Basic Concepts of Gerontology: Aging, Theories, Principles PDF

BASIC CONCEPTS OF GERONTOLOGY/GERIATRICS PMPG  A man’s life is normally divided into five main stages ➔ Old age is not without problems ➔ With increasing age, we become old, birth, development, decline, and death are the laws of life. ➔...

BASIC CONCEPTS OF GERONTOLOGY/GERIATRICS PMPG  A man’s life is normally divided into five main stages ➔ Old age is not without problems ➔ With increasing age, we become old, birth, development, decline, and death are the laws of life. ➔ Again is not merely the passage of time. ➔ It is important to recognize that people age differently. ➔ As a general rule, slight, gradual changes are common, and most of these are not problems for the person who experiences them. GERONTOLOGY VS GERIATRICS Gerontology is the study of the physical aspects of aging, as well as the mental, social and societal implications of aging. Geriatrics refers to medical care for older adult Geriatric Nursing is a specialty focused on the care of older adults. Roles of a Geriatric Nurse Direct Caregiver Teacher Leader Advocate Evidence Based Clinician What is aging? ➔ The time-related deterioration of the physiological functions necessary for survival and fertility. ➔ Is a normal process of time-related change begins with birth and continues throughout life. ➔ Is the process of growing old or developing the appearance and characteristics of old age. ➔ Expresses the continuous pressure and effect of time on our body, senses and skin. What is Progeria? Also known as Hutchinson-Gilford progeria syndrome (HGPS), is a rare genetic condition that causes a child’s body to age fast. Most kids with progeria do not live past age 13. The disease affects both sexes and all races equally. It affects about 1 in every 4 million births worldwide. Classifications of Aging Objectively - Aging is a universal process that begins at birth and is specified by the chronological age criterion. Subjectively Aging is marked by changes in - behavior and self-perception and reaction to biologic changes. Functionally - Aging refers to the capabilities of the individual to function in society. Five Types of Aging Chronological Aging - ➔ Chronological age refers to the actual amount of time a person has been alive. ➔ In other words, this refers to the number of days, months, or years a person has been alive Categories: CATEGORIES AGE IN YEARS Young old 65-74 Middle old 75-84 Old old 85-100 Elite old Over 100 Biological Aging ➔ Senescence or biological ageing is the gradual deterioration of function characteristics. ➔ This aging is also known as physiologic aging. ➔ Futhermore, biological aging refers to the physical changes that “slow us down” as human get into middle and older years. ➔ For example: arteries might clog up, or problems with lungs might make it more difficult for us to breathe. Psychological Aging ➔ Refers to the psychological changes, including those involving mental functioning and personality, that occur as human age ➔ Some people who are 65, can look and act much younger than some who are 50. ➔ Psychological ageing may be seen as a continuous struggle for identify, i.e. for a sense of coherence and meaning in thoughts, feelings and actions. ➔ Success depends on a lucky synchronization of changes through life in different parts of the personal self. Social Aging ➔ Social aging refers to changes in a person’s roles and relationships, both within their networks of relatives and friends and in formal organizations such as the workplace and houses of worship. ➔ Social aging differs from one individual to another. ➔ It is also profoundly influenced by the perception of aging that is part of society’s culture. Cognitive Aging ➔ Cognitive aging is the decline in cognitive processing that occurs as people get older ➔ Age-related impairment in reasoning, memory, and processing speed can arise during adulthood and progress into the elder years. ➔ The concept of cognitive aging, a term that described a process of gradual, longitudinal changes in cognitive functions that accompany the aging process. Senior Citizen or Elderly Refers to any Filipino citizen who is a resident of the Philippines, and who is sixty (60) years old or above. It may apply to senior citizens with “dual citizenship” status provided they prove their Filipino citizenship and have at least six (6) months of residency in the Philippines. Older Adult ➔ Most developed world countries have accepted the chronological age of 65 years as a definition of ‘elderly’ or older person. ➔ While this definition is somewhat arbitrary, it is many time associated with the age at which one can begin to receive pension benefits. ➔ At the moment, there is no United Nations standard numerical criterion, but the UN agreed cutoff is 60+ years to refer to the older population. Attitudes towards Aging ➔ Observation of family members, friends, neighbors, and your own experience with older adults. ➔ Media like newspapers, film industry, commercials in