Care of Older Adults

II. Therapeutic Communication with Older Adults ▪ Staff should be aware of basic operations (e.g.,
battery charging) necessary to keep the unit in
What is Communication?
functional order and provide the patient with the
₋ The term originates from the Latin word “commune,” opportunity to safely store and charge the device
which means “to hold in common.” as needed.
₋ The word implies that communication is a process that
involves more than one person. ₋ Refers to behaviors or gestures that convey a
₋ It is the process or means by which an individual message without the use of verbal language. It can
relates experiences, ideas, knowledge, and either enhance the delivery of a message or create a
feelings to another. barrier to understanding.
₋ It is a reciprocal process involving minimally two Examples:
people, a sender and a receiver. • Saying “STOP” loudly and with a raised hand with five
₋ Effective communication depends on the ability of both fingers extended, or Using eye contact in addition to a
to engage in the process of sharing not merely words, verbal greeting to welcome the individual.
but also concepts, emotions, and thoughts. ₋ When similar verbal communication and nonverbal
gestures are together, they can help us to deliver our
 Physiologically, communication occurs as a result of a message and improve communication.
complex interaction of cognition, hearing, speech, and
language centers. Cognition is essential to sending, ₋ Refers to the tone, pitch, speech rate, or fluency of
receiving, and interpreting information in our verbal communication.
communications. Example:
 The cortex of the brain is the primary repository for • The guard used pitch and tone to say “STOP” loudly,
cognition. Within the cortex are a multitude of thereby catching our attention. What if the guard said
interlinked storage areas that help store, retrieve, and the same word but in a normal voice—would it convey
make sense of messages coming from the world. the same meaning? A nurse, directing a patient to a
 The second cortical function that is important for clinic exam room, who says in a loud, harsh tone,
communication is language production and the ability “Come here to this room,” may be perceived by the
to speak. Language is the use of symbols or gestures patient to be stern and uninterested in him or her as a
that are common to groups and serve as a means of person.
sharing thoughts, ideas, and emotions. To communicate effectively, we should be aware of our verbal
 Broca’s area at the junction of the parietal and frontal and nonverbal vocal communications. What we say and
lobes in the dominant hemisphere is responsible for how we say it are essential to therapeutic communication.
speech production.
 Wernicke’s center at the intersection of the parietal and ₋ Refers to the use of facial gestures, body posture,
temporal lobes is the area of speech recognition. eye contact, and touch as a means of communication.
o Damage to Broca’s area and Wernicke’s Example:
center will result in aphasia. • A staff looking intently at a chart, avoiding any eye
▪ APHASIA is an acquired loss or contact or facial expression while greeting a new
impairment of language. The most patient. In this example, the staff member’s nonverbal
common cause of aphasia is brain communication speaks louder than his words. In this
damage that occurs with stroke. case, the patient may report the service was poor and
▪ Symptoms of aphasia include the staff was uninterested.
trouble speaking clearly, trouble ✓ Non-verbal communication on the part of the patient is
understanding speech, trouble also an important factor in therapeutic communication
writing clearly, trouble in a health care setting.
understanding written words, trouble ✓ The staff nurse used a simple verbal comment to clarify
remembering words, and trouble the meaning of the patient’s nonverbal behavior and
remembering object names. determine her next action. A patient’s nonverbal
 Important structures of speech are the diaphragm, communication can provide nurses insight into the
intercostal muscles, larynx, vocal cords, tongue, and person’s feelings and emotions. Learning to read the
muscles of the mouth and face. When someone patient’s nonverbal gestures is important for nurses.
sustains damage to these structures, we say the ✓ Communication involves more than one person, so
individual has dysarthria. both the sender and the receiver must be attentive and
o dysarthria refers to a group of neuromuscular demonstrate good communication skills. The goal of
disorders that affects the speed, strength, effective communication “is interpreting the messages
range, timing, or accuracy of speech and responding in an appropriate manner” (Caris-
movements, which often result in reduced Verhallen, Kerkstra, & Bensing, 1997). Through our
intelligibility of speech. communications, we are not merely sending a
message, but creating shared meaning and
₋ Is “any item, piece of equipment, or product system, understanding of an event, experience, or memory.
