Nursing care includes client teaching; in fact, much of a nurse's time is dedicated to explaining what physiological events are occurring and what course of action is necessary to restore optimal homeostatic functioning. Nurses can expect that increasing amounts of teaching time will be spent educating older clients in health care practices and chronic illness care regimens as recent population projections estimate that by the year 2000, there will be a 30% increase in the number of people over 65 in the United States.1
Behavioral scientists, educators, and nurses have been conducting research to discover if intellectual functioning does change with aging and what patterns of teaching provide the best learning experiences for elderly people. The purpose of this paper is to provide an overview of some of this research and describe implications the findings have for techniques nurses may find useful when relaying health information to older clients. Two major areas will be presented: (1) research that delineates factors that influence learning in the elderly, and (2) ideas for nursing that will enhance client learning.
Before proceeding with the research findings, perhaps a brief look at common attitudes that influence approaches to teaching the elderly will be beneficial. Despite the fact that it would be virtually impossible to find a middle-aged adult who cannot name at least several intellectually competent elderly people, the prevailing attitude in the United States is that mental abilities diminish markedly with aging. In fact when 69-year-old philosopher Paul Weiss sued Fordham University for age-bias after the appointment to the Albert Schweitzer Chair was rescinded because of his age, the judge ruled that it is clear that abilities diminish with aging and that age is not discriminatory because it cuts across all categories of race, religion, and sex.2
Casual observations of the elderly often cause other people to conclude that because the old function less well physically than the young, this decrement in function also represents a decline in the intellectual capabilities of the elderly. Myths purporting that the old cannot do a decent job and should retire, or that mental deterioration is inevitable, abound in our society.3 It is very difficult to correct misinformation regarding the elderly but certainly health professionals, namely nurses, must be acutely aware of the human potential every older person possesses.
Aging and Intelligence Research
Measuring Intellectual Function
The construct intelligence is difficult to measure and methodological issues inherent in arriving at a summary statistic called IQ deserve careful consideration. Early studies measuring lifetime intellectual functioning frequently used a cross-sectional methodology. For instance, a study conducted in a New England community divided subjects, aged 16-90, into groups according to age. These investigators demonstrated on the basis of results from the Army-Alpha test that peak intelligence occurred in young adulthood and a continuous drop in score was evident as age increased. These early reports led to widespread belief that as one grows older, the capacity for intellectual functioning diminishes.4 A priori differences between age groups are not reflected in the research findings and, consequently, all differences are attributed to the aging process alone. However, people from varied generations frequently differ from each other in many characteristics including variations in life experiences and effects of environmental circumstances.4
Problems interpreting results of data gathered by longitudinal study methods also occur. It is difficult to know which changes can be considered results of chronological aging factors and which are the result of social and environmental influences. Intervening events, such as television, nutritional habits, and illness, surely contribute to one's level of intellectual function.
Schaie and Strother attempted to solve this research problem by converting a cross-sectional study into a longitudinal series or cross-sequential study with data collected at seven-year intervals.5 New random samples were used as control groups to minimize the effects of subject attrition and retes ting influences. Results indicated that decrements in intellectual functioning found in cross-sectional studies do not exist in the cross-sequential data analysis. The findings suggest that rather than a decline in intellectual functioning, different generations perform at different levels of ability.5 Further research using the same format led Schaie and cohorts to conclude that crystallized abilities, which are a function of the information and skills transmitted to the individual by the culture, do not diminish; whereas, fluid ability, or speed and reaction time, do diminish and are probably a result of biological aging changes.4
Other practical considerations to remember when accepting the validity of studies measuring intelligence in elderly people are content of the measurement tool and general response habits of the elderly. Tests may be used that discriminate against the elderly much the same way that intelligence tests given to children are thought to discriminate against ethnic cultures and the poor in favor of white, middle-class children. Also, the elderly tend toward cautiousness when responding to test items and consequently, are less likely to guess when uncertain about the correct response.4 This tendency, which may be the direct result of discouragement from "wrong" behavior during a long lifetime, may result in a lower score.
Learning and Memory Patterns
Investigations of learning and memory processes were begun by Herman Ebbinghaus in the 1870s. Memory was thought to consist of associations between ideas and events; learning involved the time or repetitions of the tasks that were required to make correct associations.6 Evidence that elderly individuals require multiple repetitions of the task before it is learned fostered the idea that the aged are less capable of learning.
Studies conducted by Ganestrari in 1963 found that stimulus pacing interferes with the elderly's ability to respond correctly, but when allowed to use self-pacing the elderly performed as well as young subjects.7 The evidence also suggests that the added time was needed by the elderly to respond rather than to learn the task.
