The aging population in the United States is expected to continue to grow at exponential rates. The number of older adults in the United States (persons 65 and to 84 years) and the oldest old (persons 85 years and up) is expected to double between 2012 and 2050, when the population will reach 83.7 million (Ortman et al., 2014). Reasons for this shift in demographics include the large baby boomer generation that started reaching retirement age in 2011, and advances in medical treatment of acute and chronic conditions.
As people age, physiological changes can occur causing deterioration of one or more of the senses, including hearing, vision, taste, and smell (Lubinski & Welland, 1997). Statistics from the National Social Life, Health, and Aging (NSHAP) suggest that most people (94%) can expect to experience loss of at least one of these senses with normal aging, and two thirds of older adults will have losses in two or more senses (Correia et al., 2016). According to a study by NSHAP, approximately 75% of older adults had taste impairments, 70% had losses associated with touch, 22% had problems with smelling, and 20% had issues with vision (Pinto et al., 2014). Nearly half of people over 75 years old will have mild to moderate hearing loss (National Institutes of Health, 2013). The losses in sensory function can result from aging, genetics, chronic illness, accidents, or environmental influences. The purpose of this article is to examine communication between older adults and healthcare providers, focusing on best practices and devices that can enhance and benefit their health and well-being.
Hearing loss can have a significant negative effect on patient education. Hearing loss has an associated social stigma that may discourage people from seeking help or from wearing hearing aids. In an effort to not “bother” healthcare providers, people with hearing loss may not admit they didn't hear instructions and may indicate understanding, when in fact, they did not understand. Hearing loss can be sensorineural, conductive, and/or environmental. Most hearing loss associated with aging is sensorineural and deals with high-frequency pitch. This is known as presbycusis (Correia et al., 2016). Presbycusis affects both ears to different degrees and begins around the age of 50. Speech intelligibility is affected to a greater degree than hearing the sound itself. One factor that can contribute is having worked in an area with heavy noise pollution on a continual basis (Lubinski & Welland, 1997). Over 200 drugs have been identified as ototoxic. These drugs can be prescription (aminoglycoside antibiotics such as gentamicin and cancer chemotherapy drugs, such as cisplatin, and loop diuretics, such as lasix) and over-the-counter drugs (aspirin, quinine) (Cone et al., 2015). Chronic diseases, such as multiple sclerosis, cardiovascular disease, and Parkinson's disease, can be contributing factors in the loss of hearing (Yang et al., 2015 ; Yorkston et al., 2010). Conductive hearing loss is often associated with cerumen impaction, causing a decrease in hearing, a common problem for older adults (Yang et al.). Tinnitus (hearing sound, often ringing, when there is no sound) is also a sensorineural hearing loss that affects 10% to 30% of the population (Negrila-Mezei et al., 2011).
As people age, vision begins to change, starting with decreases in the size of the pupils, increases in the thickness of the lens, and reductions in opacity (Lubinski & Welland, 1997). These changes can have a direct effect on visual acuity, including night glare, perception of color, depth perception, and near vision. The prevalence of many disease conditions, such as macular degeneration, diabetic retinopathy, glaucoma, and cataracts, increases with age and length of the contributing chronic disease (Lubinski & Welland). Visual communication is supported with prescription eyewear, which enables the patient to see and read required materials.
Taste and Smell
Many older adults, including the oldest old, experience loss of taste and smell. These losses can result from normal aging, as well as from chronic illness, including Alzheimer's disease. Other causes of the loss of taste and smell can include chronic conditions, medications, surgery, and exposure to the environment, including ambient air pollution (Ajmani et al., 2016). Although the decline of these senses does not affect communication directly, the indirect effects can result in older adults to becoming isolated and depressed (Boesveldt et al., 2017).
The Communication Model
Communication errors can occur between the most capable people due to environmental factors and cognitive state (Krauss & Fussell, 1996). Understanding when communication is not effective and addressing possible causes can help professionals understand the situation and avoid possible misunderstandings (Vivian, 2007). The communication process has a simple structure that allows challenges and errors to be identified.
A common communication model is comprised of five linear parts that move the message from the sender to the receiver. Social psychologists developed the principles of this model based on information theories from the late 1940s (Krauss & Fussell, 1996). The five stages of the encoder/decoder communication model are:
- The sender is the person who is generating the message.
- Encoding the message by the sender. This encoding is how the sender packages his/her message, and could consist of speech, visuals, or a combination of methods.
