Voicing Ageism in Nursing Home Dementia Care

Abstract

Elderspeak (infantilizing communication) is a common form of ageism that has been linked to resistiveness to care in nursing home residents with dementia. Nursing home staff use elderspeak by modifying speech with older residents based on negative stereotypes, which results in patronizing communication that provides a message of incompetence. The purpose of this secondary analysis is to describe communication practices used by nursing home staff that reflect ageism. Transcripts of 80 video recordings of staff-resident communication collected during nursing home care activities were reanalyzed to identify specific elderspeak patterns, including diminutives, collective pronouns, tag questions, and reflectives. Nursing home staff used elderspeak in 84% of the transcripts during bathing, dressing, oral care, and other activities. Collective pronoun substitution occurred most frequently in 69% of the recorded conversations. Subgroup analysis of the inappropriate terms of endearment found that honey/hon and sweetheart/sweetie were most commonly used.

As the number of older adults with dementia continues to grow, successful communication between nursing home (NH) residents and staff is essential for improvement in person-centered care and resident quality of life (Buron, 2008). However, NHs are still challenged by ineffective communication practices. Elderspeak (i.e. infantilization or baby talk) is a common intergenerational style of communication between staff and residents in NHs and has been linked to restiveness of care in older adults with dementia (Herman & Williams, 2009; Williams, Herman, Gajewski, & Wilson, 2009). Younger speakers use elderspeak in attempts to accommodate for older adults in communication encounters by using modifications such as inappropriate terms of endearment, child-like speech, collective pronoun substitution, and questions that indicate a desired response (Ryan, Giles, Bartolucci, & Henwood, 1986; Williams et al., 2009). Although elderspeak is typically well-intentioned, it is actually a form of ageism that represents negative stereotypes, prejudices, and discrimination against older adults on the basis of chronological age or the perception of them being ‘old’ (Iversen, Larsen, & Solem, 2009). Elderspeak is expressed implicitly on a micro- and macro-level by care staff, and the use of elderspeak has been found to double the rates of challenging behaviors of residents with dementia (Williams et al., 2009).

NH residents have limited opportunities to interact with others and rely primarily on busy staff as communication partners. When talk is predominantly task-focused and elderspeak communication is present, negative stereotypes project older adults as less competent persons, and NH residents may react with depression, avoidance, assumption of dependent behavior, and restiveness to care (Buron, 2008; Ryan et al., 1986). NH residents have reported that their relationships with NH staff, reflected in communication, are primary predictors of their quality of life (Grau, Chandler, & Saunders, 1995). In addition, staff who establish interpersonal relationships with older adult care recipients report higher levels of job satisfaction and lower turnover rates (Brodaty, Draper, & Low, 2003).

The purpose of this study is to describe and characterize elderspeak that reflects ageism used in NH staff-resident communication. The findings will provide further information to increase awareness of elderspeak and assist in developing interventions to improve communication with older adults.

Method

Design

The current study is a secondary analysis of 80 video-recording transcripts of staff-resident communication during NH daily care activities. Transcripts of video recordings were obtained from an observational NIH-funded study (parent study), approved by the University Institutional Review Board for the Protection of Human Subjects and conducted in three Midwestern NHs between 2006 and 2007 to evaluate resident responses to staff communication. The parent study coded and analyzed staff communication (elderspeak, silence, normal adult speech) in relation to resident behavioral responses (cooperative or resistive to care) (Herman & Williams, 2009; Williams et al., 2009). In the current study, trained researchers identified, extracted, and tabulated words and phrases representing elderspeak (diminutives, collective pronoun substitutions, tag questions, and reflective forms) from each parent study transcript.

In the parent study, 20 consenting residents with behavioral symptoms of dementia and the staff caring for them were recorded during four-hour care sessions on two separate days. Four sections of the recordings, each representing a care activity (1. bathing, 2. dressing, 3. mealtime, and 4. unspecified care activity) were randomly selected for each resident, for a total of 80 recordings. As part of the parent study, recordings were transcribed using established protocols. Key words and phrases indicating elderspeak were identified and labeled using bracketing or psycholinguistic coding. Common elderspeak words and phrases identified in the literature and measured in previous research including diminutives (childish terms and inappropriate terms of endearment), collective pronoun substitution, tag questions, and reflective speech, were selected to quantify staff elderspeak use (Hummert & Ryan, 1996; Kemper, 1994). To assure reliability of transcription and coding, research assistants were trained until a standard of at least 90% agreement for transcription and psycholinguistic coding was met. Additional information about the video recordings is provided in the report of the parent study (Williams et al., 2009).

