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The discourse of friendship: Mediators of communication among dementia

residents in long-term care

Article  in  Dementia · May 2012

DOI: 10.1177/1471301211421187

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Article
Dementia
The discourse of friendship: 0(0) 1–15
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among dementia residents DOI: 10.1177/1471301211421187

dem.sagepub.com

in long-term care
Pamela A. Saunders
Georgetown University, USA

Kate de Medeiros
Miami University, USA

Patrick Doyle
University of Maryland, USA

Amanda Mosby
University of Maryland, USA

Abstract
One the most difficult challenges experienced by people with dementia and their caregivers is
their communication. The ability to communicate is essential to creating and maintaining social
relationships. Many individuals who suffer from dementia experience increased agitation and
diminished social interaction in the long-term care living setting. This paper demonstrates how,
through language, they construct social relationships. As part of The Friendship Study, which is an
ethnographic observation of persons with dementia living in a long-term care setting, we analyzed
transcripts from video- and audio-taped data and performed a discourse analysis of conversations
to show how persons with dementia who live in a long-term care setting use language to create
friendships. These analyses show that friendships are constructed using concepts such as
conversational objects, discourse deixis, indexicality, and alignment among speakers.

Keywords
alignment, Alzheimer’s disease, dementia, discourse, friendship, indexicality, social relationships

Corresponding author:
Pamela A. Saunders, PhD, Departments of Neurology and Psychiatry, Georgetown University, School of Medicine,
Washington, DC 20057, USA
Email: saunderp@georgetown.edu

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2 Dementia 0(0)

Introduction
Communication problems are among the most difficult faced by people with dementia and
their caregivers (Orange & Colton-Hudson, 1998), contributing to an increase in stress,
mortality, and decreased quality of life for both persons with dementia and their
caregivers (Dunn et al., 1994; Mittelman, Ferris, & Steinberg, 1993; Mobily, Maas,
Buckwalter, & Kelley, 1992; Schulz & O’Brien, 1994; Wright, 1993). A variety of studies
of communication-related stress show that caregivers perceive communication breakdown to
be a major problem in coping with the disease (Clark, 1995; Gurland, Toner, Wilder, Chen,
& Lantigua, 1994; Orange, 1991; Richter, Roberto, & Bottenberg, 1995; Williamson
& Schulz, 1993). For example, Williamson and Schulz (1993) found that communication
problems increase the risk of early institutionalization of the person with dementia. Better
understanding of the processes of communication used by persons with dementia in creating
and maintaining relationships in the long-term care setting might reduce the negative
impacts of communication problems (Orange, 1991). The present paper is part of a larger
ethnographic project, The Friendship Study, examining social interactions of persons with
dementia who live in the long-term care setting.

Background
In the last three decades, most of the research regarding dementia has focused on the
neurobiologic or the neuropsychological processes of the disease (Harris, 2002) and has
made efforts to link these findings with the presentation of symptoms. The aim of
treatment has been almost exclusively to improve cognition and to manage undesirable
behaviors through pharmacologic and behavioral efforts, as well as by the manipulation
of the physical environment. There is a growing body of literature studying psychosocial
dimensions of persons with dementia (Clare, 2002, 2003; Clare, Goater, & Woods, 2006;
Clare & Pearce, 2006; Downs, 1997; Harman & Clare, 2006; Hughes, Louw, & Sabat, 2006;
Keady & Nolan, 1995; Keady, Nolan, & Gilliard, 1995; Kontos, 2006; Leibing & Cohen,
2006; Pearce, Clare, & Pistrang, 2002; Sabat, 2001; Van Dijkhuizen, Clare, & Pearce, 2006;
Cotrell & Schulz, 1993). This current project broadens this body of research by examining
how persons with dementia living in a long-term care setting interact socially and suggests
ways that formal and informal caregivers may learn from these interactions.
Starting with the personhood movement, Kitwood and colleagues (Kitwood, 1993, 1997;
Kitwood & Benson, 1995; Kitwood & Bredin, 1992) have attempted to bring to the forefront
the person-centered approach to dementia research and care. In this approach, the person
with dementia is viewed and treated under the assumption that she or he retains an identity
with which to construct and maintain a self through usual types of social interaction. This
approach views a person with dementia as being the same as any other to the extent that her
or his ‘selfhood’ is publicly manifested in various discursive practices such as telling
autobiographical stories, taking on the responsibility for one’s actions, expressing doubt,
declaring an interest in care, decrying the lack of fairness in a situation (Sabat & Harré,
1992). Our paper examines the language of persons with dementia to show how they
establish social relationships with their conversational partners in the institutional setting.
Kitwood (1993) developed a person-centered approach to evaluating dementia care in
formal settings, called Dementia Care Mapping. He examined the viewpoint of the person
with dementia, using both empathy and observational skills. Working within this

