Elderspeak to Resident Dementia Patients Increases Resistiveness to Care in Health Care Profession

Abstract

Resistiveness to care is very common among patients of dementia as these patients do not take medicines, meals or bath very easily. Indeed, it is a very challenging task for health caregivers and there is a significant rise in time and cost involved in managing dementia patients. Amongst different factors, the type of communication between resident dementia patients and health caregivers is an important contributing factor in the development of resistiveness to care. Elderspeak (baby talk) is a type of communication in which health caregivers adjust their language and style while interacting with elderly and dependent patients. It involves the use of short sentences, simple grammar, slow and high pitch voice, repeating phrases to provide a comfortable and friendly environment to patients. Most of the time, caregivers tend to adapt elderspeak as they handle weak and fragile older patients for routine activities. Although elderspeak is meant to provide support, warmth and care to patients, yet patients perceive elderspeak as patronizing and it induces negative feelings about self-esteem. Scientists have found a correlation between the development of resistiveness to care and the extent of elderspeak in communication. Therefore, there have been strategies to develop alternative communication strategies by avoiding the use of elderspeak. Moreover, the beneficial effects of such communications have been documented as it improves the quality of life, reduces aggression, agitation and psychosocial symptoms. The present review discusses the scientific studies discussing the use of elderspeak in communication and development of resistiveness to care in resident patients of dementia.

• What do we already know about this topic?

• Resistiveness to care is a very challenging task for health caregivers involved in managing dementia patients. The type of communication between patient and health caregiver is an important contributing factor in the development of resistiveness to care.

• How does your research contribute to the field?

• Elderspeak in which health caregivers adjust their language and style is perceived as patronizing by the elderly and dependent patients. It induces a negative feeling about self-esteem and contributes to the development of resistiveness to health care.

• What are your research’s implications towards theory, practice, or policy?

• The development of communication strategies by avoiding the use of elderspeak may help in improving the quality of life, reducing aggression, agitation and psychosocial symptoms in dementia patients.

Introduction

Dementia refers to a set of symptoms that loss of memory loss, cognitive impairment, difficulties in problem-solving and paucity of language. Initially, these symptoms are not noticeable; however, with the progression of the disease, these become severe enough to impair the day to day activities. There are different types of dementia, including vascular dementia, Alzheimer’s disease, dementia due to Parkinson’s disease, dementia with Lewy bodies, frontotemporal dementia (Pick’s disease), Creutzfeldt-Jakob disease, HIV infection associated dementia. Amongst these different types, dementia due to Alzheimer’s disease is the most common and vascular dementia (due to stroke) is the second most common type.^1,2 There is an exponential rise in patients suffering from dementia from the age of 65 and to 90 years. Approximately, the rate is doubled every 5 years. ³ Recent studies have also shown the high prevalence rate of dementia due to multiple etiology, including vascular origin, ⁴ Alzheimer’s disease.^5,6

Resistiveness to care is very common among patients of dementia, which adds a substantial load on health caregivers.^7,8 In dementia patient with limited communication skills, there are chances of development of communication deadlock between health caregivers and resident patients. Health caregivers find difficulties in communicating with patients suffering from dementia. ⁹ Therefore, it is a need for good conversation techniques or interventions to overcome the communication barrier between patient and caregivers. ¹⁰ The improvement in communication may not directly decrease the neuropsychiatric symptoms in dementia patients; however, it does have the potential to improve the quality of care and life. ¹¹ Scientists have developed different “Communication Enhancement” models, which help in identifying individual problems and enhancing communication skills to meet individual demands. ¹² Elderspeak is a very prevalent type of communication among health caregivers while dealing with old age patients, particularly patients of dementia. Although this modified form of conversation or communication is meant to provide friendly behavior to patients, yet it is found to produce negative effects. ¹³ It often leads to communication block and development of resistiveness to care in patients.^14,15 The present review discusses the association between resistiveness to care and elderspeak in resident patients of dementia.

