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Strategies for communicating with older dental patients
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Strategies for communicating with older dental patients Pamela S. Stein, Joanna A. Aalboe, Matthew W. Savage and Allison M. Scott JADA 2014;145(2):159-164 10.14219/jada.2013.28 The following resources related to this article are available online at jada.ada.org (this information is current as of June 28, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/2/159
This article cites 36 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/2/159/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
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ORIGINAL CONTRIBUTIONS
Strategies for communicating with older dental patients Pamela S. Stein, DMD, MPH; Joanna A. Aalboe, RDH, MPH; Matthew W. Savage, PhD; Allison M. Scott, PhD
A
dvances in nutrition, medicine and technology have led to an older, healthier population. For the first time in history, people older than 65 years outnumber people younger than 18 years.1 In 2011, the first baby boomers reached retirement age. According to the Federal Interagency Forum on AgingRelated Statistics, by the year 2030, the number of U.S. adults 65 years or older will reach 72 million, representing a 100 percent increase since 2000.2 Thus, dental professionals can expect to care for an increasing number of older adults. Consequently, it is important for dentists to take steps to prepare for the changing demographics in their practices. Communication between dental professionals and patients has been recognized as an integral part of providing optimum patient care,3,4 but further research and practical strategies in this area are warranted. Anderson5 conducted a study, the results of which showed that reassuring, listening and
abstract Background. Communication between dentists and patients 65 years or older is a critical aspect of providing optimum care, particularly given the increasing number of older adults and the communication barriers they often encounter. Methods. The authors conducted a targeted literature review of the broad health communication literature and published health literacy guidelines to examine the barriers to effective communication that are specific to the older adult population, as well as strategies for overcoming these barriers. Results. Findings from health communication and health literacy research provide insight into techniques to improve communication with older patients, such as preparing an agenda for the appointment, exhibiting warm nonverbal behavior, listening attentively, asking open-ended questions, using simple language, presenting key points one at a time and providing patients with written instructions. Conclusions. Physical, psychological and literacy issues pertaining to both patients and providers present barriers to effective communication. Practitioners can surmount these barriers by enacting communication strategies tailored to older adults. Practical Implications. Dentists can overcome barriers to communication and improve the quality of patient care by considering the communication barriers specific to older adults and enacting strategies to overcome these barriers. Key Words. Aging; communication; literacy; older adults. JADA 2014;145(2):159-164. doi:10.14219/jada.2013.28
Dr. Stein is an associate professor, Division of Public Health Dentistry, Department of Oral Health Science, College of Dentistry, Chandler Medical Center, University of Kentucky, 1117 S. Limestone, Lexington, Ky. 40536, e-mail [email protected]. Address correspondence to Dr. Stein. Ms. Aalboe is an assistant professor, Center for Oral Health Research, Division of Public Health Dentistry, Department of Oral Health Science, College of Dentistry, University of Kentucky, Lexington. Dr. Savage is an assistant professor, Department of Communication, College of Communication and Information, University of Kentucky, Lexington. Dr. Scott is an assistant professor, Department of Communication, College of Communication and Information, University of Kentucky, Lexington.
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ORIGINAL CONTRIBUTIONS
advising were just as important to patients seeking dental care as was providing relief from their chief complaint. However, the literature contains few reports that are specifically focused on how to improve communication between dentists and older patients.6 Fortunately, recommendations for working with this population can be garnered from the broader health communication literature and published health literacy guidelines. The purpose of this article was to draw on health communication research to provide dental professionals with strategies to improve communication with older patients in their dental practices. We review known barriers to communicating with older adults and then describe strategies to overcome these challenges. Barriers to Communicating with Older Patients
Communication between health care providers and older adults may be challenging for reasons related to the physiological impact of the normal aging process and conditions that occur with more frequency in older adults. In particular, sensory decline that often accompanies older age can result in a number of communication difficulties. Age-related sight impairment, such as cataracts, glaucoma or presbyopia, can diminish a person’s capacity to process the nonverbal conversational cues that frequently are communicated visually. Hearing loss in later life (that is, presbycusis) also interferes with interaction by necessitating louder and slower speech. Older people experiencing difficulty hearing may use a variety of communicative strategies, including requesting repetition, pretending to understand and avoiding conversation altogether, to moderate the effect of the impairment on their interaction.7 Moreover, people with hearing loss often rely on lip reading, making impairment in both sight and hearing an even greater barrier to communication. As people age, they also experience difficulty in language production. Older adults experience higher rates of verbal disfluency,8 greater difficulty with word retrieval9 and more frequent tip-of-the-tongue experiences10 than do younger adults (that is, 64 years or younger). Physiological changes due to the normal aging process explain why older adults rely on more medications than does any other age cohort. To that end, polypharmacy may affect alertness and the ability to think clearly.11 Further, 12 percent of adults 65 through 69 years and 18 percent of adults 85 years or older are affected by clinical depression,2 which may decrease engagement and responsiveness in conversation.12 In addition to these physical changes that result from aging, older patients are affected by their own psychosocial changes and by others’ perceptions. Older adults experience normal psychological changes that may affect how they communicate with dentists. They may believe that the authority of health care profes-
sionals should not be questioned.9 These generational perceptions of older adults have the potential to inhibit open communication with health care providers. For example, older adults sometimes view their symptoms as a natural part of the aging process,13,14 and they may not want to “bother” health care providers with their problems. This skepticism may explain, at least in part, why older patients tend to be more passive in medical encounters.13,15 Older people frequently do not raise all of their important medical concerns when talking with their physicians,15 and they often desire less involvement in medical decision making than do younger patients.13 Furthermore, researchers have documented an adverse effect on conversational skill in older adults,11 possibly because opportunities for social contact may diminish with age.16 Health literacy. Inadequate health literacy also may be a communication barrier for older adults. Health literacy has been defined as “the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions.”17 According to the National Assessment of Adult Literacy, adults 65 years or older have lower health literacy than that of younger adults, and only 3 percent of those 65 years or older are proficient in health