Verbal communication (i.e., speech) is the most commonly used method to relay information to a listener. More importantly, health care providers use speech to relay essential information about medical care, scheduled activities, instructions, and procedures to patients along with words of support and encouragement during uncertain or challenging times. Results from a recent observational study found that staff working in nursing homes use speech approximately 80% of the time when engaging with patients (Knollman-Porter et al., 2019). However, many older adults receiving medical or supportive care have cognitive and/or communication challenges that negatively impact their ability to understand information expressed verbally (Helm-Estabrooks et al., 2013; Weirather, 2010).
Communication Challenges for Older Adults
Worldwide, approximately 50 million people have dementia (World Health Organization, 2019), which can lead to expressive and/or receptive cognitive-communication deficits (Kempler & Goral, 2008). Furthermore, an estimated 1 million people in the United States currently have aphasia, a disorder that impacts the expression and understanding of language, in addition to writing and reading (National Institute on Deafness and Other Communication Disorders, 2015). These deficits, alone and combined, can negatively influence a patient's ability to express and/or comprehend information that is essential and/or desired (Helm-Estabrooks et al., 2013), yet these older adults benefit from medical or supportive services provided by health care providers. In addition, 68% of people aged ≥70 years have some degree of hearing loss, which can further exacerbate communication deficits (McCreedy et al., 2018), resulting in a misunderstanding of the intended message and feelings of frustration (Alzheimer's Association, n.d.; Code et al., 1999; Parr, 2011).
Recent essential and mandated face mask use for health care providers, secondary to COVID-19, creates an additional barrier for those with cognitive, communication, and/or hearing challenges. Historically, findings from research and clinical practice suggest that people with more advanced stages of dementia and/or impaired ability to understand speech continue to demonstrate the ability to comprehend non-verbal facial expressions and vocal tone (Guaita et al., 2009). Adults with hearing impairment also benefit from observing a speaker's lip movements, vocal tone, and facial expressions to enhance understanding. However, face masks hide these supplemental non-verbal expressions of emotion and meaning that many people with communication impairments rely on for understanding the intended message. Finally, masks can soften the speaker's voice, presenting additional barriers to successful comprehension.
Person-Centered Care and Effective Communication
The aim of person-centered care (PCC) is to respect and act upon older adults' needs and preferences and ensure patients' values guide care decisions (Davis et al., 2005). A person-centered approach is more likely to encourage communication and increase staff and patient satisfaction than a task-centered approach (Koren, 2010; McCabe, 2004; Sharp et al., 2018). One of the primary attributes of PCC is incorporating effective communication during interactions with patients (Hashim, 2017). Effective communication includes interactions that involve the engagement of both parties and incorporates a variety of conversational topics that are relevant to both participants (O'Hagan et al., 2014; Simmons-Mackie & Kagan, 1999). When used appropriately, these communication methods can facilitate feelings of well-being, confidence, and an overall positive self-image (Steger & Kashdan, 2009). However, if an older adult cannot understand the spoken information provided by the health care provider, this breakdown in communication can lead to social isolation and frustration (Alzheimer's Association, n.d.; Crogan & Evans, 2008; Parr, 2011), resulting in depression and/or anxiety and thus negatively impacting overall quality of life (Morris et al., 2015; Steger & Kashdan, 2010).
Communication Strategies and Supports
Multiple cognitive processes are required to functionally comprehend spoken information. Communication supports that facilitate understanding may reduce cognitive demands and improve comprehension. According to the Resource Allocation Theory, people with communication difficulty may experience problems allocating attention in accordance with task complexity, leading to deficits when task demands exceed a person's abilities (McNeil et al., 2004). Therefore, the use of supplemental communication methods (discussed later in this article) may lessen cognitive load and facilitate comprehension for patients who experience these difficulties (Brown et al., 2018; Preisig et al., 2018; Simmons-Mackie & Kagan, 1999; Wilson et al., 2012).
