Class 1 Communicating with older adults

Communication in aging

• Communication is one of the most important capacities of human beings 

• Basic communication strategies are all applicable in communicating with older adults 

• Meaningful communication with active involvement in society is key to “aging well”

• Enhancing communication with older adults is a foundational skill in gerontological nursing that has rewards for both the nurse and the older person 

Common communication challenges

• Sensory impairment, including normal age changes 

• Language impairment (Ex: aphasia)

• Cognitive impairment (Ex: dementia)

• Also attitudes of nurses/public towards older adults (ageism)

Sensory impairment 

• Both visual and hearing impairments

• Common and can interfere with communication 

Major causes of visual impairment among older adults

• Cataracts, macular degeneration, and glaucoma 

Common causes of hearing loss among older adults include

• Sensorineural and conduction issues 

Hearing loss statistics

• Almost half of older adults above 65 have some kind of hearing loss.

• Yet it is underdiagnosed and undertreated in older people 

Hearing loss may lead to…

• Social isolation

• Communication differences related to hearing loss could be frustrating for both the speaker and the listener

Hearing loss 2 major forms

1. Conductive hearing loss

2. Sensorineural hearing

Conductive hearing loss

• Results from abnormalities that reduce the transmission of sound to the middle ear. Infection, perforated eardrum, fluid in the middle ear or cerumen accumulation can all be caused.

Sensorineural hearing loss

• Loss results from damage to the inner ear or neural pathways to the brain. It is usually treated with hearing aids or cochlear implants 

Prelingual deafness

• Deafness that occurs before the acquisition of spoken language 

Strategies for communication: hearing loss

• Do not shout when speaking (high pitch makes it more difficult)

• Never assume loss is due to old age as it could be treatable such as infections or cerumen buildup

• Make sure hearing aids are functioning 

• Pay attention to articulation, speed of speech, tone, and clarity, face the person and stand at the same level 

• Reduce background noise 

Visual impairment 

• Vision normally declines with age

• Colors become dimmer and images become less clear

• Diagnosis of blindness does not equate to complete loss of vision 

Major causes of visual impairment and blindness

• Cataracts

• Macular degeneration

• Glaucoma

• Diabetic retinopathy

Visual impairment may have consequences on…

• Functional ability

• Safety

• Quality of life

Cataracts

• Caused by damage to the lens and by fatty deposits in the lens 

Cataracts Causes:

• Hereditary, age 

Cataracts Risk factors:

• Excessive sunlight

• Poor dietary habits

• Diabetes

• Hypertension

• Kidney disease

• Trauma to the eyes

• History of alcohol and tobacco use.

Cataracts Assessment:

• Clouding of the ocular lens, appearance of halos around objects, blurring, sensitivity. 

Cataracts Management: 

• Surgery 

Cataracts Post surgery:

• Avoid heavy lifting, straining, and bending.

• Use eye drops 

Macular degeneration

• Age related, affects the macula, the central part of the eye. Causes progressive loss of central vision, leaving only peripheral vision intact.

Macular degeneration Risks:

• Age

• Family history

• Smoking, obesity

• Excessive exposure to sunlight

Macular degeneration treatment:

• No cure

• Treatment options limited to slowing progression 

Glaucoma

• A progressive process in which the fluids of the eye are blocked causing gradual buildup of intraocular pressure (IOP) and damage to the optic nerve.

Glaucoma Risk factors:

• Age

• Steroid use

• Injuries

• Family history

• Diabetes

Glaucoma Management:

• Managed by medications that decrease IOP such as beta-blockers, laser surgery

Diabetic retinopathy

• Due to diabetes, the retina is affected, blood and lipid leak and lead to macular edema and exudates.

• Diagnosed by fundoscopy

Diabetic retinopathy Intervention:

• Strict blood sugar intake and control, cholesterol and blood pressure control, laser treatments 

Drusen

• Yellow deposits under the retina, often found in people over the age of 60

Funduscopy

• Ophthalmoscopic examination of the fundus of the eye 

Keratoconjunctivitis sicca

• Diminished tear production with age 

Lipofuscin

• An age-related, fatty brown pigment found in the liver, retina, kidneys, adrenals, nerve cells and heart tissue

Tonometry 

• Procedure used by eye care professionals to determine the intraocular pressure of the eye

Strategies for communication: Visual impairment 

• Make sure to have the person's attention before talking 

• Speak promptly, and clearly, get to the the persons level

• Use analogy of a clock to help locate objects (meal at 3 o’clock)

• Ensure adequate lighting, use large printing with proper contrast

Strategies for communication: Visual impairment (Blind)

• Offer arms while walking, safety precautions, don't interfere with guide dogs.

