I never know what he says after I leave his office. It’s like he’s talking Russian. I try to follow what he’s saying, but he talks too fast and uses words that mean nothing to me. I don’t want him to think I’m stupid…I’m not stupid. I may be old and slow, but I’m not stupid.

L.P.I., 91 years old
College graduate and fluent reader
(personal communication, Feb. 14, 2009)

Communicating in a manner in which the older adult can understand and use health information is a professional, ethical, and legal responsibility of the nurse. Older adults are the fastest growing segment of the population in the United States (US). Projections forecast that by 2030, 20% of the U.S. population will be age 65 or older (Federal Interagency Forum on Age-Related Statistics, 2008). The 2003 National Assessment of Adult Literacy revealed that only 3% of adults age 65 and older were proficient in health literacy skills (Kutner, Greenberg, Jin, & Paulsen, 2006). Low health literacy among the elderly is associated with higher hospitalization rates, an inability to manage chronic diseases, and increased mortality (Baker, et al., 2007; Gazmarian, Williams, Peel, & Baker, 2003; Sudore et al., 2006). The National Academy for an Aging Society estimates that $73 billion in unnecessary healthcare costs can be attributed to inadequate health literacy through misunderstood health information and subsequent patient noncompliance (Center for Health Care Strategies, 2000). Promoting health literacy in older adults is a public health imperative. Communicating in a manner in which the older adult can understand and use health information is a professional, ethical, and legal responsibility of the nurse. Yet many nurses lack the knowledge and skills that are needed to adapt their routine patient education strategies to effectively meet the specific learning needs of the elderly patient. This article describes the effect of age-related changes on health literacy, addresses the challenges inherent in communicating with and teaching older adults, and suggests age-appropriate teaching strategies that the nurse can implement to improve the health literacy of an aging patient. Suggestions for evaluating comprehension are also provided.

Cognitive Aging: Effect on Health Literacy

Health literacy is defined as the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health (World Health Organization, 2009). Being health literate involves a multitude of cognitive processes that are challenging for any one at any age. Retrieving prescriptions and referrals, selecting providers from a list of names and addresses, calculating when to take multiple medications, interpreting medical terminology, comparing different insurance plans, and sifting through a myriad of health-related information available in magazines, on the Internet, and on television are just a few of the complex thought processes that are involved in selecting, understanding, and using health-related information. Comprehension, problem-solving, comparing and contrasting, reasoning, computing, adapting, and synthesizing are all higher order cognitive processes required for health literacy. Psychologists agree that although cognitive aging varies between individuals, certain types of cognitive capacities decline with increasing age in most adults (Kintsch, 1998). Older adults tend to process information at a slower pace, have less working memory (the ability to process multiple bits of information at a given moment), and experience difficulty in comprehending abstractions (U.S. Department of Health & Human Services, n.d.). Nurses can assist their older patients to compensate for cognitive aging by using a specific set of teaching and communication techniques. The teaching challenges posed by cognitive declines in fluid intelligence, the older learner’s inability to manage multiple messages at one time, and a decreased capacity to draw conclusions from inference must be addressed to effectively promote health literacy in this population. Each of these challenges will be discussed below.

Processing the Message

Rushing an older adult to demonstrate a new skill can lead to incapacitating anxiety, frustration, and unwillingness to perform for fear of failure and shame. Older adults learn new information at a slower rate than younger adults due to a decline in fluid intelligence, defined as the reasoning and processing components of learning (Beier & Ackerman, 2005). In addition to processing information at a slower rate, reaction and response times increase significantly after age 65 (Morrow, Weiner, Steinley, Young, & Murray, 2007). Older adults are at a disadvantage when learning complex psychomotor tasks which have to be performed within certain time constraints. Rushing an older adult to demonstrate a new skill can lead to incapacitating anxiety, frustration, and unwillingness to perform for fear of failure and shame. Teaching should be paced, slow, and deliberate. Encourage the older adult to establish a personal timeline for learning, allowing for extra time during and across teaching sessions.

