Elderspeak - It could be life threatening
A new term is creeping into the medical dictionary as the population ages – elderspeak. Research has shown elderspeak can lead to a negative attitude towards ageing and this in turn can reduce life spans by more than seven years, writes Peter Waterman.
Elderspeak is broadly defined as a ‘manner of communicating to older people using a slow rate of speaking, simplified syntax, vocabulary restrictions, and exaggerated prosody on the assumption that their age makes them cognitively impaired’. The operative word in this definition is ‘assumption’. Assuming that ageing and cognitive impairment go hand-in-hand is one which is not only incorrect, it can quite literally be life-threatening.
Examples of elderspeak include platitudes like calling older people ‘dearie’ or ‘love’ rather than by their name. It includes speaking louder and slowly just because a person is older. And it is something which we have all probably been guilty of at some stage.
Research has shown elderspeak can lead to a negative attitude towards ageing and this in turn can reduce life spans by more than seven years.
In fact, the problems of talking down to older people has become so serious that the Nursing and Midwifery Council (NMC) in Britain has issued guidelines telling nurses to use patients’ preferred names and speak ‘courteously and respectfully’ to ensure dignity in care. In its controversial guidelines, the NMC states that: ‘It is essential as a nurse, in whichever setting you work either in the hospital or community, that you always provide fundamental care by ... speaking to older people courteously and respectfully, addressing them as an adult without the use of terms such as “dearie” or “love”’ and ‘finding out what they would like to be called and then using their preferred name’.
Seniors themselves plead not to be spoken to as if they were children.
Michael O’Neill from National Seniors Australia said it was important not to be condescending or paternalistic when speaking to older people.
“The position we have been strong about is that in regards to advice directed to older Australians we must ensure that the comments and feedback are age appropriate, age specific, and not paternalistic or ageist in the way the message is delivered,” he said.
Approaching older Australians’ health issues and messages in a way that was not condescending and not paternalistic was a really important part of getting a message across.
“Too often we see or hear depictions of older people being treated almost as children simply because they are older. We see the ‘here petal, here darling’ approach taken in a paternalistic way,” Mr O’Neill said. “But we are talking about people who have been through a lot of life and remain mature adults and should be approached in a serious but positive manner.”
Researchers at Yale University in the US warned of the dangers of using patronising language when talking to older people and pointed to words which depict the elderly as being similar to small children – words such as ‘sweetie’ and ‘dear’. They found speaking needlessly slowly and loudly also to be damaging. They also found such behaviour can be distressing and affect health. They said that the worst offenders were often healthcare workers who thought they were being kind. In addition, it was found many older patients are annoyed by doctors who address their children rather than them.
The author of the researchers’ report, psychologist Professor Becca Levy, said: “Those little insults can lead to more negative images of ageing. “And those who have more negative images of ageing have worse functional health over time, including lower rates of survival.”
The study also found that those who have a positive attitude towards ageing live on average 7.5 years longer than those with a negative attitude. This is a bigger increase in lifespan than is provided by the benefits of frequent exercise or not smoking. The research found that for people with mild to moderate dementia, the results of elderspeak were even more alarming. Patients became aggressive and uncooperative, and if spoken to as though they were infants, they would scream or refuse to do anything.
“Elderspeak sends a message that the patient is incompetent and begins a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal and the assumption of dependent behaviours,” Dr Levy said.
Speaking from Yale University in Connecticut, Dr Levy said while there had been no research into whether there is more awareness of problems of elderspeak with the rising ageing population, the problem “certainly has not disappeared”.
“It’s very important to avoid elderspeak when getting a health message across,” Dr Levy said. “My research is mainly on how negative stereotypes can have a negative impact on the health outcomes on various individuals. “So any form of elderspeak that provokes negative stereotypes of ageing can be damaging. “Clearly if there is an ability to treat people with as much respect as possible, regardless of age that will have benefits for them.”
However, Dr Levy agreed there was some controversy over the use of terms of endearment in some situations such as informal conversations.
“The key is to be as thoughtful as possible and not just speak automatically and throw in terms of endearment,” she said. “You need to be really thoughtful about who the person is and see if there are ways to show them that they are respected and that their health decisions are valuable.”
Dr Levy said there was no firm rule or guideline on whether health workers should wait for permission to use a patient’s first name.
“One strategy is just to ask people how they want to be addressed,” she said. “People are very different in how they like to be addressed and some people are happy to be addressed by their first name whereas others may say they would like to be referred to as Mrs Jones or whatever their surname is.” Nancy Pachana, Professor, School of Psychology at the University of Queensland, co-director of the UQ Ageing Mind Initiative and also National Convenor of the Australian Psychological Society’s Psychology in Ageing Interest Group, said elderspeak “definitely has been shown in research to be damaging”.
