As the “baby boomer” generation ages, an increasing number of older Americans are entering the healthcare system, posing new challenges to healthcare providers. It is estimated that in 2030, the “young old” (aged 66 to 84) will number 61 million people and the “oldest old” (born prior to 1946) will number 9 million.1 The number of Americans ages 65 and older is projected to more than double from 46 million in 2016 to over 98 million by 2060, and the 65-and-older age group’s share of the total population will rise to nearly 24% from 15%.2
Americans over age 65 visit their doctor on average 8 times per year, compared to the general population’s average of 5 visits per year.3 Physicians should prepare for an increasing number of older patients by developing a greater understanding of this population and how to enhance communication with them.3
Communication with older patients can be complicated for several reasons. One is that they constitute more heterogeneous group than younger people.3 Their wide range of life experiences and cultural backgrounds can inform the perception of their illness and willingness to adhere to medical regimens.3 In addition, sensory loss, memory decline, slower processing of information, reduced power and control over their own lives, retirement from work, and increased dependence on family may create a more complex communication dynamic.3
A recent survey4 found that only 44% of older adults using multiple medications had spoken to a healthcare provider about possible drug interactions, suggesting an important gap in communication. Another survey5 found that one-quarter of older adults had recommended treatments that they did not think they needed, and roughly one-tenth reported wanting a test, medication, or procedure they thought was needed but was refused by their healthcare provider. Even more concerning, 30% only partially understood the provider’s explanation, and 10% did not understand it at all.
“Dealing with the disconnects that can occur when communicating with older patients is a huge and challenging issue,” according to Jake Harwood, PhD, Professor of Communication, University of Arizona, Tucson.
“These disconnects are due to an array of factors, including hearing loss, cultural variations, and differing communication styles,” he told MPR.
The Role of Hearing Loss
According to the National Institute on Deafness and Other Communication Disorders (NIDCD), hearing loss is one of the most common conditions affecting older and elderly adults, with approximately 1 in 3 people age 65 to 74 and almost 50% of those ≥75 having difficulty hearing.6
Communicating with individuals who are hard of hearing involves specific skills, noted Dr. Harwood, who was involved in the development of the Gerontological Society’s evidence-based review, “Communicating with Older Adults.”7
“Face the person at eye level and make sure your face is fully visible so that they can read your lips, since people with hearing issues become very good lip readers,” he advised.
Shouting should be avoided, he warned.
“Shouting is ineffective because it raises the pitch of your voice, and the hearing loss of older adults is usually associated with higher frequency ranges, so the higher the pitch, the less likely the person will hear you.”
It is also important to consider hearing loss as a factor in the patient’s responses if the patient appears to be answering in non-sequiturs. “If the patient’s responses to your questions are incongruous, don’t assume the patient has dementia,” he emphasized.
Underaccommodation and Overaccommodation
Practitioners sometimes engage in 5 patterns that contribute to older adults’ communication problems—underaccommodation and overaccommodation.8
Overaccommodations “occur when the speaker or writer is over-reliant on negative stereotypes of aging.”8
Several studies have shown that stereotypes can lead to infantilizing communication (sometimes called “elderspeak”), which includes excessively simplistic vocabulary and grammar, shortened sentences, slowed speech, elevated pitch and volume, and inappropriately intimate terms of endearment (eg, “honey” or “sweetheart”).9,10 These can lead to a communication breakdown with cognitively intact elders as well as those with dementia.9
“One communication style we often see younger people use when addressing older people is patronizing baby talk, which older people universally dislike,” Dr Harwood observed.
Elderspeak “derives from stereotypical views of older adults as less competent than younger adults.”9 This conveys an implicit message of incompetence that can initiate a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal, and the assumption of dependent behaviors.9
“Younger people need to be aware that even in talking to a patient with dementia, this style is not appropriate,” Dr Harwood said.
On the other hand, underaccommodations “occur when the speaker or writer fails to consider how aging affects speaking and listening.”8 Underaccommodations “put older adults at risk for social isolation and neglect because they lead to comprehension failure and hence to the possibility of misunderstanding, deception, and exploitation.”8
Generally speaking, older adults tend to use shorter sentences than do younger individuals.11 They also tend to use sentences that are less grammatically complex and it is harder for them to follow more grammatically complex sentences, which put more strain on their often declining processing resources.7
“How you structure your sentences is really important,” Dr Harwood commented.
Sentences should be kept short, although not patronizing or infantilizing, and information should be presented at the beginning of the sentence.
“Long sentences tax the short-term memory, and short-term memory tends to decline with age,” he said.
He advised physicians to “practice how to present key information in at the beginning of a short sentence.”
