The ability to communicate and engage with others in meaningful interactions is fundamental to quality of life and well-being for all people. The need to communicate, to be listened to, and to feel that one’s words and messages are valued and respected does not change with age or impairment.² In fact, social contact is vital to older adults’ emotional and physical well being.³ Social interaction improves older adults’ chances of living longer and maintaining optimal functional abilities.⁴ Sadly, older people are at risk for isolation and may find fewer opportunities for social interaction. The death of friends and relatives, illnesses, and other losses such as moving out of one’s home and relocating to smaller apartments, assisted living, or nursing homes may decrease access to social support from others.⁵ Communication between nurses and older people tends to be superficial or task focused.⁶,⁷

This chapter focuses on special considerations for therapeutic communication with older adults, the effects of ageism, speech and language disorders, and sensory impairment on therapeutic communication with older people, and it presents nursing responses to enhance communication and mutual caring.

Therapeutic communication techniques that apply to all nursing situations, such as authentic presence, mutuality, active listening, clarifying, giving information, seeking validation of understanding, keeping focus, and using openended questions, are applicable in communicating with
older adults.² Unfortunately, ageist attitudes often influence formal caregivers (nurses, nursing students, residential staff) and even family members to communicate in ways that demean rather than demonstrate respect for the autonomy of older people.⁸ Ageism may be displayed when health care providers use “elderspeak” to communicate with older adults. Elderspeak is a form of speech that is overly nurturing, patronizing, controlling, and disrespectful.⁹ Based on a faulty assumption that all elders will have difficulty comprehending speech, younger people alter their speech patterns by slowing the pace of speech, using a louder, high pitched tone (similar to baby talk), and simplifying the message.¹⁰ Overly nurturing and patronizing talk is used to control.¹¹ The use of pet names or diminutives is one way that the caregiver can imply an inappropriately intimate, patronizing, or even parent-child relationship. Collective pronouns such as “we” imply that the elder is not autonomous. Tag questions are also controlling because they suggest the answer for the elder. The following example illustrates several features of elderspeak.

In the prior example, “Mamma” is a pet name, also known as a diminutive. The use of diminutives such as “sweetie,” “honey,” “grandma,” or use of a first name without the client’s permission implies inequality in the relationship, control by the nurse, and communicates disrespect for the elder. Many older people are not used to our informal styles of communicating, so ask them how they would like to be addressed. It is always desirable to use Mr., Miss, or Mrs. until you are told otherwise.

In the phrase “we need you to sit up,” “we” is a collective pronoun that communicates expectations of incompetence or a client’s inability to act without the nurse. Tag questions that include both the question and the answer are another strategy to decrease the client’s autonomy (“you wouldn’t want to spill this, would you?”). Giving control to the elder is communicated by knocking on a door, introducing yourself clearly, and asking permission to enter or providing some choice by asking, “Are you ready to walk now?”¹²

Other forms of communication that convey ageist attitudes include ignoring the older person while communicating with relatives or visitors or limiting interaction to task-focused communication. Be sure to speak directly to the elder and involve him or her in all conversations. If family or significant others are present, they may be asked for their input as appropriate, but the focus of the communication is on the elder. It is important that others not answer for elders or talk about them as if they were not present. If it is important to validate information, this can be done privately with the family or significant other. This is true when working with both cognitively intact and cognitively impaired elders.

While an understanding of basic therapeutic communication skills and adaptations for age is important, the nurse must realize that the most important communication tool they possess is the use of self. The unique contribution that nursing brings to the care of people is the intimate, knowing of the person behind the disease and the creation of relationships and interactions that support, validate, and celebrate the person as someone of value and worth.¹³ Every time a nurse communicates with someone, their words and actions affect the relationship in either positive or negative ways depending on their attitude and skills.¹⁴ Relating to the person being nursed as a fellow human being and truly reaching out on a more intimate and caring level, rather than in a rote manner, will foster the development of healing relationships. When caring for elders in a busy setting such as a hospital, it is easy for nurses to overlook the social interactions that are part of optimal relationships. Although it may consume a little more time, the importance of greeting the elder and orienting him or her to what you are doing cannot be overstated (e.g., “I’m here to talk about your discharge plans.”). Ageist attitudes and fear of our own aging often direct our communication with older people. These factors may blind our eyes to seeing the person behind the disease or impairment and prevent us from entering into caring relationships that enrich the lives of both the nurse and the person being nursed.