- Noise that is internal or external is in the middle of the model. External noise includes distractions, environmental factors, or technology issues. Internally, factors such as language, experiences preparedness, attention, stress, and knowledge related to the subject matter could be classified as noise.
- Decoding translates the sender's spoken idea/message into something the receiver understands by using their knowledge of language from personal experience.
- The receiver of the message is the final part of the linear model. For the following discussion, the patient is the receiver.
The sixth part of the communication model is feedback to ensure that the receiver has received and interpreted the message correctly. Feedback is the receiver's verbal and nonverbal responses to the message that indicate the message was received. Feedback can be as simple as a nod of the head to indicate understanding, or asking a question to clarify the message. In the case of older adults, feedback is an essential component of the communication model, especially when communicating important healthcare information (Noll et al., 2016 ; Vivian, 2007).
Another concern when communicating with older adults is being aware they may be experiencing difficulties with speech. Research by Bilodeau-Mercure and Tremblay (2016) found older adults generally had slower speech rates when compared with younger adults. They also had difficulty enunciating words with nasal vowels (such as the word “beautiful” or “main”). Their findings indicated that older adults experienced reduction in lip endurance that could affect their ability to be understood when speaking, and concluded that some older adults could benefit from speech therapy.
Use of Technology
Home healthcare providers can use technology to support patient communication and education. Digital tablets can store hundreds of informational documents, visual examples, animations, and videos that can be used to augment patient understanding of provider communications (Díaz-López Mdel et al., 2016). For patients with visual impairments, electronic tablets and smart phones can provide voice-over features that speak text, as well as enlarged text and/or extreme contrast mode to improve readability. For individuals with hearing loss, hearing aids can include a Bluetooth connection that can link to mobile devices directly into the hearing aid. Patients with physical impairments resulting from spinal cord or closed head injuries are supported through dictation and speech functions as well as alternate touch modes (Orr & Conley, 2013).
Limiting factors for use of technology by older adults include individual skills and attitudes, lack of trust in digital services, and unwillingness to learn. However, when older adults understand the advantages of using digital technologies, they are more open to using technology. Through the use of mobile devices and applications (apps), like Skype and Facetime, homebound patients can communicate directly with their home healthcare workers, physicians, and nurses to report changes in their conditions that may require immediate attention. Research by Petroulias (2017) has shown that older adults can successfully use an electronic tablet to access an app on self-care of infusion lines and to view videos on the proper way to flush peripherally inserted central catheters.
Implications for Clinicians
It is estimated that as many as 80% of people who could benefit from hearing aids do not use them (McCormack & Fortnum, 2013). There are many reasons people do not purchase hearing aids or use hearing aids they have already purchased. These reasons include perceptions of value, comfort, cost of batteries, and social stigma related to hearing aids. One common complaint is amplification of background noise that can be reduced by turning off items such as fans, televisions, and radios, especially when communicating with patients. Encourage patients to initially adapt to hearing aids by wearing them in their home where they can control background noise. After they become accustomed to hearing noises they may not have heard in a long time (the sound of zippers or a clock ticking) using hearing aids in public places will be easier. It is best to refer patients to an audiologist to help problem solve their specific issue though. There are a variety of other assistive listening devices that patients may find more acceptable than hearing aids. An audiologist can determine which of these assistive devices would be optimal for a specific patient.
Introducing older patients to tablets or smart phones can improve communication with both family and healthcare providers. There are many resources available on the Internet or as apps that can provide patient education, link the person to a wide variety of resources including support groups, or even provide socialization through use of social utilities such as Facebook.
Finally, using effective communications practices can help to minimize difficulties in the healthcare provider–older adult communication process. Written communication should be high contrast, with dark letters against a white background. Robinson et al. (2006) provided the following specific suggestions to improve communication:
- Schedule extra time for older patients who may have problems understanding teaching and may need additional time to interact with their healthcare provider.
- When making home visits, give the individual full attention by eliminating distractions, including phone calls, televisions, radios, etc. Try to make the patient comfortable and feel like he/she has your undivided attention.
- Sit face-to-face with the patient. Some patients who have difficulty hearing may be able to read lips.
- Speak slowly, enunciate clearly, use short simple words, and complete sentences. Speak to the patient as an adult, but explain medical terms that may be unfamiliar. If you have to discuss a difficult concept, try to use explanations that are simple and straightforward.
- Do not rely solely on verbal instructions, but give the patient or caregiver written instructions.
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