whether acquired commercially off the shelf, modified The receiver must be open to the ideas of the sender
or customized, that is used to increase, maintain, or and provide respect during the conversation.
improve functional capabilities of individuals with ✓ Being silent, showing attentiveness, and listening
disabilities” (Olson & DeRuyter, 2002). It helps to the sender are critical. Good listening starts with
individuals improve their mobility, communication, allowing time for conversation to occur. When we are
self-care, or vocational skills. rushed it is difficult to give the time and attention
needed to truly understand the meaning associated
₋ Is an integrated group of components including with the words spoken. Try to approach each
symbols, aids, strategies, and techniques used by conversation with an open mind and a willingness to
individuals to enhance communication (Henderson, listen.
and Doyle, 2022). Communication in Health Care
Nursing Considerations for AAC
₋ Good communication in health care is the foundation
▪ Learn from the patient or his caregiver how to use the
for optimal outcomes.
device.
₋ Nurses use therapeutic communication skills to gather
▪ Ask permission from the patient prior to handling any
assessment data from patients and their families which
assistive technology, and always be respectful by
is essential to diagnosis and care planning.
storing it in a place that is accessible to the patient and
₋ Nurses rely on communication skills to provide
that provides the greatest degree of safety for the
information and education, and to encourage patients
device.
to change behavior and promote health.
▪ All nursing staff and health care professionals who
₋ Nurses provide the caring word or touch that helps to
work with the patient should learn to use the device
relieve pain or distress.
and allow time for the patient to use the device to
communicate.
Angel Fatima Hernandez
 Care of Older Adults
₋ Communication is a two-way process, so it is 6. The ideal position when communicating with a patient
important to look at communication in health care from is one whereby the sender and receiver are seated 3–
the consumer or patient perspective. Caris-Verhallen, 6 feet apart with chairs positioned to allow for eye-to-
Kerkstra, and colleagues (1997), in a review of the eye contact.
literature on the role of communication in nursing care 7. When having a conversation with a person in a
of the older adult, discuss the distinction between wheelchair, remember to pull up a chair and position
instrumental or task-focused communications and yourself at equal height to the person.
affective communication from the perspective of the 8. For patients with impaired vision, reposition the chair
consumer. so you can be seen within their field of vision.
₋ Instrumental or task-focused communications refers to
behavior necessary for assessing and solving
problems. In this type of communication, the primary 1. Use language and terminology that are familiar to the
interest of the health care provider is to gather patient. Use language appropriate for the receiver.
information that will help them provide care for the 2. Use an interpreter to present the information to the
person. The conversations may be formal and individual in his or her primary language.
structured, such as the admission interview, a health 3. Use age-appropriate language in communication.
assessment, discussion of advance directives, or 4. Show respect by addressing the patient by his or her
patient–family education. In these conversations, the surname.
health care provider is initiating the conversation with a 5. Avoid familiar terms such as “honey,” “bud,” or
specific intent of gathering information from the “sweetie,” which can be demeaning to the individual.
patient that will be of assistance in diagnosing or 6. During the initial interview, ask the patient how he or
treating patient problems. she prefers to be addressed and make note of this
✓ Instrumental communications may be in the care plan or medical record. Our language
informal conversations as well. Informal should demonstrate respect for the individual as an
conversations include when the nurse asks adult.
the patient “What time do you want to eat?” or 7. Periodically ask the receiver to clarify what he or she
“What would you like me to order for your is hearing as a means of ensuring accurate
meal today?” Once again, the conversation interpretation of your message.
is focused on the health care provider To maximize understanding, ask the individual to repeat
requesting information necessary for what you said or tell you what this means for them in their life.
caring for the patient. In all these cases the
conversation is generally initiated by the 1. The most important skill to maximize understanding is
health care provider and the focus is a to learn to listen. Listening requires not only hearing
question about how best to care for the the words spoken, but also understanding the meaning
patient. and context in which they are spoken.