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Saunders et al. 3

framework, Phinney (2002) described the different ways persons with dementia talk about
living with the disease. She pointed out that to understand the symptoms, as people who
actually have the illness experienced and articulated them, provides a richer understanding of
the whole person. In addition, she suggested that intervention strategies are available only by
paying attention to the communicative behaviors of persons with dementia. For example,
persons in the early stages of dementia often fall silent in conversations. It may be because
they are having trouble keeping up with the pace of the conversation. This is a salient issue
for conversations between persons with dementia in the institutional setting. Conversational
partners may limit conversation because they have difficulty keeping pace or understanding
the semantic content. Knowing this, one conversational partner might try to slow down,
making extra effort to repeat or rephrase previous comments and to ensure that the person
with dementia is following along. If the partner has cognitive impairment, there may be
problems accommodating the conversational needs of the other.

Discourse studies of persons with dementia

Social psychologists and sociolinguists have a long tradition of examining the
communicative experiences of persons with dementia. Sabat and Harré (1992) suggested
that it was common to perceive strategies used by persons with dementia as symptoms of
the disease rather than as attempts to maintain selfhood. Communicative behaviors are a
relevant example of this phenomenon. For example, data collected by the present author
(Saunders, 1998a) include a conversation excerpt from the clinical setting between a
physician and a person diagnosed with dementia. When the physician asked the patient,
‘Who is the president of the United States?’, the patient responded, ‘Oh, he was forgettable’.
This statement is open to a variety of interpretations. Clinicians may call this a
circumlocution (i.e. words and phrases substituted for intended word) and view it as a
symptom of the disease, or as a way to save face (a form of semiotic, or meaning-driven,
behavior) in a humorous way, given the speaker’s inability to recall the name of the
president. To interpret this response as also a socially acceptable communication behavior
is to appreciate it as a way to present oneself as a humorous person who has certain opinions
or political views.
Sociolinguistic studies also examine the language and conversational discourse of persons
with dementia in a naturalistic setting. The goal of these studies is to understand social and
psychological interactions through a linguistic analysis. In an important early study,
Hamilton (1994) described a nursing home resident, Elsie, who maintained the ability to
ask and answer questions into advanced stages of dementia. Elsie describes her own memory
loss by saying, ‘I’ve had so many names. . . sometimes they are hard to get’. Ramanathan
(1997) examined the coherence of the speech of people with dementia, noting that
interlocutors frequently ‘take over’ the conversation, reducing opportunities for subjects
to contribute to the conversation. Previous research by the author, Saunders (1998a,
1998b) analyzed the accounts (i.e., explanations) employed by persons with dementia
regarding their memory loss as a means through which to construct personal identity.
For instance, an example of a memory account is shown here:

Clinician: What floor are we on right now?

Patient: I don’t know because I wasn’t paying attention (ha ha).

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4 Dementia 0(0)

Sociolinguistic studies as referenced above examine language as an analytical unit used by

persons with dementia. These studies shed light on how we understand social relationships of
people with dementia.

