Communicaton & Relationships – UNDERSTANDING COMMUNICATION CHALLENGES (PART 2)

Help Improve Your Relationships

Kevin Y. Kawamoto
Special to The Hawai‘i Herald

Editor’s Note: In the previous Nov. 19, 2021 issue of The Hawai‘i Herald, Kawamoto discussed some of the socio-cultural and cross-cultural factors that create challenges for effective communication. In this issue, Kawamoto continues to discuss other factors that affect our communication and relationships including physiological, cognitive and more. By understanding the perspective of those experiencing these challenges, we can become more compassionate communicators. 

PHYSIOLOGICAL FACTORS

Eye Health

Physiology is the area of health sciences that is concerned with how different parts of the body work or function. As a person ages, there are physiological changes that can negatively affect communication. For example, vision and hearing typically decline as people get older, but the degree and nature of decline differ from person to person. 

It is common for an older person to have difficulty reading fine print, threading a needle or adjusting to sudden light changes (when coming from outdoors into a dark room, for example) due to physiological changes in different parts of the eye. Depending on how severe vision impairment is, and whether or not it can be corrected, an older person’s day-to-day routine may need to be altered and modified. This includes driving at night (or at all), reading or writing letters, computer use and getting around on one’s own. If a person’s vision is impaired, it is probably best not to go to venues where the lighting is poor. Some restaurants, for example, dim the lights to create a certain atmosphere. Going into a movie theater after the movie has started can be especially disorienting, almost like walking into a dark cave where you can’t see your hand in front of your face. Avoiding such places is important if the older person also happens to be hard of hearing and looks at a person’s face and lips to help make sense of what is being said.

Ophthalmologists, optometrists and opticians are specialists who play different roles in eye and vision care. Ophthalmologists are medical doctors who can detect, diagnose and treat eye diseases and problems. They often specialize in specific types of eye diseases such as macular degeneration, glaucoma, diabetic retinopathy and cataracts, to name a few. As with many health problems, early detection is critical to care. 

Optometrists are doctors of optometry and are trained to perform sight testing and correction as well as eye exams that can lead to early detection of eye diseases that require the specialized medical skills of an ophthalmologist. Most older adults have experienced visiting an optometrist to get their vision tested and receiving a prescription for corrective lenses, which requires the services of an optician, a technologist who is trained to fit a patient for eyeglass lenses, frames, contact lenses and some other assistive devices meant to improve eyesight.

Visual problems can take many forms — blurriness, double-vision, trouble with peripheral (or side) vision, floaters, flashes of light and so on. They can be fearful and distracting, resulting in an elder withdrawing from communication and social relationships. They may discourage a person from going outside, especially if they feel unsafe. It takes the attention of a qualified healthcare professional to assess the extent of the problem and determine what can be done about it. A person’s primary care physician can advise on when it is time to visit an ophthalmologist, especially if there are signs or risk factors for eye disease.

Hearing Loss

Hearing loss to varying degrees is also common among aging adults. Most of the ear’s anatomy cannot be seen from the outside. What is visible is the pinna, which is what we see when we look at someone’s ear. The hole leading into the head is the start of the ear canal. Further down the ear canal are the middle ear chamber, ear drum, hammer, anvil, semicircular canal, stirrup, inner ear or cochlea and more. These structures are seen using specialized tools.

Hearing loss can stem from a number of different causes, including environmental stimuli such as high-volume and high-frequency noise throughout one’s life. People who constantly blast music or other audio through ear buds or headphones may regret it later on in life. The Centers for Disease Control and Prevention warns on its website that “loud sound (noise) can damage sensitive parts of the ear, causing hearing loss, ringing or buzzing in the ear (tinnitus) and increased sensitivity to sound (hyperacusis).” People can develop hearing problems later in life even after the loud noises have ceased.

The CDC says that if you have signs of hearing loss, get tested by a qualified healthcare provider. Here are the signs: Speech and other sounds seem muffled; 

• Trouble hearing high-pitched sounds (e.g., birds, doorbell, telephone, alarm clock);
• Trouble understanding conversations when you are in a noisy place, such as a restaurant; 
• Trouble understanding speech over the phone; 
• Trouble hearing speech consonants (e.g., trouble hearing the difference between “s” and “f,” between “p” and “t,” or between “sh” and “th” in speech); 
• Asking others to speak more slowly and clearly; 
• Asking someone to speak more loudly or repeat what they said; 
• Turning up the volume of the television or radio; and
• Ringing in the ears.