literacy.18 Jackson and Eckert19 conducted a study of dental patients, the results of which demonstrated declining health literacy with age. These findings suggest that dental health care professionals must consider carefully their patients’ understanding of clinical diagnoses and recommended health behaviors when communicating with older adults. Ageist attitudes. The challenges in communicating with older patients do not arise solely from the patients themselves. Health care providers also can introduce difficulty into the medical visit. There is evidence, for example, that many health care providers have ageist attitudes and that these negative attitudes can have a detrimental effect on older people’s health care.20 Ageist attitudes can lead health care providers to oversimplify speech patterns (such as slowing the rate of speech, reducing vocabulary and grammatical complexity, using overly careful articulation) and exaggerate their intonation (such as using a higher pitch or an overly familiar tone).21 This form of communication, which has been termed “elderspeak,”22 “secondary baby talk”23 and “patronizing” speech,24 is perceived as less respectful and nurturing than is neutral language,24 and recipients of patronizing speech are perceived by others,25 as well as by themselves,26 as less competent. Thus, it is important for dental professionals to resist stereotyping and to prevent patronizing speech from infiltrating their interaction with older patients. Collectively, these physiological, psychological and health literacy barriers, as well as stereotyping on the part of the health care provider, have the potential to undermine the quality of communication between den-
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ORIGINAL CONTRIBUTIONS
tists and older patients. Dental health care professionals have unique opportunities in their interactions with older patients to address and overcome these barriers before, during and after clinical appointments. Recommendations regarding how to communicate effectively with older adults can be gleaned from empirical research findings reported in health communication literature, as well as from strategies offered by health literacy scholars. We describe below these strategies for improving communication between health care providers and older patients and apply them specifically to the dental health care setting. Strategies to Improve Communication with Older Patients
Although researchers27,28 have organized and cataloged sets of communication recommendations, no inventory of strategies, to our knowledge, has been put forward that is both specific to older adults and presented within the context of dental care. To that end, we present a series of strategies for dentists and dental staff members to enhance the appropriateness and effectiveness of communication with older adults. For the most part, we have organized these strategies chronologically, from preappointment to follow-up; however, many of these recommendations apply to multiple aspects of the health care encounter. Ryan and colleagues11 provided a model for health care providers to enhance communication with older adults, suggesting that providers empower patients to expand their role from passive recipients of information to more active participants in their health care. This encouragement toward patient participation should begin before the patient comes to the office. Research findings suggest that older patients who create a written agenda before the office visit raise, on average, two more questions or concerns during the appointment than do those who do not create a written agenda before the appointment.15 In lieu of an agenda, some dentists may prefer to ask patients to simply write down questions and concerns before their appointment. In a recent report about improving health literacy in dental practices, Horowitz and Kleinman29 suggested that dentists should encourage patients to prepare a written list of questions about their oral health and bring the list to their dental appointments. Longer appointments. Another preappointment strategy for improved communication between dental staff members and older patients is to schedule longer appointments. Evidence shows that health care providers actually spend less time consulting with older adults than they do with younger adults, even though some older patients process information more slowly and prefer to have more time for communication than do their younger counterparts.8 Robinson and colleagues28 recommended that providers schedule additional time
with older patients. These patients often have more extensive medical histories to discuss. Furthermore, older adults may be nervous and may have trouble focusing, and they likely will respond best when the provider is not rushed. Longer appointment times may be particularly important for older patients who have functional limitations, such as problems with walking. Getting to the dental office may be difficult and stressful for frail or disabled older adults, such that they may be emotionally spent and physically exhausted before the appointment even begins. With these considerations in mind, we turn to strategies for improving communication during the dental appointment. The Agency for Healthcare Research and Quality and the University of North Carolina at Chapel Hill created the Health Literacy Universal Precautions Toolkit.30,31 The tool kit provides 20 tools that health care providers can implement to improve patients’ understanding of health information. The strategies provided in the tool kit may help dentists create an office environment conducive to effective communication with older adults. Health literacy experts recommend that dental practices post a list of strategies for improved communication for all team members to read on a regular basis.31 The box31 provides a succinct list of strategies that could be included in a dental office posting. The first step in creating a positive environment is to provide a warm greeting to all patients. During interactions with older patients, dental team members should face patients and maintain eye contact.31 In addition, a patient with a hearing impairment may benefit from face-to-face interactions because of the need to read lips.32 Dental professionals should remove protective face masks when speaking with older patients. Patient participation should be encouraged during the office visit. Rost and Frankel15 suggested that health care providers use the beginning of the appointment to encourage the patient to ask questions and discuss concerns (such as asking the patient to read the list he or she was asked to create before the appointment). For example, Thompson and colleagues33 suggested asking patients, “What are your concerns today?” Asking openended questions encourages older adults to participate in decision making about their care and decreases the risk of the clinician’s dominating the conversation.34 Attentive listening. During the appointment, it is important for dental care providers to limit distractions and be attentive listeners. Listening involves more than just hearing words. In addition to listening carefully to the content provided by the patient, dental care providers should listen to the way the words are spoken, looking for clues as to how the patient feels and what he or she has left out of the narration.35 Poor listening is the No. 1 complaint of patients regarding their health care providers.36 Research findings have shown that providers who give their undivided attention to patients in the first 60 JADA 145(2) http://jada.ada.org February 2014 161
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ORIGINAL CONTRIBUTIONS BOX
Strategies for communicating with older patients.* BEFORE THE APPOINTMENT dSchedule longer appointment times dAsk patients to prepare and bring a written list of questions to the appointment DURING THE APPOINTMENT dProvide a warm greeting dSit face-to-face with the patient dMaintain appropriate eye contact dAsk open-ended questions, such as “What are your concerns today? ” dListen attentively (and limit distractions) dUse simple language (and avoid medical jargon) dSpeak slowly, clearly and loudly (but do not use a patronizing tone) dPresent the most important points first dPresent points one at a time dAsk the patient to repeat the provider’s most important points (that is, the teach-back technique) dUse visual aids when possible AFTER THE APPOINTMENT dProvide written instructions for the patient to review at home dFollow up with a telephone call to check on the patient’s condition in cases of extractions, implants, root canal therapy, large restorations or other complex procedures * Source: DeWalt and colleagues.31