Managing Multiple Messages

Older adults struggle with mental multitasking. Studies have shown that older adults have a decreased capacity to process multiple bits of information at any one moment (Stevens, 2003). Well-educated young adults can rarely recall more than seven different items from their short-term memory at one time (Doak, Doak, & Root, 1996). Due to cognitive aging and short-term-memory loss in the older adult, the amount of new information presented during any one teaching session or interaction should be limited to three to five points (Cornett, 2006). Each point should be presented as a small, manageable chunk of information or concept, allowing for adequate time after each point for practice and rehearsal. Complex messages or instructions should be separated into multiple learning modules or topics, with each subsequent module being delivered at a future date or learning session. Review and repeating essential need-to-know information from previous modules must be a part of every teaching session to compensate for short-term-memory loss.

Comprehending the Abstract

Aging decreases the older adult’s capacity to draw conclusions from inference (Stevens, 2003). Vague concepts and terms like “adequate,” “several times a day,” “frequently,” or “often” can be interpreted across a wide spectrum of meanings. When communicating with an older adult, it is essential to be specific in directions related to time, order, duration, and frequency. For example, the nurse could direct the patient to “Soak your finger for ten minutes in the morning and in the evening for five days” rather than “Soak your finger twice a day until it gets better.” It is also important to emphasize the desired action (positive directions and advice) rather than what should be avoided (the negative message). For example, the nurse could direct the patient to “Take this pill on an empty stomach two hours after you eat breakfast and dinner” as opposed to saying, “Do not take this pill with food” or “Avoid taking this pill on a full stomach.” Always verify that the directions have been clearly understood by having patients repeat back specifically what they plan to do. Table 1 summarizes the cognitive effects of aging and teaching strategies that the nurse can implement to adapt to these changes.

Physical and Psychological Challenges to Health Literacy

A variety of physical and/or psychological factors may interfere with the older adult's ability to process information, demonstrate learning, or adopt the target behavior. Some of these factors include depression, fatigue, stress, functional limitations from physical aging and chronic illnesses, and lack of motivation to learn (Best, 2001; Cornett, 2006; U.S. Department of Health & Human Services, n.d.; Zurakowski, Taylor, & Bradway, 2006)  A detailed history, focusing on the patient's psychosocial and functional status is the cornerstone of the teaching plan. It is helpful to investigate the following situations:

• What is the living environment like?
• Who does the person turn to when help is needed?
• Can the older adult afford the self-help equipment that is needed to manage his or her condition?
• Are there unmet basic physical or psychosocial needs, such as pain relief, food, or living arrangements, that must be addressed before any teaching can proceed?
• Assessing, acknowledging, and addressing barriers to learning early in the patient encounter will assure that any teaching that does transpire will more likely be retained by the older learner. It is important that guided problem solving with the older adult be an integral part of teaching.

Physical Challenges

Additional lighting is always indicated when teaching an older adult, while harsh lights, direct sunlight, and glossy paper should be avoided. The aging process can cause changes in sensory and musculoskeletal function, leading to multiple physical challenges that impact the older adult’s ability to live independently and manage his or her health condition. Declines in vision, hearing, and mobility can directly affect an individual’s ability to learn and adopt necessary self-care practices. Nurses should be alert to patients who squint, rely on touch to “find” a target like a keyhole or object, cup the ear, turn one ear toward the speaker, fail to answer or answer questions inappropriately, lean close to the provider, and/or grimace with movement as these behaviors often suggest physical barriers to learning related to vision, hearing, or musculoskeletal dysfunction (Cornett, 2003). Table 1 summarizes the sensory changes associated with aging and highlights teaching strategies that the nurse can implement to adapt to these changes.

