COMMUNICATION WITH ELDERLY PATIENTS

Nama Penyusun/ NRP : Sri Susan Benedikta Siritoitet

Nama Dosen Pembimbing : Yesiana Dwi Wahyu Werdani, S.Kep.,Ns. M.Kep

FAKULTAS KEPERAWATAN

UNIVERSITAS WIDYA MANDALA SURABAYA

2017/2018
INTRODUCTION

Communication with patients has been recognized as one of the most important aspects
of nursing elderly people (Hockey 1976, Armstrong-Esther et al. 1989, Van Cott 1993).
Furthermore, communication is an important aspect of the quality of care. From several studies it
appears that poor communication is the largest source of dissatisfaction in patients (Macleod
Clark 1985, Ley 1988, Davies & Fallow®eld 1991). Consequently, the quality of care may
improve with effective communication.

Effective communication does not just depend on the acquisition of the right
communication skills (Wilkinson 1991). In the literature, three groups of variables have been
identi®ed that seem to determine the quality or quantity of nurse±patient communication:
variables related to nurses (referred to in this article as provider variables), variables related to
patients and variables related to the situation, in particular ward characteristics (Caris-Verhallen
et al. 1997a). In this paper, these three groups of variables are related to the way nurses
communicate in practice with elderly people.

General Techniques for Communicating with Older Patients

Establish Respect and Demonstrate Concern

Good patient communication is based on respect for the patient and an understanding and
appreciation of

General strategies

Prepare the environment of the examination room, in-creasing the lighting and decreasing
background noise (considering the probability of vision or hearing loss)

Address the patient and family member as “Mr.” or “Mrs.” and avoid terms such as “sweetie,”
“honey,” or “dear”

Speak slowly, clearly, without shouting, using a calm tone and pleasant expression

Use gentle touch with a light touch to the hand, arm, or shoulder
Maintain an unhurried pace, allowing the patient a few minutes to express his/her concerns if
able

Ensure it is the patient’s agenda you are addressing

Ask the elder to repeat back any important instructions

Provide written instructions in at least 14-point type

Remember the importance of psychosocial issues when caring for older patients

Cognitively impaired patients

Do not ignore the patient

Ask questions simply, using “yes” or “no” questions and simple gestures

When performing the examination, give one instruction at a time

Encounters with third party involvement

Prepare the environment of the examination room by setting 3 chairs in a triangle

Direct questions initially to the patient, then ask for input from the patient’s companion

Ask the patient and the patient’s companion to repeat back any important instructions

each patient as a unique human being. To demon-strate respect, you should address the
patient formally as “Mr.” or “Mrs.,” unless the patient has previously asked you to use first
names, and avoid using patron-izing terms such as “sweetie,” “honey,” or “dear” [8].
Communicate at eye level by sitting in a chair and directly facing the patient [8]. By doing so,
you dem-onstrate genuine interest and active listening, as well as help the patient to better hear
and understand you. A gentle touch on the patient’s hand, arm, or shoulder conveys concern and
interest [8].

Ensure the Patient Is Heard and Understands

Maintaining an unhurried pace and listening are key to effective older patient–physician
communication [8,9]. Allowing older patients a few minutes to talk about their concerns without
interruption will pro-vide more information than a rapid-fire structured history [8]. Feelings of
being rushed will cause older adults to feel that they are not being heard or under-stood [8,9].
Studies have shown that older patients and physicians often disagree about the goals of the
medical encounter [5]. Poor communication can impair exchange of information as well as
decrease patient satisfaction [5].

In general, you should speak slowly, clearly, and loudly without shouting, using short simple
words and sentences [8,10]. As older patients generally ask fewer questions and defer to the
physician’s authority [4,5], it is especially important to summarize fre-quently and invite
questions [10]. Additional general strategies for improving communication with older adults
include [8,10]:

• Gather preliminary data before the appointment, as older patients typically have complex and
mul- tiple health issues
• Have patients tell their story only once (ie, not to a nurse or assistant first and then to you)
to minimize patient frustration and fatigue
• Avoid medical jargon
• Simplify and write down instructions
• Use charts, models, and pictures
• Schedule older patients earlier in the day, as they are generally more alert and clinics tend to
be less busy

Avoid Ageism
One of the most important things to remember when communicating with older adults is
to avoid ageism. Ageism, a term first coined by Robert Butler, the first director of the National
Institute on Aging, is the systematic stereotyping of and discrimination against people because
they are old [6]. Ageism is prevalent in health care and may be reflected in such actions as
trivializing medical problems, using condescending language, providing less education on
preventive regi-mens, offering little treatment for mental health issues, using derogatory names,
spending less time on psy-chosocial issues, and stereotyping elders [7]. To avoid ageism, get to
know the older patient as a person with a defined history and accomplishments. This approach
enables you to see each older patient as a unique in-dividual with a lifetime of valuable
experiences rather than an unproductive, frail old person [11]. It is also important to not assume
that all older patients are the same. There can be “young” 85 year olds as well as “old” 65 year
olds. Each patient and each encounter should be treated uniquely.