In the following sections, we highlight strategies, supplemental communication methods (i.e., written, gestural, and picture supports), and modifications to personal protective equipment (PPE) that health care providers can implement, in isolation or combined, to improve communication with older adults. Although not exhaustive, this overview is intended to provide health care providers with a foundation for facilitating effective communication with patients and caregivers, while wearing necessary masks and other PPE.
Creating an Environment for Successful Communication
The first step to successfully supporting patient communication is to create an ideal communication environment by eliminating unnecessary sounds and distractions. Find a location that is quiet and well-lit so the patient can focus on the information being presented. Turn off any devices that may create added background noise (e.g., television) and close the door. Finally, providers should position themselves in front of the patient and gently obtain his or her attention before speaking, so that the person has time to focus on the provider and the method of communication being delivered. If the patient is in bed or seated in a chair, attempts should be made to sit beside the person at eye level for optimal visibility. Creating an ideal communication environment reassures patients that their thoughts and feelings are valued.
Speech Modification Strategies
Masks can dampen the volume (i.e., loudness) and precision (i.e., clarity) of a provider's speech, which in turn creates barriers to patient comprehension of spoken language. Providers wearing masks should increase their volume (without yelling) and over-articulate words to ward against these barriers. Over-articulating is also beneficial as it naturally slows down speaking rate (or speed). Patients experiencing processing delays and age-related hearing loss may benefit from a slower speaking rate (Janse, 2009). Finally, providers should also monitor the pitch of their voice. Age-related hearing loss is likely to affect one's ability to hear higher frequency sounds (Gates & Mills, 2009); therefore, providers with higher pitch voices should consider lowering pitch to facilitate understanding. However, providers should not lower pitch to a degree that is distracting to the patient or if it causes personal discomfort.
One method of communication support while wearing a face mask is through the use of gestures. Gestures are the movements people make with their hands and arms in isolation or combined with a spoken message to relay meaning. Specifically, pantomime is one gesture type that involves use of the hands to demonstrate objects (e.g., fork) or actions (e.g., driving a car). In contrast, emblems are common gestures specific to a given language community or culture that can relay an emotional response (e.g., thumbs up and down, salute, ok; Rose, 2006). In addition, deictic gestures convey directions (e.g., pointing).
Health care providers can use these gesture types when interacting with patients with some degree of effectiveness without the need for lengthy formal training, as long as the gestures developed are personally relevant and relay concrete information that can be easily interpreted. For example, when wanting to know if a person is thirsty, a caregiver may gesture holding a cup with his or her hand while bringing the hand to the mouth to represent drinking and stating, “Would you like a drink?” Similarly, when determining how a patient is feeling, a caregiver may state, “How are you feeling? Good? (gesture thumbs up) Not well?” (gesture thumbs down). Furthermore, a simple head nod can provide patients reassurance that they are being heard and understood. Knollman-Porter et al. (2016) found that people with severe chronic language comprehension deficits secondary to stroke exhibited increased comprehension when personally relevant gestures were presented simultaneously with spoken single words. Gestures used in health care environments can supplement communication by decreasing the need to exclusively understand spoken language, potentially decreasing patient frustration and confusion.
An additional method to facilitate communication is through the use of written supports. Providing written content simultaneously with spoken information can reduce comprehension demands by providing redundancy and by decreasing the amount of information that must be held in a listener's working memory for comprehension (Brown et al., 2019). Specifically, written supports decrease the reliance on working memory as the visual information remains, allowing the listener more time to see and process the message even after auditory information disappears (Brennan et al., 2010). In addition, use of written support can especially benefit patients who exhibit strengths in reading comprehension over listening comprehension (Lanzi et al., 2017).
Written information can also be modified in length, complexity, and text size to facilitate comprehension based on the unique needs of the person receiving the information (Brennan et al., 2010). For example, a health care provider may write key words on a piece of paper or dry erase board to help the patient comprehend medical instructions or comprehend a question being asked about previous preferences or interests. In addition, if asking yes-or-no questions, the provider may print the words “yes” and “no” on a white board and ask the person to point to either word to answer the question. Rose et al. (2012) found that adults with communication deficits associated with aphasia preferred that written information be presented with use of large, standard print font (e.g., Arial), with added white space to increase comprehensibility.