magazines and on TV. ➔ Ageism: negative attitude toward aging or older adults. ➔ Examine: ◆ To take a look at the myths and realities ◆ To separate fact from fiction ◆ To gain av value for the wisdom of lifetimes that older adults have to offer GERIATRIC OR GERONTOLOGICAL NURSING BACKGROUND ➔ It is a field of nursing that specializes in the care of the elderly ➔ Florence Nightingale and Doreen Norton provided early insights into the care of aged ➔ ANA established the Division of Geriatric Nursing Practice in 1966 with a goal to create standards for quality nursing care for the aged ➔ The standards and scope of gerontological nursing practice were developed in 1969 by ANA ➔ The term gerontological nursing replaced the term Geriatric Nursing in the 1970s ➔ Geriatric nursing is bound to be part of our professional future ➔ Older adults are the core business of health care representing the majority visits, hospital admission, and long-term care residents. THE AGING POPULATION WORLD POPULATION AGING The global population aged 60 years or over numbered 962 million in 2017, more than twice as large as in 1980 when there were 382 million older persons worldwide. The number of older persons is expected to double again by 2050, when it is projected to reach nearly 2.1 billion. In 2030, older persons are expected to outnumber children under age 10 (1.41 billion versus 1.35 billion); in 2050, projections indicated that there will be more older persons aged 60 or over than adolescents and youth at ages 10-24 (2.1 billion versus 2.0 billion). The number of persons aged 80 years or over is projected to increase more than threefold between 2017 and 2050, rising from 137 million to 452 million. Two-thirds (2⁄3) of the world’s older persons live in the developing regions, where their numbers are growing faster than in the developed regions. In 2050, it is expected that nearly 8 to 10 of the world’s older person will be living in developing regions. AGING IN THE PHILIPPINES In contrast, the 60 years and older population of the United States will increase by 5.4% from 2010 to 2030 (Help Age, 2015). The Philippines’ population increased by over 35% over the last two decades with an older adult population (60 years and older) expected to overtake those aged 014 years old by 2065 (Help Age Global Network, 2017). currently, the life expectancy of Filipinos is 57.4% years for males and 63.2 years for females. Females are projected to expect an increase of 4.0 years in life expectancy and males an increase of 4.7 years in life expectancy by 2030. IMPACT OF AGING MEMBERS IN THE FAMILY EMOTIONAL EFFECT Common emotions: “Guilt for not being able to do more for parents; anger for having to set aside your own needs or shift your priorities; and fear and anxiety; including anticipatory grief and fear of financial strain. Caring for children and aging parents at the same time can make you feel as if you do not have the emotional strength and resources for everyone. (+) “enrichment that comes with relationships between grandparents and grandchildren; increased opportunity to pass on stories and knowledge to younger generations; and the younger generations having a sense of being able to give back to parents and grandparents,” resulting in a “greater connection between family members.” FINANCIAL EFFECT ➔ Caring for aging parents often means extra costs related to home health care, medical expenses not covered by insurance and extra insurance premiums for services such as long-term care. ➔ You also may need to take off extra time from work. ➔ Some families explore options for financial support that can make family life more enjoyable, emphasizing that “there is no shame in utilizing what support is out there. STRUCTURAL EFFECT ➔ When you live with your aging parents or assume a high amount of daily care for them, you experience a change in your family roles, ➔ Thomas and Segur describe this as a “shift in family structure and hierarchy related to matriarch or patriarch no longer being in their role.” when this occurs, “someone new has to take their place. ➔ The shift can cause guilt and stress, as family members work to find a place in the new family dynamic, but it can also result in more open communication among family members ➔ The family structure shifts to being less hierarchical and more cooperative PHYSICAL EFFECT Prioritizing parents’ care can ease their pain and worry but might impact your health The time and effort of keeping up with parents’ care mean you may visit your doctors less, resulting in undiagnosed problems or conditions getting worse. Caregiving for a parent with dementia can cause chronic stress and illness Time pressure might result in caregivers and their children skipping exercise and eating more convenience foods, which contribute to poor fitness and weight gain POSITIVE EFFECT “Our thoughts frame our emotional state” When you care for aging parents, you might feel as if you are in a rut This, in turn, affects your family life, creating an environment of bitterness and resulting in more criticism and complaining. However, some families have the opposite experience by creating a positive “wiring” in their brains to produce more potentially positive outcomes These people reflect on what makes them feel good for caring for their aging parents PURPOSE OF NURSING PRINCIPLES AND THEORIES ➔ Defines our practice ➔ In gerontological nursing they must be comprehensive yet consider individual differences ➔ Tells how and why phenomena are related ➔ Leads to prediction ➔ Provides process and understanding ➔ Must be holistic and take into account all that impacts on a person throughout a lifetime of aging PRINCIPLES OF GERONTOLOGY 1. Consider individuality. Consult his preferences. 