Friendships in persons with dementia in long-term care

Research on social relationships within dementia special care units examined dementia
residents’ relationships with staff members (Cohen-Mansfield & Marx, 1992), residents’
friendships related to agitated behaviors (Kutner, Brown, Stavisky, Clark, & Green,
2000), and staff members’ perceptions of residents’ characteristics and successful
social placement (Wood, Cooper, Richardson, & Forbes, 1992). Specifically, Cohen-
Mansfield and Marx (1992) studied relationships between residents with dementia and
‘outsiders’ (e.g. family, friends not living in the nursing home) but not social
relationships among residents. They found increased agitation was associated with
fewer outside social contacts. Kutner et al. (2000) studied friendship and agitated
behaviors among 59 residents of a dementia care unit. Like Cohen-Mansfield and
Marx (1992), Kutner and colleagues found an association between friendship and
lack of agitated behavior. However, these authors did not investigate qualities that
contribute to the formation of friendships, or characterize those friendships, such as
communicative ability, cognition, and physical function (Astell & Ellis, 2006; Chen,
Ryden, Feldt, & Savik, 2000).
Wood et al. (1992) investigated whether residents’ characteristics (specifically
cognition, affect, and mood and/or behavior) influenced staff members’ perceptions of
the residents’ successful placement in a care facility, and found that negative affect and
depressed mood, rather than cognitive function or behavior, were linked with residents’
being labeled ‘unsuccessfully placed’. These authors did not investigate social
interactions among residents but rather whether or not individual residents ‘fit in’ at
the facility.
Even fewer published studies to date have explored friendships specifically among people
with dementia in long-term care. Diaz Moore (1999) conducted participant observation, as
part of his study of social interaction in the dining room of a specialized dementia long-term
care unit, and described three types of social relationships between residents: (1) ‘congenial
friendships’ based on equality of the participants; (2) the ‘clique’ based on similarity or
power of personality; and (3) ‘confidants’ based on asymmetry. Diaz Moore also
characterized staff/resident negotiations as: ‘befriending’, a positive negotiation in which a
staff member is friendly and sociable with a resident; ‘suggesting’, a negotiation technique in
which staff attempts to convince the residents to do something; and ‘invading,’ a strategy in
which staff occupies residents’ space to socialize among themselves. Diaz Moore’s work
provides important insights into how to examine the types of friendships or social
interactions that may exist.
The above studies examine the discourse of persons with dementia using
frameworks that highlight the discourse and language used by persons with
dementia. The current study illustrates examples of social relationships that are
constructed and maintained through language and discourse among residents in the
long-term care setting.

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Saunders et al. 5

Methods
The Friendship Study takes place at Cedar Hill, which is a 20-bed, assisted-living, residential,
care unit for people with moderate to severe dementia. The dementia diagnoses were
determined by the clinical team and confirmed through scores on the Mini-Mental Status
Examination (Folstein, Folstein, & McHugh, 1975). The research team collected data from
residents to characterize their cognition, language, communicative ability, and depression at
Cedar Hill (see the companion article by de Medeiros et al. in this issue). Cedar Hill is a
pseudonym to protect the privacy of the staff and resident participants of this study. The
Institutional Review Board of the Johns Hopkins University School of Medicine reviewed
and approved this study. Resident participants were recruited by first contacting their legally
authorized representative (LAR), then obtaining written informed consent from both LAR
and research participant, and then gaining oral assent from residents again at the time of
data collection (Black, Kass, Fogarty, & Rabins, 2007). Staff participants were recruited
through staff meetings where the research team described the study. Staff participants also
signed informed consent documents. The following sections describe in detail both
participant samples.

Participants
Residents. A total of 31 residents (21 women, 10 men) participated in the study over the
course of the 6-month period. Two participants described their race/ethnicity as African
American; the remainder (n ¼ 29) were European American. Years of education ranged from
8 to 20 years (mean 14 years, SD 3.6 years); see the companion article by de Medeiros, et al
in this issue for full details of the subject sample.

