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Elderspeak’s Influence on Resistiveness to Care in LTC. Kristine Williams RN PhD, FNP-BC Joint Provider Surveyor Training, Michigan Department of Community Health , September 14, 2010. Objectives. Identify common communication barriers for older adults in health care settings

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elderspeak s influence on resistiveness to care in ltc

Elderspeak’s Influence on Resistiveness to Care in LTC

Kristine Williams RN PhD, FNP-BC

Joint Provider Surveyor Training, Michigan Department of Community Health, September 14, 2010


Identify common communication barriers for older adults in health care settings

Increase awareness of the importance of communication for older adults and persons with dementia (PWD)

Understand elderspeak, it’s negative messages, & recent research findings

Identify strategies to improve communication for NH residets

the importance of communication in elder care
The Importance of Communication in Elder Care

A social connection to other people is critical for “successful aging”

Job satisfaction is higher for nurses who have close relationships with their patients

Effective Nursing Communication with Older Adult patients:

Increases patient satisfaction with care

Increase independence & self-care of older adults

Interpersonal relationships increase life expectancy

communication barriers in health care settings
Communication Barriers in Health Care Settings

Lack of Opportunities

Loss of family and friends to talk to

Rely on nursing staff for communication

In nursing homes, nursing staff provide 90% of older adults’ opportunities for communication

Nursing staff are busy caring for many patients

Staff are not well trained in communication with older adults or with persons with dementia

communication barriers
Communication Barriers

Lack of Opportunities

Ignoring Talk

When the older adult and 2 or + others are present

The older adult may not be included in conversation

The others may talk about the older adult

Suggests that the older adult is not able to participate & must be cared for by others

Ignoring talk is common

When staff work in teams

At doctor appointments with family members

communication barriers1
Communication Barriers

Lack of Opportunities

Ignoring Talk

Task Talk

Common in nursing homes

(75% of communication with patients)

Due to heavy assignments & staff shortages

Most communication centers on care tasks, not interpersonal communication that older adults value

interpersonal communication
Interpersonal Communication

Communication is individualized & specific

Indicates that the person is important & special

Listens to and responds to what the older adult says or is experiencing

Accepts the older adult’s experiences as important. Interpersonal talk may include:

Talk about the older adult’s family or former occupation

Talk about older adult’s childhood experiences

Talk about special events for this older adult

Indicates a willingness to relate to the person

communication barriers2
Communication Barriers

Lack of Opportunities

Ignoring Talk

Task Talk


what is elderspeak

An intergenerational speech style

Common in a our society, especially in health care settings

Based on subconscious stereotypes

Intended to nurture and facilitate communication with older adults

Potential negative implications

elderspeak features
Elderspeak Features

Baby talk

Diminutives (terms of endearment)

Incorrect pronoun use

Speak loudly

Shorten statements

Speak slowly

Overly caring or controlling

communication predicament model

From Ryan, E.B., Giles, H., Bartolucci, R.Y., & Henwood, K. (1986). Psycholinguistic components of communication by and with the elderly. Language and Communication, 6, 1-24.

potential negative effects of elderspeak
Potential Negative Effects Of Elderspeak

Altered self-concept/ self-esteem



Assumption of stereotypical and/or dependent behavior

Recognized by older adults as being talked down to & demeaning

dementia growing with our aging population
Dementia – Growing with our Aging Population

Growing population in older adults

5.2 million 2008

15 million 2050*

>50% of nursing home


Hospital patients

Linked to higher rates of delirium

Dementia may not be diagnosed or may not be recorded

*Alzheimer’s Association 2008

barriers to effective communication in dementia care
Barriers to Effective Communication in Dementia Care

Individual Factors

Progressive loss of ability for meaningful communication

(receptive, expressive, & internal talk)

Health Care Environment Factors

Lack of Opportunities

Ignoring Talk

Task Talk


strategies for effective communication
Strategies for Effective Communication


Address speaker by name


Reflect speaker’s feelings

Ask for more information

Respond on topic

Modify speech only as needed

Short sentences

Yes-No questions


Maintain eye contact

Appropriate Volume


Be patient

Assure a quiet environment without distractions

Approach slowly from the front

Speak before touch

communication to support personhood
Communication to Support “Personhood”

Recognition: Acknowledge the person, know their name, affirm uniqueness

Negotiation: Consult about preferences, desires, needs.

