The Health Care Triad: Optimizing Communication in Dementia Care

Family members caring for older relatives with dementing illnesses are at greater risk of adverse health-related outcomes than are family caregivers of older adults with other health disorders (1). Physicians are often the first contact in the health care system for most family caregivers of individuals who are diagnosed as having dementia (2). According to Fortinsky, “physicians are in a unique position to help family caregivers reduce the risks of adverse outcomes by carefully explaining the dementia disease process, advising how to manage symptoms as they occur, and linking caregivers with appropriate community support services” (3). The physician must skillfully engage and empower patients with dementia to optimize their participation in their health care decisions while engaging the crucial and often emotionally exhausted primary caregivers. The term health care triad in this context includes the patient with dementia, the family caregiver, and the patient’s physician.

Each member of the health care triad brings unique sociodemographic, psychological, cultural, and health-related characteristics to the relationship (3, 4). Any of these factors may influence the effectiveness of the triadic encounter. Mahoney and colleagues (5) explored cross-cultural similarities and differences in African-American, Chinese, and Latino family caregivers’ perceptions of the onset and diagnosis of Alzheimer’s disease among their relatives. All three groups were noted to normalize the cognitive symptoms of their affected family member until a critical event, usually relocation, precipitated family awareness that their family member’s behavior was not the result of normal aging. The study suggested that the three groups differed in the topic of greatest concern to the caregivers when interacting with the family member’s physician. African-American caregivers more frequently noted that physicians tended to minimize or disrespect their concerns about the memory loss of their elder family member; Chinese caregivers were concerned about stigmatization within their community of the elder family member with dementia; Latino caregivers indicated that they did not want to be pressured to place their loved one in a setting outside of the home. The authors recommended providing the public with better access to discreetly presented Alzheimer’s disease information, increasing dementia awareness among community physicians, motivating clinicians to adopt culturally sensitive communication patterns, and providing community education to reduce the stigmatization of persons with Alzheimer’s and other dementing diseases.

Patient-centered doctor–patient communication, in which the physician solicits the patient’s perspective and enhances the patient’s feelings of partnership and understanding, has been demonstrated to increase patient adherence to treatment, improve satisfaction with care, and decrease patient distress (6, 7). However, in engaging the patient and caregiver in the painful discussion about the diagnosis of dementia, physicians may fall short of optimal communication techniques. Zaleta and Carpenter (8) studied patient-centered behaviors of physicians during the disclosure of a dementia diagnosis to the patient and caregiver. The study’s physicians most frequently used positive rapport-building behaviors, followed by facilitation of questions and patient activation, which the physicians reported using to establish a shared understanding with the patient and actively solicit the patient’s perspective. The least frequent patient-centered technique observed in the study was emotional rapport building. Many physicians seemed to struggle with expressing optimal empathic attunement in these discussions.

Communicating the diagnosis of dementia can be very difficult for the entire triad. The physician attempts to disclose the diagnosis to the patient, who may not fully comprehend the implications of a dementia diagnosis, as well as to the caregiver, who may attempt to be stoic in the company of the patient (9). The triangular nature of this communication may complicate the interaction for the physician and interfere with attempts to empathically connect with both patient and caregiver. The study by Zaleta and Carpenter (8) suggested that some physicians more frequently and naturally used patient-centered communication, whereas others did so less frequently. Although it is unclear how these communication styles may affect the care received, family caregivers of individuals with dementia have reported in other studies (10, 11) that doctors did not provide adequate emotional support and social service linkages for them. Although more research needs to be done, empathic engagement with the physician treating their family member appears to be a crucial component of the triadic relationship for caregivers of a family member with dementia.