Effectively Communicating with Individuals Who Have Dementia: A Clinical Practice Framework for Case Managers

Introduction: Why Communication Must Change in Dementia Care

More than 7.2 million Americans currently live with Alzheimer’s disease—a number projected to reach over 12.7 million by 2050. Communication breakdown is among the earliest and most persistent symptoms, often progressing from word-finding difficulties to impaired speech production and comprehension.

Because individuals with dementia gradually lose the ability to express needs verbally, their behaviors—whether repeating themselves, withdrawal, irritability, or confusion—become a primary mode of communication. Understanding what these behaviors represent is essential to clinical practice and care management.

Understanding Dementia Through a Clinical Lens

Dementia, as classified in the DSM-5, represents a neurocognitive disorder marked by progressive loss of memory, language, learning ability, judgment, and orientation. With over 100 types of dementia identified—including Alzheimer’s disease, which accounts for two-thirds of all cases—communication impairments vary but follow predictable neurological patterns.

For example, Alzheimer’s disease commonly presents with:

• Verbal apraxia, or impaired coordination of mouth and speech movements
• Anomia, or difficulty retrieving words

These impairments require caregivers and clinicians to adjust their communication approach strategically.

Barriers to Communication in Dementia

Several common caregiver behaviors unintentionally disrupt communication. These include:

• Rushing interactions
• Showing impatience or raising one’s voice
• Using controlling or demanding language
• Asking memory-based questions
• Giving lengthy explanations
• Using closed-ended questions
• Arguing or insisting on factual correctness rather than honoring the person’s experience

These barriers increase confusion and emotional distress, leading to reactive behaviors. Case managers play a key role in coaching families and care teams toward more supportive approaches.

Interpreting Behavior as Communication

Symptoms and behavioral expressions are universal across dementia’s trajectory. Because individuals cannot always articulate needs, their behaviors communicate:

1. Physical needs: pain, hunger, thirst, fatigue, toileting needs
2. Emotional needs: fear, boredom, frustration, loneliness, overstimulation

The clinical question becomes: “What is the person trying to tell me?”
By reframing behaviors through this lens, caregivers and clinicians reduce reactive interventions and support proactive, person-centered care.

The Dementia Connection Model®: A Framework for Communication

The Dementia Connection Model®, the first cognitive behavioral theory in dementia care and published with Johns Hopkins University Press, integrates cognitive-behavioral principles with sensory stimulation and habilitation to promote connection and reduce distress.

The model emphasizes:

• Retrogenesis, recognizing that individuals revert to earlier developmental processing levels, like using their senses
• Consistent positive external stimuli (habilitation) to influence the limbic system and promote emotional regulation and behavioral responses
• Sensory information (touch, smell, hearing, sight, taste) to guide engagement

It’s an ABC approach—A: Situation, B: Thoughts, C: Emotions, D: Behavior—helps caregivers interpret communication challenges. Positive stimuli can improve emotional responses, leading to more productive behaviors and meaningful interaction.

Communication Strategies That Strengthen Connection

1. Nonverbal Communication [visual and tactile]: The Foundation

Nonverbal cues often matter more than words as dementia progresses. Effective strategies include:

• Approaching from the front
• Making calm, direct eye contact
• Using slow, steady movements
• Touching only with permission or when welcomed
• Using positive facial expressions, gestures, and tone of voice intentionally
• Offering nonverbal praise through smiles, nods, or gentle touch

Because mood is contagious, clinicians should maintain a calm, reassuring demeanor that helps regulate the individual’s limbic response.

2. Verbal Communication [auditory]: Keep It Simple and Supportive

Helpful verbal strategies include:

• Short, positive phrases
• Speaking slowly and using a warm, adult tone
• Using familiar words and forms of the person’s name
• Offering single-task instructions
• Allowing up to 90 seconds for a response
• Asking open-ended questions
• Validating feelings rather than correcting facts

Incorporating the person into the conversation—rather than speaking around them—helps preserve dignity and autonomy.

3. Show-and-Tell Methods [multi-sensory]

Visual supports reduce cognitive load. Effective tools include:

• Communication boards
• Hand gestures
• Props
• Clear signage

These methods enhance comprehension across all stages of dementia.

Aromatherapy for Emotional Regulation [olfactory]

Essential oils may support mood and communication by reducing stress responses and enhancing emotional comfort:

• Ylang Ylang for sociability and perceived self-esteem
• Bergamot for mood uplift and nervous system support
• Lavender for reducing anxiety, aggressive behaviors, depressive symptoms, and sleep impairment
• Cedarwood for grounding and reducing fear

These tools should be used as adjunctive, sensory-based supports within a clinically guided care plan.

Clinical Implications for Case Managers

Effective communication requires flexibility, empathy, and clinical insight. Case managers can:

• Assess communication barriers and coach caregivers in improved strategies
• Integrate sensory-based interventions into individualized care plans
• Support caregivers in interpreting behavioral expressions
• Promote environments that reduce overstimulation and anxiety
• Reinforce habilitative approaches that meet the individual where they are

When communication improves, so does the overall relationship between caregiver and care receiver—leading to reduced behavioral distress and improved quality of life.

Case Study: Enhancing Communication Using the Dementia Connection Model®

Background

Client: Mary, 82
Diagnosis: Moderate Alzheimer’s disease
Care Setting: Assisted living memory care
Primary Concerns: Increased anxiety, resistance to bathing, frequent repetition of questions, and withdrawal from social dining.

