Have you heard the one about the man with Alzheimer’s disease?BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2872 (Published 07 May 2013) Cite this as: BMJ 2013;346:f2872
- Sophie Behrman, core trainee 2 doctor, Oxford Clinic, Littlemore Mental Health Centre, Oxford OX4 4XN, UK
Working as a healthcare assistant in a nursing home I had the pleasure of looking after a woman in her 80s who had Alzheimer’s disease. Apart from the occasional “Ta, pet” her communication was limited to facial expressions and occasional tutting and sighing.
This word, “limited,” however, does not begin to describe the interactions possible and the fun and humour she brought to the nursing home. Words cannot do justice to her range of facial expressions and comic timing. Her lack of words somehow amplified what she could communicate. I have since gone on to care for people with dementia as a junior doctor and am struck by the complexity and depth of communication possible once a rapport has been established.
People with physical disability often find that they are not appropriately engaged in conversation, or some concurrent learning disability is presumed. I am concerned that people with dementia may also not be seen as worthwhile conversationalists, leaving them isolated and understimulated.
We may communicate differently with someone with dementia, perhaps tending towards more sparse language, foregoing jokes or puns with the aim of improving clarity and minimising potential misunderstanding. But is this modification of language appropriate and helpful for people with dementia or does it perhaps deny them normal interaction? Is it ethical to joke with people with dementia given that they may not understand the joke? Is it ethical not to?
Some models view dementia as a regression through the developmental stages seen in infants and children,1 based on evidence such as the re-emergence of primitive reflexes. This view of dementia may help resolve the cognitive dissonance that carers may experience between the expectation of independence in adulthood and the reality of a dependent elderly person. This regression theory is not only oversimplifying but also patronising and dangerous, negating the importance of the life experiences of people with dementia. In addition, it can be used to justify infantilisation—when people with dementia are treated without dignity and respect, perhaps as you might treat a naughty child.
Regressing through the language milestones achieved in childhood is an oversimplification of the difficulties of communication in dementia.2 The more abstract social aspect of language, which develops later in childhood, is retained after functional loss, such as nominal aphasia. A Danish study found evidence of humour, irony, and sarcasm in nursing home residents with severe dementia and high physical dependence. These features of language do not emerge until after the age of 7 to 9 years, but regression theory would place these residents at a preschool developmental stage.3
Humour and laughter induce many physiological and psychological benefits, including improvements in cardiovascular, respiratory, and immunological parameters; reduction of pain and improvements in memory and alertness; a feeling of wellbeing; and a heightened ability to deal with stressful situations.4 5 People with dementia may well also benefit. A psychoanalytical perspective ranks humour as a mature and powerful defence mechanism that may be invaluable for an individual and their family coming to terms with a diagnosis of dementia.
Use of humour also has an important social role: it reduces the depersonalisation that a person may experience, particularly in an institutional environment, facilitating a caring interaction. Humour functions as an equaliser in situations where a hierarchy is perceived, such as a doctor-patient relationship, and as a face saving strategy where an individual’s “good face” may be challenged.6
With these benefits in mind, so called humour therapy has been developed and studied in dementia with mixed results.7 Standardising humour and offering a planned intervention may make for a better trial, but perhaps this misses the point of the individuality and subtlety of humour. Interventions studied include sessions with a clown which, in my mind, conjures up the image of a child’s party and uncomfortably resonates with regression theory.
Inappropriate use of humour can be unethical and dehumanising. The review of care after the abuse scandal at Winterbourne View Hospital highlighted the abuse of patients with learning disability and is littered with words such as “mocking,” “laughter,” and “goading.”8 People with dementia may be at similar risk if humour is misused. Humour can also be misinterpreted as threatening by people with dementia, who may already be anxious, and this may inhibit further communication.
When communicating with a patient with dementia it may seem logical (and kind) to simplify your language and avoid humour to minimise potential misinterpretation. This may be doing such patients a disservice, denying them human communication as well as the benefits of humour. The use of humour must be carefully modulated to suit the patient. Used judiciously, humour may represent an under-researched, undervalued, and underused resource in caring for patients with dementia.
Cite this as: BMJ 2013;346:f2872
SB thanks Dr Allan, Dr Gulati, R and D Behrman, and J Dear.
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; not externally peer reviewed.
Patient consent not required (patients anonymised, dead, or hypothetical).