Elderspeak and its Purpose in Clinics

It is a normal human tendency to change the style of communication and alter language while interacting with infants. Similar types of changes are made in language and communication styles by health caregivers during their interaction with elderly patients. Such type of speech with elderly patients is termed as elderspeak. Therefore, elderspeak refers to changes made in language while communicating with older adults. It is also termed as infantilizing communication, secondary baby talk, over-accommodative speech or patronizing speech. The features of elderspeak include the use of very short sentences; slow speech, but elevated pitch; simple vocabulary and grammar; use of intimate words such as “good boy/girl” “sweetie” or “honey”; use of collective/plural pronouns (represented in italics), such as “Are we ready for our bath?”^7,16 (Table 1).

Table 1.

Elderspeak and Its Negative Effect on Dementia Patients.

Type of communication	Negative influence on dementia patients
• Use of very short sentences • Slow speech, but elevated pitch • Simple vocabulary and grammar • Use of collective/plural pronouns such as we and our • Use of initimate words • Good boy/girl • Sweetie • Honey	• Decrease in self-esteem • Resistiveness to care • Agitation • Emotional outbursts • Verbal and physical aggression, depression • Communication block

Health caregivers adapt elderspeak because they have to handle weak and fragile older patients who are totally dependent on daily routine activities. The data collected from 134 certified nurse assistants in the form of questionnaire showed that appropriateness of elderspeak is dependent on different contexts. Patient related features such as age, cognitive impairment and extent of dependency on nurse assistant were predominant factors affecting elderspeak. ¹⁷ The use of elderspeak is not restricted to a single country or location. Instead, studies from different countries have shown the use of elderspeak with geriatric patients. ¹⁸ The survey of about 159 older persons suggested that there are 2 dimensions of elderspeak, including “warmth” and “superiority.” There is an important role of familiarity of patients with caregivers. The patients felt a greater degree of warmth and a lesser degree of superiority from elderspeak of the familiar caregiver. With unfamiliar caregivers, patients perceived more of superiority and less warmth from elderspeak. ¹⁹ There is also an important role of patient’s perception of elderspeak. The patients having positive perceptions about elderspeak have reported higher self-esteem on an actual encounter with elderspeak. On the other hand, there was a decrease in self-esteem in patients having a negative perception of elderspeak. ²⁰ Moreover, there is an important role of age in perceiving elderspeak. In a study, older adults were able to recall more information about elderspeak in comparison to young adults after watching a video presentation of medication instructions in elderspeak. ²¹ As per the information gathered from 26 certified nursing assistants working in nursing homes and involved in caring elderly patients, elderspeak is adapted in communication for following achieving following purposes ²² :

• i. It makes patients more comfortable in nursing home

• ii. The caregivers may become friendlier with patients

• iii. The resident patients can comprehend verbal communication in a better manner

• iv. The patients may cooperate with care givers in a better manner, particularly during caring for giving activities.

Resistiveness to Care in Dementia Patients

Resistiveness to care is very common in patients of dementia and these patients generally resist taking medicines, meals or bath. ⁸ Resistiveness to care is a very challenging task and it increases subjective, objective, and a financial burden (more than 30% increase in cost) on health caregivers. ⁷ Amongst various factors affecting resistiveness, an important role of caregiver’s well being is recognized, which is linked with daily hygienic care.^23,24 Although resistiveness to care and agitation are 2 separate behavioral aspects of dementia, ²⁵ yet most of the times, resistiveness is associated with agitation and aggression. Physical, as well as verbal aggression, poses a great challenge to health caregivers and lack of effective communication is 1 of the most important factors involved in the development of aggression ²⁶ (Table 1). Improvement in behavioral interventions may reduce the development of resistiveness and associated abusive behavior. ²⁷

Avoidance of Elderspeak Reduces Resistiveness to Care in Dementia Patients

Communication failure is 1 of the most important factors contributing to the development of resistiveness to care in patients suffering from dementia and incorporation of elderspeak in communication is an important factor in producing resistiveness to care in elderly. ⁷ Elderspeak has been considered as a stereotypical behavior of young, healthy adults towards aged, weak, and dependent elderly persons. The elderly persons perceive elderspeak a form of patronizing communication, which tends to convey the message of incompetency of elderly adults. It has a negative impact on patients and may lead to a decrease in self-esteem, emotional outbursts, verbal and physical aggression, depression, communication block/withdrawal, and the assumption of dependent behaviors.^28,29 (Table 1).