Mary’s case manager notes that her communication abilities have noticeably changed over the past six months. Staff report that she becomes overwhelmed by verbal instructions, appears fearful during personal care, and often asks, “Where am I supposed to be?” multiple times each hour.

Using the Dementia Connection Model® (DCM), the care manager guides the team to improve communication, reduce distress, and rebuild meaningful engagement.

Step 1: A — Understanding the Situation

According to the DCM, communication success begins by assessing the situation and the external stimuli influencing the individual’s limbic system.

Observations

• Bathing occurs in the mornings when staff are rushed.
• Staff stand over Mary while speaking quickly.
• The bathroom is cold, brightly lit, and echoing.
• Mary has a lifelong preference for slow mornings and disliked early appointments.

Interpretation

The case manager recognizes that environmental and interpersonal stimuli are contributing to Mary’s fear response. Her brain interprets the situation as unsafe, triggering emotional distress.

Step 2: B — Identifying the Thoughts Behind the Behavior

Individuals with dementia may not process information as intended. Their thoughts are shaped by past experiences, emotional memory, and sensory interpretation.

Likely Thoughts

• “I don’t understand what’s happening.”
• “I feel rushed and confused.”
• “I’m scared because this doesn’t feel familiar.”

Mary cannot express these experiences verbally, so her behavior communicates them instead.

Step 3: C — Addressing the Emotions Influenced by the Situation

Emotions drive behavior in dementia. The case manager identifies Mary’s emotions as fear, overwhelm, and insecurity.

To influence emotions positively, the team must adjust environmental stimuli and introduce sensory-based interventions before important tasks.

Intervention

Before bathing:

1. Aromatherapy (Lavender) [olfactory]:
   Diffused lightly for five minutes to reduce anxious feelings and support calm.
2. Soft lighting [visual]:
    Staff dim the bathroom lights and use a warm bedside lamp.
3. Soothing music [auditory]:
   Mary enjoys classical piano; soft music plays to prime calm emotional pathways.
4. Warm towel ritual [tactile]:
   A warm towel is placed on Mary’s hands to introduce comforting tactile stimulation.

Mary’s emotional response shifts from fear → comfort and curiosity.

Step 4: D — Guiding Productive Behavior Through Communication

With her emotions regulated, Mary is now positioned for productive behavior, such as cooperation with care tasks.

Outcome

Instead of resisting, Mary begins responding to cues:

• She reaches for the warm towel
• She smiles when staff mirror her slow movements
• She participates in washing her hands and face
• She expresses less fear and no longer yells during bathing

Results and Clinical Implications

After implementing the DCM:

Communication Improvements

• Increased comprehension
• Reduced resistance during care
• More consistent emotional regulation
• Heightened sense of safety and trust

Behavioral Changes

• Fewer fear-based responses
• Increased participation in bathing and dining
• Decreased repetitive questioning
• More meaningful engagement with staff

Caregiver Impact

• Staff report greater confidence in communication
• Less stress and fewer escalated behavioral episodes
• Improved relationship-centered care

Conclusion

People living with dementia experience a progressive loss of communication abilities, but meaningful connection remains possible and vitally important. By shaping the situation (A), understanding the person’s thoughts (B), influencing their emotions (C), and guiding productive behavior (D), case managers can cultivate stronger, more compassionate connections that improve quality of life for both the individual with dementia and their caregivers.

Therefore, if care managers adopt the Dementia Connection Model®, they can profoundly improve outcomes for individuals living with dementia and the caregivers who support them. The stronger the connection, the smoother the communication—and the higher the quality of life for everyone involved.

More information can be found in the Johns Hopkins published book, The Busy Caregiver’s Guide to Advanced Alzheimer Disease, and at www.DementiaConnectionInstitute.org.

References

Alzheimer’s Association. (2024). 2024 Alzheimer’s disease facts and figures. https://www.alz.org

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Dementia Connection Institute. (2025). Effectively communicating with individuals who have dementia [Professional presentation]. Dementia Connection Institute.

Freitas, J. (2015). The meaning of movement in dementia care. Hearthstone Institute.

Small, J. A., & Perry, J. (2018). Training family caregivers to communicate effectively with people with Alzheimer’s disease: A systematic review. Clinical Interventions in Aging, 13, 497–513.

Tappen, R. M. (2021). Nursing interventions for dementia care: Communication strategies across the disease trajectory. Springer.

Dr. Jennifer Stelter, Psy.D., DCS, DCSCT, is Founder, Chief Executive Officer, and Creator of the Dementia Connection Model©, and Senior Living & Dementia Care Consultant. Also known as the Oil Doctor, Psy.D., she is a Licensed Clinical Psychologist, Senior Living and Dementia Care Consultant, Johns Hopkins University Press author and national speaker, and the creator of the Dementia Connection Model©. She has 30 years’ experience in the healthcare field and over 15 years in the senior living industry.

Dr. Stelter is the founder and CEO of the Dementia Connection Institute by the Oil Doctor, Psy.D., LLC, providing education, training, consultation, and clinical services to healthcare organizations and family caregivers. She is the developer and Master Trainer for the nationally and internationally accredited Dementia Connection Specialist (DCS/DCSCT) Certification Program. Also, Dr. Stelter is the author of the Johns Hopkins Press publication “The Busy Caregiver’s Guide to Advanced Alzheimer Disease”.

She has been featured in a number of podcasts, blogs, and publications, including Bridge the Gap, USA Global TV & Radio, Chicago Tribune, and McKnight’s Long-Term Care News and local to the midwest in Sun Day News, Daily Herald, Northwest Herald, and Quintessential Barrington’s Medical Guide.