind, could I talk a little bit about some of the communication strategies?


please. These are great. They're very doable and right on target. They're great.

39:50 Susan Kohler

Well, thank you. One of the things that I spent a little more time on is my very first technique that is in the book. And the reason I spent a little more time on it is because I feel that if you can kind of use this technique and use the strategies and then use the techniques that go with it, you will really start to develop your skills and really start to read that person about what you need to do. And all the other strategies start to kind of fall into place for you.

40:22 Susan Kohler

The very first technique is what I had simply titled, "get their attention." And I can't emphasize this enough. You know, it does sound simple, doesn't it? And I think we're so-- yes, exactly. We're so used to rushing through our day assuming that someone's going to be right there with us that we don't stop and really look at do we have their attention? And it isn't an attention where you're going to wave your hand and say hey hello. It's actually this, what I called-- earlier, previously, talking about some of the difficulties someone has-- it's that selective attention. And in my field we call it the working attention. It is that kind of right there in the forefront of the brain. Right there in the very, very front that's bringing in what's happening in the environment. It's taking in the information: what they see, what they hear, what's going on. And when someone has Alzheimer's or another related dementia or any communication difficulty, the working attention or the selective attention is not working well. They are simply having difficulty. And they will continue to have difficulty. And it becomes your job to grab that attention to the best of their ability at that time and to be able to help them start to process what is going on.

41:53 Susan Kohler

And remember, too, typically we're working with people who are a little older, so we've got vision and hearing difficulties anyway, most likely. So the time then to warm up the attention, to be able to participate, engage, or do a task is going to take longer. We can't come at the speed that you and I if we saw each other in Whole Foods and said hello, could just-- boom. Right into a conversation and be right there and chatting about everything. Which would be delightful, but when we have a person who has some cognitive difficulties that won't be there. So you really got to stop and look at how to get their attention. And some of the ways to do it. And I try to lay out some very concrete ways because I don't want to make it complicated. I want to make it simple. But you need to pay attention yourself to how you're trying to get someone's attention.

42:49 Susan Kohler

So the first thing I talk about is to simply come forward and use some kind of greeting. And the greeting, I know that sounds very formal in a way, but no matter what you're doing-- if the person's living with you or you're coming to visit them, you need to do something to say, hey, I'm here. I'm coming forward. I'm going to be asking some engagement here. You're kind of letting them know, we need to connect here a little bit. So if you come up and let's say you're visiting. You can come up to someone, be right in front of them, look at them, smile, and say, hi. It's Susan, your daughter. I came by because I'm so excited to see you and you may go on and talk a little bit because you also giving then that attention time to warm up. You're giving that selective attention time to focus in.

43:44 Susan Kohler

Now let's say you're at home with that person, not necessarily going to go, hey, hi, it's me. I'm here. But in a way, you can still do that. Exactly. You can say hi, I'm back. I just went over to get a little drink of water. I got a little thirsty. Are you OK? Can I get you some water? Again, if you need to engage that attention you're going to have to kind of be creative about what you want to do it about. Do I want to make it about letting them know I'm here? Or just sitting with them? You could still do that same little kind of introduction and just sit with them. And using this kind of introduction or greeting really helps them to get ready to listen. So that's the first little technique I talk about. And I think everybody who might be listening could simply just try that one thing and see what happens. Watch what happens on your approach, and if you make the approach purposeful in that way with the intent that you want to start to get their attention.

44:46 Susan Kohler

The other ways I talk about--



44:49 Susan Kohler



is such a fundamental quality of any relationship. If you're coming home from work and your partner, your children are there to eye to eye enjoy them, celebrate their presence in your life sets the mood for everything thereafter. In the morning, same sort of thing. How you wake up and greet each other. Same sort of thing. Colleagues. So getting a person's attention and engaging them in that emotional and pragmatic eye to eye-- maybe a bit of touch or maybe a lot of touch depending on the culture and then relationship, is so much a part of all of us. And so here are these people that probably don't get enough touch, enough eye to eye to be able to know that that moment captures them in this sphere of relating that's all about creating that moment for the two of you to engage in so that you can build on that. It's beautifully said.