seconds of the encounter are perceived by the patient as having spent a “meaningful amount of time” with him or her.37 Simple language. During the appointment, dentists and staff members should minimize the use of jargon and use plain and simple spoken and written language, a strategy that has been promoted by the National Institutes of Health.38 Dental care providers should speak “slowly, clearly and loudly” when talking with older patients—but without reinforcing negative stereotypes— to enhance hearing and understanding.28 However, it is important to make sure that speaking loudly and slowly does not introduce a patronizing or condescending tone of voice. Practitioners should limit content31 and break down complex topics into smaller chunks of information.29 Dentists also should take stock of the written materials in their practice to ensure that the same plain and simple language is reflected in their written communication with patients. Patient educational materials, informed consent forms, postoperative treatment instructions and other printed materials should be written without dental jargon or excessive content.29
When speaking with patients, dental care providers should present the most important points first.39 They should present ideas or instructions individually, allowing time for the older adult to process the information and ask questions.6 Providing too much information too quickly may overwhelm patients. Visual aids, such as simple brochures, videos and photographs, also enhance understanding and improve communication.28 Jacobson and colleagues40 reported that patients 65 years or older who received a simple, one-page color brochure written at below the fifth-grade level were four times more likely to ask about and five times more likely to receive preventive care from their health care providers than were patients in a control group. Teach-back technique. Repeating key messages and instructions during the appointment and checking for understanding is an important part of communicating with older patients.28 The so-called teach-back technique (asking patients to repeat instructions or other information in their own words) is a communication strategy recommended by health literacy experts for routine use by all health care professionals.41 However, the results of a 2008-2009 survey of dentists showed that fewer than one-fourth of respondents reported having used the teach-back technique.42 A possible explanation for this finding is that health care providers may be worried that using the teach-back method increases the length of the appointment30,31; however, evidence shows that using the teach-back method adds less than three minutes to the dental visit.43 Cognitive impairments. Communication during the dental appointment may present additional challenges if the older adult has cognitive impairments. Kayser-Jones and colleagues44 suggested minimizing the number of people, distractions and noise in the operatory when providing care for a patient with dementia (however, a trusted caregiver in the room may provide reassurance to the patient). Patients should be approached from the front at eye level. Nonverbal communication, such as smiling and eye contact, is important. The dentist should begin the conversation by introducing himself or herself. A patient with cognitive impairments may become overloaded with information easily. Instructions should be simple and sentences short, such as, “Please open your mouth.”44 Jablonski and colleagues45 found that resistance to oral care may be reduced in patients with dementia by using pantomime and gestures and by avoiding patronizing baby talk such as “dearie” or “sweetie.” Although the above strategies will help practitioners improve communication during the dental visit, other strategies can be used to improve older patients’ experiences and outcomes after the appointment. Dental staff members can take several steps to assist older patients in remembering key instructions regarding dental care. Most older patients do not engage in willful nonadherence; more often, they do not follow instructions because
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ORIGINAL CONTRIBUTIONS
they do not remember or understand the information.33 Research findings suggest that older patients remember less than one-half of the information provided to them by clinicians.46 Hawe and Higgins47 reported that patients have better information recall when clinicians provide them with written instructions to consult later. According to the National Council on Patient Information and Education,48 practitioners should provide important reminders in writing for the patient to take home. A visit summary written in plain and simple language31 may be helpful in providing key take-home messages. Conclusions
Rozier and colleagues42 conducted a national survey of dentists and found that most (73.3 percent) reported a lack of education in dental school regarding health communication, and many (68.5 percent) expressed an interest in receiving continuing education about this topic. This need for additional training is particularly pressing given the increasing number of older adults seeking care in dental offices and the communication barriers that older patients often encounter. It is critical that dentists learn strategies to improve communication with older patients and become the team leader in their practices; this requires that staff members abide by the policies the practice has adopted to improve communication with patients. Doing so will enable dentists and their teams to provide the best care with optimum health outcomes for their older patients. n Disclosure. None of the authors reported any disclosures. 1. Vincent GK, Velkoff VA. The Next Four Decades: The Older Population in the United States—2010 to 2050. Current Population Reports. Washington: U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau; 2010. www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed Jan. 3, 2014. 2. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key Indicators of Well-Being. Washington: U.S. Government Printing Office; 2012. http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2012_ Documents/Docs/EntireChartbook.pdf. Accessed Dec. 24, 2013. 3. Rouse RA, Hamilton MA. Dentists’ technical competence, communication, and personality as predictors of dental patient anxiety. J Behav Med 1990;13(3):307-319. 4. Yamalik N. Dentist-patient relationship and quality care 3: communication. Int Dent J 2005;55(4):254-256. 5. Anderson R. Patient expectations of emergency dental services: a qualitative interview study. Br Dent J 2004;197(6):331-334. 6. Brock AM. Communicating with the elderly patient. Spec Care Dentist 1985;5(4):157-159. 7. Stephens SD, Jaworski A, Lewis P, Aslan S. An analysis of the communication tactics used by hearing-impaired adults. Br J Audiol 1999;33(1):17-27. 8. Mathuranath PS, George A, Cherian PJ, Alexander A, Sarma SG, Sarma PS. Effects of age, education and gender, on verbal fluency. J Clin Exp Neuropsychol 2003;25(8):1057-1064. 9. Kavé G, Samuel-Enoch K, Adiv S. The association between age and the frequency of nouns selected for production. Psychol Aging 2009;24(1):17-27. 10. Shafto MA, Burke DM, Stamatakis EA, Tam PP, Tyler LK. On the tipof-the-tongue: neural correlates of increased word-finding failures in normal aging. J Cogn Neurosci 2007;19(12):2060-2070. 11. Ryan EB, Meredith SD, MacLean MJ, Orange JB. Changing the way we talk with elders: promoting health using the communication enhancement model. Int J Aging Hum Dev 1995;41(2):89-107. 12. Parnham I. Perceived control. In: Maddox GL, Atchley RC, eds. The Encyclopedia of Aging. New York City: Springer; 1987:454-455. 13. Adelman RD, Greene MG, Charont R. Issues in physician–elderly patient interaction. Ageing Soc 1991;11(2):127-148.