Validation: Acknowledge the person's emotions/feelings respond

Facilitation/Collaboration: Work together, involve the person. Enable the person to do what otherwise he/she wouldn't be able to do, by providing the missing parts of the action.

Ryan, E.B., Byrne, K., Spykerman, H., & Orange, J.B. Evidencing Kitwood’s Personhood

Strategies: Conversation as Care in Dementia (2005) in Alzheimer Text, Talk and

Context: Enhancing Communication editor Boyd H. Davis,Palgrave McMillan, New York.

research question
Research Question

Does elderspeak communication affect care for persons with dementia?

elderspeak and dementia care ninr nia small grant nr009231 02
Elderspeak and Dementia CareNINR/NIA Small Grant: NR009231-02

Is Elderspeak Appropriate for persons with Dementia?

Nursing communication precipitates challenging behaviors (Burgio et al, 2000, Talicero, Evans, & Strumpf, 2002)

Challenging behaviors disrupt care (aggression, agitation, wandering, etc)

challenging behaviors of persons with dementia
Challenging Behaviors of Persons with Dementia

Challenging behaviors that disrupt care (aggression, agitation, wandering etc)

are common

are extremely stressful for caregivers

CNA occupation high rates of injuries

progress over the course of the disease

precipitate nursing home placement

challenging behaviors
Challenging Behaviors

May result in increasing use of psychotropic medications (Talicero, et al, 2000)

Reduce quality of life for care recipients (Gerdner & Buckwalter, 1994)

Nursing communication precipitates challenging behaviors (Burgio et al, 2000, Talicero, Evans, & Strumpf, 2002)

problem behaviors or resistiveness to care rtc
Problem Behaviors or Resistiveness to Care (RTC)

Reflect decreased Quality of Life

Person With Dementia

Injuries, stress, anxiety

Indicates unmet needs, fear, boredom, communication breakdown

Increases psychotropic medication & restraint use

Family caregivers



Leading factor in Nursing Home placement

resistiveness to care rtc in the nursing home
Resistiveness to Care (RTC) in the Nursing Home

Increases Staff Time required to Provide Care

Average 24 minutes to manage one episode of RTC

May require multiple staff persons

Stress for Staff (primarily Certified Nursing Assistants)

RTC is a top concern for staff

Stress, burnout, and job dissatisfaction contribute to HIGH Turnover rates (over 100% each year)

Increases costs for NH care by 30%

model of need driven dementia compromised behavior
Model of Need-Driven Dementia Compromised Behavior

All behavior has meaning

Due to dementia, older adults may be unable to communicate their needs and wants using verbal communication

Physical behaviors may instead be used to communicate unmet needs in persons with dementia

Algase, D., Beck, C., Kolanaowski, A., Whall, Berent, S., Richards, K.,

et al., (1996). Need-driven dementia compromised behavior: An

alternative view of disruptive behavior. American Journal of

Alzheimer’s Disease, 10-19

need driven dementia compromised behavior
Need Driven Dementia-Compromised Behavior

Background Factors

Circadian rhythms

Motor ability




Gender, race, ethnicity

Marital status

Education, Occupation



Behavioral response to stress

Proximal Factors

Physiological need state




Psychosocial need state


Match of assistance to ability

Physical Environment








Physical Aggression Wandering Withdrawal Problematic Vocalization

elderspeak impact on dementia care
Elderspeak: Impact on Dementia Care

Observational study funded by NINR/NIA

Nursing home residents with dementia (N=20)

were video recorded during daily care


Oral Care



1-10 minute recordings were computer archived

Computer-assisted behavioral analysis of

temporal associations between

Resident Behavior


Staff Communication


20 Nursing Home Residents with dementia who were Resistive to care

Age 69-97 (mean 83)

MDS-COGS score 4-9 (mean 6.4)

