Communication and Aging

Communication Changes with Typical Aging

With typical aging, communication skills change subtly at least in part because of changes in physical health, depression, and cognitive decline. Aging is responsible for physiologic changes in hearing, voice, and speech processes.^5,6 A person’s age can be predicted with fair accuracy by speech characteristics including voice tremor, pitch, speaking rate, loudness, and fluency.⁷ Some language skills remain intact, whereas others tend to decline. For example, vocabulary, grammatical judgment, and repetition ability are relatively stable with age; comprehension of complex utterances and naming may decline.⁸ Although changes in communication skills such as voice may be subtle and gradual, they have clear life consequences such as avoidance of social situations.⁹

Aging with a Preexisting Communication Disorder

Conditions that are associated with preexisting, long-term communication disorders may compound the challenges faced by people as they age. MS, which is one such condition, is discussed in this article. MS is a chronic, progressive, neurologic condition, frequently with an onset in mid-life. Multiple lesions in the central nervous system result in a complex constellation of symptoms, including changes in communication especially changes in speech and cognition. Communication problems are common, and occur in approximately half of the people with MS.¹⁰ They typically do not occur in isolation, but rather as part of a collection of other physical and sensory changes. Fatigue and depression are commonly referred to as invisible symptoms of MS and are particularly distressing and disruptive.¹¹ Even when relatively mild, communication problems have an important effect on the ability to take part in valued life situations partially because of their interaction with other symptoms of MS.¹² People aging with MS report that they need more assistance and have less freedom than their peers of the same age.¹³ In a study that followed people with MS over a period of 9 years, 1 of the important changes was a narrowing of participants’ social and geographic arenas. People aging with MS stayed closer to home, dropped activities, and restricted the number of people with whom they stayed in close contact.¹⁴ Often social contacts were maintained via telephone. Thus, for those aging with a long-standing disability, the effects are cumulative reflecting normal aging processes and the potentially increasing burden of the long-standing disability.

Onset of New Communication Disorders in Old Age

In addition to changes in communication resulting from the normal aging process and those from long-standing chronic conditions, many neurologic conditions associated with communication disabilities have their onset in old age. These conditions may affect anyone regardless of disability status and are common in aging. For example, hearing loss is ranked as the third most prevalent chronic condition in older adults.¹⁵ Nearly half of adults older than 75 years have some hearing loss. Parkinson disease, which is estimated to occur in about 1% of people more than 60 years old, is commonly associated with dysarthria.¹⁶ One million people in the United States are estimated to have aphasia, commonly as a result of stroke.¹⁷ Adult onset of neurologic conditions adds to the existing burden of changes with aging. When examining changes in participation and social roles after a stroke, Desrosiers and colleagues¹⁸ found that changes could not be attributed entirely to the stroke itself but also to the process of normal aging.

In the 2008 study of Aging, Demographics, and Memory, the prevalence of dementia in persons older than 71 years is estimated to be 14% of the population, with 3.4 million women and 1 million men affected by the most common form of dementia, Alzheimer disease.¹⁹ Dementia is the general term used to describe the continuum of degenerative brain diseases characterized by cognitive impairment across multiple domains. Alzheimer disease, Pick disease, Huntington disease, Parkinson disease, multi-infarct or vascular dementia, and Lewy body disease are some of the presentations of dementia that have their own unique features but have 1 common characteristic: the presence of memory impairment, particularly impairment in the ability to learn new information.²⁰ Dementia affects communication and eventually limits social roles, because of the gradual deterioration of cognitive skills, including memory, attention, perception, executive functions, and problem solving. The degenerative course of dementing illnesses contributes to an ever-changing presentation of symptoms. In the early stages, individuals experience mild forgetfulness for names and objects, mild word finding, abstract reasoning, attention, language, and spatial cognition difficulties.²¹ As the disease progresses, moderately severe impairments in memory, language, judgment, and activities of daily living are apparent, thus increasing the need for assistance and surveillance by caregivers. Late stage patients exhibit loss of language (ie, incoherent babbling or muteness) and decreased recognition of family and self, delusions, hallucinations, repetitive, and bizarre behaviors.²⁰ Individuals with dementia experience a gradual transformation from an independent, fully functioning participant in their own life, to total dependence on others, oblivious to the world around them.

Maintaining Social Roles

Communication is not just about transactions such as exchanging information and transferring messages; it also serves an important role in establishing and maintaining social affiliation. Lubinski⁸ proposed that communication serves several critical roles in the lives of older adults, including maintaining a sense of identity, and relieving loneliness, depression, or anxiety. Communication also allows older adults to exert influence and to help others by listening, reflecting, and offering advice. If communication is compromised, social life is affected.