45:43 Susan Kohler

Well, you know, and thank you for saying that. You know, you've got me smiling the whole time you were saying that because I totally believe that. I think that even in society, we have to look at how we are connecting. We have a lot of things in our society right now that are electronic. That are keeping us from being face to face and yet, face to face encounters are so rich and so beautiful, and have so much to offer one another. That with this particular population, who can't quite initiate that with us, we need to do something that's going to help them be with us in that same way. And that's why it is a simple technique. I've had colleagues, and I've even had a number of physicians say, wow, I can use these techniques in my own interpersonal relationships. I should stop and look about how I'm communicating. And I said, exactly. And if you can be very aware of how you're doing this with someone who has a cognitive process going on who can't readily express themselves to you unless you help bring it out, this one will do so much. And you brought up in your last explanation some of the other things I tell people to do. Besides just that initial greeting and making a strong intent with that approach is to make the eye contact. And then, be in front of that person. Perhaps you're going to have to remove some environmental noises-- the television stays on a lot. We keep noise around us kind of all the time. But if you need to get that processing going on and that attention grabbed, you need to be a face to face with an ability for that person not to get too distracted by things going on in the environment.

47:40 Susan Kohler

I tell a lot of my caregivers that if there is a television on and someone else in the family may be needing to watch it, certainly you could take the person you need to deal with to another room that might be quiet. And that way you can have an opportunity to get attention much better. The other thing you have to do about getting someone's attention, Carol, is you must know that you're directing their attention to you. But you're going to have to redirect it. It's not going to just automatically stay. They're not going to be able to stay with you. Their attention won't have the strength in duration that say, you and I could have if we were having a conversation. So once that attention is fading and you can tell again, by are you connected? Look at their face. Look at their eyes. Look at their body language. Are they getting distracted? You may have to even start all over again with the introduction, with the purposeful engagement. So those are the things I talk about in the very first strategy called "get their attention."


please continue. You have eight more. They're so helpful.

48:47 Susan Kohler

I know. And like I say, I like to spend a little more time on that one because my concern is that if I just gloss over it people will simply just try to simply think attention will happen right away. And yet, it takes time to develop the skills that are going to garner that attention and keep it. And again, the processing that has to go on. So now you have someone engaged. You have someone who can participate with you. Who can interact with you. And so all of your encounters therefore are going to be safer. They're going to be richer. They're going to have some positive interactions, and it's going to be pleasurable at this point. Again, like I said, if something happens where you don't seem to have that same cooperation, go back and look. This is where we talked about the caregivers having a little difficulty when it gets confrontational. Go back and look. Did you lose their attention? Do you need to go back and gain that attention? How can you do it? Or do you need to let the situation relax a little bit and step back?

49:49 Susan Kohler

So as far as some of the other techniques I talk about I always tell caregivers to watch their voice. Use a calm speaking tone in your voice. This is something that some people will naturally kind of have, depending perhaps, culturally. People may not necessarily have a kind of calmness or a lower volume. There are some families, some cultures, I notice, where they really speak out. They assume they're working with someone who has difficulty hearing and they want to shout louder. But the truth is, if you've got someone in an engaged environment that doesn't have too many distractions, and maybe their hearing is a little faulty, you don't have to shout. You don't have to raise your voice. And particularly when you're having difficulty with someone whose behaviors are starting to get difficult, and they may be what we call escalating, having some difficulty. I always say that one of the first things you need to try to do is, if you come and talk to them in a very calm voice they'll match it because they will match the energies that they feel from you. So if they're starting to have difficulty and you come in with a calm tone of voice and you maintain that calmness in your voice; they'll match it. And that will start to bring the behaviors down. That will start to help you reengage their attention.

51:18 Susan Kohler

So using a calm tone of voice sounds very simple, but it's very effective. And it's soothing. You know, someone using a very soft, calming voice is very soothing to an individual and helps them feel a little more secure in what's going on and what the encounters about.


want your listeners to know that you are a professional singer and so your ability to use voice to move people into paying attention to you is something that you've schooled yourself to do. And the rest of us need to be mindful that we do that too. We just need to be mindful we can create that with our voice quality.

