© Borgis - Postępy Nauk Medycznych 7/2015, s. 444-450
*Katarzyna Broczek
Komunikacja z pacjentami w starszym wieku – klucz do sukcesu w opiece geriatrycznej
Communication with elderly patients – a key to success in geriatric care
Department of Geriatrics, Medical University of Warsaw
Head of the Department: Krzysztof Galus, MD, PhD
Streszczenie
Komunikacja jest procesem wymiany informacji w sposób werbalny i niewerbalny. Proces ten można analizować na wielu poziomach, z uwzględnieniem komunikatów bezpośrednich i pośrednich. Fizjologiczne zmiany zachodzące w procesie starzenia się organizmu oraz choroby wieku podeszłego mogą sprzyjać powstawaniu barier komunikacyjnych i wpływać negatywnie na możliwość porozumiewania się osoby starszej z pracownikami ochrony zdrowia. Brak odpowiednich umiejętności komunikowania się prowadzi do licznych błędów popełnianych przez personel medyczny i może spowodować poważne problemy, a nawet zakłócenie procesu leczenia. Zaburzenia wzroku i słuchu oraz zaburzenia funkcji poznawczych występujące często u osób w starszym wieku stanowią znaczące wyzwanie, które wymaga specjalnego przygotowania i uważności pracowników ochrony zdrowia. Pacjenci hospitalizowani, szczególnie ci w zaawansowanym wieku, mają inne potrzeby komunikacyjne niż osoby leczone w warunkach ambulatoryjnych. Metodą pomocną w ocenie pacjenta w starszym wieku i jego indywidualnych trudności w komunikacji może być całościowa ocena geriatryczna. Prawidłowa komunikacja nie tylko ułatwia wymianę informacji, ale również sprzyja tworzeniu przyjaznego i bezpiecznego środowiska dla pacjentów w starszym wieku oraz poprawia jakość opieki medycznej. Trening umiejętności komunikowania się powinien zatem stanowić integralną część szkolenia w zakresie geriatrii, gdyż efektywne porozumiewanie się jest kluczem do zrozumienia osoby starszej.
Summary
Communication is a process of exchanging information verbally and non-verbally. It may be analyzed on many levels, including direct and indirect modes of communication. Physiological changes accompanying aging, as well as comorbidities may create communication barriers and significantly impair understanding between older adults and health care workers. Lack of adequate communication skills lead to common errors committed by medical staff and may cause significant problems and negatively affect treatment process. Auditory and visual impairment, as well as cognitive deterioration represent situations requiring special education and vigilance of health professionals. Hospitalized patients, especially those in advanced old age, have special needs for communication, different from the outpatient setting. Comprehensive geriatric assessment may be a useful tool in evaluating the elderly patient and indicating specific individual challenges. Adequate communication not only facilitates exchange of information, but also creates friendly and safe environment for the elderly patients and guarantees quality of health care. Therefore, communication skills training should be an indispensible component of geriatric education, since it is a key to understanding the older patient.
INTRODUCTION
Interpersonal communication is a main way of exchanging information between patients and medical staff and is indispensible for efficient and adequate treatment. In older age, there are multiple factors reducing ability to communicate, including sensory organ deficiency, slower transfer of information and cognitive impairment. Lack of adequate communication skills of health care workers may affect contact with patients of any age, however it may dramatically impair communication process with older individuals. Addressing patient’s caregiver instead of the patient is not only a serious communication error, but might be perceived as a form of neglect and ageism. Understanding the complex nature and role of communication with older adults, together with critical view of one’s communication style are key factors in establishing the optimal model of communication.
DEFINITION AND LEVELS OF COMMUNICATION
The word „communication” comes from the Latin words communico, communicare meaning making common, uniting, transferring news, debating. Another Latin word communio stands for unity and belonging to a community (1). These broad linguistic meanings underline functional role of communication encompassing much wider space than just exchange of information. Levels of communication include intrapersonal or internal and interpersonal or external dimensions. Intrapersonal communication is necessary for gaining insight of one’s actions and perceiving the role of self in the process of communicating with others. Deficient internal „talk” may severely affect interpersonal relations. There are also indirect ways of communication, including exchange of information within a group or between groups of people or organizations, as well as transmitting news through the power of mass media. New ways of communication include long distance communication, e.g. via the Internet (1).
