Age-Based Stereotypes Constraining Older Adult Communication
Communication Predicaments of Aging
Although age stereotypes are not unidimensional (Hummert, Shaner, Garstka, & Henry, Reference Hummert, Shaner, Garstka and Henry1998), interaction with older adults—and even among older adults—tends to be dominated by age stereotypes of dependency and incompetence (Hummert, Garstka, Ryan, & Bonnesen, Reference Hummert, Garstka, Ryan, Bonnesen, Nussbaum and Coupland2004; Kite, Stockdale, Whitley, & Johnson, Reference Kite, Stockdale, Whitley and Johnson2005). As suggested by the communication predicament of aging model, conversational partners’ use of speech modifications based on negative age stereotypes can constrain communication opportunities and reinforce stereotyped behaviors and eventually lead to lower self-esteem and disengagement by older adults (Barker, Giles, & Harwood, Reference Barker, Giles, Harwood, Nussbaum and Coupland2004; Ryan, Giles, Bartolucci, & Henwood, Reference Ryan, Giles, Bartolucci and Henwood1986). These negative age stereotypes are reinforced when older adults are repeatedly spoken to in a patronizing manner. The danger with continuous exposure to this communication style is that older adults might begin to both internalize and accept such stereotypes. Thus, negative age stereotypes can become a self-fulfilling prophecy. The adapted model by Barker et al. (Reference Barker, Giles, Harwood, Nussbaum and Coupland2004) incorporates both intergenerational and intragenerational encounters. Moreover, the extent to which age elicits negative stereotypes and drives automatic usage of age-adapted communication is seen to relate to the societal context, as well as characteristics of the individual within the communication situation (premature cognitive commitments, level of mindfulness, age-salience). Relevant aspects of the societal context that influence the likelihood of patronizing communication toward older adults include the prevalence of positive and negative age stereotypes, group vitality (reflected by population size, sociohistorical status, and institutional support), and filial piety norms, which hold that older adults are to be respected and venerated, especially if they are family elders.
What the Media Communicate about Aging
The media (especially television) play a major role in influencing the status of older adults and in socializing audience members to the roles and characteristics of older adults (Harwood & Anderson, Reference Harwood and Anderson2002). The media are particularly powerful in cultivating and reinforcing children's perceptions of aging (Robinson & Anderson, Reference Robinson and Anderson2006). Generally, older adults are underrepresented in the media. In fact, there has only been a 1% increase in the presence of older adults in children's programming in the last 20 years (Robinson & Anderson). In contrast to the population statistics that indicate there are more older women than older men and that there are increasing numbers of minority older adults, both older women and minority older adults are a rarity in the media (Robinson & Anderson; Zhang et al., Reference Robinson and Anderson2006). Cross-cultural research on how older adults are portrayed in Indian and American magazine advertisements revealed that compared to American ads, ads in India underrepresented older adults to a larger extent and included far fewer older women than older men (Raman, Harwood, Weis, Anderson, & Miller, Reference Raman, Harwood, Weis, Anderson and Miller2006).
When represented, older adults have been depicted as unidimensional characters, holding either positive or negative characteristics, but not both. For example, some studies suggest that older adults depicted in children's programming and in some advertising showed many positive portrayals (Bishop & Krause, Reference Bishop and Krause1984; Robinson, Reference Robinson1998). However, these positive portrayals must be viewed with caution because older adults had minor roles and were experiencing health issues (Robinson & Anderson, Reference Robinson and Anderson2006; Zhang et al., Reference Zhang, Harwood, Williams, Ylänne-McEwen, Wadleigh and Thimm2006). Cultural values depicted in television commercials featuring older adults tend to focus more on health than on technology and achievement; the latter values are more predominant in commercials featuring younger age groups (Zhang & Agard, Reference Zhang and Agard2004). These cultural values only fuel stereotypic and negative attitudes that younger adults might have toward older adults (Harwood, Reference Harwood2007). Generally, media representations of older adults include predominantly negative characteristics (such as senile, villainous, and curmudgeon), minor roles, or traditional gender roles (Donlon, Ashman, & Levy, Reference Donlon, Ashman and Levy2005; Raman et al., Reference Raman, Harwood, Weis, Anderson and Miller2006).
The pervasiveness of negative images of aging on television and in other media can contribute to self-stereotyping by older adults. Coupland (Reference Coupland, Coupland and Gwyn2003) addressed the ageist messages in skin care marketing that suggest that women can avoid the pitfalls of ageism by keeping their skin looking young. Donlon and colleagues (Reference Donlon, Ashman and Levy2005) found that television exposure was more strongly related to negative age stereotypes than age, depression, education or self-rated health. However, they did not examine whether increased awareness of how older adults are depicted actually decreases negative age stereotypes. Increasing awareness of the negative depiction of older adults to older adults themselves can have serious consequences for the media. As the baby boomers age, they are expected to be less complacent about negative and offensive advertising. Older adults who categorized magazine advertisements as offensive and harmful to their age group were less likely to purchase products from such advertisers (Robinson, Popvich, Gustafson, & Fraser, Reference Robinson, Popvich, Gustafson and Fraser2003) and also attributed the persistent negative portrayal of aging to the (younger) age profile of workers in the media (Healey & Ross, Reference Healey and Ross2002).