2. Be patient, kind and sympathetic. Communicate effectively, demonstrate respect. 3. Encourage independence and encourage him to make his choices and decisions. 4. Assist elderly to achieve emotional stability. 5. Stimulate mental acuity and sensory input and physical activity to uplift their self esteem, self concept and confidence. PRINCIPLES OF GERONTOLOGY 6. Make elderly stay in home interesting and lively 7. Provide diversion /occupational therapy. 8. Maintain privacy 9. Handle them gently. 10. Make them comfortable by providing comfortable bed, bed linen etc. keep bed dry, smooth and unwrinkled. PRINCIPLES OF GERONTOLOGY 11. Encourage them to maintain body hygiene, thus regulate body temperature. 12. Assist them to take care of visual, auditory and dental aid. 13. Protect from injuries, falls and accidents etc. 14. Ensure adequate nutrition. 15. Facilitate elimination. Encourage them to maintain external genitalia hygiene. PRINCIPLES OF GERONTOLOGY 16. Encourage them to do active range of motion exercises. Maintain body alignment and posture. Encourage mobility. 17. Help elderly to establish good sleep patterns. 18. Caution elderly about the use of drugs. 19. Have them physically examined annually and whenever needed. 20. Observe any psychophysical changes which alter their body image and behaviour. THEORIES OF AGING Biological theories Psychological theories Environmental theories Developmental theories BIOLOGICAL THEORY ❖ Stochastic Theories- based on random events that cause cellular damage that accumulates as the organism ages ❖ Non Stochastic Theories - based on genetically programmed events that cause cellular damage that accelerates aging of the organism Stochastic Theories Free Radical Theory - membranes, nucleic acids and proteins are damaged by free radicals which causes cellular injury and aging Orgel/Error theory- errors in DNA and RNA synthesis occur with aging Wear and Tear theory - Cells wear out and cannot function with aging Stochastic Theory Connective Tissue/ Cross linking theory - with aging, proteins impede metabolic processes and cause trouble with nutrients getting to cells and removing cellular waste products. Non - Stochastic Theories Programmed theory - Cells divide until they are no longer able to, and this triggers apoptosis or cell death Gene/Biological Clock Theory - Cells have a genetically programmed aging code Neuroendocrine Theory- problems with the hypothalamus- pituitary-endocrine gland feedback system cause disease, increaded insulin growth factor accelerates aging Immunological Theory- aging is due to faulty immunological function, which is linked to general well-being Psychosocial Theories ❖ Sociological Theories - Changing roles, relationships, status, and generalizational cohort impact the older adult’s ability to adapt. ❖ Psychological Theories - explain aging in terms of mental processes, emotions, attitudes, motivation, and personality development that is characterized by life stage transitions. Sociological Theories Activity Theory - remaining occupied and involved is necessary to a satisfying late life. The activity theory basically says: the more you do, the better you will age. The activity theory occurs when individuals engage in a full day of activities and maintain a level of productivity to age successfully. Disengagement - Gradual withdrawal from society and relationships serves to maintain social equilibrium and promote internal reflection Subculture- the elderly prefer to segregate from society in an aging subculture share loss of status and societal negativity regarding the aged. Health and mobility are key determinants of social status. Sociological Theories Continuity - Personality influences roles and life satisfaction and remains consistent throughout life. Past coping pattersn recur as older adults adjust to physical, financial and social decline and contemplate death. Identifying with one’s age group, finding a residence compatible with one’s limitations and learning new roles postretirement are major tasks. Sociological Theories Age Stratification - society is stratified by age groups that are the basis for acquiriing resources, roles, status and deference from others. Age cohorts are influenced by their historical context and share similar