Communication problems can be frustrating to the older person and to the caregiver. The older person may become upset because of not being able to hear or understand what others are saying or because of having trouble expressing thoughts. Equally important, the caregiver may be frustrated by not being able to get messages across to the older person or because of not understanding what the older person is saying. Communication impairments include difficulty with speaking and understanding as well as difficulty reading and writing.
Some communication problems are caused by failing hearing or eyesight. Problems in hearing may make it hard for the older person to know when someone is talking or to follow the topic in a conversation. Vision problems can make it difficult to read personal letters, the newspaper or the instructions on a medicine bottle. While these problems are often permanent, their effects can often be minimized by specific communication techniques and by using devices such as hearing aids and eyeglasses.
Some communication problems are temporary and reversible, such as those that are brought on by medicines, infections, or depression. Some medicines can cause confusion or fatigue which can make it hard to understand others and to express oneself clearly. These problems can often be eliminated by changing medicine dosage.
Other communication problems are caused by structural or neurological damage from strokes, brain lesions (such as tumors), and diseases such as Alzheimer's and Parkinson's. While these disorders tend to cause permanent impairments, there are many strategies that can help the patient and the caregiver cope with ¯ and even overcome ¯ specific communication problems.
Whatever the cause, communication problems can lead older people to withdraw and become isolated, which often causes further loss of communication ability.
Identifying and solving communication disorders
As with most changes that take place with aging, communication problems are likely to develop slowly and subtly. People usually seek medical treatment when their problems
interfere with their ability to do things they usually do and are important to them ¯ such as talk on the telephone and understand or remember what they read in a letter. What is a communication problem for one person may not be for another. For example, vision problems which make reading and writing difficult may create frustration for someone who has spent much of their recreation time reading magazines and corresponding by mail. On the other hand, for people who have not spent much time reading and writing, the same difficulty may not be as important.
There are two important principles to remember when dealing with a communication problem.
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Communication is a two-way street. The speaker and hearer both play a role in causing communication problems, and both can alter their behaviors to resolve them. Conversation is a cooperative effort and all parties are responsible for improving it. It is never just one person's responsibility.
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Communication problems may require adjusting to new limitations and possibly reduced expectations. Not all communication problems can be solved completely. Therefore, you and the older person may have to accept that communication is different now. For example, poor hearing may make it impossible to carry on a conversation unless the room is quiet and the person is wearing a hearing aid. That does not mean that you have to give up conversation. It just means that you have to make sure that the older person brings to the conversation, not only his or her natural wit and special ways of expression, but also hearing aids ¯ and remember to shut the kitchen door, too.
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Many assistive devices and techniques are available to aid communication. Optimal use of these devices generally involves education from a health care professional who is knowledgeable about these problems.
Your goals are to:
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Get professional help when needed
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Inform (and educate) others about the problems and the best ways to communicate with the older person.
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Obtain communication aids/devices when necessary
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Maximize communication by using appropriate speech styles
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Encourage the older person to do exercises to improve communication
Seek medical help immediately if the following occurs.
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A sudden change in ability to speak or understand. If a person suddenly has trouble making sense, getting words out easily, or suddenly cannot comprehend what you are saying, he or she could be having a stroke. A person having a stroke may not be aware of the changes or may be unable to communicate that something is wrong. A stroke can cause a person who normally speaks in complete sentences to suddenly start speaking in sentence fragments or can stop them from talking altogether. Other symptoms of a stroke may include numbness and weakness on one side of the body, sudden vision changes and increased drowsiness. A stroke is a serious medical condition and medical care should be sought immediately.
The following symptoms should be reported during regular office hours
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A change in the sound of the voice that does not go away after a few days ¯ if it is not associated with a cold or the flu. Changes in voice, such as hoarseness or breathiness, can be caused by habits such as excessive yelling, smoking, drinking alcohol, by acid coming up from the stomach and irritating the vocal cords, aging of the vocal cords, or by diseases such as low thyroid function or cancer. A voice problem can sound the same whether it is caused by a relatively harmless habit (like throat clearing) or by a serious condition such as cancer. A primary care doctor may refer the older person to an Otolaryngologist (ear nose and throat doctor) who can look at the vocal cords and determine the cause and best treatment. Do not wait until the voice is gone to seek help. It is important to maintain whatever voice the older person has.