COMMUNICATION MODEL
In the process of communication there is a sequence of elements setting up a model of communication. It includes: a sender (Who is speaking?), a message (What is being said?), a channel (How it is being said?), a receiver (To whom it is being said?) and an effect (What is the result?). It is necessary to acknowledge the role of such additional elements as context of communication, environmental factors including noise, as well as feedback. Nonverbal communication may play a crucial role, especially in cases when the usual verbal channel of communication is compromised, e.g. in patients with speech disorders. Nonverbal communication includes such elements as: gestures, posture, body movements and visual contact. Spatial relationships between participants may facilitate or impair exchange of information. Such para-linguistic factors as voice intensity, speech speed, voice modulation, laughter may make interlocutors comfortable or may establish barriers in communication. General appearance, cloths, hair style and jewelry are additional factors influencing effectiveness of communication. Psychological approach to communication points to therapeutic communication and active listening as two skills indispensible for responsible contacts with patients (1).
BENEFITS OF EFFECTIVE COMMUNICATION
Effective communication will likely lead to better patient’s compliance and improved health outcomes, as well as lower the risk of medical errors. Role of interpersonal communication reaches far beyond the transfer of information. Adequate communication may strengthen patient’s feeling of belonging to a group or community or „having a place on earth”, it may increase security level and make supportive activities towards elderly patients more friendly and acceptable. Proper communication with hospitalized elderly patients strengthens fragile treads linking them with the reality and may prevent development of acute mental disorders such as delirium.
STEREOTYPES ABOUT AGING
There are many pejorative perceptions about old age and the aging process. Many people believe that older people, especially those in advanced age, are extremely different from the representatives of today’s society and don’t share the same needs or desires. Another misconception about older adults is that elderly people are isolated due to many health problems and have a lot of emotional problems. In spite of the fact that realities of aging seem not to fit the stereotypes, myths and misconceptions are still prevalent (2). Such phenomena should be perceived as ageism, even if they are presented with a face of pseudo-empathy for the elderly. On the other hand, many older adults share negative feelings about the old age and express pejorative thinking about being old. Understanding the above circumstances does not necessarily make the communication process easier, but it may lead to better understanding of challenges and barriers.
HOW NORMAL AGING MAY IMPAIR COMMUNICATION?
Changes due to physiological aging are usually mild and progressing slowly, however in unfavorable circumstances may become serious foes and culprits of treatment failure. Physiological changes in the brain include small decrease of brain mass, impaired regional blood flow, slower conduction of impulses, and deficits in neurotransmitters. These pathophysiological processes may impair attention, working memory, as well as access to long-term memory. The two main concepts of cognitive aging include the theory of impaired information processing and hypothesis of inhibition deficit. Inhibitory mechanisms impaired during aging are responsible for cognitive control, deleting unimportant data and suppression of improper reactions (3). In clinical practice, the above changes may produce talkativeness, circumstantiality and tendency to deviate from the topic. The situation becomes much more complicated in people with cognitive disorders due to pathological changes in the brain such as degenerative disorders, e.g. Alzheimer’s disease (AD). Speech disorders are present in most cases of AD and progress with the disease course, from mild cognitive impairment to dementia.
CAUSES OF INEFFECTIVE COMMUNICATION WITH OLDER ADULTS
Reasons of improper communication with elderly patients are often complex and include stereotypic view of the elderly, communication barriers due to physical, mental and functional disabilities of older adults and lack of proper preparation and engagement of medical staff. Medical and nursing students asked about barriers in communication most often point out features of the patients such as loss of hearing, impaired memory or prejudice towards medical staff, forgetting altogether about barriers created by medical workers (author’s data, not published). The situation may become even more complicated with medical staff having long-time experience that never underwent any training of communication skills. In the author’s experience as an academic teacher in postgraduate education, it is not uncommon to meet a physician or a nurse with 30 years of practice who does not possess essential skills of communication with cognitively impaired persons.