experiences, beliefs, attitudes, and expectations of life-course transitions. Sociological Theories Person-Environment-Fit - function is affected by ego strength, mobility, health, cognition, sensory perception and environment. Competency changes one’s ability to adapt to environmental demands Gerotranscendence - The elderly transform from a materialistic/rational perspective toward oneness with the universe. Psychological Theories Human Needs - Five basic needs motivate human behavior in a lifelong process toward need fulfillment (Maslow’s) Individualism - personality consists of an ego and personal and collective unconsciousness that views life from a personal or an external perspective. Older adults search for life meaning and adapt to functional and social losses. (Jung’s theory) ENVIRONMENTAL THEORY ❖ Radiation Theory Excessive exposure to the suns radiation puts the skin at risk during the somatic mutation process. ENVIRONMENTAL THEORY ❖ Stress theory According to Perlman(1954) “Human aging is a disease syndrome arising from a struggle between environmental stress and biological resistance and relative adaption to the effects of stressor agents. These stressors agents might include air, pollutant, chemical, psychological and sociological events.” DEVELOPMENTAL THEORY Erikson theorized that person’s life consists of eight stages. Each stage represents a crucial turning point in life stretching from birth to death, with its own developmental conflicts to be resolved. PHYSIOLOGIC CHANGES IN AGING IN VARIOUS  CIRCULATORY FUNCTIONS - CARDIO VASCULAR SYSTEM o Age-related changes in the heart muscle & blood vessels result in overall decreased cardiac function o Results to diminished circulatory functions with limited physical activities ▪ Factors Affecting Circulatory Function  limited exercise and physical activities  lifestyle  smoking  consumption of alcohol  disease of the circulatory system ▪ Assessment  Family history  Current problems (chest pain; discomfort) with exertion  Current diagnoses  History of medications (prescription, OTC, herbals)  Source of stress  Adherence to current medical regimen  Physical examination o Blood pressure o Chest sounds o Pulse rate  Stress test  Blood & serum tests  ECG’s & echocardiogram  RESPIRATORY FUNCTIONS Age-related changes to bones, muscles, lung tissue, and respiratory fluids contribute to respiratory difficulties ▪ Factors Affecting Respiratory Function  Disease  Injury  Restriction in mobility  Extended bed rest ▪ Assessment  Current medications (prescription, OTC, or herbals)  Smoking behavior  Exposure to environmental pollutants  Difficulties in breathing  Signs of decreased energy levels  Coughing and production of excessive sputum  Observe posture and breathlessness  Auscultate chest sounds  Blood & pulmonary function tests  Chest x-rays  Sputum analysis  GASTROINTESTINAL FUNCTION o Age-related changes in the gastrointestinal system are not dramatic and may not be noticed ▪ Factors Affecting Gastrointestinal Function  Decreased peristalsis (constipation)  Reduced gastric acid secretion  Lack of dietary fiber  Low levels of physical activity  Lack of fluids  Chronic constipation resulting to fecal impaction, incontinence and delirium ▪ Assessment  Ask about usual diet  Appetite and the changes  Occurrence of nausea, vomiting, indigestion, or other stomach discomforts  Bowel functions (constipation & diarrhea) o Exercise, diet, fluid intake o Medications (prescription, OTC, herbal)  Oral health o Observe condition of tongue, teeth, and gums o Check dentures GENITOURINARY FUNCTION Age-related changes in the genitourinary system along with age-related diseases can have a major impact on everyday life ▪ Factors Affecting Genitourinary Function  weak bladder muscle resulting to decreased bladder capacity  Infection  Childbirth & gynecologic surgery (incontinence)  Enlarged prostate  Chronic renal failure ▪ Assessment  History of previous or current difficulties related to frequency & voluntary flow of urine either day or night  Identify type of incontinence: stress, urge, functional or overflow  Fluid intake  Caffeine and alcohol intake (affects bladder tone)  Observe skin (dehydration)  Medication use (prescription, OTC, herbals)  Diagnostic tests o Urinalysis (blood, bacteria, or ketones) o Ultrasonography  SEXUAL FUNCTION Age does not change the drive for sexual activity or sexual relationship ▪ Factors Affecting Sexual Function  Lack of partner  Medication use (prescription, OTC, herbals)  Decrease in speed & duration of erection (males)  Decreased vaginal lubrication (females)  Chronic illnesses (osteoarthritis)  Diminished positive self-image  Lack of privacy ▪ Assessment  Ask about sexual activity  NEUROLOGICAL FUNCTION It affects all other body systems and usually involve decline in reaction time, kinetic & body balance and sleep disturbances ▪ Factors Affecting Neurological Function  Diseases (Alzheimer’s, Parkinson’s, Dementia)  Stroke ▪ Assessment  Medications  Diagnosis (history & family history of stroke  Observe & ask about previous & current impairment in: Speech Orientation Balance Expression Energy level Sensation Swallowing Memory Motor function  Occurrence of sleep disturbance, tremors, & seizures  MUSCULOSKELETAL FUNCTION Several age-related changes occur in the musculoskeletal system & lead to decreased muscle tone, strength, and endurance ▪ Factors Affecting Musculoskeletal Function  Stiffening of connective tissues and erosion of articular surfaces of joint  Decline in hormone production  Diet  Disorders (osteoarthritis & osteoporosis)  Accidents ▪ Assessment  History of musculoskeletal illnesses (OA, sore joints), injury, or surgery  Observe for posture, stance, & walking  Use of assistive devices  Observe for body language & facial expressions  Diagnostic test o Up & Go Test o Bone Density Test  SENSORY FUNCTION Age-related & disease-related changes in sensory function can have profound effects on their day to day functioning ▪ Factors Affecting Sensory Function  Problems in vision & hearing o Presbyopia – inefficient visual accommodation o Presbycusis – progressive hearing loss ▪ Assessment  Assess for reading capacity  Observe for difficulty and accuracy  Use of magnification aids  Ask about any hearing problems  Observe for appropriate responses  Assess hearing devices  Ask for any medical condition  Medications (for side effects)  Smoking  INTEGUMENTARY FUNCTION Age-related changes to the skin include loss of elasticity, slower regeneration of cells, diminished gland secretion, reduced blood supply, and loss of fat ▪ Factors Affecting Integumentary Function  Decreased mobility and extended bed rest  Skin dryness and itching ▪ Assessment  Inspection of the skin (color, hydration, circulation, & intactness)  Ask for any skin injury and treatment  Ask for any history of diseases or infection  Assess nutritional status & body weight  Assess for loss of sensation  ENDOCRINE AND METABOLIC FUNCTION Age-related changes in endocrine function include decreased hormone secretion and breakdown of metabolites ▪ Factors Affecting Endocrine And Metabolic Function  Disease or illness (Diabetes Mellitus) ▪Assessment Family history Changes in weight and appetite Fatigue Increased thirst and fluid intake Vision problems Slow wound healing Headaches Gastrointestinal problems Palpate for nodules at the neck (thyroid problems)  Assess for hyperthyroidism: o Observe for occurrence of nervousness o Heat intolerance o Weight loss o Tremors o Palpitations  Assess for hypothyroidism: o Skin changes o Fluid retention o Fatigue o Forgetfulness o Constipation o Cold sensitivity  HEMATOLOGIC & IMMUNE FUNCTION Age-related changes in the hematologic function involves decrease in blood cellular components ▪ Factors Affecting Hematologic & Immune Function  Anemia (decreased hemoglobin level) o Iron deficiency  Infections ▪ Assessment  Observe for skin color, quality of skin, and nail beds  Assess diet (iron-deficiency)  Diagnostic test: CBC  Ask about vaccinations (flu, pneumonia)  Ask about recent & current infection  Ask about sexual activity (STD’s)  COGNITIVE ASSESSMENT o Varies among older adults and are difficult to separate from other co-morbidities, other age- related changes, the side effects of medication, and changes in intellectual activity. o Cognition is usually understood in relation to: ▪ Qualities of attention ▪ Memory ▪ Language ▪ Visuospatial skills ▪ Executive capacity o Cognitive Assessment Tools ▪ Mini Mental State Exam (MMSE) ▪ Used to differentiate organic from functional disorders ▪ It measures:  Orientation  Registration  Attention & calculation  Short-term recall  Language  Visuospatial function ▪ Mini-Cog  Used to assist nurses in early detection of cognitive problems o COMMON COGNITIVE DISORDER ▪ Alzheimer’s Disease ▪ Most common form of dementia leading to a permanent decline in cognitive function  Assessment o Emphasize individualization ▪ Ask for previous preferences of care directly from the client or family members o Social ability  PSYCHOLOGICAL ASSESSMENT o presents a wide continuum from positive mental health to mental health problem o Two areas of Psychological Assessment ▪ Quality of life – positive mental health  encompasses all areas of everyday living  synonymous with successful aging  Quality of life among older adults is highly individualistic, subjective, and multidimensional. ▪ Depression – mental health problem o What Comprises Successful Aging? ▪ Physical health ▪ Independence ▪ Functional ability ▪ Longevity ▪ Engagement in social life ▪ Self-mastery ▪ Optimism ▪ Personal meaning of life ▪ Attainment of goals o DEPRESSION ▪ it is often associated with cognitive limitations  Clinical depression is the most common mental health problem among older adults & it often goes undetected  Consequences of clinical depression can be serious & induce suicidal ideations & suicide attempts  Most Common Causes of Depression o Widowhood o Loss of independence  Signs Of Depression o Sadness o Lack of enjoyment o Significant weight loss o Sleep disturbance o Restlessness o Fatigue o Feelings of worthlessness o Impaired ability to think clearly or concentrate o Suicide ideation or attempts ▪ Clinical depression may be chronic or have a shorter duration, and it is not the same as experiencing temporary feelings of unhappiness, confused thinking, and somatic complaints.  