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A voice that is hard to hear. If a person speaks so softly that he or she cannot be heard, a doctor should be consulted. One of the signs that a person's voice is too low is that other people frequently ask him or her to repeat what was said. This can be caused by many disorders including viral infections of the vocal cords, stroke, breathing problems, fatigue, and Parkinson's disease. A person's voice may also seem hard to hear by people who have a hearing loss. In this case it is not the speaker who needs attention, but the hearer.
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Incomplete or incomprehensible speech. This can include speaking in sentence fragments (for example: "table sit down") or uttering nonsense (for example, "the thing that was just here, was just there, when I said I haven't been there for a long time, since he was not that old anymore"). Difficulty expressing thoughts in a clear way can be a side effect of medicines, stroke, a temporary narrowing of vessels in the brain, head injury, and the dementia associated with Alzheimer's disease.
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Slurred speech. Unclear or funny sounding speech, sounding like someone who has had too much to drink, or is talking through the nose, can be signals of serious neurological impairment (or, of course, serious drinking.) Slurred speech is often associated with stroke, degenerative diseases such as Parkinson's and Amyotrophic Lateral Sclerosis (Lou Gehrig's disease,) a diabetic crisis, and can also be a relatively temporary problem associated with fatigue and certain medicines. If slurring is sudden and severe, it could be an emergency and a doctor should be called immediately.
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Inability to comprehend. If an older person cannot understand what others say, or has difficulty remembering or following instructions, this may be a sign of difficulty hearing, difficulty interpreting speech or difficulty remembering what was said. These problems can be caused by hearing loss, strokes, and dementia, Alzheimer's disease, and can be a side effect of medicines the person is taking. (See the chapter on "Hearing Problems" for more discussion of what can be done to improve hearing.)
Know the answers to the following questions before calling the doctor.
It is usually enough to simply describe the problem and how long it has been happening. Other information may be requested at the time of the evaluation. The questions that a health professional might ask during an evaluation of communication problems include the following:
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What level of education does the older person have?
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Is the current level of communication significantly different than in the recent past?
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Does the communication problem significantly interfere with family interactions, socializing with friends, etc.?
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Has there recently been a major change in the person's life, such as the death of a spouse or long-time friend, a move to another living situation, or retirement?
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What is the older person's daily schedule? What kinds of activities or socializing does the person do?
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Have there been any recent physical ailments, either diagnosed or undiagnosed?
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What medicines is the older person currently taking? Have there been any recent changes in medicines? (This could include either discontinuing old medicines or starting new ones.)
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Has this type of problem happened in the past? If so, what triggered it?
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9Has the older person ever been treated for this condition?
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Is there a family history of stroke, heart disease, or dementing illness?
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Is the older person currently having memory problems, either with short term memory (remembering the past 15 minutes) or with remembering past history and
childhood?
Here is an example of what you might say when calling
"This is John Brown. My mother, Doris Brown, is a patient of Dr. Johnson's. I have difficulty understanding what my mother is saying, especially on the telephone. She slurs her words and talks very softly. It has become worse over the past month or so."
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What you can do depends on (1) what the primary problem is, (2) what is causing it, and (3) how severe the problem is. For instance, if someone cannot understand what you are saying, it could be due to a hearing loss, or it could be due to a problem in the brain. Depending on the cause, the solutions will be different: a hearing loss may be treated by hearing aids and training the person to make the most out of the remaining hearing. On the other hand, hearing aids will not help people with dementia (unless, of course, they also happen to have a hearing loss.)
Many people have more than one communication problem, and everyone is unique. What works for one person might not work for another. These are meant as general guides to improve communication. If possible, seek help from a qualified speech pathologist before developing or stopping a plan.
Getting and keeping attention
Many disorders affect a person's ability to pay attention. People who cannot focus their attention during a conversation, find it difficult to understand what was said and to organize and express their own thoughts. Below are several helpful strategies.
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Communicate during periods of greatest alertness. Use these times to talk about important topics. Some people are morning people and some aren't. Many people are alert just before a meal, but may be drowsy afterward. If you must talk about a complex or important subject, such as signing an important form, or want to plan a party, choose the time when the older person is most alert.
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Talk face-to-face and maintain eye contact. A good way to get and keep a person's attention is to face him or her directly. The older person will have a greater chance of understanding you if he or she can see your face when you talk. The older person can then see your mouth move (which also helps those with hearing problems), and can see your facial expression (which can often communicate the essence of the message.) If you see that he or she is not attending, you may want to take a break or include the older person's name in what you say in order to get attention back.
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Communicate in a quiet, well-lighted area. This helps the older person see you and pay attention to you. Make sure that the lighting is helping and not interfering with the person's vision. (For example, glare can interfere with vision.)