Hearing loss can interfere with communication and be very isolating as the hearing-impaired individual misses out on group conversations, for example, that friends or family members are having.

For an evaluation of one’s hearing ability, an audiologist is the specialist who diagnoses and treats hearing and balance problems. An otolaryngologist — also called an ENT (ear, nose and throat) doctor — is a medical doctor who specializes in ear conditions such as infections or hearing loss, as well as nose and throat conditions, which can be related to each other.

Assistive technologies that help improve hearing have been around for a long time, but not everyone adjusts well to them. They can also be unaffordable for elders on tight budgets. For this reason, not all elders use a hearing aid or opt for a cochlear implant, which is a small electronic device that stimulates the nerve in the inner ear and has parts that are surgically placed by a healthcare professional qualified to perform this kind of procedure.

There are elders who own a hearing aid and paid good money for it but don’t use it because they are unable to adjust to it. Also, there are more affordable amplification devices available in the consumer market (you may see them advertised on television) but a person with hearing loss should consult a licensed professional to learn what is causing the loss and what are the best options for treatment.

Having a conversation with someone who has hearing loss can be a challenge, but there are tips that can help. Presbycusis refers to age-related, progressive bilateral “sensorineural” loss of the ability to hear high-frequency, low-volume sounds. If someone is speaking with a person who has hearing loss, it may be necessary to repeat words or sentences before comprehension occurs. To improve comprehension, it is important — whenever possible — to face the person directly, speak clearly but naturally and speak with sufficient volume without sounding as if you are angrily yelling. With some elders, one ear hears better than the other. Sit nearer to the “good ear” in a setting that has as few distractions as possible. The existence of background sounds such as a television, radio, people talking or laughing and so forth are likely to distract the person with hearing loss. Good quality communication requires attention to the physical environment as well as to the reactions of the people living in that environment.

Ear problems can also affect one’s balance due the sensation of dizziness or spinning, a condition that could be caused by benign paroxysmal positional vertigo (BPPV). In fact, the sensation itself is often described as “vertigo.” BPPV happens when tiny calcium particles get dislodged and collect in the inner ear. However, dizziness can be the result of other things, so it’s important to consult a medical professional for treatment and advice.

Vision and hearing are key senses that keep us connected to the world around us and to other people. They can be caused by the body’s normal aging process — a condition known as senescence — or they can be due to disease, injury or other causes. Paying attention to any physiological changes in one’s own body and in the bodies of loved ones, and calling attention to those changes when seeing a healthcare professional can help catch problems early on before they progress too far. 

The good news is that modern medicine can often offer a range of treatment options for both vision and hearing problems, especially if detected early enough. Preserving these two senses — or what remains of them if decline has already occurred — will also help maintain good communication ability. Assistive technologies, some of which have already been mentioned, can help compensate for hearing and vision impairments. Ask healthcare providers for recommendations to organizations that provide relevant services and supports.

When communicating with elders who have vision problems but still have sight, remember to write clearly and in larger print for letters and cards than you might be used to writing in for people with normal vision. Help look for books and other reading materials that are available in large print. If the elder uses a computer and is struggling to see the text on screen, see if there is a way of increasing the font size in the web browser.

For those who are eligible, Hawaii’s Library for the Blind and Print Disabled in Kapahulu “provides books and magazines in audio and braille for patrons who are certified as having a visual impairment or other physical limitation that prevents them from reading standard printed material,” according to the library’s website. “LBPD also has the largest collection of large print books in the state and a Radio Reading Service: a closed-circuit broadcast for registered patrons which features news from the Honolulu Star-Advertiser, grocery ads and articles and stories from other local publications.” Its toll-free phone number is 1 (800) 559-4096.

COGNITIVE FACTORS

Physiological barriers to communication are one reason for communication challenges, but cognitive factors may also present problems. Cognition has to do with our mental processes — the way that we think and make sense of things. People who study cognition have identified six domains or areas of thinking that contribute to our mental functioning. These six areas are 1) complex attention, 2) executive function, 3) learning and memory, 4) language, 5) perceptual-motor, and 6) social cognition.

