The ability to communicate effectively with our older clients and their families is essential to quality service delivery in audiology and speech-language pathology. Statistics indicate a graying of the population worldwide. Older persons (age 65 and older) now constitute about 13% of the U.S. population, a number that will increase to 20% in the next 20 years (Administration on Aging, 2009); the fastest-growing segment of that group is the very old, or individuals age 85 and older. The increase in this age group transcends gender, race, and ethnicity. It is common to have "90-something" clients accompanied to their appointments by their similarly aged spouse or 70-year-old "children."
Importance of Communication in Service Delivery
Effective communication with older persons and their families is important for three reasons. First, it is the medium through which we assess older individuals, and our intervention focuses on improving some aspect of communication. Particularly when professional time is limited, successful and efficient communication contributes to health literacy—that is, understanding and complying with presented information. This understanding, in turn, translates to cost-effective service delivery. Second, communication helps us understand the social, emotional, and financial impact of disorders and thus provide support to help older persons and families cope. Finally, through communication we create a therapeutic partnership with elders and families to facilitate carryover of intervention strategies and to reinforce their independent ability to problem-solve in challenging communicative situations.
Characteristics of Aging
Elderly clients and family members bring a variety of characteristics to the practice setting that affect how well they understand others or express themselves. There may be some combination of physical, sensory, or cognitive changes that complicate communication. Our own communication style with older adults also is critical. Clinicians may want to be aware of the some of the most important changes
that affect patients' communication abilities and strategies that might facilitate communication. Each individual has different needs, however, and clinicians should not make assumptions based simply on the person's age.
Promoting Physical Access
Older adults may present with any number of changes in physical health as well as loss of mobility that may limit access to services. Service providers should evaluate clinical treatment spaces to determine physical accessibility. Barrier-free strategies include easy access from car to building, ramps rather than steps, elevator access, level skid-free floors, wide doorways to offices and rest rooms, hand rails and grab bars, and enhanced illumination. Hallways, doorways, and furniture should be wheelchair-, scooter-, and walker-friendly. Eye-level signage should be concise with good visual contrast. The use of universal graphics and talking signs also provides access to services. Service providers should check the Americans with Disabilities Act Standards for Accessible Design (ADA, 2003) for specific information on design, construction, and alteration of offices, medical care facilities, and businesses.
Improving Visual Communication
Elders may present with presbyopia, the age-related changes in near vision, or a variety of other age-related vision disorders, including macular degeneration, glaucoma, cataracts, or diabetic retinopathy. At age 60, 1.2% of the population is visually impaired, but by age 80 this rate increases to 23.7% (Eye Digest, 2009). The degree of impairment ranges from mild (low vision) to blindness. In addition, some clients with neurological disorders (e.g., stroke or traumatic brain injury) may have vision difficulties. Reduced vision affects older adults' ability to find their way to and from the practice setting independently, to see the clinician and use nonverbal cues, and to see and respond to visual materials during assessment or intervention.
The first step in communicating with a client with vision difficulties is to identify this issue before service delivery. Approach the elder from the better vision side (if that is relevant) and introduce yourself. Ask where the best place is to stand or sit to promote visual access. Older persons should be encouraged to wear corrective lenses that are clean and appropriately placed. Some elders may use "readers" for close reading. Older individuals with macular degeneration may take advantage of adequate peripheral vision and use "eccentric (side) viewing" to look at a clinician.
Increased and consistent lighting in the service delivery area is essential and should be from either natural sunlight or full-spectrum incandescent bulbs. Task lighting on a table is helpful. Some individuals may have difficulty adjusting to lighting changes when transitioning from waiting areas to sound booths and should be given time to adjust. Whenever possible, avoid shiny surfaces that reflect glare. Assistive vision devices should be available including handheld magnifiers (with or without attached lighting) or reading telescopes. Video magnifiers can project printed information onto a TV monitor or computer screen. Practitioners should also provide wide-lined paper for writing, large felt tip pens, and signature guides. Voice-recording electronics can be used to record information for use in or outside the clinic.
Printed information presented or given to patients should be clutter-free and have sharp color contrast between text and background. Print materials should use a large font size (at least 16 points) with adequate spacing between lines. The information should be written in jargon-free, common vocabulary with well-constructed sentences in an active voice. Information that is important to remember should be bolded, bulleted, or highlighted so that it stands out. Avoid all-cap text. See the Eye Digest (2010) and Rudd (2007) for low vision resources and Brawley (1997) for lighting design suggestions.
Printed information should be written at the literacy level of the target population. Again, the use of plain language that presents information in a user-friendly, organized style is helpful. Keep in mind the visual needs of elders and literacy level when designing Web sites as well. See the Trace Center reference for further information on Web site design. (For more information on health literacy and developing appropriate print materials, go to ASHA's Health Literacy site.)
Presbycusis, or hearing loss associated with aging, may affect up to 30% of those age 65 and up to 50% of those over 75 (NIDCD, 1997). This percentage increases for the very old (age 85 and older) and for those in long-term care. Presbycusis results in the inability to understand comfortably loud speech, especially in a noisy background, and in difficulty distinguishing high-pitched sounds. Tinnitus also may be present. Unfortunately, two-thirds of older persons with hearing loss do not wear a hearing aid (National Academy on an Aging Society, 1999).