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Eliminate background noise. Turn off the TV and radio. If there are many sources of stimulation, the older person will have trouble focusing on one. The fewer distractions the better. Avoid talking in noisy or distracting places. Restaurants, airplanes, and cars are noisy and make it difficult to communicate. If possible, pick a time when you will not be interrupted.
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Have the older person sit up for conversation, if possible. If the older person is confined to bed, sit him or her up and place a pillow behind for support. If it is an adjustable bed, raise it to a level comfortable for sitting. This facilitates eye contact and makes talking easier.
Use devices to improve hearing and vision when appropriate
There are many helpful devices available for purchase, and some that you can devise yourself to improve communication. Here are a few suggestions.
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Obviously, use eyeglasses and hearing aids, if you have them. It is important that the older person wear glasses and hearing aids if they are recommended. Check that the eye prescription is up to date, and that the hearing aid is working. In addition, there are several other devices available to help hearing and vision. For example, some "low vision aids" such as a large lighted magnifying glass may help someone read or even paint when regular eye glasses are not sufficient. There are also programmable hearing aids and television and telephone amplifiers that can help someone hear in specific situations. (See the chapter on "Hearing Problems" for more discussion of these devices.)
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Use writing, pictures, and gestures to supplement spoken language. Instead of repeating yourself endlessly to someone who has trouble hearing, understanding, or remembering, you might want to post signs with important information (for example, the date and who is coming to visit today.) For people who have a difficult time speaking, sometimes gestures (including nods and hand signals) or pictures (of family members, foods, etc.) can help. Written diaries/memory books and pictures can be aids for those with memory impairments.
Adjust your communication style to fit the person's needs
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Speak slowly and clearly. If you tend to speak fast, you may need to slow your speech and enunciate clearly. But do not slow your speech down so much that it sounds distorted. This can cause even more problems.
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Select familiar topics. If a person has a hard time following a conversation, try to pick topics that are personally relevant. For example, you may find it easier to talk about a neighbor's gardening project than to discuss the inflation rate.
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Pay attention to the emotional aspects of conversation. Don't be a stickler for details at the expense of the relationship. If a person with a memory problems does not remember the day, or even your name, ask yourself, "Does it really matter?" before getting upset and correcting him or her. It is often better to have an enjoyable time conversing than a factually correct conversation. Often the most important part of the message is emotional, and this is conveyed through words, the sound of your voice, and your facial expression. Don't rely on just one mode, or think that just because someone doesn't understand certain sentences, that they cannot get your meaning. And, besides, constant correction can make the older person frustrated and makes you exhausted and irritable.
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Encourage using many words to express ideas. If the older person is having difficulty coming up with a particular word, you can ask for other information about the missing word. For example, if the person is saying that he played bingo last night, but all that is coming out is "I went to play, oh, I can't remember the word, the name of the game." You might ask how to play the game, or where it is played. Do not continuously complete the other person's thoughts or sentences; always give opportunities for the person to express him or herself before interrupting.
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In general, don't interrupt. This can increase frustration and make communication difficult.
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Avoid asking for multiple repetitions. Often what someone says is equally hard to understand the second and third times. Instead of asking someone to repeat, try one of these strategies:
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Ask specific questions. ("Are we talking about dinner?")
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Ask for another phrasing. ("Tell me in a different way.")
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Ask a follow-up question to confirm or clarify. ("Did you say you wanted to go for a walk?")
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Ask yourself if you really need to know exactly what the person said. Sometimes you may want to just let it go.
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Repeat important messages. Information can be repeated in many ways: paraphrase, write notes, make calendar entries, etc.
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Avoid overly complex sentences with open-ended questions. Speak in simple sentences, but don't talk in "baby talk." For example for someone who has trouble speaking, often the hardest questions to answer (and the hardest for you to understand) will be open ended questions such as "Where do you want to live?" Instead, ask for a simple choice such as "Would you like to live in the city or in the country?" If a person has difficulty choosing, you can simplify the question further by asking questions that only require a "yes" or "no" answer. ("Do you want to live in the city?") If the older person's speech is unintelligible, be creative about the kinds of responses to use. For example, questions can be answered by spelling out words on a board, pointing to words, with a head shake versus a nod, with thumb up versus down, or even pointing to a happy versus a sad face.
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Make complex instructions simple. You can simplify complex instructions by breaking them down into separate, short steps and by writing down what is to be done. So, for instance, instead of expecting the older person to remember and follow complicated instructions for taking medicines or using a microwave, give step-by-step instructions verbally and also write them down.