51:55 Susan Kohler

Exactly. And I think that's one of the skills you learn in getting to be a better communicator. Is your voice is going to affect somebody in a particular way? You're exactly right. I think anybody from kind of an artistic background, and you mentioned my singing background, all of the training I got as an actor and a singer, which I still luckily get to do a lot of, I use so much with my seniors and it's so enjoyable that I find that particularly the voice quality really has an impact on what they respond to. So all of us can do this, and I think you'll find it's very, very effective.

52:41 Susan Kohler

One of the other things I talk about that kind of goes along with your calmness in your voice, and I call this strategy, "watch your language." And basically it just means to pay attention to how you're saying something and what you're saying. I think it's easy to again, have our voices perhaps be too loud, be a little too harsh, especially if we're starting to get a little frustrated. If we're not getting cooperation we need to watch the tone of voice. But also, we want to watch what we're saying. We want to keep things very simple and familiar. We want to keep, probably our messages or our responses to them short. We don't need to have them be lengthy. Again, if you have a long, lengthy explanation or you say something that's pretty long in terms of sharing something to them, they may not be able to attend to that the entire length of your utterance. It requires the attention to sustain and they may not have that. The other thing about watching what you say is be prepared. You're going to have to repeat things, probably a few times. And I think that's important. I think it's important not to say, well, I already told you that. There's a reason that you're going to have to repeat it. And the reason may be that maybe yes, their attention wasn't quite there then the first time you said it. Or maybe they simply don't have an ability right now if too many moments have passed and they're not going to remember what you just said. So you will have to repeat things. and. you want to use adult language. You want to use language that you would speak to as any other friend. You don't need to change it and you want to make it positive, positive phrases.

54:36 Susan Kohler

One of the things I noticed that people do is they'll get so, unfortunately, locked into no, that's not right. Or no, don't do that. Instead of trying to find a more positive way to say that. May I help you with that? Here, I think this is a little better if I help you do this. So I may have stopped them from doing something that wasn't quite right, but I did it in a positive way in terms of my language. So I think that's very important that things are presented in a positive way.


keeping the tone and the language in a frame of mind that again, produces the joy, the pleasure, the warmth because you want that emotional attitude to be present. That may be what they're resonating with anyway as opposed to the content or the task.

55:26 Susan Kohler

Exactly. And that keeps them engaged with you and participating safely, and having interactions, and doing all the things that you would desire out of you being able to be with them or to whatever capacity you have to take care of them. It's so important that their response to you-- they'll at times certainly sense frustration, particularly in the earlier stages. They'll sense when they're not having said something quite right. And yet, if you respond positively they'll quickly know that it's OK, and we can continue on and have this good positive exchange. So I really think that's important watching your language. It's hard.

56:12 Susan Kohler

I find myself, as a clinician, when I'm in the field that sometimes when someone's been a little difficult and I've had to really watch what I need to do with them and watch how I say things, keep them engaged, particularly for safety reasons, I'm a little fatigued after I've done it because I've paid attention to what I've done and that's perfectly natural. It takes a little bit of work. And I know there are times I've said things and I thought, that's probably not how I wanted to say that. Then I have to forgive myself and try to rephrase it a little better and look at someone in the eyes and smile and laugh and those kind of things. Those are things that we'll all encounter.


have a few more minutes. Can you imagine we have three more minutes? Susan, can you imagine?

57:00 Susan Kohler

Oh my gosh.


know you have six absolutely wonderful more points, but I want to make sure these people know how to contact you. So before you go on, but we will go on, I want you to tell individuals how they can contact you for this information. How they can get a hold of your book and things of that nature.

57:18 Susan Kohler

Getting a hold of my book, one of the easiest ways to do it is online, and my website is www.g-- g like George-- r like rover-- publishing.com. It's www.grpublishing.com. And actually, the gr-- I know we've spoken about. This stands for Granny's Rocker Publishing. And my materials that I do to work with seniors is the reason I named the company that. It's for the materials for the wellness of seniors. Yeah, so that is why it's called grpublishing.com. There's also a 1-800 number that you can call. And that number is 866-743-9624. 866-743-9624. And the person that handles my online fulfillment and the 1-800 number, her name is Tony, and she's wonderful. And she will get books out to you ASAP. And on my website you can always go to susan@grpublishing.com if you have any particular questions for me. I have a lot of caregivers who will e-mail me with specific concerns and I will try to respond as best I can to the situation. And at times, even try to help them depending on where they live where they might find resources to also help them with their caregiving issues. And I will obviously, help guide and coach them through some communication techniques if that's what they need.


know you have a lot of resources listed in your book as well. I'm going to be putting that 866 number on the site so people can get a hold of that. And so please know that that's there for you. And then also, bookenergy.weebly.com has a review of your book as well other. You're going on other sites as well. Do you know what those are offhand so you can share those?

