Communication and consent

Early suspicions of a dementing disease should generally be discussed with the patient and their family. If the dementia is progressive leaving these discussions until the diagnosis is certain may be too late; the patient's ability to take part in decisions about their future treatment, and their family's future, may by then be jeopardized by cognitive decline. Only early in the course of the illness will they be able to make an enduring power of attorney, settle their will, and discuss with their doctors how they wish to be treated once the disease is well advanced.

The person with dementia will have the best chance of assimilating information if it is given in small chunks, with simple messages. Write down a summary of what has been said. Make it easy for them to express themselves by asking simple questions—if possible, ones that can be answered by yes or no. Make it difficult for them to forget appointments; inform several key people of the time and date. If possible, always have a carer present when discussing important information.

If language is impaired then be aware that the patient is likely to rely more on non-verbal cues. Avoid quick gestures and direct face-to-face confrontation if the patient appears threatened by this. A calm steady voice with the gentle use of touch will help the person understand that they are in safe and caring company.

The normal doctor-patient alliance comes under scrutiny once a diagnosis of dementia becomes likely, and thus the psychiatrist should make an assessment of the patient's capacity to consent. If the patient is unable to give informed consent then it is particularly important to discuss the management on offer with family and carers. Nevertheless, the autonomy of the person with dementia should, as far as possible, be respected.(9)

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