Communicating with older people

Communication and ageing

Some older people have conditions that can impair their capacity to communicate, for example, stroke, COPD, dementia and hearing impairments.

There are also less obvious symptoms and conditions that can affect communication with our patients particularly when they are unwell. These include:

• pain
• frailty
• mobility impairments
• self-care impairments
• under-nutrition
• dehydration
• delirium
• depression
• low mood
• anxiety
• sleep deprivation
• medication effects and side-effects
• polypharmacy
• hearing impairments
• vision impairments
• acquired brain injury.

We can use our communication skills to assess what is affecting the person’s ability to receive or give information and to show that we are interested and care.

‘The people who do come in and treat you as a person, with a family, with a history, with… a life. You respond to so much better. There’s… a link, a communication that takes place.’ (patient)

We can also use communication skills to solve problems by asking the patient about their needs, concerns and their condition.

There is increasing interest in the role health literacy plays in determining outcomes for older patients. Health literacy is a person’s ability to seek, understand and use health information and services¹.

‘...he said you got SOBOE…I had to go look it up to see what…he was talking about.’ (patient)

Only 40 per cent of adults can understand health messages in the form they are usually presented². Questions we can ask to help assess our patients’ health literacy include:

• Can you tell me why you are in hospital?
• Can you tell me about what medications you are taking and why?
• Is this an accurate understanding? If not, what appears to be the cause of the misunderstanding? (for example, insufficient explanation/language/cognition)

If we understand our patients’ health literacy and our own abilities to meet their needs we can better tailor our communication and our care to meet their needs.

Communicating with older people who have diverse needs

Older people with specific communication needs have an increased risk of experiencing functional decline in hospital. Identifying any functional or psychosocial barriers to communicating in hospital and responding to these will enable the older person to participate in their care, both in hospital and on discharge.

Vision and hearing loss

It is common for older patients to have vision and hearing impairments. These can be challenging during an inpatient stay and can limit a person’s confidence to participate in their care and ability to follow instructions, and may contribute to social withdraw.³ To reduce the risk of this happening:

• Encourage the older person to wear their prescribed glasses in hospital.
• Encourage the older person to wear their prescribed hearing aids in hospital. Check the hearing aids are on and the batteries are working if the older person is still having trouble hearing.
• Ensure your patients’ glasses and hearing aids are within their reach if they choose to remove them.
• Consider encouraging the older person to have their vision or hearing assessed if communication is difficult.

Speech impairment

Speech impairments range from mild (where there is only an occasional problem) to severe (when a person may have lost all ability to use and/or understand speech).

• If an older person is unable to use speech as an effective form of communication, work with them and their family and carers to use an alternative method of communication.
• Refer to speech pathology as appropriate.
• Use appropriate communication aids and written aids.
• Ensure the older person is given adequate time to communicate.

Cognitive impairments

Older people with cognitive impairments can communicate their wants and needs.

• Be positive in your approach to communication.⁴
• Greet the older person you are caring for by name, address and speak to them; do not ignore or talk over them.
• Include the older person in their care to the extent they are able and want to be involved.
• Allow time for the older person to express their needs.² Behaviours of concern are often expressions of unmet needs.
• Talk to family and carers; they often have valuable information about caring for an older person with a cognitive impairment.
• If the older person no longer has capacity to consent to medical treatment, identify and record the name and contact details of the Medical treatment decision maker⁵, the substitute decision-maker under the law. Shared decision-making about care will require effective communication with the Medical treatment decision maker.

They’ve got to listen to the family in that situation, and it’s very hard if they don’t, because you do know that person better than what they do, they’ve only met that person only just then.
Relative of a patient

Culturally and linguistically diverse communities

In Victoria, a significant number of older people who use hospital services are from culturally and linguistically diverse communities. Be aware that not having English as your first language can add an extra layer of complexity for an older person and their family, and may increase feelings of loneliness or isolation, both in and out of hospital.