Address Patients Directly
“Sometimes, the physician will address questions to a family member or caregiver who might have accompanied the patient to the appointment, or the family member might interject an answer to a question that has been directed to the patient,” he said.
At that point, “It is really the doctor’s responsibility to reorient the conversation back to the patient and say, ‘I would like Mom or Dad to answer, if they can.’”
Addressing the patient is appropriate even if he or she has dementia, Dr Harwood added. In that situation, “it is certainly okay for the accompanying person to provide clarifications and contribute to the conversation, but it should be a conversation in which the patient is involved, so it is not a constant back and forth only between the doctor and the caregiver.”
The role of family members is heavily influenced by culture, since aging is “a meaning-making process” in which people “internalize cultural values.”12
“In any age group it is important to pay attention to culture, but especially with older people,” Dr Harwood noted.
For example, in Asian cultures, it is “very normative for multiple family members to be involved with decision making and participating,” Dr Harwood pointed out. By contrast, “in people from Northern European cultures, it is much less common for the whole family to be involved with the conversation.” Being aware of “how aging takes place in other cultures” will inform patient-physician encounters and enhance effective communication.
Educational resources regarding aging and culture can be found in Table 1.
Beyond the Mechanics.
“As a society, we tend to talk about “older adults” as if it is one group, but there is a vast difference between a person of 65 and a person of 90,” Dr Harwood observed.
For example, people over age 80 probably have some hearing loss and short-term memory deficits, and a possibility of mild dementia. But for those in their sixties, the probability is fairly low, except perhaps for some low-grade hearing loss.
Several studies have shown that individuals integrate both positive and negative stereotypes of aging and that activation of negative stereotypes can have broad and deleterious effects on older individuals’ self-evaluation and functioning.13,14
“Whatever the age of the patient, aging is either something you are terrified of or something you celebrate, and this will change what aging will be like,” Dr Harwood said.
Communication with patients transcends the specifics of language and style and includes the provider’s own attitudes toward aging, which can be conveyed in subtle ways and will, in turn, impact the patient’s attitudes to the process.
Additional communication tips can be found in Table 2.
1. Knickman JR, Snell EK. The 2030 Problem: Caring for Aging Baby Boomers. Health Serv Res. 2002;37(4):849-884.
2. Population Reference Bureau. Aging in the United States. (2016) Available at: https://www.prb.org/aging-unitedstates-fact-sheet/. Accessed: April 10, 2018.
3. Robinson TE, White GL, Houchins JC. Improving Communication With Older Patients: Tips From the Literature. Fam Pract Manag. 2006 Sep;13(8):73-78.
4. University of Michigan. National Poll on Healthy Aging. Available at: http://www.healthyagingpoll.org/sites/default/files/2017-11/NPHA_Drug-Interactions-Report_111417.pdf. Accessed: April 5, 2018.
5. University of Michigan, National Poll on Healthy Again. Available at: https://www.healthyagingpoll.org/report/march-2018-report-too-much-good-thing-overuse-health-care. Accessed: April 7, 2018.
6. US Department of Health and Human Services. National Institutes of Health. National Institute on Deafness and Other Communication Disorders (NIDCD). Hearing Loss and Older Adults. Available at: https://www.nidcd.nih.gov/health/hearing-loss-older-adults. Accessed April 7, 2018.
7. Gerontological Society of America. Communicating with older adults. Available at: https://changeagents365.org/resources/ways-to-stay-engaged/the-gerontological-society-of-america/Communicating%20with%20Older%20Adults%20Low_GSA.pdf. Accessed: April 10, 2018.
8. Kemper S, Lacal JC. Addressing the communication needs of an aging society. In: National Research Council (US) Steering Committee for the Workshop on Technology for Adaptive Aging; Pew RW, Van Hemel SB, editors.
10. Williams KN, Herman R, Gajweski B, Wilson K. Elderspeak Communication: Impact on Dementia Care. Am J Alzheimers Dis Other Demen. 2009;24(1):11-20.
11. Busacco D. Normal communication changes in older adults. American Speech-Language Hearing Association. Let’s Talk. Available at: https://www.asha.org/uploadedFiles/0499ashamag.pdf. Accessed: April 10, 2018.
12. Fung HH. Aging in culture. The Gerontologist. 2013;53(1):369-377.
13. Kotter-Grühn S, Hess TM. The Impact of Age Stereotypes on Self-perceptions of Aging Across the Adult Lifespan. The Journals of Gerontology: Series B. 2012;5(1): 563–571.
14. Coudin G, Alexopoulos T. ‘Help me! I’m old!’ How negative aging stereotypes create dependency among older adults. Aging Ment Health. 2010 Jul;14(5):516-23.