Staff. The staff participants (n ¼ 10) were from three Cedar Hill departments: activities
(n ¼ 3), social work (n ¼ 2), and nursing (n ¼ 5). The nursing staff included certified
nursing assistants and medication aids. Staff had to be employed for at least 1 month at
Cedar Hill with a weekly workload of at least 10 hours to be included in the study.

Ethnographic observations
This study conducted ethnographic observations of residents at Cedar Hill for 10 hours per
week for 24 weeks (6 months). The research team members sat quietly in background areas
and took field notes on interactions between residents, the general social environment, and
other overall impressions. The researchers were instructed to be as unobtrusive as possible to
avoid influencing the interaction between residents more than necessary. When possible, to
capture non-verbal data such as facial expressions, physical position, ‘body language,’ and
other cues to communication, the researchers obtained videotaped footage of residents.
Video-taping was limited to common, public areas of the assisted living wing (e.g., dining
room, television lounge, hallways). Residents’ assent to video-taping and/or audio-taping
was obtained at the start of each observational session. Members of the research team
conducted this additional assent process as extra protection for the residents with
dementia to ensure they were willing to be taped each time. Only written notes were used
if residents did not assent to taping or if residents, staff members, or visitors were present for
whom consent had not been obtained. If participating residents did not assent to taping, the

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6 Dementia 0(0)

researcher took hand-written ethnographic notes. Multi-modal transcription techniques

used to transcribe videotapes include non-verbal communication such as images and
gestures (Baldry & Thibault, 2006; Iedema, 2003). Verbatim transcriptions (Du Bois,
1991) were made of audiotapes.
Most of the interactions reported in this study occurred in the dining room, which served
as the main social space for Cedar Hill residents. Since residents are free to sit in the dining
room at anytime during the day, often they lingered prior to and after meals. They would
walk through this centrally locating dinning space to their rooms and to reach the activity
rooms and other areas of the assisted-living wing. The doors of each wing were open for
residents to move freely between them.

Results
What is the motivation for people with dementia living in long-term care settings to talk to
one another? In the dining room, the present authors observed conversations around
mealtimes. These conversations resembled what one might expect to hear in any dining
room regardless of the diagnosis of the participants. The research team considered this an
important issue of inquiry: who talks to whom and why? Does it depend on similar personal
attributes of the residents, ambulatory function, language ability, or cognitive status?
One finding of the current study was that often the impetus for a conversation involved a
person or an object in the immediate surroundings. These ‘conversational objects’ were
animate items, inanimate items, and abstract concepts in the local surroundings serving to
promote interaction. Apart from the research team’s equipment (e.g., tape recorder), these
objects were part of the everyday décor at Cedar Hill. See Table 1 for a taxonomy of
conversational objects. An animate object includes people and animals. Inanimate objects
include physical or non-living objects that might be found in a home or office environment.
Conversations also focused on topics that are abstract concepts, such as ideas, feelings, or
sounds. Persons with dementia experience anomia (i.e., word-finding problems) and tend to
use function words (e.g., pronouns, determiners) more frequently than content words (e.g.,
nouns and verbs) as their disease progresses. Hence, the ways in which they referenced
conversational objects may be somewhat non-specific. The following examples will
illustrate the use of conversational objects using pronominal reference.
In the following example, Anna, a resident, is sitting with Mary, a staff member, at the
dining table. Anna initiates a conversation by indexing (i.e., pointing to) a tape recorder,
sitting in the center of the dining table. This tape recorder (an inanimate object) serves as a
conversational object. Example 1 begins with Anna’s reaching for the tape recorder and
Mary’s moving it out of Anna’s reach.1

Table 1. Taxonomy of conversational objects.