Complex attention has two parts: selective attention and sustained attention. Selective attention is the ability to pay attention to the most important and relevant information and to ignore the rest. Sustained attention is the ability to focus on something over time, such as a long conversation with one person or a feature-length movie, and not get distracted. Executive function has to do with being able to make decisions, reason things out and solve problems. Learning and memory have to do with the ability to acquire and remember new information. Language is the ability to both send and receive information through speech or writing, understand words and sentences, and respond to instructions with behaviors. Perceptual-motor skills have to do with the combined ability to perceive and move, such as hand-eye coordination. Social cognition is the knowledge of socially appropriate reactions in specific situations, such as how one would respond to a close friend who has shared a sad experience.

Because of space limitation, the previous paragraph presented an oversimplification of the cognitive domains. Each of them is more complex. There are different kinds of memory, for example. But the point is that cognitive function involves many different abilities.

When people begin to have problems with their brains due to injury, disease, misuse of drugs or other reasons, they often experience trouble with one or more of these cognitive domains. They may show signs of dementia (difficulty with memory, communicating or finding words, reasoning or problem-solving, handling complex tasks, planning and organizing, and coordination and motor functions). They may appear confused and disoriented.

These dementia symptoms can have a variety of causes, but the most common of them is Alzheimer’s disease. Other diseases that can result in dementia symptoms are vascular dementia (damage to vessels that supply blood to the brain), Lewy body disease and more. Only a qualified medical professional can diagnose Alzheimer’s disease and related disorders. To help with the diagnosis, a doctor is likely to do or order cognitive tests to see whether the tests indicate cognitive impairment, and if so, what cognitive domains seem most affected at the time of testing.

This article is not about the diseases that can cause dementia but about the communication challenges that can result because of it. The first sign that someone is in the early stages of, say, Alzheimer’s disease — which is classified as a neurocognitive disorder — is short-term memory loss. What’s important about communicating with someone who has short-term memory loss, which may result in repetitive speech, is that the person is unaware of saying or asking things over and over. As far as that person in concerned, he or she is saying or asking it for the first time. Nevertheless, the repetition can become aggravating to the caregiver and others and the responses to those repetitive comments and questions may grow increasingly angry-sounding. The compassionate response, although easier said than done, is to respond not as if responding for the seventh time in the past hour but rather responding as if it was the first time, with a demeanor and voice that reveals patience and understanding, not hostility.

The problematic speech and behaviors are due to a brain disease that the elder cannot control, as there is no cure for Alzheimer’s disease. Medications may help slow the progression if they work, but they won’t erase the effects of the disease completely. The people around the person living with Alzheimer’s disease can help by improving the communication relationship through compassionate, supportive speech and actions. An organization like the Alzheimer’s Association has a wealth of information about communicating with people who have the disease and about the disease in general. Its website is alz.org.

It’s also important to know one’s own limits. Learn as much about Alzheimer’s disease and related dementias or disorders, and find good coping and management strategies. Take a break from the caregiving responsibilities whenever possible and remember to focus on your own mental and physical health.

Specific Communication Problems

People with a brain disorder due to disease or injury may demonstrate one or more of these communication problems: anomia, or problems finding the correct word. They may pause and appear to be searching for the right word to say, and end up using a less exact word or combining other words they know as a close approximation of the word they wanted to use.

Agnosia, the loss of the ability to recognize objects, people, sounds, smells or shapes. Aphasia is a broad term that means difficulty with language. It can take different forms, such as knowing in one’s mind what one wants to say but not being able to actually say it. Or saying something that ends up making no sense to others — it has been described as a “word salad” but which makes sense to the person saying it.

In the advanced stages of Alzheimer’s disease or a related disorder, verbal communication may stop entirely or almost entirely. But the person living with Alzheimer’s disease still has feelings and emotions. They may not be able to communicate as they once did due to their brain disease, but they still feel other people’s acts of kindness, gentle words of love and support and another person’s caring presence. They can also feel negative emotions directed at them. The take-away message here is that the inability to communicate in words does not mean the inability to feel or to express oneself in nonverbal ways. Attentive caregivers will learn to be good nonverbal detectives and communicate with non-speaking people in nonverbal ways, “reading” their body language and expressing a positive, loving energy with their own.