14. Gjørup T, Hendriksen C, Lund E, Strømgård E. Is growing old a disease? A study of the attitudes of elderly people to physical symptoms. J Chronic Dis 1987;40(12):1095-1098. 15. Rost K, Frankel R. The introduction of the older patient’s problems in the medical visit. J Ageing Health 1993;5(3):387-401. 16. Grainger K. Communication and the institutionalized elderly. In: Nussbaum JF, Coupland J, eds. Handbook of Communication and Aging Research. 2nd ed. Mahwah, N.J.: Lawrence Erlbaum Associates; 2004:479-494. 17. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Health Communication. Washington: U.S. Government Printing Office; 2000:11-20. 18. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy. Washington: National Center for Education Statistics, U.S. Department of Education; 2006. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483. Accessed Dec. 5, 2013. 19. Jackson RD, Eckert GJ. Health literacy in an adult dental research population: a pilot study. J Public Health Dent 2008;68(4):196-200. 20. Grant LD. Effects of ageism on individual and health care providers’ responses to healthy aging. Health Soc Work 1996;21(1):9-15. 21. Ryan EB, Hummert ML, Boich LH. Communication predicaments of aging: patronizing behavior toward older adults. J Lang Soc Psychol 1995; 14(1-2):144-166. 22. Cohen G, Faulkner D. Does ‘elderspeak’ work? The effect of intonation and stress on comprehension and recall of spoken discourse in old age. Lang Comm 1986;6(1-2):91-98. 23. Caporael LR, Culbertson GH. Verbal response modes of baby talk and other speech at institutions for the aged. Lang Comm 1986;6(1-2):99-112. 24. Ryan EB, Bourhis RY, Knops U. Evaluative perceptions of patronizing speech addressed to elders. Psychol Aging 1991;6(3):442-450. 25. Giles H, Fox S, Smith E. Patronizing the elderly: intergenerational evaluations. Res Lang Soc Interaction 1993;26(2):129-149. 26. Kemper S, Othick M, Warren J, Gubarchuk J, Gerhing H. Facilitating older adults’ performance on a referential communication task through speech accomodations. Aging Neuropsychol Cogn 1996;3(1):37-55. 27. Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002;325(7366):697-700. 28. Robinson TE 2nd, White GL Jr, Houchins JC. Improving communication with older patients: tips from the literature. Fam Pract Manag 2006;13(1): 73-78. 29. Horowitz AM, Kleinman DV. Creating a health literacy-based practice. J Calif Dent Assoc 2012;40(4):331-340. 30. DeWalt DA, Broucksou KA, Hawk V, et al. Developing and testing the Health Literacy Universal Precautions Toolkit. Nurs Outlook 2011;59(2):85-94. 31. DeWalt DA, Callahan LF, Hawk VH, et al. Health Literacy Universal Precautions Toolkit (prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill). Rockville, Md.: Agency for Healthcare Research and Quality; 2010. AHRQ publication 10-0046-EF. www.ahrq.gov/professionals/ quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Accessed Jan. 3, 2014. 32. Baker C. You and your hearing-impaired patient. N Y State Dent J 2001;67(8):36-37. 33. Thompson TL, Robinson JD, Beisecker AE. The older patient-physician interaction. In: Nussbaum JF, Coupland J, eds. Handbook of Communication and Aging Research. 2nd ed. Mahwah, N.J.: Lawrence Erlbaum Associates; 2004:451-478. 34. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32(2):175-181. 35. Freeman R. The psychology of dental patient care, 9: communicating effectively—some practical suggestions. Br Dent J 1999;187(5):240-244. 36. Meryn S. Improving doctor-patient communication: not an option, but a necessity. BMJ 1998;316(7149):1922. 37. Baker SK. Thirty ways to make your practice more patient-friendly. In: Woods D, ed. Communication for Doctors: How to Improve Patient Care and Minimize Legal Risks. Oxford, England: Radcliffe; 2004. 38. National Institutes of Health. Plain language at NIH. www.nih.gov/ clearcommunication/plainlanguage/index.htm. Accessed Jan. 3, 2014. 39. Horowitz AM, Kleinman DV. Oral health literacy: the new imperative to better oral health. Dent Clin North Am 2008;52(2):333-344. 40. Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J, Ray S. Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates: a randomized controlled trial. JAMA 1999;282(7):646-650. 41. Weiss BD. Health Literacy and Patient Safety: Help Patients Understand—Manual for Clinicians. 2nd ed. Chicago: American Medical Association Foundation; 2007. www.ama-assn.org/ama1/pub/upload/mm/367/ healthlitclinicians.pdf. Accessed Jan. 3, 2014. 42. Rozier RG, Horowitz AM, Podschun G. Dentist-patient communication
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ORIGINAL CONTRIBUTIONS techniques used in the United States: the results of a national survey. JADA 2011;142(5):518-530. 43. Fink AS, Prochazka AV, Henderson WG, et al. Enhancement of surgical informed consent by addition of repeat back: a multicenter, randomized controlled clinical trial. Ann Surg 2010;252(1):27-36. 44. Kayser-Jones J, Bird WF, Redford M, Schell ES, Einhorn SH. Strategies for conducting dental examinations among cognitively impaired nursing home residents. Spec Care Dentist 1996;16(2):46-52. 45. Jablonski RA, Therrien B, Mahoney EK, Kolanowski A, Gabello M, Brock A. An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist 2011;31(3):77-87.
46. Rost K, Roter D. Predictors of recall of medication regimens and recommendations for lifestyle change in elderly patients. Gerontologist 1987;27(4):510-515. 47. Hawe P, Higgins G. Can medication education improve the drug compliance of the elderly? Evaluation of an in hospital program. Patient Educ Couns 1990;16(2):151-160. 48. National Council on Patient Information and Education. Enhancing Prescription Medicine Adherence: A National Action Plan. Rockville, Md.: National Council on Patient Information and Education; 2007. www.talkaboutrx.org/documents/enhancing_prescription_medicine_ adherence.pdf. Accessed Jan. 3, 2014.