59:34 Susan Kohler

You know, I have a few that I'm working on right now. I'm hoping to make all that connected to my website. So as things happen, I was talking to Dr. Carol Bernstein on Doctor Radio just this last week and we had a terrific discussion and we had an opportunity to relate to a lot of caregiver's issues that we're talking about today. One of the things, Carol, we did start to touch upon were the holidays because they're coming up. And those are important times when we want to reach out and make connections with our loved ones and holidays are probably very reassuring to a lot of our loved ones because they help orient them. They help bring again, familiarity and recognition. So the holidays are wonderful times that we can use to make connections.


children and I have gone into nursing homes and just given them Halloween trick-or-treat on Halloween. And the seniors were delighted to get their trick-or-treat. It was a wonderful moment.

1:00:46 Susan Kohler

And part of it was that you did a connection with it. You know, you came forward and you didn't just leave a bag of goodies at the door. You came and you met-- you saw each one of them. I have a great--


1:00:59 Susan Kohler

Yes. I have a great story when I started working with seniors. I had a group of people that I sang with. Kind of a small, six to eight group of people. And when we had things that we had to perform I would make one of our rehearsals, I'd say, OK guys, we're going to go and we're going to sing for some of my seniors. And that way we could also rehearse our music. And we would go and I remember the very first time we went I said to them, now when we get ready to leave, if you all would just walk through where they're all sitting and say hello to some of them, and if you want to sit down you can chat with them briefly, but make sure that you walk through them and sit with them. And I told them, make a connection. And they looked at me a little wide-eyed, like I'm not sure I'll be able to do this. And I wondered why they thought that because I always found it's so engaging to sit down and do this with down. So here I was bringing them into a new situation. So I remember the first time we sang and I had to hurry and make a phone call because I had them singing at another facility I worked at. So I walked out a little bit ahead of them and I made the phone call, let the other facility know we were on our way. And I turned around to look, expecting to see my group, and they weren't there. I looked back into where we had performed and every single one of them was sitting down engaged with one of the seniors. And I had to wait another good half hour before I had them all there. I didn't want to stop any of them from having a wonderful exchange. And they said, this was so fun. Where are we going now?


1:02:37 Susan Kohler

Exactly. And just what you did there. Going and giving trick-or-treat candy to the seniors. It's so much more about that face to face interaction than it is about-- but that brings the familiarity. That's why you're here. You know, that's why you're here. Thank you so much. It's important I think that we look at ways that we can reach out like that. It's nice to hear that in your family you're thinking of those things.


going to be a senior one day myself. We are no longer streaming online, but to the degree that people are still going to be able to listen, load this down on their iPod or the CD. Do you want to continue your nine strategies? You're about to mention use yes or no questions and two questions.

1:03:29 Susan Kohler

Two-choice questions.


so interesting.

1:03:33 Susan Kohler

This is very important. Sometimes you know, if I sit down-- if you and I sit down and chat and I say, what do you want to have for lunch? You could probably give me a list of things that you like. But to say that to someone who has difficulty communicating, they're probably not going to be able to answer that easily because it's too open-ended. So the more that you give them a prompt or a question or you reach out to them in a way where they can respond in what I say, yes, no, or two-choice. And yes/no is kind of a two-choice, they're going to be more successful answering you. Do you want to have lunch? Yes. Would you like to have something to drink? Yes. What would you like? Juice or water today? Juice. Would you like apple or grape? Apple. And typically, they're going to be able to respond better if you give them questions in a two-choice format. So I tell people in addition to watching what they say, watch your language, this is another way to use a very effective strategy because yes/no is easy to answer. Giving them the two choices lets them hear one. One is going to sound good to them. And again, from that more spontaneous level they'll give you a response. And also, Carol, in the later stages when we lose a lot of language, yes/no questions are going to be very important because they're probably going to be one of the few ways you can get information from someone, make stronger connecting interactions. They may even not be able to say yes or no, but they'll still probably nod. Or you'll notice by their nonverbal reaction to your question, even in their facial expression, whether that was a yes or no. So it's a good thing to kind of start using and get very good at. Is using yes/no and two-choice.


very clear. In other words, delineate it so that they can think specifically in the moment as opposed trying to reach into their internal thoughts, which they may not have access to anymore.