Animate Inanimate Abstract

People Plants, Trees, Flowers, Activities

(Staff, Residents) Books, Food, Equipment, (Baking, Outings)
Animals (Dogs) Toys, Musical Instruments, Furniture

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Saunders et al. 7

Example 1
1 Anna: (Reaches for tape recorder)
2 Mary: Mm mm- That’s- That can’t be touched. Bet-
3 Anna: But that- it’s mine
4 Mary: No ma’am, it’s not yours. Not yours
5 Anna: I- I put one away like that she tells me
6 Laura: Alright S¼
7 Anna: ¼Like mine¼
8 Laura: ¼I’ll get you it, OK?
9 Anna: Ok, thank you
10 Laura: You’re welcome (Laura brings Anna a glass of water) (pause)
11 Here you go Anna. That one is yours

Anna starts the conversation about a novel object sitting on the dining table. Tape
recorders do not usually appear on the lunch table; thus, its presence is a reasonable
conversation starter. Mary, the staff person, knows the tape recorder belongs to the
research team and tries to keep Anna from touching it. On line 3, Anna claims it belongs
to her by saying, ‘that’s mine’; but Mary disagrees. Anna continues by insisting she had one
in her possession and constructs her story using indefinite terms ‘one’ and ‘that’. In addition,
she supports her story with the report of a third party ‘she tells me’.
Much of the talk in this example is punctuated with discourse deixis, which is the use of
pronouns to refer to people, places, and things (Levinson, 1983). Deictic pronouns are a way
of pointing to things in the environment (Lyons, 1977) using indefinite pronouns (e.g., that,
it). On line 3, Anna refers to the tape recorder with the pronouns, ‘that’ and ‘it’. The use of
non-content words, such as pronouns, is common in the speech of persons with dementia
since anomia is a symptom of the disease. Anna makes herself very clear, as this example
shows by Mary’s response on line 4. The use of pronominal reference allows the person with
dementia to feel that she has made herself clear and initiated a conversation. Such feeling is
an important part of being a social actor in any environment.
Moving from the textual level to the discourse level, Example 1 shows that Anna’s use of
deictic pronouns functions to create cohesion and coherence. Cohesion is what makes a text
semantically meaningful and is achieved through syntactic features, such as deictic,
anaphoric and cataphoric elements2 or a logical tense structure, as well as
presuppositions and implications connected to general world knowledge (Halliday &
Hasan, 1976). Coherence is a broader interpretation by interlocutors regarding the
understandability of the interaction. Anna and Laura together achieve cohesion and
coherence through the sequence of turn taking in which they accept and make sense of
each other’s utterances.
Up to a point, the conversation in Example 1 appears still to be about a tape recorder.
Then, on lines 6 and 8, Laura, another staff member who is serving lunch, says, ‘All right, I’ll
get you it’ and offers Anna a glass of water. Now the textual cohesion is complicated by
another interlocutor. It is unclear whether Laura is trying to distract Anna by offering her a
glass of water or if Laura perceives Anna’s claim ‘that’s mine’ to refer to a glass of water. In
line 9, Anna accepts Laura’s offer and her reinterpretation of the conversational object in
question. This re-framing (Goffman, 1974) is a technique used by caregivers to minimize

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behavioral disturbances. Was Laura aware of her re-framing? Is this a conversational

diversion on the part of the staff member? The present authors suggest that Laura applied
her knowledge of the resident’s ambiguous discourse and found a solution to the issue of
tape recorder ownership.
In the following excerpt, Liz, a physical therapist at Cedar Hill, has just brought Bob, a
resident, back to the dining room after his therapy session. She assists Bob in navigating
the tables and chairs with his walker and then bids him goodbye. When Bob sits down, he
is joining John, another resident, who is already seated. The conversation with Liz,
the therapist, is included to contextualize the conversation that ensues between Bob
and John.