164 JADA 145(2) http://jada.ada.org February 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Strategies for communicating with older dental patients Pamela S. Stein, Joanna A. Aalboe, Matthew W. Savage and Allison M. Scott JADA 2014;145(2):159-164 10.14219/jada.2013.28 The following resources related to this article are available online at jada.ada.org (this information is current as of June 28, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/2/159
This article cites 36 articles, 4 of which can be accessed free: http://jada.ada.org/content/145/2/159/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
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ORIGINAL CONTRIBUTIONS
Strategies for communicating with older dental patients Pamela S. Stein, DMD, MPH; Joanna A. Aalboe, RDH, MPH; Matthew W. Savage, PhD; Allison M. Scott, PhD
A
dvances in nutrition, medicine and technology have led to an older, healthier population. For the first time in history, people older than 65 years outnumber people younger than 18 years.1 In 2011, the first baby boomers reached retirement age. According to the Federal Interagency Forum on AgingRelated Statistics, by the year 2030, the number of U.S. adults 65 years or older will reach 72 million, representing a 100 percent increase since 2000.2 Thus, dental professionals can expect to care for an increasing number of older adults. Consequently, it is important for dentists to take steps to prepare for the changing demographics in their practices. Communication between dental professionals and patients has been recognized as an integral part of providing optimum patient care,3,4 but further research and practical strategies in this area are warranted. Anderson5 conducted a study, the results of which showed that reassuring, listening and
abstract Background. Communication between dentists and patients 65 years or older is a critical aspect of providing optimum care, particularly given the increasing number of older adults and the communication barriers they often encounter. Methods. The authors conducted a targeted literature review of the broad health communication literature and published health literacy guidelines to examine the barriers to effective communication that are specific to the older adult population, as well as strategies for overcoming these barriers. Results. Findings from health communication and health literacy research provide insight into techniques to improve communication with older patients, such as preparing an agenda for the appointment, exhibiting warm nonverbal behavior, listening attentively, asking open-ended questions, using simple language, presenting key points one at a time and providing patients with written instructions. Conclusions. Physical, psychological and literacy issues pertaining to both patients and providers present barriers to effective communication. Practitioners can surmount these barriers by enacting communication strategies tailored to older adults. Practical Implications. Dentists can overcome barriers to communication and improve the quality of patient care by considering the communication barriers specific to older adults and enacting strategies to overcome these barriers. Key Words. Aging; communication; literacy; older adults. JADA 2014;145(2):159-164. doi:10.14219/jada.2013.28
Dr. Stein is an associate professor, Division of Public Health Dentistry, Department of Oral Health Science, College of Dentistry, Chandler Medical Center, University of Kentucky, 1117 S. Limestone, Lexington, Ky. 40536, e-mail [email protected]. Address correspondence to Dr. Stein. Ms. Aalboe is an assistant professor, Center for Oral Health Research, Division of Public Health Dentistry, Department of Oral Health Science, College of Dentistry, University of Kentucky, Lexington. Dr. Savage is an assistant professor, Department of Communication, College of Communication and Information, University of Kentucky, Lexington. Dr. Scott is an assistant professor, Department of Communication, College of Communication and Information, University of Kentucky, Lexington.
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ORIGINAL CONTRIBUTIONS
advising were just as important to patients seeking dental care as was providing relief from their chief complaint. However, the literature contains few reports that are specifically focused on how to improve communication between dentists and older patients.6 Fortunately, recommendations for working with this population can be garnered from the broader health communication literature and published health literacy guidelines. The purpose of this article was to draw on health communication research to provide dental professionals with strategies to improve communication with older patients in their dental practices. We review known barriers to communicating with older adults and then describe strategies to overcome these challenges. Barriers to Communicating with Older Patients
Communication between health care providers and older adults may be challenging for reasons related to the physiological impact of the normal aging process and conditions that occur with more frequency in older adults. In particular, sensory decline that often accompanies older age can result in a number of communication difficulties. Age-related sight impairment, such as cataracts, glaucoma or presbyopia, can diminish a person’s capacity to process the nonverbal conversational cues that frequently are communicated visually. Hearing loss in later life (that is, presbycusis) also interferes with interaction by necessitating louder and slower speech. Older people experiencing difficulty hearing may use a variety of communicative strategies, including requesting repetition, pretending to understand and avoiding conversation altogether, to moderate the effect of the impairment on their interaction.7 Moreover, people with hearing loss often rely on lip reading, making impairment in both sight and hearing an even greater barrier to communication. As people age, they also experience difficulty in language production. Older adults experience higher rates of verbal disfluency,8 greater difficulty with word retrieval9 and more frequent tip-of-the-tongue experiences10 than do younger adults (that is, 64 years or younger). Physiological changes due to the normal aging process explain why older adults rely on more medications than does any other age cohort. To that end, polypharmacy may affect alertness and the ability to think clearly.11 Further, 12 percent of adults 65 through 69 years and 18 percent of adults 85 years or older are affected by clinical depression,2 which may decrease engagement and responsiveness in conversation.12 In addition to these physical changes that result from aging, older patients are affected by their own psychosocial changes and by others’ perceptions. Older adults experience normal psychological changes that may affect how they communicate with dentists. They may believe that the authority of health care profes-
sionals should not be questioned.9 These generational perceptions of older adults have the potential to inhibit open communication with health care providers. For example, older adults sometimes view their symptoms as a natural part of the aging process,13,14 and they may not want to “bother” health care providers with their problems. This skepticism may explain, at least in part, why older patients tend to be more passive in medical encounters.13,15 Older people frequently do not raise all of their important medical concerns when talking with their physicians,15 and they often desire less involvement in medical decision making than do younger patients.13 Furthermore, researchers have documented an adverse effect on conversational skill in older adults,11 possibly because opportunities for social contact may diminish with age.16 Health literacy. Inadequate health literacy also may be a communication barrier for older adults. Health literacy has been defined as “the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions.”17 According to the National Assessment of Adult Literacy, adults 65 years or older have lower health literacy than that of younger adults, and only 3 percent of those 65 years or older are proficient in health literacy.18 