How we talk to older adults matters more than we think. In this episode of Plugged into Public Health, host Lauren Lavin talks with Dr. Claire Shaw, assistant professor at the University of Iowa College of Nursing, about her research on dementia care and the communication patterns that shape it. Dr. Shaw explains what elderspeak is, why it often appears in caregiving settings, and how even well-meaning speech can unintentionally trigger stress, confusion, or care refusal in people living with dementia.

The views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors, and do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Lauren Lavin:

Hello everybody, and welcome back to Plugged Into Public Health. I’m Lauren Lavin, and if it’s your first time with us, welcome. We’re a student-run podcast that explores major issues in public health and how they connect to the world around us. Today, we’re joined by Dr. Claire Shaw, assistant professor at the University of Iowa College of Nursing. Dr. Shaw’s work focuses on communication and dementia care, and specifically how the ways we speak to older adults can influence behavior, quality of care, and dignity. In this episode, Dr. Shaw helps us understand what Elder Speak is, why it often shows up in caregiving environments, and how even well-intentioned communication can unintentionally cause harm.

She also shares practical strategies for healthcare professionals and family members to foster more respectful and effective communication with older adults and those living with dementia. Now, let’s get plugged into public health. Plugged into Public Health is produced and edited by the students of the University of Iowa College of Public Health, and the views and opinions expressed in this podcast are solely those of the student hosts, guests, and contributors. They do not necessarily reflect the views or opinions of the University of Iowa or the College of Public Health.

Well, Dr. Shaw, thank you for being here today. I really appreciate you coming on the podcast. To start off, could you introduce yourself, what your role is here at the University of Iowa and how you got to where you are today?

Claire Shaw:

Yeah. So my name’s Claire Shaw. I’m an assistant professor here at the University of Iowa College of Nursing. And I have been in Iowa my whole life. I grew up in Iowa City, and then I needed a state school. I knew I wanted to be a nurse, and the University of Iowa had the only state nursing program at the time, so I came here and fell in love with Iowa nursing. When I graduated with my BSN, I just went across the street and started working in the emergency department at UI Healthcare. And I knew I wanted to go back and get my PhD, so I came back and started with dementia care research.

Lauren Lavin:

So what is your PhD in specifically?

Claire Shaw:

So it’s in nursing research, and so it’s a very research-based PhD. There’s no extra clinical experience on top of that. So very different than a nurse practitioner, which is also a doctoral degree in nursing.

Lauren Lavin:

Did you like your time in the emergency room or did that totally solidify that you did not want to keep doing that?

Claire Shaw:

It did not totally solidify that I did not want to keep doing that, but I’ve always been very into scholarship. I really like to read and write. So I did get the research bug when I was an undergrad here. And so I knew my time in the emergency room would be limited in that I really wanted to go back and do dementia care research.

Lauren Lavin:

And how did you get into dementia care and communication research specifically?

Claire Shaw:

So I was always interested in dementia care. When I was in seventh grade, my grandmother with dementia moved from Michigan to live with us in Iowa City, and she had probably moderate stage dementia at the time, and it was very challenging transition for her and my family to figure out how to be dementia caregivers for someone with Alzheimer’s disease. And so I really knew I wanted to do something in healthcare and dementia care related. How I got into communication research was just totally random. My mentor in my PhD program did that and I was a very good fit for me.

Lauren Lavin:

That’s just sometimes how it goes. But with dementia, can you explain to our listeners what, if they’re not familiar with dementia or what the symptoms and what the progression of that looks like?

Claire Shaw:

Yeah. So my research, I really try to focus on folks who are in the moderate to later stages of dementia. So it is characterized by neurocognitive decline. A lot of folks, when they hear Alzheimer’s and related dementias, they think of memory, which it is, but there’s also a lot of declines in executive functioning, which would be things like making dinner, doing the laundry, lots of declines in communication. And then what my research really focuses on is behavior. So as those neurocognitive declines happen in the brain, folks’ behavior can change and that can be really challenging for them as the person living with dementia and also their caregivers.