Results from recent studies provide further support that some people with communication difficulties exhibit a significant comprehension benefit when provided access to combined written and auditory content versus auditory content alone with relatively long narratives (Knollman-Porter et al., 2019; Wallace et al., 2019) and single sentences (Brown et al., 2019). In addition, the majority of participants in these studies preferred combined written and auditory content over the auditory alone condition to supplement comprehension.
Picture supports are another method of facilitating successful communication. As shown in Figure 1, these supports may take the form of a communication board, containing a grid display of pictures that represent basic care-related topics (e.g., toileting, hunger, pain). Picture supports can also be personalized, such as a board or book containing pictures of family, health care providers, and other meaningful topics. Picture-supported communication boards and books are most effective when they are person-centered (Simmons-Mackie et al., 2013); however, standard tools, such as Figure 1, may be more feasible in acute settings when the patient's immediate needs must take priority.
Basic needs communication board.
From Patient-Provider Communication (2020, in the public domain; permission is not required; https://www.patientprovidercommunication.org/covid-19-free-tools).
Picture supports help establish context for the patient and reinforce the linguistic message (Brookshire, 2003; McNeil, 1983). Similar to written supports, pictures can reduce demands on working memory and support attention. Research has shown that picture supports can help patients with aphasia increase topic initiation in conversation, decrease communication breakdowns (Ho et al., 2005), and participate in establishing goals for rehabilitation (Helm-Estabrooks & Whiteside, 2012). Furthermore, some persons with dementia can increase on-topic communication (Andrews-Salvia, et al., 2003), improve comprehension (Burshnic & Bourgeois, 2020), and demonstrate competent decision making (Chang & Bourgeois, 2019) with use of picture supports.
When creating or selecting picture communication aids, ensure pictures are large enough for the patient to see, and select pictures in which the subject is clear (e.g., single object with a plain background) to reduce potential distractors. Picture communication supports should be left in the patient's room and, when possible, communication boards should be laminated or use clear sheet protectors to allow for proper sanitation.
Modifications to Personal Protective Equipment
Finally, providers may choose to safely modify PPE to promote successful communication interactions. The first modification includes wearing masks with clear, vinyl windows, making one's mouth easily visible for lip-reading and other facial cues. These masks can be purchased from various companies, or even homemade, but providers should ensure they are receiving the same level of protection as they would from a typical mask. For example, some companies offer masks that are “FDA-registered” and meet the American Society of Testing and Materials' standards for Level 1 protection (>95% bacterial and particle filtration efficiency).
The second method of modifying PPE includes use of picture name tags (Figure 2). Patients with vision and/or cognitive impairments may have difficulty recognizing providers wearing masks, gowns, and/or face shields and, consequently, mistake the provider for someone who is not a health professional, leading to adverse reactions. Thus, providers may consider printing a 4×6-inch name tag displaying a friendly photograph, along with their first name and job title in large print. After an introduction, refer the patient to the name tag by pointing and saying, “If you forget my name, just look here.”
Example picture name tag. From PicSpree (2020, in the public domain; permission not required; https://picspree.com/en/photos/man-portrait-680061).
The integration of research, clinical expertise, and patient values (i.e., evidence-based practice) should be applied during new and evolving clinical situations. Historical and emerging research supporting the use of communication supports for individuals with cognitive, communication, and hearing challenges is even more relevant during the COVID-19 pandemic, secondary to health care providers' need to wear PPE. Furthermore, older adults continue to desire and benefit from understanding information about their health care even though they may have unique communication needs. Because all strategies and supports will not work with all patients, creativity, patience, and consultation from a speech-language pathologist may be necessary to find the best combination of supports for each patient. Nonetheless, health care providers are encouraged to integrate traditional and supportive methods of communication based on the patient's unique preferences and needs to foster connection and understanding. The importance of supporting patient communication will not diminish in the absence of COVID-19. Thus, we hope this article empowers care providers to make efforts to support all older adults' communication now and into the future.