1:05:47 Susan Kohler

Exactly. And let alone, then try to pull if they can, it's a lot of information that they can't sort through and make a decision about which one to give you or which word to use. You know, the other thing that yes/no questions are very, very good for is when someone has trouble communicating, particularly in the latter stages. If there's any pain or any medical issues where signs and symptoms may start to occur, they're not going to be able to tell you that. So yes/no's are going to help you locate pain if there's a source of pain. Start to talk about how they may not feel good in a particular way knowing that they have a certain medical condition. And if you use that to help get that communication going, you're going to help find out about something going on that you can get them to the doctor about before it gets too bad or out of control or symptoms become very, very severe. So it's a good, good technique.


very useful.

1:06:46 Susan Kohler

Sounds simple too, doesn't it?


It's great. Repeat, rephrase, and repair. You've mentioned some about that, but that's your next strategy-- repeat, rephrase, and repair.

1:06:57 Susan Kohler

Yes. This particular strategy, I try to make it simple because what I'm trying to say here is there are times when people say things incorrectly or can't finish a thought or can't get it out quite right. And what you do you in repeating or rephrasing or repairing what they say, is you one, validate them for trying to communicate with you. You repeat it or repair it in a way where it is correct so that they hear it correctly. But you haven't brought to their attention that they've said it so incorrectly. That they made errors and they made a mistake. You know, if someone says I'm waiting for my mother. You know, I've had a lot of patients tell me that. Hi, what are you doing? How are you? Are you here waiting for someone? I'm waiting for my mother. Now, probably they're not waiting for their mother because this is someone who is older. But they've just not been able to bring up the right word and they're not aware of that error, so you might, if you know that person a little better, get a little bit of their history. You may say, your waiting for your daughter. That's lovely. I'm sure she'll be by soon.

1:08:09 Susan Kohler

So you're going to kind of validate them for their response, but then also give them the correct answer. It helps keep their communication skills a little better, particularly if you can rephrase something that's incorrect. Using more names and labels in your particular response to them. Sometimes they may say something that's very vague, that really loses a lot of content, and it maybe something like there, it's this thing. And I have it. And they may be touching an article of clothing say for example, and you would say, I like your sweater. It's a beautiful sweater. You've had this sweater, probably a very long time. Now I'm making some of that up. I may not know that about the person, but I'm validating them and I'm responding to what they said. Sometimes you have to be a little bit of a detective or creative about what you think they're trying to say so you can repeat it in a corrected way. But it's a good thing to try to work on. It's going to maintain some good communication skills.


of the personality in some of the caregivers that I encounter are introverted and some of them are extroverted. So some of the caregivers that are introverted, they're shy. They like to follow, they don't like to initiate conversation. I think their strain level is that they really can't do introverted or shy with the elderly because that elderly needs them to be out there creating, initiating, repeating, figuring out, being an investigator. Not just being the kind person that gives what they want and not just a kind person that tries to help make their lives better. It's actually, almost being in their face. For some who's introverted, it's like being in their face, it's being gregarious. Someone who's an extrovert I could think would find this [UNINTELLIGIBLE] strategy so easy because they're used to engaging and initiating and being involved and so I'm saying that's in part so a caregiver can understand their own particular style. Knowing what they're going to have to adjust in order to reach this individual who has obviously changed their style because they're now in a state of dementia.

1:10:27 Susan Kohler

That's really, really important. I do a lot of work with caregivers in facilities and skilled nursing facilities, in homes, and I do a lot of caregiver groups where we talk about what we're doing and we really do need to be a part of, even in our caregiving, even if we get a person dressed or we help them eat or whatever, we need to be a part of their connected experience. We talk about that. That's also our job description now. And you're right. And so if we're not quite so gregarious and we come forth with a lot of things, we're going to need to find ways that even in just simply-- start with the first strategy. Look at ways you get their attention. I'm sure it's going to bring out some other things in you if you tend to be more introverted or shy. Once you see that, the light in someone's face when there's connection, I really doubt that you'll be able to contain yourself with trying to some other things and doing things. It's so rewarding.