Jackson and Eckert19 conducted a study of dental patients, the results of which demonstrated declining health literacy with age. These findings suggest that dental health care professionals must consider carefully their patients’ understanding of clinical diagnoses and recommended health behaviors when communicating with older adults. Ageist attitudes. The challenges in communicating with older patients do not arise solely from the patients themselves. Health care providers also can introduce difficulty into the medical visit. There is evidence, for example, that many health care providers have ageist attitudes and that these negative attitudes can have a detrimental effect on older people’s health care.20 Ageist attitudes can lead health care providers to oversimplify speech patterns (such as slowing the rate of speech, reducing vocabulary and grammatical complexity, using overly careful articulation) and exaggerate their intonation (such as using a higher pitch or an overly familiar tone).21 This form of communication, which has been termed “elderspeak,”22 “secondary baby talk”23 and “patronizing” speech,24 is perceived as less respectful and nurturing than is neutral language,24 and recipients of patronizing speech are perceived by others,25 as well as by themselves,26 as less competent. Thus, it is important for dental professionals to resist stereotyping and to prevent patronizing speech from infiltrating their interaction with older patients. Collectively, these physiological, psychological and health literacy barriers, as well as stereotyping on the part of the health care provider, have the potential to undermine the quality of communication between den-
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tists and older patients. Dental health care professionals have unique opportunities in their interactions with older patients to address and overcome these barriers before, during and after clinical appointments. Recommendations regarding how to communicate effectively with older adults can be gleaned from empirical research findings reported in health communication literature, as well as from strategies offered by health literacy scholars. We describe below these strategies for improving communication between health care providers and older patients and apply them specifically to the dental health care setting. Strategies to Improve Communication with Older Patients
Although researchers27,28 have organized and cataloged sets of communication recommendations, no inventory of strategies, to our knowledge, has been put forward that is both specific to older adults and presented within the context of dental care. To that end, we present a series of strategies for dentists and dental staff members to enhance the appropriateness and effectiveness of communication with older adults. For the most part, we have organized these strategies chronologically, from preappointment to follow-up; however, many of these recommendations apply to multiple aspects of the health care encounter. Ryan and colleagues11 provided a model for health care providers to enhance communication with older adults, suggesting that providers empower patients to expand their role from passive recipients of information to more active participants in their health care. This encouragement toward patient participation should begin before the patient comes to the office. Research findings suggest that older patients who create a written agenda before the office visit raise, on average, two more questions or concerns during the appointment than do those who do not create a written agenda before the appointment.15 In lieu of an agenda, some dentists may prefer to ask patients to simply write down questions and concerns before their appointment. In a recent report about improving health literacy in dental practices, Horowitz and Kleinman29 suggested that dentists should encourage patients to prepare a written list of questions about their oral health and bring the list to their dental appointments. Longer appointments. Another preappointment strategy for improved communication between dental staff members and older patients is to schedule longer appointments. Evidence shows that health care providers actually spend less time consulting with older adults than they do with younger adults, even though some older patients process information more slowly and prefer to have more time for communication than do their younger counterparts.8 Robinson and colleagues28 recommended that providers schedule additional time
with older patients. These patients often have more extensive medical histories to discuss. Furthermore, older adults may be nervous and may have trouble focusing, and they likely will respond best when the provider is not rushed. Longer appointment times may be particularly important for older patients who have functional limitations, such as problems with walking. Getting to the dental office may be difficult and stressful for frail or disabled older adults, such that they may be emotionally spent and physically exhausted before the appointment even begins. With these considerations in mind, we turn to strategies for improving communication during the dental appointment. The Agency for Healthcare Research and Quality and the University of North Carolina at Chapel Hill created the Health Literacy Universal Precautions Toolkit.30,31 The tool kit provides 20 tools that health care providers can implement to improve patients’ understanding of health information. The strategies provided in the tool kit may help dentists create an office environment conducive to effective communication with older adults. Health literacy experts recommend that dental practices post a list of strategies for improved communication for all team members to read on a regular basis.31 The box31 provides a succinct list of strategies that could be included in a dental office posting. The first step in creating a positive environment is to provide a warm greeting to all patients. During interactions with older patients, dental team members should face patients and maintain eye contact.31 In addition, a patient with a hearing impairment may benefit from face-to-face interactions because of the need to read lips.32 Dental professionals should remove protective face masks when speaking with older patients. Patient participation should be encouraged during the office visit. Rost and Frankel15 suggested that health care providers use the beginning of the appointment to encourage the patient to ask questions and discuss concerns (such as asking the patient to read the list he or she was asked to create before the appointment). For example, Thompson and colleagues33 suggested asking patients, “What are your concerns today?” Asking openended questions encourages older adults to participate in decision making about their care and decreases the risk of the clinician’s dominating the conversation.34 Attentive listening. During the appointment, it is important for dental care providers to limit distractions and be attentive listeners. Listening involves more than just hearing words. In addition to listening carefully to the content provided by the patient, dental care providers should listen to the way the words are spoken, looking for clues as to how the patient feels and what he or she has left out of the narration.35 Poor listening is the No. 1 complaint of patients regarding their health care providers.36 Research findings have shown that providers who give their undivided attention to patients in the first 60 JADA 145(2) http://jada.ada.org February 2014 161
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ORIGINAL CONTRIBUTIONS BOX
Strategies for communicating with older patients.* BEFORE THE APPOINTMENT dSchedule longer appointment times dAsk patients to prepare and bring a written list of questions to the appointment DURING THE APPOINTMENT dProvide a warm greeting dSit face-to-face with the patient dMaintain appropriate eye contact dAsk open-ended questions, such as “What are your concerns today? ” dListen attentively (and limit distractions) dUse simple language (and avoid medical jargon) dSpeak slowly, clearly and loudly (but do not use a patronizing tone) dPresent the most important points first dPresent points one at a time dAsk the patient to repeat the provider’s most important points (that is, the teach-back technique) dUse visual aids when possible AFTER THE APPOINTMENT dProvide written instructions for the patient to review at home dFollow up with a telephone call to check on the patient’s condition in cases of extractions, implants, root canal therapy, large restorations or other complex procedures * Source: DeWalt and colleagues.31