“Even with people with cognitive impairment, elderspeak means the speech of the person speaking is less comprehensible and makes the person being spoken to feel belittled, infantilised and not respected,” she said. “I can’t stress enough that this elderspeak is all wrong. Even people with cognitive impairment can process the tone of the speaker. “Everyone has been in hospital and you’re feeling bad and the nurse comes along with a cup of tea and says ‘here you go dearie’. Now no one is going to take offence at that. That would be being too PC (politically correct).
“But, it’s in the more professional interaction with people that you really want to make sure that you’re not slipping into a speech pattern that is lacking in respect.” In situations of a quick interaction or if a person was in pain or distress, then as long empathy was communicated it was appropriate to use the endearing terms, Professor Pachana said.
“I’m talking about examples where a pharmacist is discussing medication or a nurse is discussing what they are going to do, then we must avoid elderspeak,” she said. “For instance if you’re saying ‘here’s you medication and this is what it is for’, this is the time when you have to use respectful communication and think about ‘am I being respectful’. As an example, some older adults don’t like to be called by their first names. You should use the person’s surname and title until you ask permission if it’s ok to call them by their first name, or if they ask you to use their first name.
“The second thing is to ask yourself, ‘Am I giving the person permission to ask questions if I’m not being clear?’” That would involve not speaking too quickly, and pausing and checking with the person and asking ‘do you have any questions, is this all clear?’
“It is very easy to communicate to someone that they don’t have power but in a healthcare situation you want people to know what is going on and that they are going to follow the recommendations because they are part of the solution.
“The key is to be as thoughtful as possible and not just speak automatically and throw in terms of endearment.”
”I often talk to people who don’t understand why they need to take a medicine, so they don’t take it, even if it’s really important, because they don’t know why it’s important.”
Professor Kristine Williams of the University of Kansas School of Nursing, said healthcare workers often thought that using words like ‘dear’ or ‘sweetie’ conveyed that they cared and made them easier to understand.
“...If you know you’re losing your cognitive abilities and trying to maintain your dignity, and someone talks to you like a baby, it’s upsetting to you.”
“But they don’t realise the implications that it’s telling older adults that they’re incompetent,” Professor Williams said.
Elderspeak attitudes were equally hurtful to people suffering from dementia.
“The main task for a person with Alzheimer’s is to maintain a sense of self and dignity. If you know you’re losing your cognitive abilities and trying to maintain your dignity, and someone talks to you like a baby, it’s upsetting to you,” she said.
In light of the debate over the use of elderspeak, one question is whether Australia should go down the path of Britain’s Nursing and Midwifery Council and actively discourage terms of endearment.
Chair of the Nursing and Midwifery Board of Australia, Anne Copeland, said it was important that patients and nurses spoke to each other in a way that ensured there was trust and respect between them.
“However, the board’s Code of Ethics and guidelines speak in terms of what is expected of nurses and midwives rather than the other way around,” she said. “It is of course important when communicating with older people that you speak clearly and that there is clarification that they understand what you are speaking about.”
Unlike its British counterpart, the board does not advise against the use of terms of endearment but rather its Code of Ethics stresses: “Nurses value respect and kindness for self and others’ and explains this means ‘valuing respect for self and others encompasses valuing the moral worth and dignity of oneself and others. It includes respecting the individual ethical values people might have in the context of health care. Kindness is the demonstration of simple acts of gentleness, consideration and care. The practise of kindness as a committed and everyday approach to care reduces the power imbalance between a person requiring or receiving care and a nurse, by placing the nurse at the person’s service, which is the appropriate relationship.”
Its Code of Conduct states: “Nurses respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment, and of their colleagues’ and explains ‘this includes according due respect and consideration to the cultural knowledge, values, beliefs, personal wishes and decisions of the persons being cared for as well as their partners, family members and other members of their nominated social network.”
Journalist Peter Waterman is Director, National Public Affairs at the Pharmaceutical Society of Australia, and writes extensively for Australian Pharmacist Journal. He is winner of the National Press Club Excellence in Health Journalism Awards 2011 - Best News Feature for reporting on Health, Health Science or Innovation directed to medical professionals; winner 2012 Inaugural NPS National Medicineswise Awards for Best Media Report of a Medicines Story; Special Merit, 2012 OPSO Media Award for Rosie’s Story - A Carer’s View; and finalist - media, 2013 National Preventive Health Awards. He has an extensive background in journalism including working in Sydney, Brisbane, Fiji and New York and being Associate Editor of The Australian Financial Review.
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