Sample

The 80 transcripts of recorded interactions involved 52 NH staff and 20 residents with dementia. Residents’ ages ranged from 69 to 97 years, with a mean age of 82.9 years. Of the resident participants, 19 were Caucasians (15 females and 4 males) and one was African American (male). All resident participants were in the moderate stage of dementia and required assistance with activities of daily living. Staff participants were primarily female (83%) and Certified Nursing Assistants (CNAs) (78%). The staff participants were 68% white, 30% African American, 4% Hispanic, and 2% Pacific Islander. Staff age ranged from 21 to 54 years, with a mean age of 35 years. Job-tenure averaged 3.5 years in their current NH with a range of 0.1 to 18 years.

Measures

Diminutives include inappropriate terms of endearment and child-like terms commonly used in baby talk, parent-child interactions, or communication between close intimate partners. Inappropriate terms of endearment include generic names (e.g. Grandma) and intimate terms (e.g. honey, dearie, sweetie) that care staff use when addressing NH residents. Child-like terms include nicknames (e.g. Susie for Susan) or shortening words for baby talk (e.g. nightie for nightgown). Diminutives represent a culture emphasizing dependency and lack of respect of care staff to residents.

Collective pronoun substitutions provide the message that an older adult cannot act independently when a singular pronoun is appropriate. For example, “Are we ready for our bath?” is inappropriate because the care staff is not bathing with the older adult. Instead, “can I help you get ready for your bath?” provides an affirmation of the older adult as an individual with a choice capable of independent actions.

Tag questions ask a question but also indicate the desired response. For example, “You’re ready for breakfast now, aren’t you?” Tag questions restrict conversations and choices to control behavior, exaggerating the view that NH residents are unable to make decisions.

Reflective speech forms encourage NH residents to complete tasks to satisfy the care staff, suggesting that the resident is not performing an activity for him or herself. For example, “Take this medicine for me.” This form of manipulative speech is not often present in peer to peer communication because it conveys dependence, restricts conversation, and controls behavior.

Data Analysis

The actual words and phrases identified as elderspeak were extracted, categorized, tabulated, and analyzed using descriptive statistics. Subgroup analysis was performed to describe the most prevalent terms of endearment. Transcripts may include multiple types of elderspeak based on the categorization of words and phrases. Ten percent of the transcripts were analyzed by two trained research assistants to establish reliability of 90% agreement for the categorization of elderspeak words and phrases.

Results

At least one example of elderspeak communication was identified in 84% of the transcripts (67 out of the 80 transcripts). The most common form of elderspeak was collective pronoun substitution, which occurred in 69% of the transcripts (55 out of 80 transcripts). Use of diminutives, including inappropriate terms of endearment and childish terms, occurred in 53% of the transcripts (42 out of 80 transcripts). Multiple transcripts included both inappropriate terms of endearment and childish word substitution. Childish terms were used in 36% and inappropriate terms of endearment were used in 35% of the total transcripts. Tag questions were found in 49% and reflective forms were found in 14% of the transcripts (Table 1).

Table 1.

Type of Elderspeak in Video Recordings (N=80)

	Number of Recordings	Percent of Recordings
Collective Pronoun Substitution	55	69%
Diminutives	42*	53%
Inappropriate terms of endearment	28	35%
Childish Terms	29	36%
Tag Questions	39	49%
Reflective Forms	11	14%
No Elderspeak	13	16%

^*Note: Some recordings contained both endearment and childish terms

A total of 18 different terms of endearment were identified and used 73 times across the 28 transcripts that contained inappropriate terms of endearment (Table 2). “Honey” or “hon” occurred most frequently (26 occurrences or 35.6% of all terms of endearment), followed by “sweetie” or “sweetheart” (15 occurrences or 20.5% of all terms of endearment) and “grandma” (8 occurrences or 11% of all terms of endearment). “Babe” or “baby” and “sunshine” each made up 5.4% of the inappropriate terms of endearment used. Additional terms occurred less frequently.

Table 2.