seconds of the encounter are perceived by the patient as having spent a “meaningful amount of time” with him or her.37 Simple language. During the appointment, dentists and staff members should minimize the use of jargon and use plain and simple spoken and written language, a strategy that has been promoted by the National Institutes of Health.38 Dental care providers should speak “slowly, clearly and loudly” when talking with older patients—but without reinforcing negative stereotypes— to enhance hearing and understanding.28 However, it is important to make sure that speaking loudly and slowly does not introduce a patronizing or condescending tone of voice. Practitioners should limit content31 and break down complex topics into smaller chunks of information.29 Dentists also should take stock of the written materials in their practice to ensure that the same plain and simple language is reflected in their written communication with patients. Patient educational materials, informed consent forms, postoperative treatment instructions and other printed materials should be written without dental jargon or excessive content.29
When speaking with patients, dental care providers should present the most important points first.39 They should present ideas or instructions individually, allowing time for the older adult to process the information and ask questions.6 Providing too much information too quickly may overwhelm patients. Visual aids, such as simple brochures, videos and photographs, also enhance understanding and improve communication.28 Jacobson and colleagues40 reported that patients 65 years or older who received a simple, one-page color brochure written at below the fifth-grade level were four times more likely to ask about and five times more likely to receive preventive care from their health care providers than were patients in a control group. Teach-back technique. Repeating key messages and instructions during the appointment and checking for understanding is an important part of communicating with older patients.28 The so-called teach-back technique (asking patients to repeat instructions or other information in their own words) is a communication strategy recommended by health literacy experts for routine use by all health care professionals.41 However, the results of a 2008-2009 survey of dentists showed that fewer than one-fourth of respondents reported having used the teach-back technique.42 A possible explanation for this finding is that health care providers may be worried that using the teach-back method increases the length of the appointment30,31; however, evidence shows that using the teach-back method adds less than three minutes to the dental visit.43 Cognitive impairments. Communication during the dental appointment may present additional challenges if the older adult has cognitive impairments. Kayser-Jones and colleagues44 suggested minimizing the number of people, distractions and noise in the operatory when providing care for a patient with dementia (however, a trusted caregiver in the room may provide reassurance to the patient). Patients should be approached from the front at eye level. Nonverbal communication, such as smiling and eye contact, is important. The dentist should begin the conversation by introducing himself or herself. A patient with cognitive impairments may become overloaded with information easily. Instructions should be simple and sentences short, such as, “Please open your mouth.”44 Jablonski and colleagues45 found that resistance to oral care may be reduced in patients with dementia by using pantomime and gestures and by avoiding patronizing baby talk such as “dearie” or “sweetie.” Although the above strategies will help practitioners improve communication during the dental visit, other strategies can be used to improve older patients’ experiences and outcomes after the appointment. Dental staff members can take several steps to assist older patients in remembering key instructions regarding dental care. Most older patients do not engage in willful nonadherence; more often, they do not follow instructions because
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they do not remember or understand the information.33 Research findings suggest that older patients remember less than one-half of the information provided to them by clinicians.46 Hawe and Higgins47 reported that patients have better information recall when clinicians provide them with written instructions to consult later. According to the National Council on Patient Information and Education,48 practitioners should provide important reminders in writing for the patient to take home. A visit summary written in plain and simple language31 may be helpful in providing key take-home messages. Conclusions
Rozier and colleagues42 conducted a national survey of dentists and found that most (73.3 percent) reported a lack of education in dental school regarding health communication, and many (68.5 percent) expressed an interest in receiving continuing education about this topic. This need for additional training is particularly pressing given the increasing number of older adults seeking care in dental offices and the communication barriers that older patients often encounter. It is critical that dentists learn strategies to improve communication with older patients and become the team leader in their practices; this requires that staff members abide by the policies the practice has adopted to improve communication with patients. Doing so will enable dentists and their teams to provide the best care with optimum health outcomes for their older patients. n Disclosure. None of the authors reported any disclosures. 1. Vincent GK, Velkoff VA. The Next Four Decades: The Older Population in the United States—2010 to 2050. Current Population Reports. Washington: U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau; 2010. www.census.gov/prod/2010pubs/p25-1138.pdf. Accessed Jan. 3, 2014. 2. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key Indicators of Well-Being. Washington: U.S. Government Printing Office; 2012. http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2012_ Documents/Docs/EntireChartbook.pdf. Accessed Dec. 24, 2013. 3. Rouse RA, Hamilton MA. Dentists’ technical competence, communication, and personality as predictors of dental patient anxiety. J Behav Med 1990;13(3):307-319. 4. Yamalik N. Dentist-patient relationship and quality care 3: communication. Int Dent J 2005;55(4):254-256. 5. Anderson R. Patient expectations of emergency dental services: a qualitative interview study. Br Dent J 2004;197(6):331-334. 6. Brock AM. Communicating with the elderly patient. Spec Care Dentist 1985;5(4):157-159. 7. Stephens SD, Jaworski A, Lewis P, Aslan S. An analysis of the communication tactics used by hearing-impaired adults. Br J Audiol 1999;33(1):17-27. 8. Mathuranath PS, George A, Cherian PJ, Alexander A, Sarma SG, Sarma PS. Effects of age, education and gender, on verbal fluency. J Clin Exp Neuropsychol 2003;25(8):1057-1064. 9. Kavé G, Samuel-Enoch K, Adiv S. The association between age and the frequency of nouns selected for production. Psychol Aging 2009;24(1):17-27. 10. Shafto MA, Burke DM, Stamatakis EA, Tam PP, Tyler LK. On the tipof-the-tongue: neural correlates of increased word-finding failures in normal aging. J Cogn Neurosci 2007;19(12):2060-2070. 11. Ryan EB, Meredith SD, MacLean MJ, Orange JB. Changing the way we talk with elders: promoting health using the communication enhancement model. Int J Aging Hum Dev 1995;41(2):89-107. 12. Parnham I. Perceived control. In: Maddox GL, Atchley RC, eds. The Encyclopedia of Aging. New York City: Springer; 1987:454-455. 13. Adelman RD, Greene MG, Charont R. Issues in physician–elderly patient interaction. Ageing Soc 1991;11(2):127-148.