In order to avoid elderspeak in communication, special communication training programs have been designed for nurse assistants to meet the psychosocial needs of adults.^30-33 A case study has shown a correlation between staff elderspeak communication and resident resistiveness to care in a nursing home. ³⁴ Another study employed General Sequential Querier (GSEQ) software to study the behavior of patients of dementia in response to elderspeak communication. It was shown that elderspeak triggered negative vocalizations, such as loud speaking, screaming, yelling, and crying in patients. Such negative vocalization has a severe impact on nursing care. The avoidance of the use of elderspeak by nursing staff may lead to an improvement in behaviors. ³⁵ Apart from it, there is an important role of emotional tone in communication with dementia patients during bathing or caretaking activities. ³⁶ Instead of elderspeak, scientists have developed different communication training program including “The Communication Enhancement Model” for nursing assistants to avoid elderspeak and employ communication which is respectful, non-patronizing and caring for resident patients suffering from dementia.^14,31

Recent studies by Williams and coworkers have demonstrated that improvements in communication by avoiding elderspeak led to an improvement in behavioral manifestations of dementia along and reduced resistiveness to care in a nursing home. Indeed, the authors conducted a randomized clinical trial in 13 nursing homes in which 29 staff persons and 27 dementia patients were included. Their interaction was video-recorded before and after communication intervention and at a 3-month follow-up. The intervention was communication training that is, Changing Talk to Reduce Resistiveness to Dementia Care (CHAT) in which staff was asked to reduce their use of elderspeak. The results indicated that with the decline in elderspeak declined from (from 34.6% to 13.6%), there was a significant decline in RTC declined (from 35.7% to 15.3% points). ³⁷ The authors described that CHAT training program led to a significant reduction in cost and time in managing behavioral symptoms and in the complete care of dementia patients. ³⁸ Moreover, the employment of “person-centered communication” in 39 nursing assistants from 11 nursing homes as a part of 3-session Changing Talk communication training led to significant improvement in behavioral and psycholinguistic measures ³⁹ (Table 2). Another recent study has shown that lexically and grammatically rich communication with little elderspeak led to a significant reduction in resistiveness to care, linguistic isolation, and minimal chances of breakdown down of communication. The authors devised 3 alternative ways of communications with older patients including offered and requested blessings; jokes and narratives and concluded that avoidance of elderspeak is key to reduce resistiveness to care. ⁴⁰ Vachon et al described the beneficial effects of different communication strategies adapted by caregivers or medical staff to patients suffering from Alzheimer disease. The communication strategy included the use of short and syntactically simple sentences; semantic memory, not of episodic memory; more information; removal of environmental distractions, the specific topic of conversation, use of close-ended questions, paying personal attention to the needs of patients and using supportive speaking. Along with it, communication strategy in which patients were insisted to use a specific word, slow speech and use of repeated words/information led to communication deadlock between caregivers and patients. ⁴¹

Table 2.

List of Experimental Studies Showing the Bad Effects of Elderspeak on Dementia Patients.

S. No	Study	Key points	References
1.	A case study	A correlation between elderspeak communication and resistivity to care	Cunningham and Williams 34
2.	Experimental study involving nursing staff (n = 52) and residents with dementia (n = 20)	Elderspeak triggered loud speaking, screaming, yelling, and crying avoidance of elderspeak by nursing staff improved behaviors	Herman and Williams 35
3.	Randomized clinical trial in 13 nursing homes involving 29 staff persons and 27 dementia patients	Decrease in elderspeak from 34.6% to 13.6% declined resistivity to care from 35.7% to 15.3%	Williams et al 37
4.	Experimental study involving 39 nursing assistants from 11 nursing homes	Changing talk communication training led to improvement in behavioral and psycholinguistic measures	Williams et al 39

Conclusion

Health caregivers are prone to use elderspeak while communicating with dependent, weak and fragile dementia patients. However, instead of producing beneficial effects, such type of communication decreases the self-esteem of patients, produces negative feelings, agitation, aggression and leads to the development of resistiveness to care. The avoidance of elderspeak and employment of alternative communication strategies are found to reduce resistiveness to care and a feeling of well being in dementia patients. The adaptation of communication strategies avoiding the use of elderspeak may help in reducing aggression, agitation and psychosocial symptoms in dementia patients.