Influence of Stereotypes on Older adults
Given that older adults also hold negative age stereotypes, the natural question is whether these stereotypes affect older adults in meaningful ways. The research evidence suggests that both negative and positive self-stereotypes affect older adults in terms of their functional and sensory abilities. The research on negative self-stereotypes illustrates the power of internalized perceptions on various abilities. When older adults were explicitly exposed to negative age stereotypes, their performance on memory tests was lower than older adults who were not exposed and to younger adults who were exposed (Hess, Auman, Colcombe, & Rahhal, Reference Hess, Auman, Colcombe and Rahhal2003). When negative age stereotypes were presented at speeds that permit perception without conscious awareness, older adults experienced more cardiovascular stress even before they had to deal with anxiety-producing stressors (i.e., mathematical and verbal challenges) (Levy, Hausdorff, Hencke, & Wei, Reference Levy, Hausdorff, Hencke and Wei2000). Finally, older adults who held negative stereotypes, especially related to physical appearance, showed more decline in hearing after 3 years (Levy, Slade, & Gill, Reference Levy, Slade and Gill2006).
The influence of positive self-perceptions on functional health, mortality, and will to live is promising. Levy and colleagues (Levy, Slade, & Kasl, Reference Levy, Slade, Kunkel and Kasl2002) found that older adults who held positive self-perceptions were more likely to report better functional health, and that perceived control partially mediated the relationship between self-perceptions of aging and functional health. In another study, Levy and colleagues (Levy, Slade, Kunkel, & Kasl, Reference Levy, Slade and Kasl2002) found that older adults with positive self-perceptions lived almost 8 years longer than those who held less positive perceptions. They also found that the will to live partially mediated the relationship between self-perceptions and longevity. Both studies found these compelling results after controlling for baseline measures of functional health, self-rated health, age, gender, race, and socioeconomic status. Older adults who were subliminally exposed to positive age stereotypes showed improvements in motor function (Hausdorff, Levy, & Wei, Reference Hausdorff, Levy and Wei1999). These results suggest possibilities in terms of interventions aimed at improving functional and cognitive abilities.
Perceptions of Intergenerational Communication
Within English-Speaking Contexts
Ageist stereotyping can lead to age-adapted ways of speaking to older adults. Patronizing talk to older adults and other targets such as those with disability threatens the self-esteem of recipients whether it be directive talk (low care, high control), baby talk (high care, high control), overly personal talk (high care, low control) and superficial talk (low care, low control) (Hummert & Ryan, Reference Hummert, Ryan, Robinson and Giles2001). Moreover, constrained by expectations of such talk, older adults can reinforce age stereotypes with painful self-disclosures (Bonnesen & Hummert, Reference Bonnesen and Hummert2002).
Elderspeak is the accommodation of communication based on the perceived needs of older adults and includes simplified syntax and vocabulary, slow speaking rate, and exaggerated prosody. In a masterful series of experiments, Kemper and Harden (Reference Kemper and Harden1999) elicited evaluations of different components of elderspeak used by young adults in a referential communication task with older adult listeners. Semantic elaborations and reducing grammatical complexity without shortening sentences benefited older adults in comprehension and self-rated performance, whereas receiving short sentences, slow speech rate, high pitch, and pitch variation led older adults to report more communication difficulties. Similarly, Gould, Saum, and Belter (Reference Gould, Saum and Belter2002) found a benefit in older adult memory when medication instructions were given in elderspeak, while younger and older adults agreed on the negative and positive aspects of such talk.
Comparing evaluations of family communication with teens, peers, and elders, Williams and Garrett (Reference Williams and Garrett2002) found that communication with older adults was viewed more positively as respondent age increased across the adult range, and that communication with both older adults and adolescents was viewed as problematic. Hummert and Morgan (Reference Hummert, Morgan, Hummert and Nussbaum2001) showed that direct control strategies were evaluated negatively in decision-making conversational scenarios involving a middle-aged woman with either her young adult daughter or her older adult mother, but were more acceptable with the older mother.
Communication and stereotyping are mutually reinforcing in a variety of ways. Chen and King (Reference Chen and King2002) found that old adults expressed greater satisfaction with intergenerational communication than young participants, and that a positive age stereotype for the opposite age group was associated with higher levels of intergenerational communication satisfaction for both groups. Interestingly, Polizzi and Millikin (Reference Polizzi and Millikin2002) supported the notion that researcher terminology can affect elicited attitudes toward older adults, with the term “70–85 years” eliciting more positive attitudes than the terms “old” or “elderly.”