Example 2
1 Liz: You’re welcome. Thank you: Oops be careful of your walker.
Have a good lunch
2 Bob: OK
3 Liz: I’ll see you I’ll see you on Monday, ok?
4 Bob: OK
5 Liz: We’re going to work on this (points to walker) again
6 Bob: Today (speaks to John sitting across the table from him)
7 John: Shakes his head. I’m not even sure. I don’t know what day it is
8 Bob: No I said¼
9 John: ¼Oh¼
10 Bob: ¼She said, I’ll see you on Monday,
I said ‘today’ (smiles and laughs) (pause)
11 Takes me back about six years ago
12 Haha (Bob starts eating lunch)
13 John: (coughs)

This example illustrates the use of indexicality to create linguistic and social meaning. An
indexical behavior or utterance points to (or indicates) some state of affairs. Indexicality is a
phenomenon far broader than language, one that, independently of interpretation, points to
something, such as smoke as an index of fire (Peirce, 1932). In discourse analysis, indexicality
functions to show how speaker-meaning can be viewed on the sentence level and on the
discourse or interactional level.
In Example 2 on line 6, when Bob said ‘today’, he means he would rather not wait
until Monday to see the physical therapist. Then he addresses his comments to John in
an attempt to start conversation. Liz, the therapist, is the conversational object. The
presence of an attractive young woman serves as a way for one gentleman to initiate
conversation with another. The conversational object is indexed by the word3 ‘today’
and points backward to Liz’s comment on line 3 as well as forward to the present
moment of the lunch table with his dining companion. In pointing backward, Bob
uses an indexical to create meaning and continuity in his discourse. At the same time,
he uses an indexical to point forward. First, he points forward by moving the
conversational center to a new interlocutor, John, and second he points forward by
talking about himself. On line 11, he recalls himself in the past. From this example,

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Saunders et al. 9

we see Bob using language to create coherence in his discourse along a time continuum
from present to past. Bob’s cognitive status of being diagnosed with dementia in the
mild stages as defined by clinical criteria does not interfere with his ability to construct
his own identify as a gentleman who notices ladies and recalls himself as a younger man.
He uses this identity construction in his discourse and to construct his social
relationships.
The next example illustrates an inanimate item as the conversational object and highlights
the use of function words for indexing a social relationship. Here two residents were
sitting down for lunch when a staff member interrupts the conversation to offer a cup of
coffee.

Example 3
1 Bob: How are you doing?
2 Clara: OK.
3 Staff: Would you like a hot cup of coffee?
4 Bob: Yes, I would. [getting ready to sit down]
5 These things don’t move on the carpet at all. [Bob tries to move table]
6 Clara: Not too much. [laughing]
7 Bob: Not at all. [Bob begins to eat and silence returns to the table]

This is an example of a typical interaction between two residents. The conversational

object introduced on line 5, refers to the lunch table. The conversation is short and
punctuated by staff interjections as seen on line 3 when the staff member offers Bob a
cup of coffee. Bob and Clara align themselves with each other using linguistic devices such
as indefinite nouns as in line 5, when Bob says, ‘these things don’t move’. Alignment, as
described by Goffman (1974), is the way we position ourselves in a social interaction. This
may be done by shifting our footing, stance, or the positions that interlocutors take up in
relation to one another and their utterances. Shifts in footing can affect task, tone, social
roles, and interpersonal alignments (Goffman, 1981). Bob is constructing conversational
cohesion through his linguistic usage. Clara’s response ‘Not too much’ serves to support
the construction of coherence in that she agrees with Bob’s assessment that the table does
not move too much on the carpet. Bob continues to align himself with Clara when he
completes the interaction with a repetition of Clara’s statement on line 6, ‘Not too much’.
Indexicality, as a discursive component of the social relationship, is being co-constructed
by Bob and Clara when they align themselves using function words, adverbs, and
prepositions.
Despite the limited verbal exchanges of persons with dementia in long-term care settings,
repeatedly the data revealed that residents aligned themselves to their conversational
partners. Sometimes the work of making friendly conversation can be challenging when
staff members and meal logistics interrupt. Because these conversational interactions can
be so brief, staff members may overlook them and thus may not recognize them as examples
of friendships being created and maintained.
In the next example, two residents are engaged in a conversation that is recognizable as a
friendly interaction based on the topic of food and caring for others.