Effect of aging on vision. As many as two-thirds of adults with visual problems in the US are over the age of 65 (U.S. Department of Health & Human Services, n.d.). Presbyopia (the loss of the ability to focus and visually accommodate) is the most universal, age-related visual change (Lighthouse International, 2009). Many older adults wear glasses, bifocals, or corrective lens to accommodate for presbyopia. It is important to remind patients to bring their glasses to their appointment and to give them time to put their glasses on prior to starting the teaching. More serious pathologies such as cataracts, glaucoma; and macular degeneration account for many of the visual problems experienced by the older patient. Peripheral vision decreases with glaucoma, and cataracts cause objects in the field of vision to appear cloudy. Patients with macular degeneration lose central vision and cannot see written text. Verbal instruction in clear language and also audiotapes are useful when teaching patients with severe compromises in their vision from macular degeneration and cataracts. A normal effect of aging on the pupil is that it becomes smaller, allowing less light to enter the eye (Lighthouse International). For this reason, older adults need more light than younger adults to see; yet haze in the aging cornea scatters light and causes a sensitivity to glare (Marmor, 1998). Additional lighting is always indicated when teaching an older adult, while harsh lights, direct sunlight, and glossy paper should be avoided. The lens of the eye may yellow in advanced age, resulting in selective absorption of colors on the blue end of the spectrum (Lighthouse International). Because older adults have difficulty seeing and distinguishing differences between blues, greens, and shades of purple, nurses should avoid using colors on the blue end of the spectrum in written text and color-coded directions.

Male voices...are actually heard more clearly by older adults than high pitched sounds typically associated with the female voice. Effect of aging on hearing. More than 50% of older adults are affected by hearing loss or impairment (University of Washington, 2007). Increased rigidity of the small bones of the middle ear, decreased elasticity of the eardrum, and inner ear atrophy are all normal physiological changes associated with aging that lead to hearing loss. Presbycusis and the inability to discriminate between certain speech sounds are common problems that interfere with the older client's ability to hear teaching instructions. High-pitched sounds and words with "f', "s", "k", and "sh" sounds are difficult for the older adult to discriminate (National Institute on Deafness and Other Communication Disorders, National Institute of Health, 2007). Male voices (because the pitch is low) are actually heard more clearly by older adults than high pitched sounds typically associated with the female voice. Female nurses are advised to concentrate on lowering the pitch of their voice and speaking clearly and slowly. Because pitch is not the same as loudness, raising the voice is not necessary and may be interpreted as shouting to the patient. Nurses can compensate for hearing loss by facing the older client and enunciating words clearly. The face, mouth, and lips of the professional should be visible to the patient throughout the interaction to facilitate lip reading. Eliminating extraneous environmental noises, such as background music, staff chatter, or hallway commotion can also enhance the likelihood that the client will hear your instructions.

Effect of aging on motor function. The physical effects of aging on the musculoskeletal system must be considered when the goals of teaching are determined (Best, 2001). Acute and chronic musculoskeletal disorders can cause joint pain and stiffness, decreased dexterity and range of motion, and delayed response times. Fine and gross motor skills are often compromised with aging. Tasks such as drawing up medication in a syringe, picking pills up out of a small box or holder, reaching, sitting for long periods, and standing are often difficult for many older adults. Nurses can facilitate learning by scheduling frequent breaks and providing straight-back chairs with arms for seating during teaching sessions. Appropriate use of adaptive equipment should be demonstrated, with adequate time allowed for the patient to practice.

Audio recordings and videos are also useful for older adults with visual or hearing deficits. An effective recording is one in which the narrator delivers the message at an appropriate pace, speaks clearly, and keeps background music or noise to a minimum or absent all together. Effective videos are those in which older adults are featured and portrayed in a positive manner. Computer-assisted technology, such as DVDs, online videos, podcasts, and the Internet, can be helpful for the 56% of older adults who use the Internet (Jones & Fox, 2009). Table 2 provides a partial list of reputable, online health resources that are designed specifically for older adults to access and view on the web.