Ryan, Anas, and Gruneir (Reference Ryan, Anas and Friedman2006) examined the meanings of overhelping and underhelping in conversations between a salesperson and young or old targets with or without visible disability. Compared to a professional style, young and old respondents agreed that underhelping was the most negative, and that overhelping was associated with reduced customer satisfaction and salesperson effectiveness. “Blame the recipient” effects occurred in evaluations of both underhelped and overhelped customers. Within a similar paradigm, Ryan, Anas, and Vuckovich (Reference Ryan, Anas and Vuckovich2007) evaluated young and older targets with or without hearing loss who showed communication problems. Regardless of age, targets were judged less severely for communication difficulties if known to use a hearing aid. These findings could help those counseling older adults with hearing loss, given that “faking it” can lead to serious interpersonal problems.
Perceptions of age excuses have also been the topic of several studies. A study of the conversational management of memory failures in older adults by Ryan, Bieman-Copland, Kwong See, Ellis, and Anas (Reference Ryan, Bieman-Copland, Kwong See, Ellis and Anas2002) showed that while age excuses may relieve socially awkward situations, they serve to reinforce age stereotyping of the older forgetter, especially from the perspective of young respondents. Erber and Prager (Reference Erber and Prager2000) showed that offering an age excuse for forgetting afterward served targets better than giving it before as a self-handicapping strategy. Newspaper content analysis supports the increasing usage of the term “senior moments” to describe a range of memory failures associated with old age (Bonnesen & Burgess, Reference Bonnesen and Burgess2004).
There is evidence for acceptance of negative age stereotypes by older adults in nursing home and hospital settings where cues of dependence are more salient than in community settings (Hummert & Mazloff, Reference Hummert and Mazloff2001; Ryan, Kennaley, Pratt, & Shumovich, Reference Ryan, Kennaley, Pratt and Shumovich2000). Interestingly, there are variations in the sources of patronizing speech for older adults in community versus nursing home settings. Compared with friends, same-age family members, younger family members, and familiar service workers, community-residing older adults reported only receiving patronizing speech from unfamiliar service workers. However, nursing home residents received patronizing speech from all speaker types (O'Connor & St. Pierre, Reference O'Connor and St. Pierre2004). Finally, we see the blame the victim effect when older adults are evaluated negatively in interactions where the other person uses patronizing speech (Hummert et al., Reference Hummert, Garstka, Ryan, Bonnesen, Nussbaum and Coupland2004; Savundranayagam, Ryan, Anas, & Orange, Reference Savundranayagam, Ryan, Anas and Orange2007).
Cross-Cultural Comparisons
How do perceptions of aging and communication with older adults differ among cultures? Many Eastern (Chinese, Japanese, Indian, etc.), Latino, and Native American cultures are collectivist and subscribe to filial piety (Barker & Giles, Reference Barker and Giles2003; Gallois et al. Reference Gallois, Giles, Ota, Pierson, Ng, Lira, Lasry, Adair and Dion1999; Harwood, Reference Harwood2007). This can include forms of address that honor older adults and reinforce their higher status. Older adults, especially in Native American cultures, tend to be revered for their wisdom and lived experience, and hold the responsibility for transmitting cultural traditions to younger generations (Graves & Shavings, Reference Graves and Shavings2005).
However, given the urbanization of many cultures, especially those in East Asia, younger adults are moving into urban areas and leaving older adults in rural areas. Moreover, while families have more generations living at one time, there are fewer family members within each generation to care for older adults. These changes have resulted in more nursing homes in Eastern countries (Ikels, Reference Ikels2004), more negative attitudes toward older adults in some societies (e.g., Hong Kong) than in North America (Harwood, Reference Harwood2007; Harwood et al., Reference Harwood, Giles, McCann, Cat, Somera and Ng2001), and fewer meaningful roles for older adults (Bhat & Dhruvarajan, Reference Bhat and Dhruvarajan2001).
Indeed, recent research revealed changing cultural values and more multidimensional perceptions of aging in Eastern and Latino cultures, especially as these societies become more Westernized. Research by Zhang and colleagues (Zhang, Harwood, & Hummert, Reference Zhang, Harwood and Hummert2005; Zhang & Hummert, Reference Zhang and Hummert2001) support the idea that younger adults in Asian cultures are beginning to view the age hierarchy as undemocratic. Younger Asian adults also held fewer positive stereotypes of older adults than Western younger adults, especially in terms of benevolence (Giles et al., Reference Giles, Noels, Williams, Lim, Ng and Ryan2003; Pecchioni, Ota, & Sparks, Reference Pecchioni, Ota, Sparks, Nussbaum and Coupland2004). Similarly, Ryan and colleagues did not find greater positivity toward older adults within their Asian sample (Ryan, Jin, Anas, & Luh, Reference Ryan, Jin, Anas and Luh2004). In fact, they found that participants from Chinese, Korean, and Canadian cultures held both positive (i.e., storytelling and social skills) and negative beliefs (i.e., hearing and memory) about communication skills of older adults, with stronger positive beliefs endorsed by older adults than younger adults from both East and West. However, younger adults are not the only ones who hold negative perceptions of aging. The research on self-stereotyping among older adults of different cultures also suggests that they hold negative attitudes towards their age group (Boduroglu, Yoon, Luo, & Park, Reference Boduroglu, Yoon, Luo and Park2006).