• Ask your patient and their family and carers if they need an interpreter and, if so, organise this through your hospital’s interpreting services. Consider the older person’s and family’s wishes if there is a preference not to use an interpreter.⁶
• When selecting an interpreter, consider confidentiality, kinship and gender issues.⁶
• Focus on the older person’s strengths and wishes⁷. Be positive in your approach to communication.³
• While written aids that have been professionally translated might be helpful, be aware that literacy might be a barrier to use. Over-reliance on written materials should not replace individualised care.⁶
• Be aware that literacy might be a barrier to completing forms.
• Try to learn a few basic words in the language of your linguistically diverse patients.³
• Try to link together patients on the ward that speak the same language; for example, by sharing a room.
• Cue cards can be helpful, but should not be used in place of accredited interpreters. Cue cards can be used by our patients, families and carers to communicate simple needs such as hungry, thirsty, telephone. We can use the cards to communicate simple instructions or ideas.
• Connect older people to culturally specific and/or bilingual community services and clinicians, as appropriate.
• Be prepared to explore the cultural context of some symptoms and diseases. For example, in some cultures there is a stigma around dementia and depression and a patient may use a different term to describe their feelings, for example they may say they are 'heart sick'.
• Always check your understanding of what the older person has said.⁴
• Screening and assessment tools often have cultural biases and many ‘standard’ tools have not been validated in multicultural samples in Australian hospital. Seek specialist advice for appropriate use and interpretation of results.

Aboriginal and Torres Strait Islanders

In Australia, many Aboriginal and Torres Strait Islanders experience morbidities typically associated with advancing age, such as cardiovascular disease and dementia, up to 20 years earlier than non-Aboriginal people. Therefore, from the age of 45, functional decline in hospital is a concern for Aboriginal and Torres Strait Islanders.

Be mindful that Aboriginal and Torres Strait Islanders come from a variety of cultural and personal backgrounds.⁷

• Many Aboriginal and Torres Strait Islanders find institutions such as hospitals particularly daunting or frightening, and being in hospital may trigger feelings of loneliness and isolation from networks. Ask the person to identify strategies that might help them during their stay, and optimise their ability to retain social connections on discharge.
• To enable culturally safe care, identify with your patient and their family or carer if a cultural liaison officer is required and make a referral if needed.
• Communicate with your patient, their family and carers to identify if an interpreter is required and organise this through your hospital’s interpreting services.
• When selecting an interpreter consider confidentiality, kinship and gender issues⁶.
• While written aids that have been professionally translated might be helpful, be aware that literacy might be a barrier to use. Over-reliance on written materials should not replace individualised care.⁷
• Literacy might be a barrier to completing forms.
• Source information and advice from Aboriginal and Torres Strait Islander people and culturally specific organisations.
• Connect people to culturally specific and bilingual community services and clinicians, as appropriate.
• Communicate with your patient, their family and carers to build a picture of all family members and significant others. It is not always obvious who has final authority in relation to an Aboriginal or Torres Strait Islander’s health and wellbeing.⁸
• Be aware that an illness may be seen as affecting the entire family, in terms of origins, symptoms and management.⁸
• Screening and assessment tools often have cultural biases and many ‘standard’ tools have not been validated in multicultural samples in Australian hospitals. Seek specialist advice for appropriate use and interpretation of results.

Communication and discharge planning

The relationship between hospital care and ongoing community care within a complex health system can be difficult to understand and navigate for an older person, family and their carers. Discharge summaries should be clear and complete and promote continuity and quality of care in the community.¹ The older person and their family and carers, as appropriate, should understand the discharge summary and be provided with copies to keep, so they can refer to the summary and provide it to community services as required.

The older person should leave hospital knowing:

• their next contact with the health system (next appointment)
• their key contact within the health system (for example their GP) and how to contact them
• the medications and ongoing management or care they should be undertaking until the next appointment
• the medical, functional and psychosocial issues that were identified during the admission
• what to be aware of on discharge
• who to call if they need help or advice.

Psychosocial interventions can play a significant role in an older person’s recovery after discharge. If loneliness or social isolation has been identified as a risk factor, ensure you have identified meaningful activities for the person and refer them to appropriate and accessible resources and community programs.⁹

Shared decision-making between us as clinicians, the older person, family and carers (as appropriate), is imperative to effective discharge planning. One method that has been trialled in a Victorian health service to assist discharge communication is Care Transfer Video.¹⁰ Care Transfer Video involves videoing ward rounds before discharge so patients can take home the discussions on a USB stick to watch with their families, GPs and other services as appropriate for follow-up. CareTV helps patients to remember details from their admissions and the plans for their ongoing care.