FOCUSED Caregiver Training
The FOCUSED caregiver training program was created by Ripich, Wykle, and Niles (1995) for nursing assistants working closely with patients with Alzheimer's disease. FOCUSED stands for the seven basic principles of the program:
F: Functional and face-to-face
O: Orient to topic
C: Continuity of topic--concrete topics
U: Unstick any communication blocks
S: Structure with yes/no and choice questions
E: Exchange conversation--encourage interaction
D: Direct, short, simple sentences
How to use FOCUSED principles in conversation
F: Face the patient directly, attract their attention, and try to maintain eye contact.
O: Orient the patient to the topic by repeating topic words several times, repeat sentences exactly, and give them time to process and comprehend what you said. Note: This does NOT mean to speak more slowly.
C: Continue the same conversational topic for as long as possible and introduce changes in topic to prepare the patient for the switch.
U: "Unstick" the patient when they use the wrong word by suggesting the word they intended and repeating the sentence with the correct word. Ask "Do you mean..?
S: Structure questions so they present the patient with a simple choice, i.e. "yes/no" and only provide a maximum of two options at a time. It is also important to try to provide options that are appealing to the patient, as we want to encourage interaction, not have it be associated with negative outcomes.
E: Begin conversations with pleasant and everyday topics and keep up normal conversational exchange as much as possible. Ask questions that the patient will find easy to understand and answer and give them clues if they need help finding the answer.
D: Use short, simple, and direct sentences. Pronouns like she, him, they, etc. should be avoided since they can cause confusion and proper names should be used whenever possible to keep content clear. Hand signals, pictures, and facial expressions can be used to reinforce meaning, especially during the later stages of the disease.
The three main stages
There are three main stages of cognitive and communicative decline in progressive dementias such as Alzheimer's, with Stage 1 being the least impaired and Stage 3 being the most severely impaired. Below are two tables that show how the 3 main stages of Alzheimer's correspond with the 3 stages of communication decline that occur.
F: Functional and face-to-face
O: Orient to topic
C: Continuity of topic--concrete topics
U: Unstick any communication blocks
S: Structure with yes/no and choice questions
E: Exchange conversation--encourage interaction
D: Direct, short, simple sentences
How to use FOCUSED principles in conversation
F: Face the patient directly, attract their attention, and try to maintain eye contact.
O: Orient the patient to the topic by repeating topic words several times, repeat sentences exactly, and give them time to process and comprehend what you said. Note: This does NOT mean to speak more slowly.
C: Continue the same conversational topic for as long as possible and introduce changes in topic to prepare the patient for the switch.
U: "Unstick" the patient when they use the wrong word by suggesting the word they intended and repeating the sentence with the correct word. Ask "Do you mean..?
S: Structure questions so they present the patient with a simple choice, i.e. "yes/no" and only provide a maximum of two options at a time. It is also important to try to provide options that are appealing to the patient, as we want to encourage interaction, not have it be associated with negative outcomes.
E: Begin conversations with pleasant and everyday topics and keep up normal conversational exchange as much as possible. Ask questions that the patient will find easy to understand and answer and give them clues if they need help finding the answer.
D: Use short, simple, and direct sentences. Pronouns like she, him, they, etc. should be avoided since they can cause confusion and proper names should be used whenever possible to keep content clear. Hand signals, pictures, and facial expressions can be used to reinforce meaning, especially during the later stages of the disease.
The three main stages
There are three main stages of cognitive and communicative decline in progressive dementias such as Alzheimer's, with Stage 1 being the least impaired and Stage 3 being the most severely impaired. Below are two tables that show how the 3 main stages of Alzheimer's correspond with the 3 stages of communication decline that occur.
The ways you communicate with your loved one may differ over the course of the disease stages. All of the FOCUSED strategies are suitable for use at any stage, however, the goals of the communicative exchange are likely to differ drastically as the disease progresses. Below are the communication goals for each of the three stages of Alzheimer's.
Communication goals over the three stages:
Stage 1: Maintain normal communication as much as possible. All 7 points in the FOCUSED program may benefit the patient and keep them engaged in the conversation. This could potentially have the added benefit of supporting morale and mental status in this early stage of the disease.
Stage II: At this stage, the communication of many Alzheimer's patients will be noticeably compromised, some more severely than others. All 7 points of the FOCUSED program are relevant, but it is especially important to continue with a typical pattern of conversational exchange (turn-taking). This shared interaction is crucial, even if it consists only of a head nod or eye contact, because it requires the cooperation of both partners and shows that the Alzheimer's patient it engaged in the interaction. This turn-taking should be continued and conversation still maintained even if the content is confused or fragmented, or if the topic is not followed.
Stage III: Nonverbal gestures, key words written on cards, and pictures should be used to maintain communication at this stage. The FOCUSED program can still be used even when the patient has lost the ability to speak. It is at this stage that extra attention should be paid to using alternative forms of communication. Cards can be made with single key words written on them such as "bathroom," "tea," or hungry." Pantomime hand signals (like hands under head for "sleep") can also be used to reinforce meaning. Pictures of family members and events, such as a memory book, can also be effective at helping the patient maintain connections and may stimulate interaction. Like in stage 2, the patient's communication may be only a nod or smile, but even these small signals are a successful communication.
Ripich, D., Wykle, M., & Niles, S. (1995). The FOCUSED program: A communication skills training program helps nursing assistants to give better care to patients with Alzheimer's disease. Geriatric Nursing, 16(1), 15-19. doi:10.1016/S0197-4572(05)80073-4
Copyright © 2013, 2014 Lee Ann Faria. All rights reserved.