2017). The second phase is the working phase: the space for ex- amining existing problems and finding acceptable solutions to overcome them (Boyd, 2017). This phase is where the majority of the interpersonal relationship for assessing, implementing, and evaluating take place. It typically happens over time. A sense of comfort is felt in this phase for the older adult and the healthcare worker. The older adult has emotional safety in this phase and is able to address mental health struggles. The healthcare worker is cautioned that transference is common in this phase (Boyd, 2017). Goals toward recovery should be reached during this phase. The final stage of the framework is the resolution phase: the termina - tion of the services and relationship take place in this stage (Boyd, 2017). Not all relationships will follow through to the resolution Communication is a vital key for the healthcare worker to prop- erly meet mental health needs of older adult clients. A healthcare worker can provide dignity and respect when the older adult cli- ent feels heard (Jack et al., 2019). The National Institute on Aging (NIA) has recommendations for improving communication with the older adult. Communication with older adults is often hin- dered by declining sensory, cognitive, and physical abilities (NIA, 2021a). Therefore, a healthcare worker must utilize a variation in communication techniques—tailored to suit the needs/abilities of the client. These can aid the healthcare worker’s ability to elicit in- formation for proper assessment and intervention. They also have recommendations for communicating with the older adult who has hearing, visual, or cognitive deficiencies. Hearing and vision are both normal biological processes that decline with age and need to be accommodated when assessing and intervening with the older adult to ease the information exchange. Recommendations for improving communication with the older adult include the following (NIA, 2017): ● Use an older client’s preference for being addressed and in- clude their proper titles such as Mr., Mrs., Ms., Dr. ● Avoid endearing terms such as honey and dear . ● Ensure comfort for them and provide adequate chairs or ad- just the setting as needed. ● Choose your words wisely and clarify when confusion seems apparent; some words are used flippantly, such as depression and crazy . ● Proceed with cultural competence. ● Encourage the client to write or take notes if desired. ● Suggest that a family member or caregiver be present during interactions and be involved in tasks to provide support. ● Include reassurance of understanding and use the teach-back method when applicable to the older adult and the family members or caregivers. Recommendations for accommodating hearing impairments in- clude the following (NIA, 2017): ● Assess that the client can clearly hear you. If they cannot, ask if they use a hearing aid and make sure it is being used properly if needed. ● Use a regular pitch and volume. Raising your voice actually decreases understanding for those with hearing difficulties. ● Posture yourself directly in front of the client for face-to-face contact, which enhances their ability to read your lips if need- ed. ● Decrease background noise and close doors if they’re com- fortable with it. ● Spell words out if confusion is present nonverbally. ● Have a piece of paper ready if you need to write or they want to write to you. ● When transitioning is going to take place in the interview, tell them verbally that you are changing the subject, for example, “I’m going to move on to the next part of this interview.” Recommendations for accommodating visual impairments in- clude the following (NIA, 2017): ● Assess whether the client can clearly see. If they need eye- glasses, ask if they brought them. ● Proper lighting is necessary for the older adult. Reduce glare for screens.
phase. But if they do, the healthcare worker can say “good-bye” and reflect on the progress made by the older adult as well as the social support put into place for continued success (Boyd, 2017). The components of trust that build rapport, culture consideration, empathy, and professional boundaries can be applied through- out Hildegarde Peplau’s framework. The healthcare worker can visualize the potential psychiatric therapeutic relationship with the older adult client prior to initiation with the goal of improved interactions. The healthcare worker can also have an awareness for the progression and evolution of the therapeutic relationship, including its termination. ● Ask for their preferred method of learning when providing in- structions (verbal, written, visual, pictures, etc.) ● If writing, make sure they can read it. ● If using printed materials, 14-point font is suggested. Recommendations for accommodating cognitive impairments in- clude the following (NIA, 2017): ● Be patient and allow for ample time to reduce feeling rushed. ● Ensure you have the client’s attention prior to starting. ● Orient and reorient the client as needed throughout the in- teraction. ● Use a familiar setting for the interview if possible. ● Include family, friends, or caregivers with client consent. ● Avoid medical jargon and rephrase to understandable word- ing. ● Present one question or direction at a time. ● Choose open-ended (e.g., “How does that make you feel?” or “What do you think might have contributed to this feeling?”) or closed-ended questions (e.g., “Did you get any sleep last night?” or “Have you been feeling sad and down lately?”) based on the client’s ability to answer (closed-ended ques- tions are often easier if cognitive deficits are present). ● Consider following up with the client within the week to assess for understanding and allow for questions. ● Encourage cognitively stimulating activities, exercise, and a healthy diet. Hearing, visual, or cognitive impairments that are clinically prohib- itive to communication will require the healthcare worker to utilize more extensive variations in technique, and possibly require pro- fessional assistance or assistive devices. If professional assistance and assistive devices are required, the healthcare worker can collaborate with experts, such as case management, to mitigate communication barriers for the older adult client. A brief review of verbal and nonverbal communication with older adult considerations can benefit the healthcare worker. Nonver - bal communication is gestures, expressions, and body language (Boyd, 2017). It encompasses more of the interaction than verbal communication. The psychiatric older adult client can be difficult to interpret if disabilities or cultural differences are present. Using understandable language to verbally validate nonverbal observa- tions can help clear any perceived deficiency in the information exchange. Ten techniques can be used to improve the psychiatric interview with the older adult: acceptance, confrontation, doubt, interpre- tation, observation, open-ended statements, reflection, silence, and validation (Boyd, 2017). Acceptance is a therapeutic way to encourage information exchange in an open manner and is use- ful for establishing trust and building rapport (Boyd, 2017). The healthcare worker can practice this by saying things such as “It is ok to tell me about it—I would like to hear how it made you feel.” Confrontation is used with discretion when trying to confront re- ality for the older adult (Boyd, 2017). The healthcare worker can use confrontation gently to address inconsistencies; however, it has the potential to divide the therapeutic relationship and cause discourse in communication. Doubt is also used cautiously when a healthcare worker is certain the older adult is incorrect about factual information. The healthcare worker should assess for the
COMMUNICATION AND LIMITATIONS WITH OLDER ADULTS
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