The person with severe cognitive decline will likely present with a variety of communication challenges. They can’t help it or control it. They may act different from their “old selves” before their disease advances to its current stage. They may have also developed psychological problems such as anxiety, paranoia or depression. At some point, verbal communication may become less important than “soul-to-soul” communication — a connecting of the spiritual beings of two individuals rather than the connection through language.

A growing amount of neuroscientific research is available demonstrating how complex language use is. For most people, the left hemisphere of the brain is responsible for speech, grammar, meaning-making, word comprehension, and other language skills. The parts of the brain in the left hemisphere responsible for language often work together but can also be studied in isolation to determine where in the brain are specific language abilities centered. For example, there is a region called Broca’s area, which is associated with speech production and articulation. Another region called Wernicke’s area is involved in comprehension and language processing. Specific language disorders can be traced to damage or injury to certain areas of the brain but being as complex as it is, there is research suggesting that healthy parts of the brain might help compensate for the damaged or injured areas in some instances. The brain is also involved in the functioning of the human sensory system, including vision and hearing, so brain damage can also affect our ability to see, hear, smell, taste, and touch. Brain research is an exciting and evolving field that continues to yield insights into communication disorders and treatments.

Communication challenges can also be caused by an individual’s personality or emotional health. Some people are naturally extroverted (e.g., outgoing and social) and others are introverted (e.g., shy and private). Some people are conflict-avoidant while others are confrontational. People’s moods may affect the way they communicate. A depressed person may not be very communicative. Someone in a manic state of bipolar disorder may be hyperverbal (extremely talkative). All of these things affect the communication relationship.

The Environment

Communicating with people who have multiple communication challenges — physiological, cognitive and psychological — may be aided or hindered by the physical environment. Is the room too hot or too cold for the elder? Is there too much or too little light? An overstimulated physical environment with loud noises from electronic devices, inconsistent lighting, people talking, random clutter, and too much to look at can result in psychological distress and discomfort. By contrast, a calm and quiet environment with relaxing music in an uncluttered space can have the opposite effect. But everyone is different. There is no “one size fits all” solution that works for everybody. Modifying the physical environment to make it a pleasant and safe place may take some experimentation and require both adding and removing things in the living area.

Effective communicators are attentive communicators, constantly assessing or evaluating the surroundings and the people in it (including themselves!) to determine what is working and what isn’t. What can be changed to make things better, to make communication more successful?

Five Simple Tips

These five simple tips may help improve the communication relationship and doesn’t cost a lot in terms of money, time or effort.

1. Sometimes small changes in nonverbal behavior can make a big difference in the quality of the relationship between you and the person you are communicating with. Remember that nonverbal behavior includes facial expressions, tone of voice, body language, respect of other people’s personal space, and attention to creating a physical setting that is conducive to good communication.
2. People tend to be creatures of habit. They establish patterns in their day-to-day routines. Be aware when patterns are broken and ask yourself “Why?” Is there something wrong? Is there something I can help with? Broken patterns or routines may be a type of nonverbal communication indicating a need for assistance.
3. Be as aware and critical of your own cultural biases as you are of others’ cultural biases. Just because people don’t do or say things the way you do doesn’t mean they are wrong. Differences can be interesting and fascinating, even though they may be unfamiliar territory to you.
4. What appears to be the case at the surface may not be the case beneath the surface. Just because someone appears to be unable to communicate normally, for example, does not mean there is something wrong with their intelligence or comprehension. With certain brain disorders or diseases, their thinking may be working fine but their ability to speak — to put their thoughts into spoken words and sentences — may be impaired. If that is the case, you can talk to them normally and at the same time try to help them with communicating their thoughts.

People even in the advanced stages of a disease that impairs their cognitive ability are still capable of feeling. They have emotions, even though their cognitive decline may be advanced. They may even be able to engage in nonverbal communication. Speaking words, sentences, and paragraphs is not the only way to communicate. Conveying a positive and reassuring energy in silence is also a powerful way of communicating compassion and concern. Those of you who are animal lovers know this experience. Your dog (or cat) doesn’t have to say “I love you” in words to express the sentiment.

In summary, normal age-related changes in the human body as well as pathological causes (e.g., disease- or injury-related) can impact interpersonal communication with elders. Assistive devices, medical treatment and compensatory strategies can help improve the communication relationship, as are knowledge, understanding and compassion.

Kevin Y. Kawamoto, MSW, Ph.D., has taught classes at the university-level in both gerontological social work and communication.