The Patient with Sensory Deficits

Few adults escape age-related visual and hearing defi-cits, both of which will require
adaptations in commu-nication. Studies indicate that 16% to 24% of individu-als over age 65
have hearing loss that interferes with communication [12,13]. For those over 80, the num-ber
rises to more than 60% [14]. Aging results in au-ditory functional decline known as presbycussis,
which particularly affects high-frequency sounds. These are the consonant sounds that impact the
patient’s un-derstanding of the beginning and end of words. For example, if you say “Take the
pill in the morning,” the patient will hear the vowels in the words but may think you said “Rake
the hill in the morning” [15–18].

Age-associated visual deficits include reduction in pupil diameter; yellowing of the lens,
which makes it difficult to distinguish short wave lengths such as lav-enders, blues, and greens;
and a decrease in elasticity of the ciliary muscles, which results in decreased ac-commodation
when printed material is held at various distances. Additionally, many elders have eye diseases
that lessen visual acuity (eg, cataracts, macular degen-eration, glaucoma, ocular complications of
diabetes). More than 15% of adults over age 70 reported their vision as poor, and an additional
22% reported their vision as only fair [13]. For those over age 80, 30% reported vision as
impaired [14].

Approach to Communication
When communicating with an older adult with hear-ing loss, face the patient so he or she
can lip read and pick up visual cues. Minimize background noise, and speak slowly, clearly, and
in a normal tone [8]. Shouting hampers communication, distorting high-frequency tones and
making it more difficult for the patient to understand your words [8]. If your voice is high
pitched, deepening the pitch when you speak can help the patient hear you better [8]. When
giving in-structions for medications, tests, or treatments, avoid asking the patient if he or she
understands. Hearing-impaired people will likely answer “yes,” not realizing that they have not
heard everything or have misun-derstood some of the information. A better approach to checking
the patient’s understanding is to ask the patient to repeat the instructions [8]. Finally, because
hearing worsens later in the day, early appointments are generally better [17]. If available, a
voice amplifier (a small, portable device that amplifies the physician’s voice and transmits it into
headphones worn by the patient) has been shown to greatly facilitate commu-nication with
hearing-impaired patients [16].

When communicating with visually impaired pa-tients, the environment of the clinic can
be enhanced by improving illumination, using contrasting colors to make objects stand out (eg,
door frames around doors, chairs against the clinic floor), and using large letters and contrasting
colors in any signs [11]. Two sources of light, background lighting and a close light, are
recommended [11]. Any written material should be printed in at least 14-point type on buff-
colored paper [8,11]. When discussing treatment plans, keep in mind the potential safety issues
of vi-sion impairment. For example, older patients some-times will put their medications in one
container and depend on color recognition to identify them. This can be a safety issue, as many
medications are white, pale blue, or pale green, which will appear gray to the aging eye. The
colors of red, orange, and yellow are seen best and can be incorporated into care. In another
example, a patient who is having difficulty drawing up insulin might be instructed to place a red
placemat on the table, which will make it easier to see the syringe and vial. Similarly, red contact
paper can be wrapped around the handles of a walker, a cane, or oxygen tubing to help an older
patient locate these important items [8].

The Patient with Dementia

As of 2008, approximately 5.2 million persons in the United States had some form of
dementia, and this number is predicted to double over the next 30 years. As a result, physicians
can expect to see more pa-tients with dementia and to have these patients come in for visits
accompanied by family members or other informal caregivers [3]. (Note that the term caregiver
is used from this point to refer to any visit companion who is an informal caregiver.) Assessment
and treat-ment of older patients with dementia will need to in-clude consideration of the
caregiver as well [11,19].

There are many levels of dementia, which pose a variety of communication difficulties.
Patients in mild stages often experience subtle word-finding problems. As dementia progresses,
patients use a high proportion of nonmeaningful words, such as “these,” “things,” and “you
know.” In severe dementia, pa-tients may use unintelligible jargon or may be mute. Dementia
adversely affects patients’ receptive and expressive communication. Most patients have memory
loss with some difficulty with recall of recent events. Some will have very short concentration
spans and find it difficult to stay on a particular topic [21].

Approach to Communication
The most critical factor in communicating with the patient with dementia is to establish a
caring relation-ship as soon as possible. Of utmost importance is to treat the person with dignity
and respect. There is a tendency to infantilize patients with dementia or to speak to them as if
they are children. It must be remembered that patients with dementia are losing their ability to
communicate, not their intelligence. They are adults who have lived productive lives and deserve
respect. In addition, patients with dementia are very sensitive to others’ emotions. In general,
these patients respond more to how someone talks to them rather than what is actually said [21–
23]. Consequently, it is critical to approach these patients in a calm, pleasant manner. Patients
with dementia rely heavily on nonverbal communication, so it is important not to allow body
language to give the impression that you are in a hurry [20,22,23].

