Communicating with Older Adults

Concepts of normal aging

Effective communication with older adult adults requires a thorough understanding of the normal health-related changes associated with aging. Aging is a term used to describe “advancing through the life cycle, beginning at birth and ending at death” (Pankow & Solotoroff, 2007, p. 19). Although aging is a lifelong process, the most common interpretation refers to physiologic decline, and associated mental and social changes occurring in late adulthood.

Aging is a normal physiologic process, accompanied to a greater or lesser degree by changes in appearance and energy levels, degenerative changes in organs and tissues, a weaker immune system, sensory losses, and decreased functional capacity related to mobility. Aging affects physical strength, stamina, and flexibility, and ultimately, an individual’s ability to negotiate the physical environment. Cotter and Gonzalez (2009) define “successful aging as the ability to adapt flexibly to age-related changes without relinquishing the central components of self-definition” (p. 335).

Older adults are often treated as if they represent a single cohort, when, in fact, there are huge differences in their life experiences, opportunities, capabilities, interests, and relationships. As people live longer, the term older adult or senior is broken down into three age cohorts: young old (65–74 years), old-old (75–84 years), and oldest-old (85 years and older) (Moody, 2010). A lot of older adults are frail and can have reduced function because of age-related disease, but many will retain a high level of physical and intellectual function until close to their death.

Each person’s experience of the aging process is unique, reflecting his or her genetic makeup, personality, life experiences, as well as environmental and cultural factors. Aging is a life process influenced by many factors, some of which are preventable or reversible. Although genetic and physiologic factors are not totally within an older person’s control, learning adaptive self-management strategies can make a major difference in an older adult’s overall health and quality of life.

Aging need not be a negative experience. Healthy older adults generally have more time and less responsibilities. There is time to travel, engage in activities one didn’t have time for previously, develop new interests, take a course, take an active role in community activities, share their talents with others, and enjoy family and grandchildren. Our attitude toward aging can become a self-fulfilling prophecy. Bortz (1990) states:

Biggs (2001) notes that positive stories of aging need to be told and incorporated into contemporary social policy. Older adults often lack the developmental supports provided earlier in life. People take pride in teaching and supporting children and young adults to achieve the life building skills they need as their developmental needs change. Articles detail the signs and symptoms of degenerative changes, with less attention paid to what older adults need to enhance quality of health and well-being.

Aging has direct and indirect effects on communication and interpersonal relationships. Nurses working with older clients need to have a thorough understanding of the aging process and positive respect for their struggles. Exercise 19-1 provides you with an opportunity to explore your personal ideas about aging.

Theoretical frameworks used in the care of older adult clients

Assessment strategies with older adult clients

New situations can cause transitory confusion for older adults, apart from cognitive impairment. Many clients are aware of the stereotypes associated with aging and are reluctant to expose themselves as inadequate in any way. Knowing what to expect helps decrease anxiety and build trust. Continuity of care with one primary caregiver, when possible, helps foster the development of a comfortable nurse-client relationship.

Older adults are likely to be more responsive when time is taken to establish a supportive environment before conducting a formal assessment. Otherwise, it can be difficult for clients to discuss emotional issues associated with the aging process or their physical ailments. Sensitive issues such as loneliness, abuse and neglect, caregiver burden, fears about death or frailty, memory loss, incontinence, alcohol abuse, and sexual dysfunction will only be discussed within a trustworthy relationship (Adelman, Greene, & Ory, 2000).

Older adults appreciate having the nurse provide structure to the history-taking interview by explaining the reasons for it and what it will involve (Cochran, 2005). Asking clients to share something about themselves and their life history, apart from the reasons for the health visit or admission, helps to establish rapport and increases the client’s comfort level.

By relating their life stories and exploring options relevant to their current health situation, older adults are able to step back and look at their situation in the present from a broader perspective. Nurses get to know the client as a person, rather than categorically as an “older adult.” Box 19-1 identifies communication guidelines for assessment interviews.

Moody (2010) maintains that old age “is shaped by a life time of experience” (p. 2). Assessment of older adult clients begins with their story. As they relate their story, look for value-laden psychosocial issues (e.g., independence, fears about being a burden, role changes, and vulnerability) and client preferences. These are significant issues for older adults clients that may not be directly expressed.

Helping clients identify sources of social support, personal resources, and coping strategies helps soften the impact of physical and emotional stressors associated with age-related transitions (Gilmer & Aldwin, 2003). Exercise 19-4 provides a glimpse into the life stories of older adults.