₋ The second type of communication from the patient 2. We must be open-minded and provide opportunities
perspective is affective communication, which focuses for the individual to share their thoughts with us. It
on how the health care provider is caring about the means allowing time to communicate and focusing
patient and his or her feelings and emotions. attention on the person at the time of the conversation
Affective communications tend to be more informal 3. Minimize environmental distractions not only helps
and more difficult for health care providers. the individual with whom we are communicating, but
✓ There is a greater degree of vulnerability for also helps us maintain our focus.
the health care provider in affective or Words backed by actions help develop trust. A relationship
psychosocial communications to develop an built on trust and concern for the welfare of others is critical
emotional or personal relationship with to optimal health outcomes. These simple techniques can be
the patient. By electing to spend time with the applied to all of our communications.
patient and allowing him time to talk about his Consistent with schedules and promises. If not possible
life and emotions, the nurse conveyed her during the scheduled time, --please inform.
interest in knowing him as a person. Challenges in Communicating with Older Adults
✓ Affective communication is important in long-
term health care relationships, be it a nurse
practitioner treating a patient with chronic ✓ Cognitive damage may occur secondary to metabolic
illness in the clinic or a nurse working with a damage, stroke, or hormonal or degenerative disease
patient in long-term care or in the home. Think ✓ The mini-mental state exam (MMSE) is a reliable
about ways a nurse can demonstrate caring screening tool to assess cognitive function. Individuals
about the person rather than merely caring with cognitive deficits secondary to diffuse cortical
for the person. damage present with signs of dementia, including
decreased attention span, memory loss, word finding
problems, and perseveration.
1. Arrange a simple conversation rather than doing an ✓ Early on in the disease process, conversation and the
assessment on the run. opportunity to share memories with others can be
2. Greet the person by name and ask a non-threatening rewarding and energizing for the person.
and open-ended question, thereby engaging the ✓ Regular conversation helps orient the individual to
person in conversation. “Tell me about yourself and daily activities and creates a structure that
what brought you here today” invites the person to promotes independence.
share information about themselves in a non- ✓ Conversation that encourages thought and
threatening. reflection can help keep the mind active. Just as
3. Arrange an environment conducive to communication. exercise is important to the maintenance of physical
The environment should be comfortable, provide function and mobility, mental exercise is equally
privacy, and minimize distractions that could be important.
barriers to communication, such as noise or poor 1.1 Alzheimer’s disease
lighting. • One of the most common problems affecting cognition
4. Respect personal space and territory when and memory among elderly.
arranging an environment conducive to conversation. • Dialogue should be encouraged for as long as
When entering an older patient’s space, simple possible.
gestures such as asking permission to sit or move the • Use simple instructions and ask yes or no questions.
furniture conveys a sense of respect for the person. • Use cues from the person’s behavior and reactions to
5. If the individual uses assistive equipment such as a decide whether to modify your approach.
wheelchair, cane, or communication device, ask • Be aware of one’s own body language and tone of
permission before touching the equipment. It is voice as well.
equally important to ask where items should be placed • Nurses may need to experiment with various types
prior to leaving the room to facilitate independence of communication, and approaches may need to be
and provide safety. modified as the person’s dementia progresses.
Angel Fatima Hernandez
 Care of Older Adults
find today’s date and mark it so we can find it later.”
1.2 Aphasia (speech deficit) Ask one question at a time.
• An acquired loss or impairment of language that occurs 17. If the individual becomes upset or agitated, ease up
as a result of damage to the speech centers in the and use distraction to change the topic or provide a
dominant hemisphere of the brain. period of quiet to allow a cool-down period.
• Individuals with aphasia should be evaluated by a 18. Show interest in the person.
speech language pathologist who can provide 19. If it is difficult to hear the person, gently ask his or her
instruction on the best strategies to use with each to speak louder.
person. 20. Provide time for conversation. Sometimes it will take a
• The most common types of aphasia are global aphasia, while to get the message out. Sometimes it is easier for
Broca’s aphasia, and Wernicke’s aphasia. the person to tell a story than respond to a direct
Patients with a global aphasia typically have problems question.
understanding language as well as producing speech. 21. Don’t laugh at responses, no matter how bizarre.