14. Gjørup T, Hendriksen C, Lund E, Strømgård E. Is growing old a disease? A study of the attitudes of elderly people to physical symptoms. J Chronic Dis 1987;40(12):1095-1098. 15. Rost K, Frankel R. The introduction of the older patient’s problems in the medical visit. J Ageing Health 1993;5(3):387-401. 16. Grainger K. Communication and the institutionalized elderly. In: Nussbaum JF, Coupland J, eds. Handbook of Communication and Aging Research. 2nd ed. Mahwah, N.J.: Lawrence Erlbaum Associates; 2004:479-494. 17. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Health Communication. Washington: U.S. Government Printing Office; 2000:11-20. 18. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy. Washington: National Center for Education Statistics, U.S. Department of Education; 2006. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483. Accessed Dec. 5, 2013. 19. Jackson RD, Eckert GJ. Health literacy in an adult dental research population: a pilot study. J Public Health Dent 2008;68(4):196-200. 20. Grant LD. Effects of ageism on individual and health care providers’ responses to healthy aging. Health Soc Work 1996;21(1):9-15. 21. Ryan EB, Hummert ML, Boich LH. Communication predicaments of aging: patronizing behavior toward older adults. J Lang Soc Psychol 1995; 14(1-2):144-166. 22. Cohen G, Faulkner D. Does ‘elderspeak’ work? The effect of intonation and stress on comprehension and recall of spoken discourse in old age. Lang Comm 1986;6(1-2):91-98. 23. Caporael LR, Culbertson GH. Verbal response modes of baby talk and other speech at institutions for the aged. Lang Comm 1986;6(1-2):99-112. 24. Ryan EB, Bourhis RY, Knops U. Evaluative perceptions of patronizing speech addressed to elders. Psychol Aging 1991;6(3):442-450. 25. Giles H, Fox S, Smith E. Patronizing the elderly: intergenerational evaluations. Res Lang Soc Interaction 1993;26(2):129-149. 26. Kemper S, Othick M, Warren J, Gubarchuk J, Gerhing H. Facilitating older adults’ performance on a referential communication task through speech accomodations. Aging Neuropsychol Cogn 1996;3(1):37-55. 27. Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002;325(7366):697-700. 28. Robinson TE 2nd, White GL Jr, Houchins JC. Improving communication with older patients: tips from the literature. Fam Pract Manag 2006;13(1): 73-78. 29. Horowitz AM, Kleinman DV. Creating a health literacy-based practice. J Calif Dent Assoc 2012;40(4):331-340. 30. DeWalt DA, Broucksou KA, Hawk V, et al. Developing and testing the Health Literacy Universal Precautions Toolkit. Nurs Outlook 2011;59(2):85-94. 31. DeWalt DA, Callahan LF, Hawk VH, et al. Health Literacy Universal Precautions Toolkit (prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill). Rockville, Md.: Agency for Healthcare Research and Quality; 2010. AHRQ publication 10-0046-EF. www.ahrq.gov/professionals/ quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Accessed Jan. 3, 2014. 32. Baker C. You and your hearing-impaired patient. N Y State Dent J 2001;67(8):36-37. 33. Thompson TL, Robinson JD, Beisecker AE. The older patient-physician interaction. In: Nussbaum JF, Coupland J, eds. Handbook of Communication and Aging Research. 2nd ed. Mahwah, N.J.: Lawrence Erlbaum Associates; 2004:451-478. 34. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32(2):175-181. 35. Freeman R. The psychology of dental patient care, 9: communicating effectively—some practical suggestions. Br Dent J 1999;187(5):240-244. 36. Meryn S. Improving doctor-patient communication: not an option, but a necessity. BMJ 1998;316(7149):1922. 37. Baker SK. Thirty ways to make your practice more patient-friendly. In: Woods D, ed. Communication for Doctors: How to Improve Patient Care and Minimize Legal Risks. Oxford, England: Radcliffe; 2004. 38. National Institutes of Health. Plain language at NIH. www.nih.gov/ clearcommunication/plainlanguage/index.htm. Accessed Jan. 3, 2014. 39. Horowitz AM, Kleinman DV. Oral health literacy: the new imperative to better oral health. Dent Clin North Am 2008;52(2):333-344. 40. Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J, Ray S. Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates: a randomized controlled trial. JAMA 1999;282(7):646-650. 41. Weiss BD. Health Literacy and Patient Safety: Help Patients Understand—Manual for Clinicians. 2nd ed. Chicago: American Medical Association Foundation; 2007. www.ama-assn.org/ama1/pub/upload/mm/367/ healthlitclinicians.pdf. Accessed Jan. 3, 2014. 42. Rozier RG, Horowitz AM, Podschun G. Dentist-patient communication
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ORIGINAL CONTRIBUTIONS techniques used in the United States: the results of a national survey. JADA 2011;142(5):518-530. 43. Fink AS, Prochazka AV, Henderson WG, et al. Enhancement of surgical informed consent by addition of repeat back: a multicenter, randomized controlled clinical trial. Ann Surg 2010;252(1):27-36. 44. Kayser-Jones J, Bird WF, Redford M, Schell ES, Einhorn SH. Strategies for conducting dental examinations among cognitively impaired nursing home residents. Spec Care Dentist 1996;16(2):46-52. 45. Jablonski RA, Therrien B, Mahoney EK, Kolanowski A, Gabello M, Brock A. An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist 2011;31(3):77-87.
46. Rost K, Roter D. Predictors of recall of medication regimens and recommendations for lifestyle change in elderly patients. Gerontologist 1987;27(4):510-515. 47. Hawe P, Higgins G. Can medication education improve the drug compliance of the elderly? Evaluation of an in hospital program. Patient Educ Couns 1990;16(2):151-160. 48. National Council on Patient Information and Education. Enhancing Prescription Medicine Adherence: A National Action Plan. Rockville, Md.: National Council on Patient Information and Education; 2007. www.talkaboutrx.org/documents/enhancing_prescription_medicine_ adherence.pdf. Accessed Jan. 3, 2014.
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