Psychosocial communication supports

Older adults who are institutionalized in nursing homes appreciate short, frequent conversations. Like everyone else, the need to be acknowledged is paramount to older adults’ sense of self-esteem. Heliker (2009) describes a story sharing intervention identified as “a reciprocal give-and-take process of respectful telling and listening that focuses on what matters to the individual and minimizes the power of one over another” (p. 44). Conducted in long-term care facilities, this strategy emphasizes simple one-on-one human conversations with older adults about topics of interest to them.

Everyone has a story to tell. The use of short stories to frame conversation as a shared experience reminds clients that they have a valued social identity that goes beyond descriptions of their health. Each time an older adult tells their story, they remember when they saw themselves as a valued, productive member of society and that someone cares to listen. Nurses can teach and model this communication strategy with nursing assistants.

The conversational world for older adults can narrow for many reasons, for example, mobility, death of friends, and transportation. Spontaneous current events to draw from as a means of starting a conversation are not as available. A limited conversation repertoire happens with cognitively intact older adults, and they may repeat stories.

Repetitive stories can be frustrating for nurses. Rather than thinking, “Oh my, here he goes again with that old ‘Model T’ car story,” it is better to respond to the story and enter the conversation as fully as possible. Each conversation is an opportunity to gain insight into the person who he or she was, what aspirations and dreams were fulfilled or unfulfilled, what contributions are valued, and what goals are yet to be attained.

Social and spiritual supports

Social isolation compromises the health and well-being of older adults (Strine, Chapman, Balluz, & Mokdad, 2008). Staying engaged with life to whatever extent is possible and stimulating the mind are two critical strategies healthy older adults can use on a daily basis to promote health and well-being as they grow older.

Quality friendship is an incomparable resource for older adults. Social support for older adults may need to be more proactive and wide-ranging than for younger people, because the older adults’ physical or intellectual vulnerability. They may require instrumental support with self-management of IADLs from family and friends. Helping family members and friends balance necessary assistance with the client’s need for autonomy is a delicate art.

Bishop (2008) notes, “Social and spiritual ties share an interdependent link to positive psychological well-being in late adulthood (p. 2). For people who have lost a “people” support system, connection with a personal God or faith can be a very important source of support. Older adults express their spirituality through prayer, reading their bible, and engaging in religious or spiritual practices.

Awareness of a shortened life span promotes thinking about existential issues, death, and for some, the need to work through unresolved life issues. Spiritual interventions relevant to the care of older adults include instilling hope, prayer, and talking about the client’s spiritual concerns. Helping clients cope with unfinished business and find forgiveness for self and others is identified as an important nursing intervention (Delgado, 2007). Clients with advanced dementia will often respond positively to spiritual hymns remembered from the past and to Bible readings.

Environmental supports

Maintaining independence for as long as possible with a good quality of life should be a goal for older adults. Independence is something most people take for granted as a younger adult, but it becomes a significant issue for older adults and their caregivers. Corey and Corey (2006) note, “As we age, we have to adjust to an increasingly external locus of control when confronted with losses over which we have little control” (p. 403).

The nurse plays a critical role in helping older adults maintain their autonomy. For older clients, being independent means that they are still in charge of their lives. As nurses assist clients to clarify values, make choices, and take action, a stronger understanding of their unique needs and strengths emerges. Older adults need to take as much responsibility for their choices and goal setting in health care as is possible.

Dialogues linking successful past coping experiences with present situations make it easier for the client to imagine possible individualized coping skills in the present. At the end of the dialogue, the nurse might summarize what the client has expressed and follow up with, “I enjoyed talking with you. You’ve had a fascinating life. What do you think is next for you?”

Nurses need to be sensitive to the unexpressed fears of older adults around surrendering their independence. Formal support services in the community, home health aides, and informal family supports can be critical factors in enabling frail older adults to remain independent.

You may need to directly observe environmental supports, bearing in mind a potential association in the older adults’ mind between accepting help and relinquishing independent living. For example, an older adult in cardiac rehabilitation told his nurse that he had a bedside commode and no stairs in his home. When the nurse visited the home, there was no commode, and the client’s home had a significant number of stairs. He told the nurse that he was afraid she would take steps to make him move if these facts were known.