Language is typically nonfunctional in all modalities, Acknowledge your inability to understand and your
speaking, reading, and writing. At times the individual may frustration. It’s probably a mutual feeling that both
repeat a sound or word over and over. Although the parties share.
individual may have difficulty speaking, he or she may
understand nonverbal gestures. It is important to include all 1. Include the individual in conversations. Look at the
patients with aphasia into social groups. person as well as others during conversation.
₋ Nonverbal gestures such as nodding toward the 2. Treat the person as an adult.
individual as you address them make the individual 3. Provide time for the individual to speak.
feel included. 4. If you don’t understand the person, politely say so: “I’m
Broca’s aphasia is a non-fluent, agrammatic expressive sorry, I can’t understand what you are saying to me.”
aphasia. Individuals with Broca’s aphasia typically have good 5. End the conversation with a smile.
auditory comprehension. They are able to understand what is 6. Environment: Position yourself across from the person
said to them; however, they have difficulty producing so they can see your face and you can see theirs.
intelligible speech. This is often quite frustrating for these 7. Understanding: Speak naturally. Don’t raise your
individuals, because they know what they want to say but voice—it won’t help.
just can’t get it out in words that have meaning to the 8. Speak slowly using simple words and sentences.
receiver. 9. Use simple gestures to supplement your message.
₋ Communication requires great patience. 10. Tell the patient one thing at a time.
₋ It is important to give the patient an opportunity to 11. Announce topic changes and allow a few minutes
speak, because with time and therapy these before proceeding.
individuals may make important gains in learning to 12. Look at the person and listen as they speak.
communicate with others. 13. If you don’t understand, ask them to describe the
Wernicke’s aphasia is a fluent aphasia. The individual is word, use another word, say or write the first letter,
able to speak and produce language, although the speech point to the item, or describe the context for use.
may contain many odd words and sounds. Wernicke’s 14. If the individual is able to write, ask them to write the
aphasia is characterized by impaired auditory word or use a word board to spell the word.
comprehension, so in this case the individual has great 15. Follow instructions from the speech language
difficulty understanding what is said. Often, he or she pathologist to improve the consistency of
must rely on our nonverbal gestures to understand communication.
directions or questions. It takes time and patience to
communicate with individuals with aphasia. 1. Remember that speech impairment is not related to
₋ Nurses should structure activities and provide intelligence.
opportunities for these individuals to be engaged 2. Use age-appropriate language.
in some form of communication. 3. Make a note in the medical record if the individual uses
₋ Refer to speech therapist. an AAC device. If you know the individual uses an AAC
device, store it in an accessible location so it is readily
available for use.
1. Approach persons in a nonthreatening manner within 4. Provide a quiet environment with minimal
their visual field. distractions can help facilitate understanding.
2. Sit quietly with the person and gently touch her hand. 5. Face the person as they are speaking for facial cues
3. Be respectful of the patient’s belongings. and gestures that can enhance understanding.
4. Ask permission before moving objects. 6. Speak in a normal tone because the patient has no
5. Show concern; stop and have a conversation—don’t problem in hearing.
limit communication to times when you need 7. Encourage the person to speak slowly and use
information. simple sentences or single words.
6. Post a few pictures, a calendar, or a daily schedule in 8. Allow time for the patient to respond. Don’t try to
the patient’s room and use it to enhance conversation complete their words or sentences.
or promote recall. 9. If there is no speech (aphasia, presence of an artificial
7. Sit so you are facing the person when speaking. airway, post-operatively after oral surgery):
8. Avoid a setting with a lot of sensory stimulation—it can 10. Assess the individual’s yes/no reliability. Establish a
be distracting to the person. system for yes/no communication (picture board or eye
9. Maintain eye contact; it will help keep the patient blink—1 yes, 2 no).
focused on you and the topic. 11. Post rules for use at the bedside and in the medical
10. Be respectful of space. record. Ask yes/no questions and allow the person time
11. If the individual chooses to get up and start walking to respond. Confirm response before acting.
mid-conversation, ask if you may follow.