Strategies for communicating with older persons with hearing loss begin with modifying the acoustical environment through the use of soundproof materials and acoustic design, and using vision-enhancing strategies. Ideally, personal hearing assistive technology will be available. Other strategies include coming into the visual field of the elder and announcing yourself to avoid startle. Ask to turn off a radio, television, or computer and avoid talking in the presence of competing noise. Encourage those who have a hearing aid to use it. Be sure the device battery is working and the device is inserted properly and turned on.
In all cases, face the patient while talking and be sure that your face is well-lit and easy to see. Lighting strategies for those with vision impairment also assist those with hearing impairment. If the patient has accompanying low vision, ask where is the best place for you to position yourself so that your face is visible. Use natural volume, intonation, and gestures. Prime the elder with the topic to be discussed. Use well-constructed but not overly lengthy sentences that avoid the use of unclear pronouns. Build in pauses to facilitate comprehension and allow the patient to ask questions. Check occasionally for understanding and be prepared to repeat or rephrase. Remember that at least 21% of older adults present with both hearing and vision loss (Lighthouse International, 2000).
Normal aging changes include reduced cognitive processing speed, difficulty remembering new information, and distractibility. For most older individuals, communication is facilitated by simple accommodations such as slightly slower, well-constructed, and repeated presentation of information in an active voice. The most important information should be presented first and repeated again at the end. Avoid the use of "do not" and "it is not true" statements. Focus on what the individual needs to do rather than what he or she should avoid. Providing a written summary of key points is helpful.
Some elders will demonstrate the progressive cognitive decline associated with dementia, particularly Alzheimer's disease (AD). About 10% of those older than 65 and 50% of those over 85 have AD (ASHA, 2004). Communication will deteriorate over time for those with AD and conversations will become increasingly difficult.
Strategies to facilitate communication begin with gaining attention in a distraction-free setting, facing the individual, maintaining eye contact, and using supportive verbal and nonverbal communication. Present one idea at a time. Use concrete and familiar vocabulary in short sentences. Again, introduce topics clearly, avoid pronouns, and repeat key information without adding new ideas. Ask "yes/no" questions or provide two choices to facilitate participation. Listen for themes in responses and monitor the elder's emotional tone. Give the patient adequate time to respond and check for comprehension. Do not expect the person with AD to remember information and avoid arguing or correcting faulty memories.
Depression is characterized by pervasive sadness, loss of interest, somatic complaints, sleep disturbances, motor agitation or retardation, loss of concentration, and possible suicidal thoughts (Surgeon General, 1999). Depression may affect at least 20% of elders in the community and 37% of those in long-term care settings (Surgeon General, 1999). Many older persons fail to report feelings of dysphoria and their depression may go undiagnosed. Depression may be associated with personal losses and a variety of age-related disorders including sensory loss, AD, and stroke. Depressed elders may avoid interaction, speak slowly, show memory difficulties, or become argumentative.
It is important to have a supportive verbal and nonverbal attitude during conversations with older patients who have depression. Do not trivialize depression or suggest that the person is seeking attention or that everything "will be all right." Conversations may take more time. Use clear, well-constructed statements indicating what you are doing and why. Encourage the person to express opinions and respond to them meaningfully, but be prepared for periods of silence and sometimes opposition. Remember not to take this personally.
With normal aging, elders may have some difficulty understanding verbal or written material that is more complex in length and syntax. Comprehension also is complicated by cognitive, emotional, and sensory impairments. Clinicians may find that older individuals are less efficient in their communication, use more words and ambiguous words, and show less cohesion in their conversations (Garcia & Orange, 1996). Some individuals tend to go off-topic, making efficient information exchange more difficult. To accommodate these changes, clinicians should offer more clinical time to older adults. Reinforcing key words and summarizing topics helps to maintain topic cohesion. Clinicians also need to monitor their own nonverbal communication to avoid signaling impatience or annoyance.
Of critical importance with communicating with elders and those with AD is to avoid "elderspeak," a style of condescending speech often used with older persons (Williams et al., 2003). Elderspeak is characterized by slower rate, exaggerated intonation, elevated pitch and volume, greater repetition, use of diminutives and collective pronouns, and simpler vocabulary and grammar than is expected. It is frequently described as "sing-song" or "child-like." Communication partners may think that such stylistic changes show warmth and facilitate communication with older persons, but in fact, elders perceive them negatively and eventually withdraw and decline (Ryan, Giles, Bartolucci, & Henwood, 1986). The best way to avoid elderspeak is to monitor one's own communication style with older individuals. Occasional audio/videotaping of interactions with older adults is an excellent monitoring strategy. Information about ways to improve patient-provider communication is available on ASHA's Patient-Provider Communication site.
Interacting with Caregivers
Although it may be more efficient to interview caregivers alone, it is important to balance interaction with both the client or patient and caregiver so that both feel a sense of contribution. Address both persons by name in an adult-like manner (Mr. Jones, Mrs. Smith). Maintain eye contact with both persons and monitor nonverbal communication that indicates agreement or disagreement with statements made by the other party.
Assume that older clients hear and understand even when not responsive. The goal of having the caregiver present is to include this person as an integral member of the communication team, one who understands the nature of the problem and is committed to solving communication dilemmas. Keep in mind, too, that older family members may also display age-related characteristics that affect their ability to understand and express information. Clinicians should respond to both persons' questions and contributions.
Practicing clinicians will find that using a few easily incorporated strategies will improve outcomes and health literacy, create greater efficiency, and reduce frustration. Clinicians need to create a physical and a social environment in which messages can be sent easily and received accurately by both elders and family members.