Psychological Considerations

The manner in which adults adapt psychologically to the effects of aging varies across individuals and cultures. Mood, attitude, outlook, self-concept, and personality may all be affected by aging (Cornett, 2006). A teaching environment in which psychological distractions have been kept to a minimum facilitates learning in the older adult. An atmosphere of respect, sensitivity, and patience will allay feelings of anxiety, low self esteem, loss of control, and depression, as these psychological conditions can all reduce motivation and incentive to learn. A calm, optimistic, and deliberate manner on the part of the nurse can create an environment that supports success and risk taking in the older adult. Enhancing a patient’s receptivity to teaching, increasing the teaching’s value and meaningfulness for the patient, and helping patients see the relevance of the teaching for their lives all facilitate learning, as described below.

Schedule teaching sessions in mid-morning when energy levels are high. Receptivity to teaching. Depression is a common problem in the older adult that can significantly affect one’s receptivity to teaching. Preoccupation with the loss of friends, spouse, financial independence, or personal control can lead to decreased concentration, indecisiveness, and agitation. Nurses are encouraged to teach older adults in this frame of mind only the most important points of essential information. The teaching should be brief, to the point, and provided in a calm and quiet manner. Nonverbal cues on the part of the patient, such as lowering the eyes, looking around the room, or wringing the hands suggest decreased tolerance, inattention, or agitation, and should be quickly recognized and respected by the nurse.

An older adult's previous experience with education and learning often affects receptivity to teaching. Past frustrations and failures are barriers to new learning at any age. Nurses should help the older adult identify past learning successes to build self-confidence and promote risk taking when new behaviors have to be learned. Many older adults are reluctant to risk failure and embarrassment in interpersonal situations. It is important that attitudes about learning and fears associated with learning are assessed early in the teaching process and addressed. This can be done by asking the patient, “What has worked best for you in the past when you have needed to learn something new?” Opportunities for successful learning should be provided early in the teaching plan, with genuine praise and positive reinforcement given often.

Value and meaningfulness. In determining what to teach, it is important to assess what is valued and meaningful to the older adult. Nurses will want to determine what activities are perceived by the learner as important in maintaining his or her quality of life and what the patient enjoys doing on a regular basis. Once these internal motivators are identified, the information taught can be centered on the performance of activities and achievement of goals that are meaningful to the learner. Older adults are more likely to learn and retain new information that is perceived as relevant to their life (Cooper, Booth, & Gill, 2003). Teaching strategies should be individualized and engaging within a realistic context of the limitations of the older adult’s physical and psychological condition.

Consider the case of Mrs. J., a 78-year-old patient with chronic obstructive pulmonary disease (COPD). Early in the nurse-patient encounter, it was assessed that Mrs. J. loved to fish in the pond near her home. However, she made the assumption that since she had developed “breathing problems,” she could no longer go fishing. Throughout the course of Mrs. J's care, all self-care teaching related to managing her COPD was focused on getting Mrs. J. back to fishing. The plan was shared with the nursing staff, her providers, and her family who encouraged and supported her. After months of working with Mrs. J., she was able to go fishing, linked to portable oxygen, yet satisfied that her goal had been achieved. Nurses can promote health literacy in an older adult by using familiar examples which build on the individual's previous life experiences.

Relevance. Nurses can promote health literacy in an older adult by using familiar examples which build on the individual's previous life experiences. The knowledge that an individual has retained across the life span provides a cognitive base that can be used in problem solving (Park & Gutchess, 2000). Patients should be asked what they know about a subject being taught, and what life experiences they have that are related to the new knowledge or skill. For example, an older patient who is a newly diagnosed diabetic could be asked if he has friends or family members who appear to be living well with diabetes. The patient could then be asked to describe exactly what he or she has observed others doing to manage and live with their disease. The nurse can then relate the teaching to these observations, correct any misinformation, and teach new skills that build on the relevant experiences of the older adult.