Access to Health Care

Although maintaining social roles is important to people as they age, another significant concern is the ability to access services that they perhaps have not needed in the past, or that they now need to a greater degree. Health care is a primary example of these types of services. The ability to communicate successfully, including speaking, listening, reading, and writing, is a critical factor in obtaining health care. The importance of communication is reflected in Ruben’s³² suggestion that in the 21st century a person’s fitness for survival will be defined in terms of his or her ability to communicate effectively. Communication disabilities are especially common in the hospital setting. Although they are estimated to occur in 5% to 10% of the general population, this rate is higher in people who are hospitalized. Ebert and Heckerling³³ found that approximately 16% of patients on general inpatient services had 1 or more severe disabilities affecting communication. These patients were more likely to be older men. The presence of a communication problem was significantly associated with an increased risk of experiencing a preventable adverse event.³⁴ Patients with communication problems were 3 times more likely to experience adverse events than those without such problems.

Limitations in communication also have an undesirable affect on outpatient health care, where time is increasingly limited for patient visits and health care relies more on communication via written information, telephone, and computer (eg, e-mail). Research focused on the Medicare population suggests a significant relationship between the presence of communication problems and dissatisfaction with health care including overall quality, accessibility, and receipt of information.³ Iezzoni and colleagues³⁵ also found that older people with hearing or vision problems affecting communication were more likely to be dissatisfied with physicians’ understanding of their conditions and with the time spent discussing their problem and answering questions.

In their review of empiric studies examining the physician-older patient interaction, Adelman and colleagues³⁶ found that several dimensions were better with younger rather than older patients. These included physician responsiveness (eg, the quality of questions), agreement in setting major goals, and joint decision making. Another issue that distinguished physician visits in the geriatric population is the frequent presence of a third party. As much as half of the time, the older patient is accompanied to the visit by someone else who may play the role of advocate, passive participant or antagonist.³⁶ The third party may play an important role in decision making and be a conduit for education. The term ageism has been used to describe an important barrier to good communication between health care providers and older patients.³⁷ This type of bias may lead to communication that is characterized by stereotyped expectations rather than the recognition of highly variable individual characteristics of older patients. It is also associated with interaction patterns in which the physician dominates.

Communication in Heath Care Settings

Health literacy, defined as the ability to understand the basic health information and services necessary for making appropriate decisions about health services, is becoming an increasingly critical factor in health care communication. It has been estimated that one-third of people older than 65 years have inadequate or marginal health literacy.⁴⁰ This proportion is no doubt much higher in those with communication disabilities. Although accommodations such as wheelchair ramps to allow physical access to health care and other facilities are now taken for granted, similar accommodations to improve access to health care settings for those with health literacy issues are often not acknowledged as part of standard clinical practice.⁴¹

Iezzoni and colleagues³⁵ suggest that 3 types of accommodations in health care settings are needed to improve access to health care for people with communication disorders. These include brick and mortar (eg, a quiet room with furniture that allows eye to eye contact), tools (eg, reading material appropriate for people with aphasia), and policy changes (eg, longer appointments). A list of general suggestions for communicating with older adults with communication disabilities is provided in Box 1. Excellent resources are also available to guide patients in talking with doctors.⁴² Other guidelines are being developed and effective written materials are available.^43,44 For example, Hoffman and Worral⁴⁴ suggest that key stakeholders pretest and give feedback about educational material for people with communication disorders, particularly disorders affecting language comprehension or cognitive function. Their recommendations for effective written material focus on content (eg, inclusion of a clear purpose statement), language (eg, aim for 5th to 6th reading grade level), organization (eg, use subheadings and bulleted lists), layout (eg, use large print), and illustrations (eg, use simple line drawings).

In addition to these types of accommodations, it is important to identify the roster of decision makers who will be involved in the care of each individual patient. This set of decision makers may be large, diverse, and changing, and may include those who accompany the older person to the health care visit and those who do not, for example, distant adult children.⁴⁵ Once the set of decision makers has been identified it is important that educational materials are provided to all and that a partnership is formed between health care providers and decision makers. The goals of this partnership include identification of the problems, potential option or options and expectations, and the pros and cons of each option. The health care provider should determine the patient’s preferred format for receiving information (written, verbal, Internet), explore the concerns, and identify the preferred level of involvement in decision making. The health care provider should also check the patient’s understanding of the information and provide ample opportunity for questions. Arrangement should be made for future review of the decisions.

Enhancing Everyday Communication

By definition, communication involves an exchange between people. Thus, the focus of intervention to address communication disabilities must be on the person with the disorder and the communication partner. Research suggests that training communication partners such as nursing assistants in residential facilities can bring about encouraging changes such as more positive communication without increasing care-giving time.⁴⁶ Several programs for enhancing everyday communication are available. Some of these programs provide a general framework for enhancing communication, including approaches to enrich communication opportunities (eg, modifying the physical and social environment in resident care facilities) or enhancing communication effectiveness through identification of communication strategies for the person with the communication disorder and frequent communication partners. These strategies may involve manipulating the environment by decreasing background noise, distractions, and distance between speakers.^4,47–49 Other programs involve training in specific techniques, such as use of memory books and other written and graphic cues for people with dementia.⁵⁰