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Example 4
1 Lilly: Listen, you better go get something for yourself to eat.
2 Anna: I am not hungry.
3 Lilly: You are very foolish.
4 Anna: My stuff can sit there.
5 If I get hungry
6 I can get it myself.
7 Lilly: You’re not at home now.
8 Anna: I am.

Here Lilly urged Anna to get something to eat and the conversational object is food, an
inanimate item. Lilly expressed, in line 1, her concern for Anna’s state of hunger. Caring for
one another is what friends do for each other. Anna disputed Lilly’s concern, ‘I am not
hungry’ and informed Lilly on line 4 what her plans are if she gets hungry. While Lilly and
Anna seemed to disagree on one level, this author proposes that the indexical behaviors
reveal friendship or, at least, caring between the speakers. Each line is similar in length,
about four or five words. The structure of the sentence follows a similar syntactic pattern
(subject–verb–object). The repetition of pronouns shows alignment. On lines 1, 2, and 5 Lilly
repeats the second person pronoun, ‘you’. Anna matches this pattern by responding
consistently on lines 2, 5, 6, 8 with the first person pronoun, ‘I’. This example illustrates
the concept of indexicality in that the speakers align themselves using language and syntax
that is synchronous and at the same time indexes their social identities: Lilly as the caregiver
and Anna as the self-sufficient.

Discussion
The conversations among persons with dementia reveal many of the elements of
conversation that one would expect in the conversation of non-impaired adults. The
topics chosen to talk about related to their environment: the food, the furniture, and the
people around them. Their discourse serves socially to construct the residents’ identities as
well as their social relationships. While staff members may subscribe to a person-centered
philosophy, may thoughtfully design the physical environment (Brawley, 2006; Briller &
Calkins, 2000), and may plan activities accordingly (Davis, Byers, Nay, & Koch, 2009),
even still, they may not then be aware of the ways in which language in conversational
interaction functions in the social relationships among persons with dementia.
Conversational interactions reveal that residents with dementia in long-term care do
develop and maintain relationships. These relationships focus on the mundane (e.g., the
furniture) as well as personal (e.g., taking care of oneself). The construction of these
relationships is revealed through the discourse: the use of conversational objects and
linguistic elements that show alignment between friends.
Conversational objects are indexed using definite and indefinite pronouns. Residents with
moderate to severe dementia use their linguistic resources to communicate with staff and
other residents, and this use of language is well within their conversational skill set. A
conversational object is an analytical tool to identify the start of a conversation. While
this study highlights the conversational discourse between residents, this same analytical

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Saunders et al. 11

tool can easily be applied to the conversations between resident and staff members. The
identification of conversational objects allows for the analysis of coherent conversations, as
well as of misunderstandings, as seen in Example 2, with Bob and John’s conversation about
the staff member. Bob is doing his best to have a friendly conversation with John about his
memories of himself at a younger age. John in turn is trying to make sense of what John was
saying. This misunderstanding reveals much about how persons with dementia communicate
despite cognitive impairments. That is, they communicate using indefinite linguistic reference
and use alignment of social identities (old self versus young self) thus revealing how social
relationships are constructed in this setting. That is, there may be misunderstandings, and
yet the relationship still perseveres as relationships do among non-diagnosed people who
experience misunderstandings in conversation.
While staff communication was not itself examined here, it was inevitable that it would
appear as part of the communicative interaction in the long-term care setting (Small, Gutman,
Makela, & Hillhouse, 2003). Between staff members and residents, conversational objects
motivate conversation and smooth interaction. In Example 1, the conversational object
starts out as a tape recorder. However, as the conversation ensued Laura, another staff
member, interprets the conversational object to be something else. While it is not clear
whether re-framing is a conscious move on Laura’s part, there was some resolution to the
issue when Anna accepted the glass of water. Vasse, Vernooij-Dassen, Spijker, Rikkert, and
Koopmans (2010) reviewed the literature on staff interventions designed to improve
communication strategies among residents in long-term care facilities. While the meta-
analysis found no overall effects, several of the single-task session interventions with
residents (e.g., life review) and one-on-one tasks embedded in activities of daily living
showed improved communication. Future studies of intervention should include
information for staff members about how persons with dementia use language to construct
their social relationships. In addition, such training should emphasize how the role of the staff
members themselves influences social interaction among residents and how such influence can
be improved further.