The evidence on communication behaviors used with older adults might reveal outcomes resulting from age stereotypes. Compared to their counterparts in Western countries, both younger and older adults in Eastern countries evaluated their communication with nonfamily older adults as more problematic than with younger adults (Pecchioni et al., Reference Pecchioni, Ota, Sparks, Nussbaum and Coupland2004). In both cases, older adults were perceived as nonaccommodating. Despite the generalized perspective that older adults of developing countries are more respected than older adults in Western countries, there is evidence that the respect might stop at mere formalities. For instance, although older adults are generally healthy and socially active in rural Ghana, they received respect at a very superficial level. The communication behavior of younger adults revealed that they did not listen to the wisdom or advice of older adults, and consequently older adults experienced loneliness (van der Geest, Reference Van Der Geest2004). Similarly, results from a large cross-cultural study on intergenerational communication revealed that Asian younger adults’ behavior was governed largely by obligation (Gallois et al., Reference Gallois, Giles, Ota, Pierson, Ng, Lira, Lasry, Adair and Dion1999). Study results showed that Asian younger adults felt more obligated to give practical support to older adults than their Western counterparts, who reported that they would personally provide continued communication and contact with older adults.
Grandparent–Grandchild Communication
Perceptions of grandparent–grandchild communication offer the most positive data concerning intergenerational interactions involving university-age adults (Harwood, Reference Harwood2007; Pecchioni & Croghan, Reference Pecchioni and Croghan2002). Grandparents reported that communication within this family relationship involves expressions of affiliation, pride, and mutual exchange, as well as the stress of physical and emotional distance associated with adolescence and leaving for college (Harwood & Lin, Reference Harwood and Lin2000). Grandchildren reported maintaining this relationship through face-to-face visits, telephone, and writing (letters, e-mail), with telephone contact being most linked to relationship quality (Harwood, Reference Harwood2000a). From both generations, accommodative communication behaviors are associated with solidarity between grandparents and grandchildren (Harwood, Reference Harwood2000b).
Indeed, frequency and quality of grandparent contact has often been cited as the primary way in which youth learn positive attitudes toward old age. This expected link between grandparent relationships and young adult attitudes toward older adults in general has been examined through several multivariate studies. Soliz and Harwood (Reference Soliz and Harwood2003) explored the variation in relationships with multiple grandparents and found links between variation in perceived communication and perceived variability in old age. However, varied experiences with different grandparents were linked to more negative attitudes toward older adults in general. Based on complex theories of how intergroup contact can affect attitudes, Harwood and colleagues (Harwood, Hewstone, Paolini, & Voci, Reference Harwood, Hewstone, Paolini and Voci2005) then incorporated the key variable of age salience because grandparents are unlikely to be perceived as typical if they are seen as family and talked with in a person-centered manner. They found that contact with the closest grandparent has more influence on attitudes toward older adults when age is salient in the grandparent relationship. Moreover, accommodation mediated the effect of contact on attitudes while self-disclosure and individuation influenced the effect of contact on perceived variability among the old. Following up on age salience, Soliz and Harwood (Reference Soliz and Harwood2006) found that personal communication (social support and reciprocal self-disclosure) was correlated positively with perceptions of shared family identity, whereas intergroup communication (under- and overaccommodation) was related to age salience.
Communication During Medical Encounters
Communication predicaments are highly likely in helping situations, such as patient–doctor interactions (Braithwaite & Eckstein, Reference Braithwaite and Eckstein2003; Braithwaite & Thompson, Reference Braithwaite and Thompson2000). The literature on patient–doctor interactions reveals many ways in which physicians treat older patients differently than their younger patients. Physicians tend to spend less time with older adults, use a more condescending and less patient tone with older adults, overuse technical language, control the interview, ask older adults fewer questions, use close-ended questions, do not include them in joint decision making, and are less likely to recommend preventive strategies such as exercise (Allman, Ragan, Newsome, Scoufos, & Nussbaum, Reference Allman, Ragan, Newsome, Scoufos, Nussbaum and Hamilton1999; Thompson, Robinson, & Beisecker, Reference Thompson, Robinson, Beisecker, Nussbaum and Coupland2004). These communication patterns are exacerbated within the hospital context, where the doctor primarily holds the power and control over the doctor–older patient relationship, and care tasks (e.g., bathing, feeding, etc.) are based on staff needs instead of the older adult's needs (Coe & Miller, Reference Coe and Miller2000).
