Sean Maguire's medical records indicate that he is resistant to care. Sean is 87 years old; he has dementia and impaired hearing and vision. His lower legs are covered in wet malodourous dressings, and there is a pool of viscous fluid under his feet. It has been some time since he has agreed to have his dressings changed. As a nurse, my job is to remove his dressings and carry out an assessment of his legs. The plan is to wash his legs and if, as suspected, he has weeping venous eczema, his legs will need to be soaked in potassium permanganate. Thereafter, the legs will need to be redressed. The patient's co-operation will be required for this.
At first glance, Sean might appear cantankerous, uncooperative and difficult, but he is struggling to make sense of the world.
People with dementia have difficulty processing information and do best in familiar environments. Like all individuals, they react differently to illness and changes in circumstances, such as hospital admission, something that Sean required as he had been struggling at home. People with dementia are on a journey, and every person's journey is different. Some individuals find their confusion to be distressing and can become weepy, depressed and demotivated. Others, like Sean can refuse care and become upset and angry (Alzheimer's Society, 2020a; Lakhan, 2019).
Sight and hearing loss become more common as people age (Alzheimer's Society, 2020b). Hearing loss is associated with increased cognitive decline (Action on Hearing Loss, 2020a; Alattar et al, 2020), as it makes it more difficult for the person with dementia to make sense of the world and affects cognitive performance (Lin and Albert, 2014).
Additionally, people with dementia are more likely to have sight loss than older people who do not have dementia, and 250 000 people are living with dementia and sight loss (Royal National Institute of Blind People (RNIB), 2020). Almost 50% of people with sight loss can have this corrected simply by having glasses with the correct prescription (Bowen et al, 2016). Inability to see clearly increases confusion and disorientation, as the person is unable to see important visual cues in the environment and has a reduced ability to interact with others (Alzheimer's Society, 2020c).
In Sean's case, I needed to communicate effectively if I was to obtain his consent and co-operation to treat his legs. When I knocked and entered his room, he looked up and seemed surprised to see me. I suspected he did not hear me knock. I introduced myself, and he leaned forward and peered at the name badge. ‘So your name is Linda?’ ‘Yes,’ I said, and began to explain that I needed to remove his leg dressings. He looked bewildered. ‘I'm sorry, I can't hear you’. I raised my voice and offered to speak louder, thinking that the mask that I was wearing was muffling my words. Sean explained that that was not the problem. ‘I am deaf Linda, I have hearing aids but they do not help. I cannot hear you if I cannot see your lips. Can you take off your mask?'
The COVID-19 pandemic is ongoing, and trust regulations are that nurses should wear a surgical face mask on the ward and appropriate personal protective equipment (PPE) when caring for patients. The Alzheimer's Society (2020b) recommended that, when caring for people with hearing loss and dementia, nurses should ensure that the person has their hearing aids. Sean had his in place, and they were working. It is also recommended that nurses should reduce background noise and distractions and make sure the area is well lit. They were in a single room, the door is closed. The room was well-lit and the ward outside was quiet. Additionally, it has been suggested that nurses should find out the person's preferred way of communicating–for example, lip reading, using gestures and expressions, letting the individual see their face when communicating and use visual clues and prompts. I wore a mask, so Sean could not lip read. He was further disadvantaged by the fact that the mask covered half my face and reduced visual clues. I was unable to use gestures and prompts in the same way that I could have had I not been wearing a mask.
I could have offered to write things down, but Sean was clearly visually impaired and could just about read the large writing on the name badge. Or I could have tried using my phone to write messages in large text but suspected that he would struggle with this as well. Sean had been swabbed for COVID-19 and had tested negative. Similarly, I had been swabbed for COVID-19 regularly, and my last test from 3 days previously had been negative. Neither of us had symptoms that could be indicative of COVID-19. The risk of me removing my mask to either of them was very low. However, the risk of Sean declining treatment if I was unable to communicate with him was moderate to high, so I decided to remove my mask.
Suddenly, everything became easier. Sean told me to call him by his first name and thanked me for removing the mask. He said, ‘You are the first person I've talked to. I have been so cut off.' Over the next hour, I removed Sean's dressings and washed his legs in warm water and emulsifying ointment. Sean had previously had his legs washed with emulsifying ointment without adverse effects. Sean had weeping venous eczema, and I soaked his legs in warm water with potassium permanganate (British Association of Dermatologists, 2015). I then dried Sean's legs and applied moisturiser, dressings and bandages.
As I was preparing to leave, Sean said, ‘Thanks for taking off your mask, Linda, I hadn't a clue what you were going to do and that's scary.’ In removing my mask, I was able to communicate with Sean, to obtain his co-operation and treat his legs as required.
There are 12 million people who are deaf or hard of hearing in the UK, and those who lip read are unable to do so when a person is wearing a face mask. Face coverings with clear panels are being developed, and 250 000 of these have recently become available to NHS and care workers who care for those with hearing loss and dementia (Evening Standard, 2020). People with hearing loss find these more helpful than standard face coverings (Action on Hearing Loss, 2020b).
Most NHS trusts require nursing staff to wear face masks when delivering clinical care, and this is entirely appropriate in the midst of the COVID-19 pandemic. However, nurses should be aware that the use of face masks can make it more difficult for some patients to understand and co-operate fully with care and treatment. Whenever possible, nursing staff should consider alternative methods of communication, such as writing, when communication is affected by the use of face masks.