Caregiver Guide: Communication Problems

Understanding the Problem

Communication is the act or process of using words, sounds, signs, or behaviors to express ideas, thoughts, feelings, etc., to someone else.
Communication problems can be frustrating for the older person and his or her 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.
Communication is the way to connect with the world, but it doesn’t have to be verbal – our pets don’t talk and they let us know what they want! It can help for caregivers to be creative in the ways they communicate.

Causes of communication problems

Some communication problems are temporary and reversible such as those 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. Changing the medicine dosage, or the medicine itself, often can eliminate these problems.

Other reasons are background noise in the environment (like in a clinic waiting room), difficulty understanding regional and ethnic accents. For the older adult, dry mouth or poorly fitting dentures can affect clarity of speech.

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 that make reading and writing difficult may create frustration for those who have 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:

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.

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.

Your goals are to:

  • Call for professional help when needed
  • Inform (and educate) others about the problems and the best ways to communicate with the older person
  • Obtain communication aids/devices when necessary
  • Maximize communication by using appropriate speech styles
  • Encourage the older person to do exercises to improve communication

Click on each of the topics below to read more.

When To Get Professional Help

Call the healthcare provider immediately or go to the emergency room if the following occurs

A sudden change in ability to speak or understand

If a person suddenly has trouble making sense, getting words out easily, or 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 persons who normally speak in complete sentences to suddenly start speaking in sentence fragments or it 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.

Use the acronym FAST to remember the symptoms of a stroke

  • Face - is one side of the face drooping down?
  • Arm - can the person raise both arms, or is one arm weak?
  • Speech - Is speech slurred or confusing?
  • Time - Time is critical!  Call 9-1-1 immediately!

Call the healthcare provider during office hours to discuss the following problems

A persistent change in the sound of the voice that is not associated with a cold or the flu

Changes in voice, such as hoarseness, 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, thyroid dysfunction, vocal cord paralysis, 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 provider may refer the older person to an otolaryngologist (ear, nose, and throat specialist) 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.

A voice that is hard to hear

If a person speaks so softly that he or she cannot be heard, a healthcare provider 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, thyroid disease, and Parkinson's disease.

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.

Slurred speech

Unclear or funny sounding speech, slurring, or "talking through the nose," can be signals of serious neurological impairment. Slurred speech is often associated with stroke, degenerative diseases such as Parkinson's, and amyotrophic lateral sclerosis (Lou Gehrig's disease), and also can be a relatively temporary problem associated with fatigue, alcohol use, and certain medicines. If slurring is sudden and severe, it could be an emergency and a healthcare provider should be called immediately.

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, stroke, or dementia, and can be a side effect of medicines the person is taking. 

Know the following information before calling the healthcare provider

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 doctor might ask during an evaluation of communication problems include the following:

  • What level of education does the older person have?
  • Is the current level of communication significantly different than in the recent past?
  • Does the communication problem significantly interfere with family interactions, socializing with friends, and similar social situations?
  • Has there recently been a major change in the person's life, such as the death of a partner or long-time friend or a pet, a move to another living situation, or retirement?
  • What is the older person's daily schedule? What kinds of activities or socializing does the person do?
  • Have there been any recent physical ailments, either diagnosed or undiagnosed?
  • What medicines is the older person currently taking, including over-the-counter, herbal, and other remedies? Have there been any recent changes in medicines? (This could include either discontinuing old medicines or starting new ones.)
  • Has this type of problem happened in the past? If so, what caused it?
  • Has the older person ever been treated for communication problems?
  • Is there a family history of stroke, heart disease, or dementing illness?
  • 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?

What You Can Do To Help

What you can do depends on what the primary problem is, what is causing it, and 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 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 suggestions 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. Following are several helpful strategies.

Communicate during periods of greatest alertness

Use these times to talk about important topics. Some people are morning people. 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 an event, choose the time when the older person is most alert.