Because older people have a larger life experience to draw from, they may need more time to answer questions or provide information. Sorting through thoughts may require intervals of silence, and word retrieval may
be slower for older people. “Older people use fewer proper nouns, more general nouns, and more ambiguous references as they age” (p. 95).¹⁵ Avoid hurrying older patients and try to give them a few extra minutes to talk about their concerns or express their feelings. Listen attentively and patiently, not interrupting the person. If you tend to speak quickly, especially if your accent differs from the elder’s, try to slow down further and give the older person time to process what you are saying.¹⁶ Repeating or rephrasing questions, asking for clarification, and frequently seeking validation of what you think you heard are other techniques that facilitate communication. Pay attention to the client’s gaze, gestures, body language, and the pitch, volume, and tone of the patient’s voice to help you understand what the person is trying to communicate. Both eye contact and physical touch communicate caring from the nurse and can aid in understanding and being understood without words. Sundin and Jansson describe eye contact as “looking through soft eyes and seeing the person with the heart” (p. 114).¹⁷

Open-ended questions may be difficult for some elders. The older person may try to respond with what they think you would like to hear rather than what it is they would like to say. Some elders fear “being a bother” or may be concerned about taking up too much of your time. When using closed questioning to obtain specific information, the elder may feel pressured, and the appropriate information may not be immediately forthcoming. Older people may also be hesitant to provide information for fear of the consequences. An example might be a question related to falls. If the person lives alone and has been falling in their own home, sharing that information may mean that they have to move to a more protective setting.

Assessment questions can be anxiety producing situations for elders. Older people may not be able to answer correctly because of fear and nervousness, or they may feel threatened if questions are asked in a quizzing or demanding manner. It’s often helpful to begin an assessment by saying something like: “I am going to ask you some questions. Just relax and try to answer the best that you can.” It is important to create an environment of acceptance, support, and caring and to put the elder in the best situation for meaningful communication. This may mean communicating at their best time of day or when they are rested as well as communicating in a quiet and private environment with minimal distractions. Starting the conversation with casual topics (weather, special interests) before beginning a detailed assessment may put the person at ease. Asking them to share their major concerns first, regardless of the priority of the nursing assessment, is also important.

Memories are important to elders, and some may want to talk about their past and share their memories with you. Careful listening to stories and reminiscence is a more complete way to enter into their life and come to know the person. Older people bring us complex stories that are derived from many years of living. To enter into the world of an elder and come to know them in their wholeness requires time and patience and a belief that the story and the person are valuable and meaningful. The metaphor of an old house can be used to illuminate knowing wholeness of older adults. When you think of an older adult, picture a house with many rooms, doors, and windows. Life stories are revealed slowly and only after trust has been established. It may take a long time for you to be invited in to see all of the rooms. If you remain on the front porch or sit only in the formal living room, the story you hear may be very different from the one you hear when you are invited to share the treasures and memories of the rest of the house.¹⁸

Stories serve as a mirror in that they image those life events most dear to the storyteller, and the language of stories helps us uncover that which makes life meaningful. Sandelowski describes story as a narrative knowing, which is essential knowing for providers of health care. Stories are “critical sources of information about etiology, diagnosis, treatment, and prognosis from the patient’s point of view” (p. 25).¹⁹ Without this knowing, older people are subject to less than accurate diagnoses, labels that reflect ageist attitudes, and treatment that focuses on incomplete knowing. With no knowledge of the person’s story, how can we begin to extend our care, to understand behavior, to diagnose and treat concerns, and to design responses that nurture wholeness? As Coles states, “the people who come to see us bring us their stories. They hope that we tell them well enough so that we understand the truth of their lives. They hope we understand how to interpret their stories correctly” (p. 7).²⁰ When nurses take the time to listen to older people share memories and life stories, they communicate respect and valuing of the individual and his or her life as something very important to be treasured.

Both the nurse and the person being nursed grow as a result of interactions grounded in respect and valuing.

Elders may have sensory impairments that put them more at risk for experiencing communication difficulties than people of younger ages. This may be especially true for frail elders such as those in nursing homes where it is estimated that “nearly half of the residents never talk to other residents because of hearing and speech difficulties” (p. 96).¹⁵ Communication with older people who have sensory deficits requires special skills. Nurses may not recognize sensory impairments or appreciate their impact on the individual’s functioning, or they may view sensory impairments as obstacles to communication and limit communication with older people. Assume that the person can hear, see, or understand you unless you know in advance that this is not the case.⁸