Identifying and overcoming barriers to learning: low literacy levels and vision impairment in elderly diabetics.
Have you ever asked your elderly diabetic how their blood sugar was running and they say, "I didn't take it today" or they make excuses about the subject. It may be that your elderly diabetic has low health literacy or vision impairment. Knowles' principles of adult learning have been used to identify learning styles. Knowles realized that adults learn differently than children. He described adult learners as people who perform best when asked to use their experience levels to apply new knowledge to solve real-life problems. Adult learners' motivation is an internal process that occurs from curiosity (as cited in Billings & Halstead, 1998/2005). This motivation to learn can be harnessed to encourage any new learning skills to overcome the barriers of low health literacy and decreased vision while managing their diabetes. Adults will make a commitment to learning when the learning goals are useful and relevant. Past experiences and maturity provide insights to adult learners. Social interaction and a unique learning environment are important to the adult learner (Billings & Halstead, 1998/2005). Elderly diabetics can learn new skills and overcome barriers with the proper educational tools.
My diabetic seniors wish to learn how to manage their disease and are excited when I bring them a new glucometer that is simple and doesn't have to be coded before use (i.e. Contour or Breeze glucometers by Bayer). Decreased vision and low health literacy can negatively affect the elderly learner's comprehension level. Basic glucometer instructions and understanding multiple medications can sometimes confuse seniors with these barriers.
Resolving Barriers to Learning
Elderly patients with diabetes have an increased risk of developing cognitive problems. Older diabetic patients with cognitive dysfunction may not be able to follow complicated regimes and are at an increased risk of treatment complications. There is a need for goal adjustment and simplification of their diabetic treatment plans (Munshi et al., 2006). Several barriers affect elderly patients with diabetes. Several of these barriers include the following: visual acuity, decreased hearing, alterations in cognitive processes, low health literacy and lack of caregiver support. Decreased vision and low health literacy can negatively affect the elderly learner's comprehension level.
Ruholl states that geriatric patients can be challenging to teach and that elderly patients differ from other patients. Some of their physical and psychological issues are difficult to cope with and can affect their motivation and ability to learn. Arming seniors with knowledge about such changes and adapting appropriate teaching skills can help older adults become successful learners (Ruholl, 2003).
Low Visual Acuity
The first barrier that can interfere with a diabetic teaching/learning experience is decreased vision. A patient's visual acuity can greatly diminish with age. The lens of the eye becomes less elastic, the cornea more translucent and the pupil smaller. Older clients are sensitive to poor lighting and deal poorly with glare. Elders see better by the light of bright incandescent bulbs. Elders' depth perception is not always accurate and their peripheral vision may be narrow. Cataracts can cause the lens to become opaque and yellow which affects color perception (Ruholl, 2003).
Retinal changes can cause elderly patients to experience difficulties with cool colors. For example, they may have decreased green, blue and violet color vision. As a result, these elderly patients may not be able to distinguish the different colors of pills or capsules. A blue pill may appear faded or gray. This visual impairment can be compensated by checking to see if the elderly patient needs new glasses. Ask the client to read a newspaper held about 14 inches from his or her eyes. During learning sessions, sit at the kitchen table with plenty of overhead lighting in the room. Ask the elder patient to put on their glasses when performing teaching about medication bottles. Provide bright lights while teaching in the home. Position the light so it doesn't hit the reading material directly, causing a glare problem. For example, you can use a floor lamp that is located next to a recliner. Use a bright overhead light instead of a desk lamp to review a brochure on diabetes or how to properly use a glucometer. A desk lamp can give off light that hits the brochure at an angle and creates glare (Ruholl, 2003).
Provide your elderly patients with printed materials that possess bright contrasting colors including orange and red, with bold, crisp letters for easier reading. The nurse can provide a magnifying glass if necessary. A magnifying glass is a great accessory to add to your nursing bag for elderly home patients. Provide written literature with an easy-to-read font and type size no smaller than 12 points. Refer to pills by name and shape instead of by color. Remember, generic drugs may look different than trade name drugs. Teach the patient the drug's proper name and recommend large print labels on prescriptions by the pharmacy (Ruholl, 2003). Recently, I helped an elderly patient set up her pill box. I suggested placing old prescriptions into a zip lock bag to store separately from her current medications. Elderly patients save older prescriptions due to limited finances.