Physicians’ communication skills discussed earlier can decidedly affect the degree of medical success achieved for older adults. Indeed, these barriers are more dissatisfying for women than men. Both not calling a person by name and calling a person by first name were perceived as signs of unequal power between physicians and patients (Allman et al., Reference Allman, Ragan, Newsome, Scoufos, Nussbaum and Hamilton1999). Most older women in the United States use Medicare to cover their medical visits, and Medicare only pays for 80% of physician charges. Compared to women who have other sources of medical payment, poorer women were more likely to experience medical encounters that were tardy or rushed, or where physicians made little eye contact (Allman et al.).
Older adults are more likely to be excluded or not fully included in the presence of differences (e.g., age, disability, language differences). For example, family members may speak on behalf of older adults, making it difficult to voice their opinions in future encounters (Adelman, Greene, & Ory, Reference Adelman, Greene and Ory2000). Compared to dyadic encounters where the older adult and doctor are more likely to have similar levels of participation, older adults’ levels of participation were reduced by about 17% in triadic encounters (Ishikawa, Roter, Yamazaki, & Takayama, Reference Ishikawa, Roter, Yamazaki and Takayama2005). In addition, family members tend to take more active roles during the encounter by directly asking questions and providing information about the older patient, even if the doctor addresses the patient directly (Coupland & Coupland, Reference Coupland, Coupland, Hummert and Nussbaum2001). There is diversity in the types of roles family members occupy during health encounters. They include emotional support, note taker, memory aid, advocate, and interpreter (Ellingson, Reference Ellingson2002). Despite this diversity, overhelping behaviors where family members speak for older adults often result in patients deferring to family members for responses and can contribute to excess disability (Ryan, Anas, & Friedman, Reference Ryan, Anas and Friedman2006; Ryan, Bajorek, Beaman, & Anas, Reference Ryan, Bajorek, Beaman, Anas, Harwood and Giles2005). Moreover, when family members collude with doctors, the older patient is likely to feel alienated or reprimanded for not following treatment plans (Coupland & Coupland, Reference Coupland, Coupland, Hummert and Nussbaum2001). The problem of family members dominating conversations is not specific to medical encounters; it is also relevant within the family caregiving context. Edwards (Reference Edwards, Hummert and Nussbaum2001) advised caregivers to ask open-ended questions, avoid interrupting, and try to balance giving information with asking for information.
There are similar cautions when interpreters are used in medical encounters. When using interpreters, the patients’ content, meaning, and affect of speech can be altered. In addition, it is difficult to build rapport with a physician and be more engaged in the treatment decision-making process when an interpreter is used (Aranguri, Davidson, & Ramirez, Reference Aranguri, Davidson and Ramirez2006). Similar findings are documented with minority patients, who are also less involved in decision making, experience less patient-centered communication, and are less trusting of physicians (Johnson, Roter, Powe, & Cooper, Reference Johnson, Roter, Powe and Cooper2004; Johnson, Saha, Arbelaez, Beach, & Cooper, Reference Johnson, Saha, Arbelaez, Beach and Cooper2004). Even though these interpreter studies are not specific to aging, they are relevant to older adults because the communication encounter might be worse when language barriers are combined with negative age stereotypes that are rampant in health care settings.
One of the most understudied yet prevalent issues related to language and aging within medical contexts is the impact of bi- or multilingualism on health assessments. De Bot and Makoni (Reference de Bot and Makoni2005) cautioned that most research focuses on monolingual contexts despite the reality that bi- or multilingual older adults are part of many of our communities. Baker (Reference Baker, Worrall and Frattali2000) contended that language-related diagnoses (e.g., aphasia) are more likely to be accurate if assessments are conducted in multiple languages because of possible residual abilities with one language. Baker also stated that specific communication tasks within assessments must be in the language that the client would have used previously. For example, if communication tasks involve interacting with a grocery clerk or with family members, each task must be assessed in the language that the client would have used before the onset of the communication disorder. These points highlight the importance of diversifying the language abilities of health professionals.
It is important to appreciate the heterogeneity within the older adult population and tailor health recommendations and medication instructions to the abilities and preferences of older adults. For instance, older adults with high levels of cognitive ability tend to prefer standard pharmacy instructions that discuss drug interactions. However, older adults with lower levels of cognitive ability preferred patient-centered instructions (e.g., large print, text-related icons, and simplified language) that supported comprehension and memory by minimizing demands on sensory and cognitive abilities (Morrow, Weiner, Steinley, Young, & Murray, Reference Morrow, Weiner, Steinley, Young and Murray2007). Zandbelt, Smets, Oort, Godfried, and de Haes (Reference Zandbelt, Smets, Oort, Godfried and de Haes2007) investigated the extent to which (1) physicians facilitated or inhibited patients to express their perspective, and (2) patients actively contributed to the conversation. Patients were more likely to actively contribute to conversations when the physician used facilitating communication. However, physicians’ inhibiting behavior did not affect patient expression. The authors concluded that physicians may exhibit inhibiting behaviors as a response to the increased participation by patients. Other considerations for physicians include not denying older adults preventive health recommendations because of their age. Physicians also need to create a social environment that allows older adults to disclose sensitive issues such as loss, death, and abuse, especially because those issues might be the underlying reasons for the medical visit (Harwood, Reference Harwood2007).