Autonomic nervous system arousal is another factor that can interfere with the performance of elderly clients in a learning situation. Research findings based on free fatty acid levels as an indication of autonomic response, indicate that arousal continues to increase even after the stimulation stops.6 Studies using electroencephalogram data demonstrate that the elderly maintain long-lasting aftereffects following stimulus input. The aftereffect activity is thought to obscure subsequent stimuli thereby hindering learning.8
Task relevance is another important consideration when evaluating learning among elderly subjects. Studies conducted by Hulicka revealed that when asked to perform irrelevant associative tasks, the elderly were clearly not motivated and the attrition rate reached 80%.9 Other studies demonstrate that there is an age-related decline in the ability to ignore irrelevant information.10
Memory obviously plays an important role in learning and several researchers have attempted to understand what, if any, changes occur in the ability of elderly people to remember. While a thorough discussion of memory research is beyond the scope of this paper, some general findings may prove useful and are presented. They are that the arcuracy and storage capacity of the memory does not differ significantly between age groups. However, it does take the elderly-longer to retrieve information from the memory system.6
Not only can the old dog be taught new tricks, the new trick is frequently self-taught. People who have valued education throughout their lives do not stop educational processes at age 65. Eight out of ten elderly read magazines; almost all older people engage in informal learning experiences via television, newspapers, and personal interactions. Ten percent of all the enrollees in formal continuing education programs are in their 60s and another 4% are in their 70s."
Health professionals can improve effectiveness of teaching efforts if they recognize client characteristics that modify learning and intellectual function. The health status is certainly an obvious characteristic to health care providers. The ill aged do show a comparative drop in learning compared with well older persons." Sensory impairment including failing vision and hearing as well as diminished touch, smell, and taste can contribute to an apparent lack of learning. Personal and/or social maladjustment to the aging process may manifest itself as anxiety and defensiveness." The health professional should not confuse this behavior with lack of interest or motivation.
Socioeconomic status throughout life has implications for learning in the later years. Some individuals have a greater commitment to mastering new knowledge and this may be reflected in their socioeconomic status. Learning styles may vary between socioeconomic levels. Evidence suggests that blue collar workers are more apt to seek information from informal, interpersonal contact with family and friends rather than from mass media and experts." Adult learners with simplistic and absolute ways of dealing with knowledge and values have difficulty learning when confronted with diversity, uncertainty, and reliance on self-education." Openness and receptivity to the teacher's approach and content may facilitate learning. Obviously if the learner is put on the defensive, there is a decrease in knowledge learned.
Implications for Nursing
Most health education aims at providing information that will influence the client's behavior toward healthful practices. It is worth remembering that the client is the only one in a position to determine what is ultimately learned and, generally speaking, the more participatory the client's role is in the learning experience, the greater the learning that takes place.12 Teaching geared only to the mass responses reflected in research studies will not be effective for the client who is the exception to the rule. There is at present no magic formula that, when applied appropriately, will change or modify undesirable behavior or guarantee the practice of healthful behaviors.
However, based on what is known about adult learning in general and geriatric learning in particular there are some strategies nurses can use to facilitate learning. One technique might be to emphasize abilities by centering on the crystallized knowledge that has been part of the client's enculturation, rather than by requiring learning activities based on fluid responses. Along with this is use of words that convey similar meanings to the client. Meanings of words in our vocabulary frequently change with each generation and it is essential for the client and health care provider to have the same definition for words used in the communication.
Structuring content by outlining major aspects of the material to be presented may serve to facilitate the client's memory of major points. Reiteration of the concepts is also valuable. Health professionals need to eliminate irrelevant detail from the content as older clients demonstrate difficulty sorting the relevant from the irrelevant.
Adults typically prefer to use what they have learned soon after the learning has occurred.12 Teaching sessions that use return demonstrations have been shown to be an effective way to imprint the learned task and meet this need. Return demonstration also offers an opportunity for feedback that can recognize and applaud new competencies.
The importance of allowing the elderly client to establish the pace for learning is vital for successful encounters. Multiple media approaches are a part of self-pacing and allow the client to self-select learning tools that are most individually effective.
Knox stresses the importance of a "memorable encounter" as providing greater saliency, thereby increasing learning intensity and useful memory registration.12 Health providers can achieve a memorable encounter by maintaining a comfortable environment, being well-prepared and expert, and planning the sessions at times convenient for the learners. Tantamount to success are communication skills and an abiding interest in the uniqueness of each individual client.
Nurses who practice in client contact areas can expect to deliver care to increasing numbers of elderly people. Thus, it is important for nurses to understand techniques that promote health care learning and to develop skills that are beneficial for providing teaching/ learning experiences involving older clients.
Intellectual function and the capacity for learning neither cease nor diminish because a chronological age has been reached. Most elderly people continue to engage in learning throughout their lifetime although learning style preference and amount of learning actively pursued vary greatly from one individual to another. Health care providers are most successful when they capitalize on the unique potential for learning and growing that inherently resides in every person.
The author wishes to thank Dr. LaVerne Gallman, Associate Professor, University of Texas at Austin School of Nursing for her editorial assistance and encouragement.
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