Upon entering the examination room, you should approach the patient directly and
slowly, making eye contact and exhibiting a pleasant expression. A calm tone of voice and a
gentle touch on the arm or shoul-der will usually convey concern and caring. You should
reintroduce yourself, even if you have known the pa-tient for many years. It is often effective to
begin the interview socially and to spend a few minutes chatting or reminiscing with the patient.
Reminiscing is a more effective communication technique with a patient with dementia because
long-term memory is often retained. For example, you might ask simple questions about the
patient’s past and then listen closely. Remi-niscing helps to overlap the past, present, and future
time spheres and helps reduce stress [22,24].

Questions should be asked simply and slowly

[22]. Jargon and use of figurative terms should be avoided, as patients will interpret these
statements literally [22]. For example, when asking a patient to describe epigastric pain, you
should avoid asking if it is a “burning” pain. Simple physical gestures can be helpful. You can
place your hand over your chest and move it up and down. Sometimes closed-ended (“yes” and
“no”) questions may work best [21,22]. Wait 15 to 20 seconds before repeating the question,
using the same words [22]. Routinely quizzing with orientation questions will likely cause
frustration. Pa-tients with dementia cannot answer these questions because of memory loss
[22,23]. Listening closely to patients with dementia is critical. Although you may not understand
everything, a few words in the con-versation may provide an idea of what the patient is
attempting to convey. Caregivers often can decipher bizarre or out of place words that are
grounded in the patient’s past experiences [22,23].
When performing the physical examination, it is preferable to give one instruction at a
time [22]. For example, if you want to examine the patient’s gait, it is best not to say, “Please
stand up, walk across the room, and walk back.” It would better to begin by saying, “Please stand
up.” Then, after the patient has accomplished this task, proceed with, “Please walk across the
room.” Patients with dementia can easily misinterpret touching of the body during the physical
examination. It is important to convey respect and ask permission with each step of the
examination. For example, “May I listen to your chest?” (and show the stethoscope), “May I
check your abdomen?” (and then examine the abdomen), and so on [22].

The Patient Who Is Accompanied by a Caregiver

A major characteristic of the geriatric clinic visit is the presence of a third person, with a
family member or other informal caregiver present in at least one third of geriatric visits [11].
Although caregivers can as-sume a variety of roles, including advocate, passive participant, or
antagonist, in most cases they have their loved one’s health as the priority. Caregivers are critical
to the health care system. Not only do they as-sist with nutrition, activities of daily living,
household chores, medication administration, transportation, and other care for older adult
patients, they help to facilitate communication between the physician and patient and improve
patient involvement in their own care [25,26]. It is essential to treat older patients in the context
of their caregiver(s) to attain the best outcomes for both [8,27].

Approach to Communication

At the first visit, in order to protect the patient’s privacy, it is best to see the patient alone
and to ask the patient’s permission to speak to the caregiver alone [28]. In subsequent visits, if
agreeable to the patient, the caregiver can join the patient during the appointment [28]. When a
caregiver is present during the clinic visit, the communication becomes a 3-way interaction. To
facilitate communication, you should arrange chairs so that the 3 of you are sitting in a triangle.
Then, you can pose questions to the patient and then ask for input from the caregiver. Caregivers
can clarify older patients’ concerns and reinforce any

instructions that are provided to patients. Important-ly, you need to involve the patient in the
encounter, even if a caregiver interjects by answering questions. Patients are frequently excluded
or minimized during visits in which a third person is present, so it is impor-tant that you always
try to fully involve the patient in all decisions [8,29].

The doctor-patient-caregiver relationship is dy-namic, changing over time as patient and

caregiver needs change. Caregivers can provide descriptions of symptoms, changes in
functioning, and assessments of medication effects. Since the caregiver is integral to the patient’s
care, it important to be alert for verbal and nonverbal signs of physical or emotional stress of the
caregiver [28]. Caregivers’ perceptions of patients’ ability to perform activities of daily living are
highly correlated with caregivers’ level of distress. Thus, you should ask questions that elicit de-
scriptions of the patient’s level of functioning and ob-serve for signs of stress or depression in
the caregiver. Praise for the caregiver provides encouragement to both patient and caregiver [30].

Conclusion
The ultimate benefit of applying these communication techniques will be improvement in
outcomes for older patients and their caregivers. Evidence indicates that outcomes of health care
for older adults are dependent not only on care of biomedical needs but also on the caring
relationship created through effective commu-nication [31]. With effective physician–older
patient communication, patients are:

• More likely to share their symptoms and con-cerns, which will enable the physician to
make a more accurate diagnosis [32];
• More likely to follow through with physician recommendations [33];
• Less likely to skip doses or stop a medication because of side effects, perceived nonefficacy,
or drug cost [33,34]; and
• More likely to self-manage diabetes with diet, exercise, blood glucose monitoring, and
foot care [35].
 Decreases in diagnostic testing costs have also been associated with better physician–older
patient com-munication [34]. Ultimately, the interview itself can be therapeutic for the older
patient. The physician– older patient relationship goes far beyond medical care and, like all
successful relationships, is based in closeness and trust. Open and frequent communica-tion
between the physician and older patient is the most important element in this relationship
[11,31].