The responsibility for effective communication encounters in the health context also lies with older adults. As mentioned earlier, older adults do contribute to negative stereotypes by using age excuses or internalizing the sick role in older adulthood. In health encounters, older adults’ responses to questions about how they are doing almost always include an assessment of health given their age (Coupland & Coupland, Reference Coupland, Coupland and Hamilton1999). In some cases, older adults view aging and medical ailments as inextricably linked, and use humor to lighten such self-disenfranchising remarks. However, their assessments are not always negative. Mentioning age within the context of health reflects a sense of pride for being healthy in older adulthood. Yet, Coupland and Coupland cautioned that this pride in and of itself suggests that good health in older adulthood is exceptional. Some older adults are more resistant to explanations by doctors that certain symptoms are not due to old age or that certain negative health habits can be changed in older adulthood. Coupland and Coupland included a rare but fascinating account in which a physician vociferously challenged age excuses when used as justification not to quit smoking and drinking. This account illustrates how difficult it is for physicians to contest self-stereotypes, but also how important it is for both physicians and older patients to actively work toward interactions that promote positive perceptions of health and aging.
The current cohort of older adults tends to prefer the power differential where the doctor is the expert. Consequently, they may ask fewer questions during medical encounters, especially within the managed care context where doctor–patient time is limited. However, patients who actively participate during medical visits receive more information from physicians on topics such as treatment options and side effects (Cegala, Street, & Clinch, Reference Cegala, Street and Clinch2007). Such information may increase patient compliance and positive health outcomes. Research on both doctors’ and patients’ perceptions of what constitutes competent patient communication reveals that providing relevant information, asking questions, and being prepared for the medical visit with an agenda are all useful strategies (Cegala, Gade, Lenzmeier Broz, & McClure, Reference Cegala, Gade, Lenzmeier Broz and McClure2004; Greene & Adelman, Reference Greene, Adelman, Hummert and Nussbaum2001). In addition, doctors preferred that patients prepare by thinking about medical concerns before the visit. They also want patients to learn about the illness, provide a detailed medical history, and include other relevant issues.
Enhancing Communication
Older Adult Assertiveness
Several communication accommodation models address how interlocutors can individualize their talk to older adults, thereby avoiding the pitfalls of patronizing communication (Barker et al., Reference Barker, Giles, Harwood, Nussbaum and Coupland2004; Hummert et al, Reference Hummert, Garstka, Ryan, Bonnesen, Nussbaum and Coupland2004; Ryan, Meredith, MacLean, & Orange, Reference Ryan, Jin, Anas and Luh1995). To highlight options for people with disabilities to interrupt the negative feedback loop of the communication predicament, Ryan et al. (Reference Ryan, Bajorek, Beaman, Anas, Harwood and Giles2005) developed a model featuring selective assertiveness as the term for choosing one's battles and responding (vs. reacting) in a clear, calm, confident manner. Older adults’ responses to patronizing advice (Hummert & Mazloff, Reference Hummert and Mazloff2001) reflected several potentially assertive options (direct, appreciative, and ignoring), with a clear indication that these are more likely in a community context than in a hospital context. Within problematic clinical encounters in the community, young and old evaluators agreed that assertive seniors were most competent and likely to be satisfied in a future encounter (Ryan, Anas, & Friedman, Reference Ryan, Anas and Gruneir2006). Within the nursing home, Ryan et al. (Reference Ryan, Kennaley, Pratt and Shumovich2000) found less support for assertiveness (not part of the nursing home resident role) in declining to participate in an activity. Indirect assertiveness (declining with humor) was more successful. Finally, a study of assertive versus passive responses in problematic service encounters by visually impaired older women needing help demonstrated higher evaluations of competence and future success for assertiveness and provided further evidence for the importance of contexts (Ryan, Anas, & Mays, Reference Ryan, Anas and Mays2008). The assertiveness advantage was greater in the community than in the hospital setting and for the more serious situations. This theoretical perspective and these findings suggest specific ways in which older adults might be encouraged to respond more effectively by carefully choosing features of assertiveness to match the demands of problematic situations.
Communication Between Nursing Home Staff and Residents
As a response to the negative outcomes reflected in the communication predicament of aging model (Ryan et al., Reference Ryan, Giles, Bartolucci and Henwood1986), the communication enhancement model (Ryan et al., Reference Ryan, Meredith, MacLean and Orange1995) delineates how social partners, especially health care professionals, can adjust their communication to meet the actual needs of older adults. The model encourages interventions that emphasize appropriate speech accommodations, supportive physical environments, and creating positive social environments. Such interventions empower both the older adult and the social partner (Savundranayagam, Ryan, & Hummert, Reference Savundranayagam, Ryan, Anas and Orange2007). For instance, long-term care staff who used personhood-based language were rated more positively than staff who used directive language (Savundranayagam, Ryan, Anas, et al., Reference Savundranayagam, Ryan, Hummert, Weatherall, Watson and Gallois2007). Residents with dementia were also rated more positively in the personhood scenarios even though their responses in both personhood and directive scenarios were identical. Carefully simplified language, suggested by Kemper and Harden (Reference Kemper and Harden1999) as an effective language modification, strengthened those effects by showing staff as less patronizing and residents as more competent. In support of the communication enhancement model, these results offer evidence that appropriate changes in staff communication benefit both staff and residents.