1:11:39 Susan Kohler

I know I go into a lot of homes when I'm doing some home visits. And again, if I see the person that is the caregiver and then the care recipient, the person they're taking care of, sitting there and they're watching television. Right away, we start to work on how we can, perhaps do our day where maybe we want to have part of that television time, it's quite all right, but how do we even engage the television time? How do we say something about what's going on there? And then when would it be appropriate, let's not have that on, and let's do an activity. Let's engage in something. And all of that is so very important. It's so very important because you're right, caregiving isn't any more just about I need to make sure that they have this and that and this and that. I need to make sure they get engagement time. And it can happen all during the things you do. Once you see how this works you'll be able to do it while you do the other tasks that you've been called upon to do. So, it's a very good point that you bring up. Yes.




1:12:45 Susan Kohler

Yes, I was going to say, that's why a lot of people will e-mail me. They'll say, what do I do when this happens or what do I do-- or you know, I give them ideas to go try. And I say, make sure you come back and tell me what happened. You need feedback and you need some give and take so that you've got someone to bounce these ideas off of and what happened because you know this when you do have that interaction with someone else, oh, I tried this and this worked. It validates that and it helps you do it more because then it brings it to fruition because you've spoken it out loud and shared it with someone. You've tried it on someone you're taking care of and then you had someone you could talk to about that. It just absolutely anchors it even more. It's a good strategy, good technique.

1:13:27 Susan Kohler

So one of the ones that probably, if you feel kind of introverted and you don't know what to do is orient and reorient frequently. And a lot of times this feels very repetitive, but since a person can't sustain, remember that working attention to remember the new information all the time, you do need to give orienting information and then reorient all throughout your day. And it actually becomes kind of fun because you get to say what's going on. A lot of times when I approach someone, I'll try to use the time of day and say something about that time of day. For example, I may come forward and say, good afternoon. Oh my goodness, it's 3 o'clock. I can't believe it's already 3 o'clock in the afternoon. This is the time I love to have tea. Would you like to have a cup of tea with me? And so right away I'm bringing in information. I'm giving them time to warm up their attention. I'm giving them time to hear that it's the afternoon. I repeated the time a few times. I repeated that it's tea time a few times. And that way you can help them be in that particular moment about what's going on in and what this encounter's going to be. Now, you need to do that throughout the day, throughout all the activities you do.

1:14:46 Susan Kohler

With a lot of my professional caregivers I ask them to come forward and state what they're doing. And do it in a very orienting way. Mr. Jones. it's 11:30 and this is the time that we need to get ready for your lunch. We're going to get ready for lunch now. Lunch will be very, very soon. And that way you know you're helping them know what's about to happen. If someone's in the earlier stages you can also use very clear visual aids. They still can respond a lot to large-- I know I tell people to make very large calenders. And show that when they're talking about certain things or holidays. So not only are we orienting about what the moment may be in the day and being creative about what's happening at that time, weather's a great orienting idea to bring about. Especially, depending on where you live, there's something unique about every place you live in about the weather. Whether it's too cold, too hot, always just right, always sunny, always rainy, always snowing.



1:15:55 Susan Kohler

Exactly. Always changing. People always respond. We always talk about the weather. It's always part of what we have to do during the day. People like to hear that. Even if they can't respond. You made that overture to connect with them. There's a lot of things you can do to promote the orienting and then remember, reorient frequently. Reorient when they say something. There's a lot of times you'll work with someone or you'll be with someone and you'll have a conversation and for example, you and I are talking right now. We're recording this and it's close to Halloween. And if we talk about Halloween and someone says, oh, Halloween, yes. They may even say it later. You know, what is that if you have a bag of candy. It's for Halloween. Halloween is coming. You may say that three or four times. That's wonderful. You've had three or four opportunities to connect. And so you've said the same information. It was worth it.


also talk about using touch as a way of connecting.