Safety supports

Although there will always be a delicate balance between the client’s needs and restrictions or supports needed for safety, usually at least some areas can be negotiated. Simple interventions to promote independence include the following:

Modern technology presents new possibilities to support the independence of older adults. Telehealth assistive services encompass virtual health visits, reminder systems, home security, social and health alarm monitors, and compensatory supports for failing functional abilities (Magnusson, Hanson, & Borg, 2004). Although telehealth is currently unavailable in many areas, innovative technology is likely to become an increasingly important component of support care for independent older adults.

Advocacy support

Fundamental rights of older adults in health care settings are identified in Box 19-5. Nurses play an important service in explaining treatment to clients and families, and helping them frame questions for physicians and hospitalists. Nurses assume advocate roles with older adults around the following issues:

Role modeling is an indirect form of advocacy, affecting the interpersonal relationships older adults have with their caregivers. Nursing assistants or professional caregivers provide the majority of care for older adult clients. Role-modeling excellent care and respect for the dignity of the older client, regardless of medical condition, is important. It is noted by family and nonprofessional staff, and has a ripple effect on the care that they provide.

Nurses can refer client family members to local Alzheimer’s disease and related dementia support groups. Support groups provide a place to talk about the challenges of caring for their family member. The 36-Hour Day (Mace & Rabins, 2006), developed from the insights of family members coping with dementia in a loved one, is an excellent resource.

Health promotion for older adults

The CDC maintains that health-damaging behaviors such as poor nutrition, inactivity, and alcohol and tobacco abuse contribute heavily to the onset of disability in the elderly. They recommend an integrated health promotion approach to address common risk factors and comorbidities in older adults (Lang et al., 2005).

Older adults are much more health conscious today. They benefit from health promotion activities tailored to their stage of life. It is never too late to practice good nutrition; engage in healthful exercise such as strength training, walking, and yoga; connect with social relationships on a regular basis; and improve safety factors.

At the same time, healthy older adults are not young people. Their nutrition, exercise, and other health needs are different. Health promotion strategies need to be modified to meet the unique requirements of this population (Nakasato & Carnes, 2006). Box 19-6 identifies areas of relevant health promotion activities for older adults.

Through regularly scheduled health promotion activities, nurses can assist clients in learning about a healthier lifestyle. Nurses can engage older adults in health promotion activities by appealing to their interests and by incorporating cultural values in the presentation. Examples of relevant activities can include:

Supporting adaptation to daily life

Box 19-7 outlines early cognitive changes seen with dementia. Memory loss is a consistent finding. Structure and consistency in the environment are important themes to consider. In the early stages, nurses can help clients develop reminder strategies such as making notes to themselves and using colored labels, alarms, or calendars. Focusing on what the client can do, rather than on deficits, does not change the course of the dementia. This strategy taps into the functions still available to the client and decreases feelings of hopelessness (Cotter, 2009).

Apraxia, defined as the loss of the ability to take purposeful action even when the muscles, senses, and vocabulary seem intact is a common feature of dementia. The person appears to register on a command but acts in ways that suggest he or she has little understanding of what transpired verbally. In the following case example, the caregiver observes the client’s difficulty. Notice how her response supports his ability to function. The client in the example had been the president of his company before being diagnosed with dementia.

Supporting communication

Difficulty with communication is a hallmark of dementia. The dementia client’s loss of communication is a gradual process initially and most clients can maintain superficial conversation, with empathetic support. Miller (2008) notes that dementia affects basic receptive (decoding and understanding) and expressive (conveying information) forms of communication. These deficits impact the person’s capacity to think abstractly and solve problems. Clients may have more difficulty with communication when stressed or tired. Identify yourself and address the client by name before beginning each conversation. Clients benefit from frequent orientations, word sharing, and redundancy. Box 19-8 summarizes communication guidelines.

The use of cues in communication is helpful to the older adult with short-term memory impairment. Word retrieval to express ideas diminishes (aphasia) over time. The dementia client, unable to continue, stops in mid-sentence or continues with phrases that have little to do with the intended meaning (Mace & Rabins, 2006). Allow extra time for clients to decode the material.