12. Speak in normal tones. Use age-appropriate language. • As the receiver it is important not to fake or pretend
13. Start with a familiar topic. Sometimes this means you understand.
talking about the past, then through conversation • If the message is not clear, ask the individual to
bringing the person back to current circumstances. repeat, write, or communicate key words by using
14. Talk about people or events known to the person. This gestures.
may mean referring to a deceased family member—the
individual will let you know if this reference is • Individuals with visual impairments have no difficulty
comforting or distressing. hearing or speaking; however, they will miss
15. For many individuals, pleasant memories from the past nonverbal communication. These individuals will have
are a source of comfort. difficulty reading signs or relying on visual cues for
16. Orientation questions can be confusing and frustrating orientation or education purposes. Printed materials
for the person, so rather than asking, “What’s today’s may need to be large or translated into Braille to
date?” consider asking, “Where’s the calendar? Let’s maximize understanding.

Angel Fatima Hernandez

 Care of Older Adults
8. When speaking, face the person directly so that he or
• Individuals with hearing loss fall into one of two groups, she can see your lips and facial expressions. The
the hearing impaired and those who are deaf. preferred distance is 3–6 feet from the person.
• Individuals with a hearing impairment have a 9. use written notes to maximize understanding and
reduced ability to hear across the spectrum of involve the person in the conversation.
sound. 10. Avoid chewing, eating, or smoking as you speak—they
• Individuals who are deaf cannot hear. They rely on will make reading your speech more difficult.
one of several forms of sign language as their primary 11. When using an interpreter, face the individual not the
language. interpreter—when asking as well as listening to a
response.
1. Gently call out to the individual when entering the room 12. Be mindful of your nonverbal expressions during
and identify yourself and anyone with you in the room. conversations—remember you are conversing with the
If the individual can see shapes or outlines, stand person, not the interpreter.
where he or she can see you. The best location will 13. Allow the individual to be involved in making
vary—make a note on the medical record alerting other decisions—don’t assume it takes too much time to ask.
staff to the patient’s needs. 14. Provide time for the individual to return to
2. Minimize distractions. communication and keep your focus on the person.
3. Describe the environment and where you are located 15. Ask questions to clarify the message; if needed, have
in relation to the person. the individual write his/her response
4. Explain what you are doing, especially when you are
moving and creating sounds in the room (e.g., storing
dressing supplies in the closet, preparing equipment to
draw blood, etc.). Make certain not to move frequently
used objects.
5. Alert the person when you will be touching them.
6. Oral communication with touch is more important
than nonverbal gestures that they cannot see; use an
appropriate tone of voice.

1. To get the attention of the person, touch the person

gently, wave, or use another physical sign.
2. Store assistive devices—hearing aid, notepad, and
pen—within reach of the individual.
3. Make certain any emergency alarms essential for
safety have a light or visual alert to get the individual’s
attention in case of emergency.
4. Allow time for the conversation.
5. If the individual uses a hearing aid, check to see
whether he or she is wearing it and that it is turned on.
6. Minimize background noise (turn off the radio or TV
and close the door to minimize distractions from the
hall).
7. When speaking, face the person directly so he or
she can see your lips and facial expressions. The
preferred distance is 3–6 feet from the person.
8. Speak clearly in a low-pitched voice; avoid yelling or
exaggerating speaking movements—it won’t help.
9. Use short sentences.
10. Don’t hesitate to use written notes to maximize
understanding and involve the person in the
conversation.
11. Avoid chewing, eating, or smoking as you speak; they
will make reading your speech more difficult. Keep
objects (e.g., scarf, hands) away from your face when
speaking.
12. Allow the individual to be involved in making
decisions—don’t assume it takes too much time to ask.
13. Provide time for the individual to speak.
14. Ask questions to clarify the message; if needed, have
the individual write a response.

1. Note on the patient’s record that the individual is deaf

and may need an interpreter.
2. Document if the individual uses American Sign
Language or other assistive communication.
3. Use a TDD phone or relay service to communicate with
the person.
4. Use an interpreter for conversations regarding health
care decision making.
5. To get the attention of the person, touch the person
gently, wave, or use another physical sign.
6. Store assistive devices—notepad and pen—within
reach of the individual.
7. Make certain any emergency alarms essential for
safety have a light or visual alert to get the individual’s
attention in case of emergency. Allow time for the
conversation—functional as well as social.

Angel Fatima Hernandez