By Alekhya Johnson, Mary-Lynn Peters, Wendy Zeh, and Barbara Liu

What images come to mind when you see the word “aggressive” in a patient’s chart? What about “wandering” or “violent”?

An 85-year-old man with dementia is admitted to hospital. While being showered, he grabs the care provider. The following note is added to his chart: “patient is aggressive”. Weeks later, his application to long-term care is declined and his discharge is deferred. An assessment by a behavioural care specialist reveals no other documented behavioural incidents; and that the patient had grabbed the provider because he was startled by the shower.

An 82-year-old woman at a reactivation care centre walks around the unit for something to do. Her behaviour is documented as “wandering” and this word is carried over into her long-term care application. Her application is declined due to concern she would require a secure unit, delaying her discharge. She did not require a secure unit.

A 75-year-old man with dementia is on an orthopedic surgery unit. When being turned, he raises his fist and strikes his care provider. The word “violent” is added to his chart. He is referred to the geriatric team for recommendations to manage his behaviours. The team determines that he has poorly controlled pain. When this is addressed, his physical behaviours stop.

These examples reveal how language can influence an older adult’s care, length of stay, and journey within the health system. Patients with dementia are especially vulnerable as behaviours may be one of the ways in which they communicate unmet need. When care providers use vague words and phrases without context it can provoke fears, negative stereotypes, implicit biases, and reactive decision-making for other care providers. In contrast, person-centred language, which is specific, objective, and respectful, gives care providers important clues about how to minimize responsive behaviours, resulting in better care, documentation, and outcomes.

Consider the difference between saying “uncooperative” versus “resists bath if left uncovered”. The former conjures up assumptions that the patient may be generally resistant to multiple activities for no discernable reason, while the latter offers a specific scenario where care strategies might be tested to minimize behavior (e.g., ensuring the patient is covered, considering room temperature, etc.).

The impact of language in healthcare has received a significant amount of attention worldwide in the last decade, with guidelines and resources produced by Alzheimer Society Canada, Dementia Australia, NHS England, Obesity Canada, Diabetes Canada, Diabetes Australia, American Medical Association, Mental Health Commission of Canada, and others. In 2017 the Toronto Academic Health Sciences Network (TAHSN) published a person-centred language guideline for acute care settings that includes practical examples of how to accurately describe behaviours.

The Regional Geriatric Program (RGP) of Toronto, with funding from the Public Health Agency of Canada, has been supporting the implementation of this guideline at three healthcare organizations: Trillium Health Partners, Sunnybrook Health Sciences Centre, and Unity Health Toronto. Point-of-care staff, managers, physicians, and administrators have responded positively to the concept of person-centred language:

“I wanted to write “patient is agitated” but then remembered. So, I wrote “patient is agitated-their voice increasingly louder and said “get out of here!””

“When you hear on report that the patient is very aggressive, I’m already thinking that my shift is going to be bad or I’m scared of the patient, so it’s important to know what they mean by aggressive”

The RGP of Toronto, in collaboration with the Behavioural Supports Ontario Provincial Coordinating Office, has produced a suite of educational tools with practical examples of how to use person-centred language in acute care settings including a pocket card, video reels, teaching aids, posters, huddle games, an e-course, and more. All of these resources are available for free download online. Join the movement to use person-centred language in your communication and patient documentation!

Alekhya Johnson, MPH, Mary-Lynn Peters, RN(EC), NP-Adult, MSc, Wendy Zeh, RN, and Barbara Liu, MD, FRCPC are part of the Regional Geriatric Program (RGP) of Toronto.