Anything to help reduce the client’s anxiety about groping for thoughts that do not come easily is useful. Helping clients put words or thoughts together allow the conversation to continue. Nurses can support clients by filling in missing words, or supplying a logical meaning, and then asking the client if this is what he or she meant. Another strategy is to almost finish a sentence and have the client supply the last word. If there are terms the client typically substitutes for common words or phrases, for example, the word “clock” for asking about time, use the client’s term. You also can ask the client to point to an object or describe something similar if you don’t understand what the client is referencing (Miller, 2008). As dementia progresses, clients become increasingly unable to understand and express complete thoughts. Eventually the client with dementia cannot carry on even simple conversations. Use questions that can be answered with a yes or no for clients with less verbal skill. Note whether the client’s behavior is consistent with the yes or no answer, and follow up if the behavior is incongruent with the words.

Restate ideas using the same words and sequence, and validate the meaning of a client’s response. Instead of using abstract prompts (like a specific time), use words directly applicable to the client’s daily routine, such as “before lunch” to anchor the client’s recognition of time frames. If a client rambles, you can refocus attention by selecting a single relevant thought from the stream of loosely connected ideas.

Cognitively impaired clients often are unable to follow instructions that consist of multiple steps. Breaking instructions down into single smaller steps helps mildly impaired clients master tasks that otherwise are beyond their comprehension.

Asking mild to early moderate cognitively impaired older adults about their past life experiences serves as a way to connect verbally with those who might have difficulty telling you what they had for breakfast 2 hours ago. Nurses should appreciate that when cognitively impaired adults share memories they are giving a gift to the nurse by sharing part of themselves when they may have very little else to give.

Remote memory (recall of past events) is retained longer than memory for recent events. Family members can be encouraged to reminisce with dementia clients. This can be a meaningful experience for the family member even when the client cannot actively engage in the discussion, as it is a means of connecting. It is not uncommon for a dementia client to show through facial expression or garbled words that he or she too experiences the connection, even if only for a fleeting moment. Or it may come later.

Reality orientation groups

Reality orientation groups are used with older adults experiencing moderate-to-severe cognitive impairment. Focusing on their personal environment, these groups keep people in touch with time, place, and person. Topics can include landmarks in the dining room, routes to the dining room or bathroom, the date, time and weather, what people would like to wear, and so on. Reality orientation groups may be conducted daily or weekly with three to four clients (Minardi & Hayes, 2003).

Validation therapy

Validation describes a therapeutic communication process used in later stages of dementia. Developed by Naomi Feil, validation recognizes that a client is responding to a different reality related to time, place, or person (Minardi & Hayes, 2003). Rather than confronting dementia clients with “facts”—that people they knew or places they have lived are no longer available to them—the nurse focuses on the personal meaning events and people hold for the client. For example, you might say, “Tell me about Mary,” or “What was it like living on M street?”

Defusing catastrophic reactions

Older adults with memory loss lack the cognitive ability to develop alternatives. They emotionally overreact to situations, and can have what look like temper tantrums in response to real or perceived frustration. Older adult tantrums are called catastrophic reactions, and they represent a completely disorganized set of responses. Usually there is something in the immediate environment that precipitates the reaction. Fatigue, multiple demands, overstimulation, misinterpretations, or an inability to meet expectations are contributing factors (Mace & Rabins, 2006).

The emotion may be appropriate, even if its behavioral manifestation is not. Warning signs of an impending catastrophic reaction include restlessness, body stiffening, verbal or nonverbal refusals, and general uncooperativeness.

Instead of focusing on the behavior, try to identify and eliminate the cause(s) (Hilgers, 2003). Use distraction to move older adults away from the offending stimuli in the environment; use postponement. For example, you could say, “We will do that later; right now, let’s go out on the porch,” while gently leading the person away. Direct confrontation and an appeal for more civilized behavior usually serve to escalate rather than diminish the episode.

Sundowning is the term used to describe episodic agitated behavior occurring in the late afternoon or early evening with clients in the middle stages of dementia. Common childlike behaviors of whining, agitation, and temper tantrums characterize the syndrome. Small doses of medication are used to alleviate symptoms. Caution is needed to avoid over-sedating the client.

Caring for clients with advanced dementia

As the dementia progresses, people lose control over most of their body functions and will experience one or more psychopsychiatric symptoms. They will require total care, which, in many cases, will include formal and informal caregiving strategies. Table 19-2 identifies common neuropsychiatric symptoms associated with advanced dementia, with suggested behavioral communication interventions.

Treatment goals for clients with advanced dementia should emphasize dignity, quality of life, and supportive comfort strategies, rather than focusing on prolonging life (Rabins, Lyketsos, & Steele, 2006).

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