The research program of Williams also supports the communication enhancement model. Williams and colleagues (Williams, Reference Williams2006; Williams, Kemper, & Hummert, Reference Williams, Kemper and Hummert2003, Reference Williams, Kemper and Hummert2004) developed a brief intervention that informed long-term care staff of the importance of socialization for older adults. The intervention also focused on communication barriers specific to the nursing home context and the positive and negative aspects of elderspeak. Using actual and simulated videotaped staff-resident interactions, participants were able to (1) identify aspects of elderspeak in their own interactions and those of others and (2) reenact the interaction using effective communication strategies. Findings revealed that participants gained knowledge about their own communication patterns, especially their use of elderspeak. They also used fewer psycholinguistic features of elderspeak (e.g., diminutives, shortened statements, and simplistic vocabulary) after training. It will be helpful to find out if this intervention positively affects the residents as well, especially in terms of social engagement.
Communication interventions focused on improving nursing home staff and family member interactions with residents also show promising results. Interventions aimed at teaching staff to use memory aids and specific verbal and nonverbal communication skills were able to reduce depressive symptoms in residents with dementia (McCallion, Toseland, Lacey, & Banks, Reference McCallion, Toseland, Lacey and Banks1999) and improve communication between staff and residents with mild and moderate cognitive impairment (Allen-Burge, Burgio, Bourgeois, Sims, & Nunnikhoven, Reference Allen-Burge, Burgio, Bourgeois, Sims and Nunnikhoven2001). However, another intervention for improving communication among residents, nursing staff, and visiting family members showed that only family members improved communication patterns with residents. In turn, residents were improved in terms of depression, verbal behavior, and agitation (McCallion, Toseland, & Freeman, Reference McCallion, Toseland and Freeman1999).
Finally, interventions intended to improve communication between nursing home staff and family members can have indirect benefits for residents in long-term care, especially for residents who are unable to communicate their needs and concerns due to cognitive impairments. As in the case of acute-care medical encounters discussed earlier, family members play an important role in long-term care facilities because they help staff by sharing the residents’ life histories, preferences, and unmet needs (Port et al., Reference Port, Gruber-Baldini, Burton, Baumgarten, Hebel and Zimmerman2001). This type of help has been linked with lower levels of disruptive behaviors and increased levels of resident involvement (Dobbs et al., Reference Dobbs, Munn, Zimmerman, Boustani, Williams and Sloane2005; Foley, Sudha, Sloane, & Gold, Reference Foley, Sudha, Sloane and Gold2003). By including family members and staff, Pillemer and colleagues (Reference Pillemer, Suitor, Henderson, Meador, Schultz and Robison2003; Robison & Pillemer, Reference Robison, Pillemer and Gaugler2005) developed the Partners in Caregiving program that trained both groups on effective communication, empathy development, and conflict resolution. The most recent results stemming from this intervention show that there are improvements in communication between staff and families. What is most striking is that residents with dementia in the intervention group showed significant improvements in many disruptive behaviors such as cursing or verbal aggression, self-abuse, sexual advances, inappropriate dress, constant requests for attention, and wandering (Robison et al., Reference Robison, Curry, Gruman, Porter, Henderson and Pillemer2007).
Computer-Mediated Relationships
Although there are interventions targeted to social partners of older adults, especially within the health care context, older adults themselves can remain actively engaged in life through a variety of communication-based strategies. In this next section, we will discuss how technology is becoming a useful tool for older adults to maintain a sense of self and competence, especially in the face of health and social losses that can be physically and socially isolating. Personal computers, software, teaching approaches, and accessibility options on computers and the Internet are increasingly being improved to include and engage people with a variety of abilities and disabilities (Charness, Park, & Sabel, Reference Charness, Park and Sabel2001).
Older adults are using the Internet to develop and maintain relationships with family members and friends, reconnect with past hobbies, gather information, be engaged with interest groups, increase personal control, and be mentally active (Fox et al., Reference Fox, Rainie, Larsen, Horrigan, Lenhart and Spooner2001; McMellon & Schiffman, Reference McMellon and Schiffman2002). Older adults who participated regularly in online groups received social support and companionship and also reported lower scores on perceived stress (Wright, Reference Wright2000). In addition, being a competent communicator also contributed to lower scores of perceived stress and greater satisfaction with the support offered by their online network. These types of networks provided more emotional support and validation than other types of social support (Query & Wright, Reference Query and Wright2003).