Cognitive processes often diminish in older adults. They process information slower and learning takes more effort. Elderly individuals are less tolerant of newness and can become overwhelmed with a wealth of information. Providing written instructions, along with the theory of Geragogy (the art and science of helping older adults learn) addresses the cognitive, physical and sensory deficits of aging. The amount of new information an individual can handle was found to be seven items, plus or minus two. New information must be practiced frequently or it will be forgotten in as little as 18 seconds. This limited short term memory in the elderly client demonstrates the importance of written instructions. Teaching sheets increase adherence by supplying reminders of any verbal instructions that would have been forgotten. Learning needs of patients with vision loss may include low vision reference materials and injury prevention strategies (Hayes, 2005). I make a simple list of steps, in large font, to do every day and post it on the senior's refrigerator as a reminder. Use active instead of passive voice when presenting verbal instructions to a patient.
Low Literacy Level
Inadequate health literacy adversely affects the health of the elderly. There have been qualitative studies that revealed patients' struggles to complete forms, understand medication regimes and interact with health care providers. In the largest study of health literacy, one third of English-speaking patients at two public hospitals were unable to read basic health information. Patients with low literacy have poorer health outcomes. The National Academy for Aging Society estimates excess health care costs by patients with low literacy may reach 73 billion per year (Parker & Schwartzberg, 2001).
Many adults who are 65 and older have significant difficulties reading and comprehending pertinent medical information. The relationship between health literacy and age showed a strong trend, with the prevalence of inadequate health literacy increasing from 15.6% of people ages 65 to 69 to 58% of those aged 85 or older. Consequences due to poor health literacy include poor health status, reduced compliance, knowledge deficits, increased hospitalizations and health care expenses. Poor readers usually do not ask questions to obtain necessary information. Individuals who are illiterate often fail to follow written medical instructions about their care (Hayes, 2005).
Patients with limited reading skills take words literally, rather than in context, and tire of long passages. These clients often skip over unfamiliar words. In general, the literacy level is approximately five grade levels lower than the last completed school year. Written teaching information for older adults should be presented at the 5th to 6th grade reading level (Hayes, 2005).
Written instructions, for the elderly, need to be written in a geragogy, schema-based format. Adults tend to organize information into a schema of two categories in a specified order: 1) General information about the medication; 2) Explanation of how to take the medication; and 3) Outcomes (side effects and anticipated benefits). When the schema information is presented in a list format rather than in paragraphs, elderly individuals have improved comprehension and recall of the medical instructions. This format written in a 5th grade reading level or below, printed in 14 to 16-point font such as Arial, should be pertinent, specific and personalized for the client. Teaching points should be bulleted or in list format. Interventions and demonstrations should be presented in a quiet, well-lit room. Slow, concise verbal delivery followed by written instructions is appropriate for the elderly client (Hayes, 2005).
In conclusion, utilizing the above techniques increases positive outcomes among elderly diabetic clients. Misunderstanding can lead to patients taking the wrong dose of medication or not realizing potential side effects. As a Patient Educator, my reward is making a difference in the lives of senior diabetics and assisting them in living a better quality of life. Hopefully, these suggestions will improve the lives of your patients as well.
by Glenda A. Harsen, MSN, RN
About the Author
Glenda A. Harsen, MSN, RN, said nursing is her passion. Harsen's experience consists of medical-surgical nursing, home health, long term care, administration, correctional nursing and patient education. She is employed at Enhanced Care Initiatives in Nashville, Tenn., as a Patient Educator teaching geriatric patients how to manage their chronic diseases to obtain a better quality of life. She is currently in faculty training to teach an online class for the University of Phoenix. In March 2009, Harsen completed a Master's Degree in Nursing Education from Walden University.
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