SOCIAL ASSESSMENT o social functioning affects health and disease outcomes & health status affects the ability to socialize and interact with others o as people age, they may find their social networks become smaller o Collect information on the presence of a social network o Interaction between the older adult and family, friends, neighbors, and community ▪ Nursing Assessment:  Identification of social network and social support  SPIRITUAL ASSESSMENT o integral part of comprehensive assessment & provides a basis for an individualized plan of care o religiosity and spirituality are not synonymous ▪ Religious belief may foster spirituality; spirituality may not be specific to a religious belief. o Guidelines for Spiritual Assessment ▪ 1. The concept of God or deity. ▪ 2. Personal source of strength and hope. ▪ 3. Significance of religious practices and rituals. ▪ 4. Perceived relationship between spiritual belief and health.  OBESITY o became a major health problem and associated with chronic diseases and disability o it causes adverse effects when paired with other organ’s diseases o Nursing Assessment: ▪ Assess for overweight and obesity (history of weight change) ▪ Diet Communication with Older Adult COMMUNICATION - links all of us to each other and to the environment and is a key factor in how we relate and co exist. People use communication to provide and receive information from others for a variety of reasons Why is communication important with the elderly? retains good physical and emotional wellbeing; maintains a sense of control and achievement in the modern world; communicate feelings, needs, opinions, and wishes for the future; and allows to talk about and cope with difficult situatons. Why are older adults afraid of communication? The older adults: don't want to bother others or be seen as someone who is a complainer; and don't have the mental capacity to talk to others or to fully express themselves immediately. It is only over time that you get the whole story. Tips to Improve Communication with the Older Adults Use proper way in addressing them. Make older patients comfortable. Take a few moments to establish rapport. Try not to rush. Avoid interrupting. Use active listening skills. Demonstrate empathy. Avoid medical jargons. Be careful about language. Write down take-away points. Communicating with the Older Adults Allow extra time for older patients. Avoid distractions. Minimize visual and auditory distractions. Sit face to face. Maintain eye contact. Listen without interrupting the patient. Speak slowly, clearly and in normal tone. Use short, simple words and sentences. Stick to one topic at a time. Simplify and write down your instructions. Use charts, models and pictures to illustrate your message. Frequently summarize the most important points. Give patients an opportunity to ask questions and express themselves. Schedule older patients earlier in the day. Greet them. Allow them to sit in a quiet and comfortable area. Make things easy for them to read by making signs, forms and brochures. Be ready to physically escort the patient. Check on them from time time. Keep the patient relaxed and focused by using touch. Say goodbye to end the visit on a positive note. Walk with the patient to the checkout desk, thank them for their visit and tell them goodbye. Communication Changes Typical with Aging Changes in physical health Depression Cognitive decline Physiologic changes in hearing, voice,and speech processes Compensating for Hearing Deficits Make sure your patient can hear you. Talk slowly and clearly in a normal tone. Avoid using a high-pitched voice. Face the person directly at eye level (lip-read or pick up visual clues). Keep your hands away from your face while talking. Keep a notepad handy so you can write what you are saying. Tell your patient when you are changing the subject. Background noises can mask what is being said. If your patient has difficulty with learners and numbers, give a context for them Compensating for Visual Deficits Provide adequate lighting, including sufficient light on your face and try to minimize glare. Let patients wear eyeglasses if needed. Provide handwritten instructions. If the patient has trouble reading, consider alternatives such as recording instructions, providing large pictures or diagrams, or using aids especially configured pillboxes. When using printed materials, make sure the type is large enough and the typeface is easy to read. Barriers to Effective Communication Physical barriers Perceptual barriers Emotional barriers Cultural barriers Language barriers Gender barriers Interpersonal barriers Withdrawal