Lauren Lavin:

What kind of behavior changes do you see?

Claire Shaw:

So it’s very individual for everyone. There’s a list of behaviors that we consider behavioral and psychological symptoms of dementia, also sometimes called neuropsychiatric symptoms, and they vary a lot. So one would be apathy or depression, which would be not interested in doing the things you love to do. So let’s say somebody always loved watching their soap opera every day at 2:00 PM, all of a sudden they’re not interested in their soap opera anymore, to very challenging behaviors like aggression, which could be verbal, physical, hitting. One that’s very common is wandering, where a person really likes to wander and it can be kind of aimless or purposeless, sleeping issues, and then other very challenging ones like disinhibition, which would be someone disrobing or doing something that is viewed as inappropriate that they normally wouldn’t have done. And these behaviors all really vary from person to person and also stage of dementia, they vary quite a bit.

Lauren Lavin:

And how aware are people with dementia that they’re going through this process? Like when they notice these behaviors, like are they able to notice the behavior changes and all of that or does the cognitive decline prevent them from realizing what’s happening?

Claire Shaw:

I think it really depends on their stage of dementia early on. We know now that cognitive decline and the changes in your brain can start happening very early before we ever see symptoms and behavior themselves. Once those behavior changes start and somebody’s in mild dementia, they can absolutely recognize and experience them as later stages. People can also recognize them in periods of what we call lucidity, that they recognize them, but some people aren’t aware at all and the people that are most impacted are their family caregivers, their friends, or their formal caregivers like nursing staff.

Lauren Lavin:

Are there physical changes that happen in the brain that result in dementia? So like you said you could see it years before. What would you be seeing?

Claire Shaw:

Yeah, so there’s lots of different ways to diagnose dementia. Some of it is just a conversation you have with your provider and then tests you take to show that you have cognitive decline. There’s more traditional methods like having an MRI scan and seeing actual parts of your brain atrophy. And there’s a lot of new research into biomarkers of dementia and different ways to diagnose it early on.

Lauren Lavin:

Because is it partly genetic at least, is that what’s believed?

Claire Shaw:

They think like many disorders, particularly related to aging, there are so many factors that go into it. So genetics is certainly a component. Environment is a huge component and many other things.

Lauren Lavin:

Multifactorial, like so many things like you said. So now we’re going to turn to the communication part of your research, specifically around elder speak. So can you define what elder speak is?

Claire Shaw:

Yeah. So part of my research, like I said, I really study behaviors in dementia and part of my research has really looked at what communication by a caregiver contributes to behavior. And so, one aspect of that communication I study is called elder speak. And in the simplest terms, elder speak is communication to an older adult that sounds like baby talk.

Lauren Lavin:

Okay. And is it something that like caregivers like family do? Is it nursing staff? Who primarily does this type of elder speak?

Claire Shaw:

Great question. So when I use the term elder speak, I’m always talking about someone who is not a loved one. So because baby talk can sound different by different people. And so I pretty much always talk about nursing staff because I’m a nurse. So I really focus on formal caregivers, which are nurses, nursing assistants, but it would apply to any type of formal caregiver, which could be a physician, it could be a respiratory therapist, a physical therapist, anybody providing care. And then it could also be in the community as well, a community member or when you go to the doctor’s office, it could be the person checking you in or the bus driver you take to the doctor’s office, the bus driver. But typically I’m not talking about family or close friends, loved ones.

Lauren Lavin:

And why would people use elder speak to talk to people with dementia?

Claire Shaw:

Because they want to come across as caring. So that’s the really tricky thing about educating about communication. If you think about who you baby talk in life, I’m a mother, I am a communication researcher, but I baby talk my children all the time. I love my children. I want them to feel loved and cared for. A lot of times I also am telling them what to do. And so I minimize the control aspect by softening it with baby talk and that’s appropriate with my loved ones, but may not be appropriate in a healthcare environment because I do not have that relationship with a patient that I would with my own child.