75% Women

95% Caucasian

Nursing Staff

78% CNAs

83% Female

68% Caucasian, 30% African American

2% Hispanic

Age 21-54 (mean 35)

analysis of behavior states
Analysis of Behavior States

Frame by frame coding of behavior states of:

Nursing Staff Communication

Normal talk



Resident Behavior

Resistive to care (RTC)



Temporal relationships coded using Noldus

Observer Pro behavioral software

resident behavior resistiveness to care scale
Resident BehaviorResistiveness to Care Scale

Resident Behavior

Resistiveness to Care

Turn away

Push away

Grab object

Grab person


Pull away

Clench teeth





Each behavior is rated for frequency, duration, and intensity to achieve a total score of 0-156

High IRR 90% agreement between coders

Mahoney, E.K., Hurley, A.C., et al., (1999). Development and testing of the Resistiveness to Care Scale. Research in Nursing and Health, 22:27-38)

resident behaviors rtc
Resident Behaviors – RTC

Resistive to Care, Neutral, Cooperative,

Turn away

Push away

Grab object

Grab person


Pull away


Clench teeth





staff communication elderspeak
Staff Communication - Elderspeak

Staff communication

Normal Talk, Silence,


altered prosody

altered touch

altered expression

tag questions

altered gesture



altered proxemics

childish terms



short words

altered eye contact


exaggerated praise


laugh at

change subject

change data temporal relationships1
Change Data – Temporal Relationships

Looked for changes in resident behavior

Looked back 7 seconds

Determined what state of nursing communication was in use


This study supports a relationship between staff elderspeak communication & RTC

We can reduce elderspeak communication with staff training*

Research to test the effects of training on RTC is needed to confirm this hypothesis.

(*Williams, 2006; William, Kemper, & Hummert, 2003)

emotional tone
Emotional Tone
  • Underlying (nonverbal) messages
  • Imbalance of
    • Care
    • Respect
    • Control
  • Three dimensions
    • Overly nurturing
    • Directive
    • Affirming
emotional tone ratings not at all very 1 2 3 4 5
Emotional ToneRatings not at allvery1……...2……..3…….4……. 5

















Twenty naïve raters listened to clips of bathing and rated the emotional tone of the staff communication in each

Reliability was high IRR across all dimensions (n=60, Chronbach’s alpha = .94)

Correlations between RTC and the three dimensions of Emotional Tone

RTC significantly correlated with Controlling tone

As controlling tone ratings ↑RTC ↑

RTC was not correlated with Caring or Respectful tone

Hummert, M.L., Shaner, J.L., Garstka, T.A., & Henry, C. (1998). Communication with

older adults: The influence of age stereotypes, context, and communicator age.

Human Communication Research, 25 (1), 124-152.

emotional tone rtc
Emotional Tone & RTC
  • Correlations
    • Higher CONTROL ratings were associated with RTC

(r = .49, p =.03)

    • Relationships between CARE & RESPECT with RTC were not statistically sigificant

Affective messages of staff-resident interactions effect resident cooperation during care.

Communication using a controlling tone correlated with an increase in RTC.

Further research training staff to communicate in less controlling tones is needed to examine if this will improve resident cooperation with care.

Communication minimizing controlling tone may decrease RTC in dementia nursing home care.

training staff to reduce elderspeak communication
Training Staff to Reduce Elderspeak Communication

CHAT 3-sessionTraining

CNAs recorded before & after

Significantly reduced use of

Terms of endearment “honey”

“we” pronouns “Are we ready for our bath?”

Continued after 2 months

Decreased Task-talk 25%

Improved Emotional Tone

Increased RESPECT,

Decreased CONTROL

No effect on CARE

Nursing Forum 2009


Funding from the National Institute of Nursing Research and National Institute on Aging

Research Team Members

Nursing home administrators and staff

Families and Resident Volunteers

Layton Prints from KUMC Landon Center on Aging collection

Williams, K., Herman, R., Gajewski, B., & Wilson, K. (2009). Elderspeak communication: Impact on dementia care. American Journal of Alzheimer’s Disease & Other Dementias, 24, 11-20.

  • Kristine Williams

Associate Professor

University of Kansas School of Nursing

3901 Rainbow Blvd., MS 4043

Kansas City, KS 66160