Language impairment 

• Affects a person's ability to communicate in one or more ways:

  • Speaking

  • understanding

  • reading

  • writing

  • gesturing

• Speech-language pathologists (SLP) should be consulted to come up with rehabilitative plans 

Language impairment Types:

• Wernicks aphasia (Receptive)

• Broca's aphasia (expressive)

• Verbal apraxia and dysarthria

• Anomic/Nominal aphasia

• Global aphasia 

Aphasia

• Most common language disorders follow CVA or stroke. There may be little or no speech, broken speech, or fluent but empty content

Wernicks aphasia

• Person speaks easily but the content does not make sense. They may also have difficulty understanding spoken language

Broca's aphasia 

• Usually understand others but speak very slowly and use a minimal number of words. They experience difficulties in communicating orally and writing

Apraxia

• An impairment in the ability to manipulate objects or perform purposeful acts, including ability to speak.

Verbal apraxia

• There is a disruption in the brain's transmission of signals to the muscles controlling speech. When the person thinks about what to say they struggle speaking, but when they do not think about what to say, the person may be able to say many words/sentences correctly

Anomic/Nominal aphasia

• Patients understand and speak readily but have difficulty finding the words. Difficulty finding the right words, inability to name objects

Global aphasia 

• Affects most of the language areas of the brain, person cannot understand words or speak coherently

Dysarthria

• A speech disorder caused by weakness or incoordination of the muscles used for speech

Strategies for communication: Aphasia 

• Explain situations, and treatments and treat the person as an adult, using non-patronizing language 

• Be patient and allow plenty of time to communicate in a quiet environment. Speak slowly 

• Ask questions that can be answered with a nod or a blink. Instruct to use nonverbal responses or yes/no questions 

• Use visual cues, and gestures, and have paper and pencil available 

• Encourage all speech, do not be too quick guessing words/sentences

Cognitive impairment 

• Dementia affects thinking, memory and language 

• Communication challenges can vary depending on the type of dementia 

  • Alzheimer's disease is the most common 

• Early stages affect thinking and memory 

• Mild to moderate stages begin to affect language

• By the late stage, communication can be very challenging; both expression and understanding can be impaired

Basic communication strategies: summary 

• Include the person in social gatherings and conversations.

• Ensure the hearing aids are in and glasses are on 

• Explain situations, treatments and anything else that is pertinent to the person.

• Treat the person as an adult and avoid patronizing and childish phrases.

• Talk as if the person understands.

• Be patient and allow plenty of time to communicate in a quiet environment 

• Speak naturally.

• Speak slowly, ask one question at a time, and wait for a response.

• Do not shout.

• Repeat and rephrase as needed

Enhanced communication strategies 

• Compensatory strategies

• Connecting strategies

Enhanced communication strategies: Compensatory strategies

• “Compensate for impairment” by reducing the information processing demands on the person with dementia 

  • One idea sentences 

  • Limit demands on recent memory 

  • Speak at a normal rate (don't slow down)

  • Eliminate distractions

  • Redirect when necessary 

  • Avoid ambiguous references and topic shifts 

  • Repeat when necessary 

  • Yes/no questions 

Enhanced communication strategies: Connecting strategies

• “Connect with the person on a relational level” by affirming their retained abilities and supporting their expression of self

  • Clarifying 

  • Exploring

  • Moderating

  • Connecting 

  • Validating

  • Assisting

It is not only what you say

• Repeated use of yes/no questions can be perceived by the person with dementia as over-accommodating 

• Viewing the person as incapable of generating his/her own response could lead to a loss of self-esteem

Purposeful communication 

• Reality orientation

• Validation therapy

Purposeful communication: Reality orientation

• Provide orienting information (about person, place, and time) to “confused” older adults 

• Purpose is the give people better understanding of their surroundings, improves sense of control; and self esteem 

Purposeful communication: Validation therapy

• Empathizing and accepting a person's reality

• Purpose is to promote security, meaningful communication and social interactions 

Ageism 

• Involves ways of thinking about older adults based on negative attitudes and stereotypes 

• A tendency to structure society based on the assumption that everyone is young, thereby failing to respond to the real needs of the older persons 

• Ageist attitudes often interfere with nurses ability to communicate effectively (When the nurse believes all older people have memory problems). This will subsequently cause respect, dignity and communication problems

• It is important for nurses to engage in self-reflection and analyze own attitudes and prejudices 

Elderspeak 

• A form of ageism in which a person alters their speech on the assumption that the older person has difficulty comprehending.

• Elderspeak is unfortunately very common in practice settings such as LTC where staff use patronizing language, pet names and other styles of defective communication 

• Nurses may not be aware that they are using elderspeak, therefore it is very important to be aware and self-reflect in every aspect of our practice and communication 

Characteristics of elderspeak 

• Speaking slowly or loudly

• Using a singsong voice 

• Using patronizing language:

  • “We, us, our,” in place of “you”

• Using pet names, honey or sweetheart 

• Answering questions for the older person (Ex: “You would like your dinner now wouldn't you?”)