1:17:01 Susan Kohler

Yes. I think that probably speaks for itself. I know that culturally you touched upon it, there's different ways or different accepted approaches that may use touch. And people ask me all the time, what if someone doesn't want to be touched? And I've told them that in all the years that I've done this I have yet to encounter someone who has not responded to just a really gentle-- even just a little subtle touch. Again, you would want to approach that person and not run and give them a big bear hug, but you want to approach that person and give them time to see who you are. And if when that moment feels good and you look at their eyes, if you reach out and just touch their hand, it's so wonderfully reassuring. it's so beautiful. It's another signal to that person. I'm here. I'm here with you. And it's calming and reassuring, and it helps with getting attention, and it'll reinforce attention.

1:18:08 Susan Kohler

Let's say they're starting to get a little distracted, simply by touching them you might be able to redirect that attention and it's simple as that. It communicates nonverbally. And you know what? It says, I love you. Just to every human being on the planet to say I love you with just a gentle touch is just wonderful. So it really provides a basic affection that all human beings need and so I always make sure that we spend a moment whenever I'm training caregivers, and let them know about touch. Sometimes with certain caregivers who have certain responsibilities, we talk about how important it is to always let people know when they're going to be touched if you're giving care, so that they know that touch is coming in a loving way. It's coming in a caring way to provide care. And so it's an important strategy to be aware of.

1:19:02 Susan Kohler

Watch. Sometimes you spontaneously reach out and don't know you've touched someone. Watch what that does to them. Very, very important technique to use. You know another technique that is also important is learning to be a good listener. And this is probably where we all need to work on this strategy again, no matter who we're speaking to or working with or coming in contact with in our daily lives. We need to be good listeners, and listening is also not just what you do in terms of hearing what's going on, but also watching what's going on. And if we can listen and watch verbally, nonverbally what's going on we're going to be able to make communication and connecting much more stronger, much will rewarding for both people. Because again, when behaviors start to get out of hand it might be that you weren't looking and listening to certain signs that were telling you, I need things to be a little different here. I can't respond to you right now or I need help responding to you. What you're asking me to do I can't understand. So learning to be a good listener is very important. And it takes time because sometimes you have to wait, and watch, and then there may be silence. And I think we're kind of uncomfortable when there's silence. Not knowing what that's about. But we need that time some time to see, will they respond? Do they need to respond? Do I need to slow down? What are they trying to tell me? What's happening here? So maybe you need to go back and when you look at them and they're not quite attending anymore or not able to participate, you might have to have a little small talk. Stop the activity, sit down with them. Learn to be a good listener is very, very important. Not easy. But if you do, you're going to find that you're going to really be able to make the connection stronger and your communication skills will get much better. You'll really be able then to know what it is you want to do. But again, that takes time to develop.


the words and the nonverbal cues to be listened to and observed in another individual. Valuing it, so you pause and wait and take it in.

1:21:23 Susan Kohler

Right. And when someone knows that someone is actually stopping and listening to them, we see that in our own conversations. When we're interacting with people and they're sitting there and they're listening. It feels really good for us. You're right. We're getting validated in a way to have our responses heard. Every individual needs that, and in the case of working with someone who has this kind of difficulty in communicating, they really do need to be reassured that we want to be there for them and that's the way to do it.

1:21:58 Susan Kohler

The last strategy that we can touch upon is, and the way it's written in the book, it's in italics, and it says, "don't argue."


like this one.

1:22:07 Susan Kohler

And the reason I put it that way-- yes, is exactly. Is to just add a little lightness to the fact that it's so easy to get confrontational. It's so easy to want to push your agenda and push what you wanted to have them hear you say. And yet, if they simply can't at that moment, you can't get confrontation, you'll only escalate the behaviors you don't want. I have dos and don'ts in my book. The dos and don'ts for don't argue I think you already saw.

1:22:40 Susan Kohler

The first line says, "don't argue," and then it says, "you won't win." So if you think about it that way, and then it repeats that strategy three times. That's all you have to remember about don't argue. You're not necessarily going to make that person change by your agenda at that moment, by you imposing what you need done. That's why we have to watch that because you may have to stop and they may say-- maybe they want to do something different at that moment and you're going to have to make that time and go ahead and shift with that so the behaviors don't escalate. But then, as you work with that person, you get them reengaged, see if you can't go back to the activity you were trying to do. Those are the things I like to talk about with that particular strategy.