Age-appropriate Teaching Strategies for the Older Adult

Age-appropriate teaching strategies for the older adult must be planned, purposeful, and adapted to accommodate the special needs of the elderly patient. Because of the high prevalence of inadequate health literacy in this population, all teaching should, at a minimum, include practices that have been demonstrated as effective with low literacy learners. However, specific strategies that adhere to the principles of gerogogy should also be an integral part of every nurse’s teaching repertoire to promote health literacy in this special population. Gerogogy is a model of teaching older adults that is based on the work of Knowles’ Adult Learning Theory (Hayes, 2005). Teaching interventions within this framework are designed to compensate for the cognitive, sensory, and physical effects of aging, and to promote independence and achievement of the older learner’s full potential. Age-appropriate teaching strategies that are based on the principles of gerogogy include the following:

• Approach the older adult in a way that communicates respect, acceptance, and support (Cornett, 2006). Create a learning environment in which the patient can comfortably acknowledge what is and is not understood.
• Schedule teaching sessions in mid-morning when energy levels are high. Several brief teaching sessions on different days are more appropriate than one lengthy session that might fatigue the patient.
• Allow additional time for the older adult to process new information by pausing after presenting each new concept or bit of information. Validate understanding by using the teach-back technique (described below) before moving on.
• Link new knowledge or skills to clearly identifiable past experiences. Reminiscing and storytelling help the older adult reconnect with lived experiences and serve as a valuable strategy to facilitate learning.
• Keep the content practical and relevant to the older adult’s daily activities, social structure, and physical function. Emphasize safety and maintaining independence. Older adults are motivated to learn content that is perceived as a means to immediate resolution of a problem.
• Help the older adult focus during each interaction by minimizing distractions, limiting the message to a few (five or less) essential key points, and avoiding extraneous information.
• Speak slowly, but not so slowly that the patient becomes distracted or bored (Osborne, 2005). Face the patient when speaking and sit at the same level as the patient.
• Speak clearly and concisely, using words that are familiar to the older adult. Be sensitive and respectful of the mores, beliefs, and values of the older generation.
• Give the older adult written material that reinforces the major points of the teaching. Text should be easy to read (fifth-grade or below), using large print (14-16 point font) with high contrast between the print color and paper (preferably black print on white or light cream, non-glare paper). Essential points should be bulleted or in list formats. Table 3 provides a partial list of websites that health professionals may use as a guide in designing effective teaching materials specifically for older adults.
• Use visuals which represent older adults in a positive way, avoiding stereotypic cartoons and situations that are not relevant to the lifestyle practices of older adults. Simple line drawings, pictographs, and photo novellas are effective adjuncts to verbal instructions for visual learners.
• Encourage patients to keep written information in a location in their home that is frequently seen, such as near the phone, on the bedside table, or on the refrigerator, so that it can be referred to often. Age Pages, produced by the National Institute on Aging (n.d.), is an excellent series of free handouts available on a wide variety of topics that can be used effectively in the process of teaching older adults.
• Give specific directions using concrete terms. Rather than directing a patient to “increase the calcium in your diet,” list specific foods that are good sources of calcium and note how many times a day these foods should be eaten.
• Engage the older adult by encouraging participation during the teaching. Demonstrate, rather than describe, a new skill or procedure; and have the patient practice the skill with you.
• Relate new information or target learning to cues within the patient’s home or daily routines to assist with recall. Suggest that the patient perform a learned behavior regularly, for example, every time teeth are brushed, a favorite television show is watched, or after the dog is walked.
• Repeat essential points frequently throughout the teaching session and have patients paraphrase the new information in their own words. Be consistent in the selection of words that are used throughout the teaching to help the older adult mentally process the information and recall it.

  Older adults should be encouraged to invite a family member or trusted friend to attend and actively participate in each teaching session. If permitted by the patient, involving a significant other in the patient’s education is an effective way to promote health literacy in the older adult. Friends and family members can act as surrogate readers for the patient, reinforce information provided in the clinical setting, and clarify information that may have been misunderstood by the patient upon returning home (Schwartzberg, 2002).