Online support networks offer older adults the opportunity to seek support through a more diverse group of individuals who are not family members. Unlike family relationships that might hold obligations, online networks include more voluntary relationships that are based on common interests or stressors, as in the case of caregiving or disease-related forums (Wright & Query, Reference Wright, Query, Nussbaum and Coupland2004). With family members, older adults may not feel comfortable sharing their distress over concerns such as health and disability. However, online support networks allow older adults to maintain their identities in the face of adversities by communicating about sensitive or stigmatizing issues. Self-disclosure can be done more safely given the anonymity of online groups. Interestingly, older adults in online discussion forums tended to use more positive than negative age identities themes. These included active engagement, a sense that their minds can overcome physical declines, wisdom and maturity, and the freedom of age (Lin, Hummert, & Harwood, Reference Lin, Hummert and Harwood2004). Moreover, communicating with others who are experiencing similar problems makes it easier for individuals to empathize with each other and exchange comforting messages (Preece & Ghozati, Reference Preece, Ghozati, Rice and Katz2001).
There still remains a digital divide in terms of the characteristics of older adults who use computers. Typically, those who use computers are part of the young-old group, are male, and have greater education (Selwyn, Gorard, Furlong, & Madden, Reference Selwyn, Gorard, Furlong and Madden2003). Selwyn and colleagues cautioned that the reasons for not using computers are not limited to income, but are also related to the perceived relevance of such technology in the lives of older adults. Training older adults to use computers is not always enough to improve psychosocial factors such as loneliness or depression (White et al., Reference White, McConnell, Clipp, Branch, Sloane and Pieper2002). Perhaps training interventions may be more successful if they explained the relevance of computer use in the personal lives of older adults and used less negative age-stereotypic outcomes such as loneliness and depression.
Conclusions
In this review, we have focused on the role of age stereotypes in influencing intragenerational and intergenerational communication within the context of family relationships, health care encounters, and computer-mediated relationships. We have discussed the powerful role of self-stereotypes on cognitive and functional abilities of older adults. Some of the research findings send cautionary notes about (1) the depiction of older adults in the media, (2) how easily age defines the person in medical encounters, (3) how age is inextricably linked with ill-health, and (4) how technology needs to be personally relevant to older adults. Yet, other findings offer hope in the ability of older adults to (1) remain meaningfully connected with their family members (especially grandchildren), (2) be actively engaged in health maintenance and promotion, (3) use appropriate features of assertiveness to match situational demands, and (4) create and maintain relationships through new technologies.
The positive findings reflect the Ryan et al. (Reference Ryan, Bajorek, Beaman, Anas, Harwood and Giles2005) elaborated predicament model of intergenerational communication, which illustrates the active role that older adults can and do play in confronting negative stereotypes. Future research should consider how contextually appropriate communication can to lead to increased functional effectiveness, self-esteem, satisfaction, and well-being for older adults and their communication partners, as outlined in the Barker and colleagues (Reference Barker, Giles, Harwood, Nussbaum and Coupland2004) model. Coupland and Ylänne-McEwen (Reference Coupland, Ylänne-McEwen, Ammon, Dittmar, Mattheier and Trudgill2005) called for a sociolinguistics of aging that would emphasize the diversity in conversational experiences among older adults, especially with younger members of their families and service professionals. Such discourse analyses (as in Coupland & Coupland, Reference Coupland, Coupland, Hummert and Nussbaum2001) would reveal how language is central to the negotiation of age identities. Similarly, more research should be targeted toward the grandparent–grandchild relationship because it holds promise for effective and satisfying intergenerational communication and also because kinship care is becoming increasingly prevalent (Fuller-Thomson & Minkler, Reference Fuller-Thomson and Minkler2000).
As our communities become more multicultural and multilingual (de Bot & Makoni, Reference de Bot and Makoni2005), it will be important to examine how older adults negotiate their identities in the face of multiple layers of differences, especially in contexts that are likely to be disempowering. In addition, there is a dearth of research on aging in multilingual contexts. Future research should investigate the strengths of older adults who are bi- or multilingual, especially in light of recent evidence that bilingualism protects older adults from declining executive functioning because of the lifelong management of two languages (Bialystok, Craik, Klein, & Viswanathan, Reference Bialystok, Craik, Klein and Viswanathan2004). In addition, future research should also consider the challenges of aging within multilingual family and professional contexts.
Finally, the research community needs to reexamine the types of outcomes used to evaluate the effectiveness of interventions. We must not forget our own responsibility to combat ageism in terms of the research questions we pursue and the way in which we ask those questions. We too must be mindful of the heterogeneity and resilience of older adults as we examine the ways in which language and communication are used to negotiate age identities.
ACKNOWLEDGMENTS
We acknowledge financial support from a grant to E. B. Ryan from the Social Sciences and Humanities Research Council of Canada and grants to M. Y. Savundranayagam from the Hartford Foundation's Geriatric Social Work Faculty Scholars Program and the Center on Age & Community at the University of Wisconsin–Milwaukee.