Terms of Endearment Present in Video Recordings

	Count	Percent of Total Diminutives
Honey/Hon	26	35.6%
Sweetheart/Sweetie	15	20.5%
Grandma	8	11%
Baby/Babe	4	5.4%
Sunshine	4	5.4%
Mom/Momma	2	2.7%
Buddy	2	2.7%
Girly	2	2.7%
Missy	1	1.4%
Silly	1	1.4%
My Man	1	1.4%
Sleeping Beauty	1	1.4%
Treasure	1	1.4%
Woman	1	1.4%
Bubbles	1	1.4%
My Irene	1	1.4%
Dear	1	1.4%
Good Boy	1	1.4%
TOTAL	73	100%

Discussion

Elderspeak is commonly used by well-intentioned care providers who may not realize the negative message and outcomes for older adult recipients. The implicit message of elderspeak is incompetence of older adults. When utilized in NHs, residents may withdraw, experience reduced self-esteem or depression, and may enact their own stereotypes of a frail elder by behaviors such as assuming dependency. Older adults who are able to communicate express their dislike of being talked down to by care staff who use elderspeak (Williams & Warren, 2009). Although concealed and often unknown to the speaker, elderspeak is used to control behavior, convey dependence, restrict conversation, and imply lack of competence (Ryan, Hummert, & Boich, 1995).

The parent study for this secondary analysis used behavioral coding to evaluate the sequential relationship between staff elderspeak use and resident resistiveness to care, finding that residents were more than twice as likely to respond to elderspeak with resistive behaviors (Herman & Williams, 2009; Williams et al., 2009). Due to the implicit nature of elderspeak, care staff may not realize implications of ageism that impact stereotypes, prejudice, and discrimination in older adults. For example, tag questions and reflectives impact the residents’ right to choose, and diminutives and collective pronouns are demeaning and do not indicate a mutually respectful relationship. Awareness of the elderspeak phenomenon and how it can impact older adults is important for improving care in nursing homes and other long term care settings.

Elderspeak is most likely a cognitive component of ageism and occurs without malevolence or conscious awareness. Educating NH staff about elderspeak and its implicit messages has been successful in reducing staff use of elderspeak and resulted in reduced restiveness to care in NH residents with dementia. There are several training programs available to improve communication in NHs. Specifically, the Changing Talk (CHAT) intervention, designed by the PI of this study (KW), is a brief (3 sessions) program that engages NH staff in taking the perspective of the resident and identifies elderspeak by substituting more effective communication practices (Williams, Perkhounkova, Bossen, & Hein, 2016; Williams, Perkhounkova, Herman, & Bossen, 2016). The CHAT intervention focuses on limited aspects of care—such as the diminutive terms used in care—is simple and can be accomplished by staff during their busy workday.

The CHAT program is currently being expanded and evaluated in an online module format to increase the access to and reach of the intervention. Additionally, an elderspeak application is being designed that allows staff to record communication during care, upload the file via computer to a secure server for analysis using natural language processing, and receive private feedback on the use of diminutive terms. Self-monitoring of diminutive use may have a significant impact on elderspeak reduction for certain staff. In this secondary analysis, inappropriate terms of endearment were identified in 28 of the 80 video recording transcripts, but were used 73 times in those 28 recordings. Certain staff may have a higher prevalence of diminutive usage and identifying this pattern using our innovative technology will allow for further reduction of elderspeak. As language processing improves, the CHAT program will be expanded to evaluate the other components of elderspeak.

Limitations

Limitations of this study include reliance on secondary data from a relatively small sample of nursing homes, and a small number of residents and staff in each NH. In addition, video recording was used to collect examples of staff-resident interactions and the presence of the videographer may have altered natural communication. Despite these limitations, this study provides valuable information about the existence and characteristics of elderspeak communication that occurs in today’s nursing homes.

Conclusion

Elderspeak—a common intergenerational form of speech that reflects ageism or implicit bias about aging—is common in health care provider and patient communication. Descriptive information on specific elderspeak patterns used in NH practice adds to our understanding of the elderspeak phenomenon. This study used a secondary analysis of communication in three NHs to provide a snapshot of elderspeak and its prevalence. Understanding the elderspeak communication patterns increases the awareness of this speech style that reflects ageism. Future research utilizing innovative technology will be used to educate NH staff on elderspeak and individually make staff aware of their personal elderspeak usage and patterns. Additional research should address the implementation and feasibility of elderspeak training in NHs. Communication training to reduce elderspeak should be a priority for NHs to reduce restiveness and increase person-centeredness of care.