Lauren Lavin:

Right. Yeah. I definitely use it with my pet cat.

Claire Shaw:

Yes, exactly. And I’m sure your cat loves it.

Lauren Lavin:

So when people use elder speak, would you normally say that you characterize it as negative if it’s outside of that family relationship? Like it’s negatively impacting the patient?

Claire Shaw:

It completely depends on the response. And so that’s where this gets tricky because we want to talk to people how they want to be spoken to. And when you’re thinking about someone with dementia who has those neurocognitive changes, who has communication declines and you’re already having trouble communicating with them, it is very challenging to figure out how to best speak to them, particularly in a healthcare environment. And so the problem is that we assume this is how they want to be spoken to. So my favorite study on elders speak that’s ever been done is the first study on elder speak that’s ever been done, which was done in 1981.

Lauren Lavin:

Oh wow, that was a while ago.

Claire Shaw:

And so not healthcare folks, but these group of psychology faculty thought they heard an interesting type of talk in a nursing home. So they went into the nursing home and they recorded a bunch of nurses and aides talking to residents. Then they went to the daycare on campus and recorded a bunch of preschool teachers talking in the two-year-old room.

Lauren Lavin:

Oh, my goodness.

Claire Shaw:

They went back, they took these recordings and they had their students listen to them and their students could not tell a difference of when they were talking to… Nurses talking to residents to teachers talking to two year olds. And then they went on to do other research to show that as soon as the nurses left the room, they started talking differently to each other. So it’s not like the nurse just always talked in this way, that their communication changed, particularly when they were talking to someone especially frail like someone with dementia.

Lauren Lavin:

So I mean, that was the first study, which that’s incredible. How do you study this today?

Claire Shaw:

Yeah, so there’s been a big trajectory of research on elders speak throughout the years, starting with these early studies, just identifying that it was a phenomenon, that this was a thing that happened, that people changed the way they talk when they’re providing care to frail older adults compared to non-frail adults. And then they looked at specific attributes, what that constitutes elders speak, and then they looked at, is it helpful? Maybe it is helpful. And so how I landed in this area of research is my mentor, Dr. Christine Williams, she decided to, in nursing homes, try to link elder speak to an outcome. And so what she discovered was that when nurses use elder speak, patients are more likely to have reactive aggression or rejection of care.

Lauren Lavin:

That is really interesting. So my grandmother actually has dementia, which is partly why I was interested in this episode in particular. So a lot of what you’re saying, I’m like relating to my own experience with my grandmother and just thinking about like how I talk to her and how other people do. So all of that lens as I’m thinking about this. So what key findings did you have with elder speak in relation to patient behavior in your own work?

Claire Shaw:

So in my own work, so I work still with Dr. Williams and we do research in nursing homes still really linking communication between behavior. I’ve also started to expand this work into the hospital setting where we do see a correlation between care encounters that have more elders speak to care encounters that have more rejection of care.

Lauren Lavin:

And when you’re doing this like in a healthcare setting, are you recording the interactions? And if so, do you worry about how people change their behavior when you’re watching them? The Hawthorne effect, I believe that’s called.

Claire Shaw:

That is called the Hawthorne Park. Yeah. So in nursing homes, how Dr. Williams did it is she did video record all of this behavior. And in nursing homes, you can make these relationships with residents and families because they live there. It’s their home. And so you get to know staff really well, you become a fly on the wall and they get used to being the video recorder in the room. And then in the hospital setting, we do not have that luxury to get to know patients as well because they’re in and out. The goal is to get them out of the hospital as fast as we can. And so in that setting, we do observations where we watch their behavior and then we do audio recording as well and link the observations to the audio after the fact.

Lauren Lavin:

And how are you able to link the elders speak to outcomes like aggression or refusal of care?