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. Make sure the older person can then see your mouth move and your facial expression. If you see that he or she is not paying attention, you may want to take a break or include the older person's name in what you say in order to get attention back.

Communicate in a quiet, well-lighted area

This helps the older person see and pay attention to you. Make sure that the lighting is helping and not interfering with the person's vision. While bright light often helps, it also can create glare that interferes with vision.

Eliminate background noise. Turn off the TV and radio

Turn off the TV and radio. If there are many sources of stimulation, the older person will have trouble focusing on only 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, when you want to communicate, pick a time when you will not be interrupted.

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 him or her for support. If the person is in 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. Following are a few suggestions:

Use eyeglasses and hearing aids

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.

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, such as the date and who is coming to visit that day. For people who have difficulty speaking, sometimes gestures (including nods and hand signals) or pictures (of, for example, family members or particular foods) can help. Written diaries/memory books and pictures can be aids for those with memory impairments. In addition, people who do not understand spoken language may be able to understand when speech is accompanied by a meaningful gesture or key words in writing.

Adjust your communication style to fit the person's needs

Speak slowly and clearly

If you tend to speak fast, you may need to slow your speech and speak clearly. But do not slow your speech so much that it sounds distorted. This can cause further problems.

Select familiar topics

If the older person has a hard time following a conversation, try to select topics that are important to him or her. For example, you may find it easier to talk about a neighbor's house than to discuss the inflation rate.

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 problem 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 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. Also remember that constant correction can make the older person frustrated and can exhaust and irritate you.

Encourage using many words to express ideas

If the older person is having difficulty thinking of 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, where it is played, or offer a few choices. Do not continuously complete the other person's thoughts or sentences; always give opportunities for the person to express him or herself before interrupting.

In general, don't interrupt

This can increase frustration and make communication difficult.

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:

  • Ask specific questions ("Are we talking about dinner?")
  • Ask for another phrasing ("Tell me in a different way.")
  • Ask a follow-up question to confirm or clarify ("Did you say you wanted to go for a walk?")
  • Ask yourself if you really need to know exactly what the person said Sometimes you may want to just let it go.

Repeat important messages

Information can be repeated in many ways, such as paraphrasing, writing notes, making calendar entries, or other ways you can devise.

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 the responses to) 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 require only 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, a head shake or a nod, thumbs up or thumbs down, or pointing to a happy or a sad face.

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. 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

Inform everyone who talks to the older person what type of communication problems he or she is having

Make suggestions as to how everyone can help with communicating with the person.

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 and social isolation. Encourage others to talk to the person with communication problems but pay attention to the way they communicate 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.

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 process. If the older person hesitates in answering a question, it may not be because of poor hearing or comprehension. It may be that he or she needs a longer time to process the question and to think of 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, try to understand what is causing the problem before you try to help.

Maintain the older person's dignity

Don't assume that he or she cannot understand you and don't "talk down" to the person.

Keep talking

Interacting with people will help prevent isolation and depression.

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 what he or she wants to say, take a break, such as looking out the window. 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.

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.

Carrying Out and Adjusting Your Plan

Problems you might have carrying out your plan

"I've run out of patience with Dad. He doesn't try to understand me anymore."

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.

"I've tried three times to get Mother to tell me what she wants for lunch, but she won't tell me."

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.

"I have Parkinson's and not being able to talk is part of the disease."

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 talking, speaking slowly, and opening the mouth when speaking. With therapy and practice, these can become automatic habits and the person with Parkinson's will be heard much more easily.

"Mother has other problems that are more important."

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 problems you might have carrying out your plan

What other problems could get in the way of doing the things suggested in this section? 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?

Checking on Progress

As a caregiver, you can help the older person's ability to communicate by improving your own 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.

What to do if your plan isn't working

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 healthcare provider can make a referral. Speech pathologists can also be located by contacting your hospital's speech pathology department or through a home health agency.