Evaluate Comprehension

The teach-back technique...is an effective way to evaluate comprehension in all learners. The teach-back technique, in which the patient is asked to paraphrase and/or demonstrate an instruction that was just taught, is an effective way to evaluate comprehension in all learners (American Medical Association, 2000). Demonstrations lend themselves well to opportunities for behavioral reinforcement, guided problem solving, and recognition for success. Posing realistic situational questions for the older adult to answer is an effective way to assess comprehension. This simple "scenario" approach to evaluation assesses the learner's ability to use the new information in similar situations at a later time. Nurses can also observe the older adult patient teach a family member or friend about their care. In this way, the nurse can assess the level of the patient’s comprehension and provide feedback concerning additional learning needs (Billek-Sawhney & Reicherter, 2005).

A follow-up phone call, if time allows, is another effective means of evaluating learning outcomes. Open-ended questions which elicit information related to the new knowledge or skill taught can be a valid measure of comprehension. Examples include the following:

• What have been the results of your morning blood sugar checks?
• How often and when do you do your Kegel exercises?
• Some people feel weak before lunch after taking this medicine. Tell me what you would do if this happens to you.

Nurses should never ask “Do you understand?” as the question typically elicits an invalid “yes” response from the patient who is avoiding the appearance of being ignorant. Also, a lack of questions from the patient does not necessarily indicate comprehension. Many older adults are part of the generation who were taught at an early age that it is disrespectful to question a medical professional. In evaluating comprehension, the older learner should be able to demonstrate the newly acquired skill, verbalize the key points of the instructions, correctly answer situational questions, and/or successfully complete a learned task.

Summary

Use visuals which represent older adults in a positive way... Inadequate health literacy disproportionately affects older adults in the United States. The complexities associated with managing chronic disease and the cognitive and sensory changes associated with aging compound the challenges of teaching this highly vulnerable group. Collectively, older adults are part of a highly diverse population, each presenting with a unique set of motivators, abilities, and learning styles. In order to promote health literacy in the older adult, nurses should use a variety of age-appropriate teaching strategies to enhance comprehension. Table 4 provides a summary of these strategies that can be used in the process of teaching an older adult. Routine communication and teaching techniques used with younger adults must be adapted to compensate for the age-related changes that affect the older adult's ability to process, recall, and use health-related information. Clear communication that is purposeful and individualized, multiple teaching strategies that are specific and tailored to accommodate the cognitive, physical, and psychological changes associated with aging, and a patient-centered approach that demonstrates support, acceptance, and respect are actions that the nurse will want to take to promote health literacy in the older adult.

Author

Carolyn I. Speros, DNSc, APRN, ANP/FNP-BC
E-mail: csperos@memphis.edu

Dr. Carolyn Speros received a BSN from Vanderbilt University, a Master’s in Education (MEd) from the University of Memphis, and an MSN and a DNSc from the University of Tennessee Center for the Health Sciences. Dr. Speros is board certified as both an Adult and a Family Nurse Practitioner. She is currently Associate Professor of Nursing at the University of Memphis’ Loewenberg School of Nursing and in practice as a nurse practitioner in the Memphis area. Dr. Speros began her nursing career at Methodist Hospitals of Memphis where she designed and directed the Learning for Life program of education for patients. The program was recognized with three national patient education awards by the American Hospital Association. Methodist was the only hospital in the country ever to receive three of these prestigious awards. Dr. Speros later joined the UT Department of Family Medicine as a nurse practitioner. While there, she established and conducted a highly successful patient education "clinic within a clinic" for the chronically ill, older patients of the practice. Dr. Speros has delivered numerous presentations to audiences across the country on topics related to patient education, staff education, health promotion, and health literacy. Her area of research focuses on systems and strategies that promote health literacy in vulnerable populations.

© 2009 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2009