Health Literacy

Literacy and the Older Adult

Article from the Boston Globe’s On Call Magazine, October 1999

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

When there is a lot to learn, there is also a lot healthcare professionals can do to help seniors learn it.

Mrs. Jones is a 78-year-old woman who has worked most of her life and who values her independence. She has been diagnosed with congestive heart failure, coronary artery disease with angina, hypertension, diabetes, and arthritis. Over the last several years, she has been in and out of the hospital multiple times. She now lives with her daughter and her daughter’s children, and due to her many chronic illnesses, she experiences good days, bad days, and very bad days.

On good days Mrs. Jones is able to help around the house, baby-sit the grandchildren, and take brief walks. On bad days, she needs to rest and requires assistance with some of her personal-care activities. On very bad days, she needs the attention of her healthcare team.

Mrs. Jones is on a modified diet and must restrict her intake of both sweet and salted foods. She takes six different medications, each with its own dosing schedule. She needs to monitor and record how she feels each day and notify her care providers when there are significant changes in her health. She also needs to make and keep numerous outpatient appointments and prepare for an ongoing battery of medical tests.

With so much information to learn and keep straight, Mrs. Jones risks losing her independence if she cannot understand and follow the directions she has been given. But even though she has a high-school education, Mrs. Jones has difficulty learning new information now that her hearing is diminishing, her vision is getting worse, and she is feeling anxious about her failing health.

Older Adults Face Multiple Obstacles to Learning

Joanne Schwartzberg, MD, director of Aging and Community Health at the American Medical Association, is concerned about people like Mrs. Jones. “People are often faced with multiple illnesses and problems, and treating and handling these conditions is extremely complicated. To maintain independence and functioning, older adults have to become very good students,” Schwartzberg says. But being a student when you are over sixty years old can be very difficult. “They’re scared,” Schwartzberg says, “on a lot of medications, and often education is an afterthought.”

Learning new healthcare information requires strong reading skills as well as strong math and problem-solving skills. Studies have shown, however, that older adults often have difficulty in these three areas. Schwartzberg points out that many factors can contribute to learning difficulties in older adults. For instance, early in this century many people only went to school for a few years. Consequently, they may never have acquired strong reading skills. In addition, reading skills decline if they are not used, and many of these people may now be getting the bulk of their information by watching TV or listening to the radio rather than by reading.

Other factors that may affect an older person’s ability to read and learn new information are the sensory and cognitive changes that often accompany aging. Also, the side effects of some medications can impair both cognitive processing and problem-solving skills. “We’re in an area where we know what is happening, but we can only speculate as to why,” Schwartzberg says. “It’s an area that needs further research.”

Working with Seniors to Help Them Understand

Here are ways you as a healthcare professional can make it easier for older patients to read, understand, and follow medical instructions.

  • Create a “shame-free” environment for learning. Use a gentle and supportive approach, and be non-judgmental about people’s reading difficulties. Let the person know that many people have difficulty learning new information.
  • Ask about a person’s learning preferences, and then adapt your teaching style to meet that person’s needs. For example, you can read materials aloud with a patient and then highlight key points to personalize this information.
  • Encourage the patient to invite family or friends into the teaching sessions. Not only does this establish a warm and supportive environment, but it also educates those who later can reinforce and clarify information.
  • Choose teaching materials that use large print, upper- and lower-case letters, and illustrations that depict seniors. Also, look for materials that are verifiably written at a sixth-grade or lower reading level. (Remember that “reading level” is not an indication of the content of the material but rather a measurement suggesting the ease with which the content can be accessed.)
  • Verify understanding by finding out what a person understands and what he or she doesn’t. Find our what patients think is happening, and what they still need to learn. You can do this by asking concrete questions and offering opportunities for patients to let you know how they will implement their care plan. Rather than asking, “Do you understand?” ask instead, “Tell me what will you do and show me how will you do it when you are on your own tomorrow.”

In 1998, the House of Delegates of the American Medical Association adopted a policy that recognizes limited literacy as a barrier to the access and delivery of healthcare. This policy acknowledges that approximately one quarter of the adult population has difficulty understanding both oral and written healthcare information, and that this can be a barrier to effective diagnosis and treatment.

How to Find Out More

  • American Medical Association (1999). “Health Literacy: Report on the Council on Scientific Affairs.” Journal of the American Medical Association, 281, 552-557.
  • Brown, H., Pristula, R., Jacobs, B., Campbell, A.(1996). Literacy of Older Adults in America: Results from the National Adult Literacy Survey. National Center for Education Statistics. US Department of Education.
  • Jackson, R., Davis, T., Murphy, P., Bairnsfather, L., George, R. (1994). “Reading Deficiencies in Older Patients.” The American Journal of the Medical Sciences, 308(2).
  • Murphy, P., Davis, T., Jackson, R., Decker, B., Long, S. (1993). “Effects of Literacy on Health Care of the Aged: Implications for Health Professionals.” Educational Gerontology, 19, 311-316.
  • Pearson, M., Wessman, J. (1996). “Gerogogy.” Home Healthcare Nurse, 14(8).

Article reprinted with permission from On Call magazine and published by a division of Boston Globe Media.