Generally good ideas
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Inform everyone who talks to the older person what type of communication problems he or she is having. This way everyone can help.
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Create opportunities for socializing. When people have problems communicating, other people tend to talk to them less and so they get less stimulation. This can lead to further loss of communication skills. Encourage others to talk to the person with communication problems but pay attention to the way they communicate (see above on speaking styles) and be aware that talking can be tiring as well as stimulating for the older person, so be sensitive to how tired he or she is.
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Be patient. If the older person has a disease that affects the way the brain processes information, normal brain functioning may be slow or distorted. When you ask a question, the information may take longer to get through. If the older person hesitates in answering a question, it may not be because of not hearing or understanding you. It may just be that he needs a longer time to process the question and to formulate an answer. If you repeat the question unnecessarily, it may cause frustration when the person is already in the midst of trying to answer you. In general, be sure you know what is causing the problem before you try to help.
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Maintain the older person's dignity. Don't assume that he or she cannot understand you and don't "talk down" to the person.
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Keep talking. Interacting with people will help prevent isolation and depression.
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Take breaks. If you can tell that the older person is becoming frustrated with the conversation - either because of not understanding or not being able to express himself or herself, take a break. This gives you both a rest, and also gives you a chance to regroup your thoughts and to think of a better way to communicate.
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Encourage exercises to improve speech. A speech pathologist may prescribe exercises to change and improve speech habits. For example, by just speaking more slowly or opening the mouth wider, a person can be more easily understood. You can help by encouraging these exercises and insuring that they are done regularly and properly.
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"I've run out of patience with Dad. He doesn't try to understand me anymore."
Response: When does Dad understand? This will tell what he is capable of doing. Try to match your expectations with what he can do at his best. Very possibly Dad is running out of patience with you because you are expecting too much of him. Set reasonable goals for yourself and your dad.
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"I've tried 3 times to get Mother to tell me what she wants for lunch, but she won't tell me."
Response: Your mother might need more time to respond than you are giving her. Or it could be that her ability to process your question is becoming further impaired. Consider other ways of communicating, such as showing her pictures or a menu or written choices.
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"I have Parkinson's disease so not being able to talk is part of the disease."
Response: Parkinson's disease may make it harder for you to talk, but many problems from Parkinson's can be overcome. There are ways to compensate including remembering to use more effort when you talk, speaking slowly, and opening your mouth when you speak. With therapy and practice, these can become automatic habits and you will be heard much more easily.
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"Mother has other problems that are more important."
Response: Communication is an essential part of life and is basic to human relationships. So many things depend on communication, such as getting your basic needs met, companionship, and emotional support. If your mother cannot communicate, she's shutting herself off from the world and from a richer life. It is important to maintain her communication strengths and enhance her ability to interact with others.
Think of other obstacles that could interfere with carrying out your plan
What additional roadblocks could get in the way of doing the things suggested in this chapter? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?
You need to develop plans for getting around these roadblocks. Use the six problem-solving steps in the chapter on "Using the Eldercare at Home book to solve caregiving problems."
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Using the techniques in this chapter should help you and the person to communicate better. As a caregiver, you can help the older person's ability to communicate by improving your communication skills and by encouraging him or her to work to develop new skills too. Ask yourself if you are using simple words, avoiding confusing topics, talking when the person is most alert, and being sensitive to when the person is upset and when you are upset.
If communication problems are serious and persist, review the section on when to get professional help. The older person may need to be evaluated by a speech pathologist. Speech pathologists are trained in understanding how aging and changes in the brain or nervous system affect communication. They can show you and the older person ways to compensate for lost skills and show you how to improve your ability to communicate. The older person's doctor can make a referral. Speech pathologists can also be located by contacting your hospital's speech pathology department or through a home health agency.
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For additional information:
American Lung Association
1740 Broadway
New York, NY 10019
212-315-8700
1-800-586-4872 (LUNG-USA)
www.lungusa.org/pub/
Provides general information as well as information on specialized services; their mission is the promotion of lung health. One of their special sections is on Adult Lung Problems.
American Heart Association
1-800-242-1793
www.americanheart.org
Offers information on diet, exercise, and breathing problems, as well as a program to help persons stop smoking.
American Cancer Society
1-800-227-2345
www.cancer.org
Provides general health information and offers stop smoking programs.
National Institute on Aging
800-222-2225
www.nih.gov/nia
Offers a pamphlet "A Good Night's Sleep."