Common communication barriers and errors
Difficulties and barriers in communication may be due to patient-related and medical staff-related problems (tab. 1 and 2). It is worth stressing that the list of factors related to medical staff is much longer, but rarely acknowledged. Another group of factors influencing the quality of communication are external factors, such as the environment, noise, the presence of other people during the conversation. An important error in communication is connected with spatial relationship with the patient, e.g. bending over the patient, standing over the patient who is sitting or lying in bed, approaching the patient from behind. It automatically creates a feeling of an overwhelming power and gives a „clear” but often unintended message of „Who is ruling here”. Such patronizing or infantalizing way of addressing older people, especially those with cognitive decline, is considered „malignant social psychology” (4).
Table 1. Patient-related barriers in communication.
| Impaired hearing or/and vision |
| Cognitive impairment, dementia |
| Delirium and other states of disordered consciousness |
| Slowing down of thinking, speech, information processing |
| Circumstantiality of speech and tendency to deviate from the topic |
| Parkinson’s disease, stroke |
| Mood disorders, depression, anxiety |
| Avoiding contact with others |
| Previous experience of maltreatment and ageism |
| Over-suspiciousness and misconceptions concerning healthcare |
Table 2. Medical staff-related barriers in communication.
| Way of speaking: too loud, too quickly or very slow |
| Patronizing tone of voice, lack of partnership with the patient |
| Lack of ability to formulate precise questions, using complex sentences, using negation and expressions suggesting answers |
| Lack of active listening skills |
| Reacting with anxiety and anger to difficult situations, lack of problem solving skills, inadequate ability to control emotions |
Using improper forms of address: honey, sweety, etc.
Using non-personal expressions |
| Using a lot of diminutives |
| Talking only to the relatives of the patient, neglecting the patient, talking „over the patient’s head” |
| Not concrete or misleading transfer of information |
| Devoting time to activities related to the patient, but not dedicating enough time to communicate with the patient |
| Neglecting patients for whom „nothing can be done” |
| Paying attention to problematic non-compliant patients and neglecting cooperating, compliant patients |
| Lack of competence to discuss matters related to the times of patient’s youth, e.g. lack of basic knowledge on history of the country or general knowledge; lack of cultural competence |
| Conviction that impaired verbal communication means total lack of possibility to communicate |
| Trespassing one’s competences, patronizing speech and behavior, deciding for the patient |
| Lack of insight, lack of self-distance |
Errors in delivering information on diagnosis and prognosis
Providing information about a diagnosis of a serious disease with poor prognosis, e.g. advanced cancer or Alzheimer’s disease is a stressful event for the patient and the caregiver, as well as a great challenge for the physician responsible for the transfer of information. A lot of communication errors may occur in such situations, including misunderstanding, fragmented information resulting in patient’s anxiety, addressing only the caregiver and not the patient etc. When delivery of important information is planned, such meeting should be carefully pre-planned and organized in a way providing maximum possible comfort for the patient. A psychologist may help by providing support and facilitating effective communication (5).
EXAMPLES OF COMMUNICATION PATTERNS AND ERRORS
Two cases of communication patterns observed in the past by the author in a nursing home patients and two cases in a hospital setting are presented below.
Case 1
A patient is addressing a nursing assistance dressed in a visibly short coat in the following humorous way: „Your coat is very long, please be careful not to trip over it!”. The reaction of the nursing assistance is as follows: she says nothing to the patient, but looks hurt, than she says to her colleague: „Look! They even criticize our work suits!”. This type of communication may be described as an open, friendly, humorous and active behavior of the patient and rigid, unpleasant, over-reactive behavior of the nursing assistance. It is worth stressing that the patient had known the nursing assistance for over 10 years of living in the nursing home.
Case 2
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Piśmiennictwo
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