1:23:28 Susan Kohler

I have a wonderful story in my book because I remembered so vividly that in one of the facilities I worked at we had a woman who got up and started to get to her closet after she'd already been dressed. And the person who had been working with her, the staff caregiver had said, what are you doing? I want you to go to the activity. Now this was the caregiver's agenda-- go to the morning activity. And the woman looked at her and said, I have to get dressed because my mother's coming. So right away, that particular caregiver decided to tell her that was wrong. Tell her her mother wasn't-- you know, your mother is not coming because she's dead, which was, I think, a horrible thing to say. But I witnessed this and it got the woman very, very upset. So I sat down with the woman on the bed and I said, I'm so sorry. That's one of the things you can do for someone like this in a situation that doesn't seem to go well, is just say I'm so sorry. I'm so sorry that you feel upset. Is there something I can do for you? Or I'm sorry I don't understand. I'm sorry I can't understand what you need. And actually, we started talking, and I said to her, your mother's coming. How lovely. Let's go pick out something for you to wear. So we changed her blouse. And she felt comfortable; she sat down. And later, Carol, her daughter came to visit her. That's what she was trying to tell us. Somehow she knew she was going to have a visit from her daughter. So positive was very important.


I just want to stay with all the caregivers out there that we know that the frustration level is going to be high and that these times of connection, communication, oh, wouldn't it be lovely and perfect for it to happen that way all the time so that you're maximizing every moment with the senior, but on the reality side of it, there are times when you as caregivers have to get a job done or get medicine taken or get something that you need to be getting finished with your children or your job or so forth and so on. That all those things, these shoulds, these have-to's, they are part of your reality as well. And to be gracious with your imperfections and your inability to do everything without frustration, without arguing. It's understandable. At the same time, Susan, this phrase of don't argue is beautifully freeing of giving up the argument and figure another strategy for moving around the moment because it'll go faster for you.

1:26:03 Susan Kohler

Exactly. That's what you've got to do. And that is so well put. We really have to start forgiving ourselves because they won't all go great, all the encounters. I had that opportunity to observe, so I was the one, quote, being the good listener to try to find out what's going on. And I was able to step in and then model for the caregiver what might have helped that situation. So it happens well for everybody in that sense. That doesn't mean that I haven't had all positive exchanges myself. None of us.

1:26:35 Susan Kohler

But I've to learn like you say. How can I now step back and I do, because I do this all day long, I'm thinking, what do I need to do now? I need to change a little bit here. I need to change my strategy. I probably want to try this. And then I'll try it and then I'll make a note of that with that person. And then I'll let staff know or caregivers know, this really connected that person. Could you try that? And then I go back and follow up with them going, did that work? What did you sense? Or what's happening? Some of them dynamic exchanges I've had with caregivers who really managed to have a lot of success with their caregiving are ones that we kept this dialogue going because the more we talked about what was working, what wasn't, and how our behaviors were shaping and helping that person we were dealing with, the more successful both the caregiver and care recipient had in their daily activities. So it's tremendously important.

1:27:31 Susan Kohler

I think the foundation for care is communicating, and that's why I'm trying help everyone understand and let them know that in terms of being a caregiver, one of the things in the book, it does say, try them out. Come back and read the strategy again. Maybe it'll ring with you and resonate with you in a different way. Maybe you'll find a better way to make it work. Maybe you'll find some new ways that make it work you can share with me that I can share with other caregivers. I think we're all into this to be ready to develop. We've really never, as a society been asked to reach out to these people. We may not have had them around or in terms of our seniors, they were on the little more of fringe of society. We need to bring our seniors back, and particularly, this group that has difficulty that won't be able to come back unless we help bring them in. This is kind of like, we're the group that gets to work at this now and hopefully, down the road years and generations to come, we'll have definitely started a very, very good way to get interaction and communication and [UNINTELLIGIBLE].


Susan, thank you so much for your time. I so appreciate this. You take very, very good of yourself. And audience, make sure to look into, what is it? www.grpublishing.com.

1:28:57 Susan Kohler

Thank you. Have a good day. Bye.