Conclusion
While research on the subjective experience of dementia is a growing field (Pearce et al.,
2002; Sabat, 2001; Woods, 2001; Clare, Rowlands, Bruce, Surr & Downs, 2008), additional
research is necessary to understand how the person diagnosed copes with the difficulties (the
realities of their) everyday life. The Friendship Study used both ethnographic and
neuropsychological assessments to explore communication and social relationships among
persons with dementia in the long-term care setting, as well as to examine individual views of
friendship (see the companion article be de Medeiros et al. in this issue), all while keeping the
perspective and the experience of the persons with dementia as a focus of this research.
Using discourse analysis, the conversational examples in this paper illustrate how persons
with dementia use specific linguistic behaviors to construct and maintain relationships with
their fellow residents. These conversational interactions are evidence of how these
individuals construct their own social identities and, in so doing, their social relationships.
Using language, these individuals align themselves with each other to form social bonds at
the conversational level. At the same time, using language in their daily conversations, they
indexically construct social meaning and social relationships with their table-mates. The

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12 Dementia 0(0)

individuals observed herein are very capable of forming and maintaining friendships, or
pleasant social relationships despite their cognitive or physical impairments. Future
studies will examine interventional strategies with staff and family caregivers to improve
social interaction in long-term care settings.

Acknowledgment
This research was supported by a grant from the Alzheimer’s Association (NIRG-08-91764).
Many thanks are given to Philip A. Saunders for thoroughly proof-reading this and many
other manuscripts.

Conflict of interest statement

The authors declare no conflicts of interest in preparing this article.

Notes
1. Transcription conventions are modified from Du Bois (1991).
2. Anaphora is an instance of one expression referring to another. A cataphoric reference is used to
describe an expression that co-refers with a later expression in the discourse.
3. ‘Today’ in this context may be analyzed as a noun or an adverb depending on the completion of
the sentence. Assuming the rest of the sentence was ‘Today I would like to have another
appointment’, then it would be an adverb modifying time.

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Pamela A. Saunders, PhD, is an Associate Professor in the Departments of Neurology and

Psychiatry at Georgetown University School of Medicine. Her research focuses on the
identity, and the preserved, communicative abilities of persons with dementia. In addition,

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she teaches medical students how to communicate in clinical settings. She is the author of
multiple articles on language, communication, and dementia as well as in the arena of
medical education.

Kate de Medeiros, PhD, is Assistant Professor of Gerontology in the Department of

Sociology and Gerontology, Miami University, Oxford, Ohio. Her research focuses
broadly on the construction of selfhood in old age and includes work on friendships and
self expression/performance through autobiographical writing for a variety of older
populations. She has published work on the complementary self in old age, narrative
explorations of selfhood, neuropsychiatric symptoms in dementia, and the meaning of
suffering.

Patrick Doyle, MA, is a doctoral candidate in Gerontology at the University of Maryland,

Baltimore County. His research has focused on how caregiving practices, physical
environments, and social interactions influence the lived experience of people with
dementia residing in long-term care settings. In his dissertation research, he is examining
how a person-centered model of care is interpreted and applied by various stakeholders
within a dementia-specific long-term care setting.

Amanda Mosby graduated from Indiana University with a master’s degree in social and
cognitive psychology. She has directed a variety of research studies that have focused on
sociological, behavioral, and public health issues including memory performance in older
adults and the concept of generativity in childless older women. She is currently a research
associate at the University of Maryland Baltimore County in the Department of Sociology
and Anthropology.

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