Claire Shaw:

Yeah. And so it’s like a lot of statistics. So in the nursing home with the videos, we can do a more robust analysis with actual time sequential analysis because we have the video to show, “Oh, if this is said, this is the behavior that follows,” and we’re able to show that reverse relationship is not true. In the hospital setting, it’s a correlation. So you’re saying in these observations with more elders speak, there’s more rejection of care while controlling for a lot of other factors that we know contribute to rejection of care. So things like delirium, things like pain level, things like gender, those kinds of things.

Lauren Lavin:

And do you know what type of care they’re usually refusing?

Claire Shaw:

So we use the global term rejection of care for any sort of care encounter. A lot of times nurses cluster care. So if you think about when a nurse goes in to do their assessment, they’re also giving meds. They’re also doing a bed bath. They’re also doing hygiene. So a lot of the times it’s hard to distinguish the care they’re doing because it’s kind of a cluster of care, but that is a really important research question. And I actually have an undergraduate research assistant right now working on a project to look at just that by trying to parse out within the care encounter what’s really triggering the rejection of care beyond just communication.

Lauren Lavin:

And are patients able to understand when they’re being spoken to this way, do you notice that they can communicate like, “I don’t want to be talked to this way.” And if so, what does that look like?

Claire Shaw:

So I think it’s very hard when you have dementia to recognize that. And so a lot of times we think of when behaviors like aggression are triggered in dementia, they’re triggered because there’s a lower stress threshold. So let’s say somebody was talking to me a certain way and I didn’t like it, I might be able to cope with that and internalize it because I do not have neurocognitive decline, but someone with a cognitive decline, they may not be able to cope with that. They have what we call a lower stress threshold and the behavior is exhibited from it. So one thing we try to educate nurses about is if this behavior is occurring, one strategy you could try is changing the way you talk. Just test it out. If you’re calling someone baby or honey, instead of calling someone Mrs. Smith, try Mrs. Smith and see if that helps.

Lauren Lavin:

Oh, that makes a lot of sense. So do the caregivers know that they’re speaking this way or is it kind of news to them when you go to educate and they didn’t really realize that they were using this type of elder speak?

Claire Shaw:

I would say typically it’s a surprise. It’s not the most well known concept out there. We’re obviously trying to make it more well known with things like this, but I would say typically people are surprised. And then when they hear about it, they definitely resonate with it. What I never want when I’m educating on this is for someone to feel bad that they’ve been doing this because this is just a culture. It’s the way we talk. It’s the way we’ve been trained to talk. And for some people it might work. For some people it might not work and it’s just about recognizing you were doing this because you care. Maybe let’s try caring in this way instead.

Lauren Lavin:

Right. So what practical strategies do you give to both healthcare caregivers as well as family caregivers on ways to communicate effectively with loved ones with dementia?

Claire Shaw:

So for healthcare caregivers, it can always be a little bit frustrating because what I really recommend is that they talk normal. And so in the example I give, so I go back to my time as an ER nurse and I say, “Okay, in room 32, I have a 40-year-old farmer here with abdominal pain. In room 33, I have an 80-year old retired farmer with dementia here with abdominal pain.” Really, my communication does not need to be that different between these two rooms, especially if I make sure that 80 year old has their hearing aids in, things like that, I can really talk pretty similarly. So if I’m saying, “Hi, sir,” to the 40-year-old farmer, I should be greeting the 80-year-old farmer, not like, “Hi, mister,” I should say. “Hi, sir.”

Lauren Lavin:

Right. And beyond that, do you worry about the cognitive ability to understand? If you’re talking to them both the same way, is that of a concern or do you just still treat them the same way communication wise and deal with what they don’t understand later?

Claire Shaw:

No, I definitely think it could be a concern, but that could be with any patient. So just because of their cognitive decline in age doesn’t necessarily mean I need to go and automatically think there’s a deficit. With any patient, there could be a communication deficit. So I should be constantly assessing that, making sure they can hear me, making sure they know who I am, why I’m here, what I’m doing. That should be across the board.

Lauren Lavin:

Right. That reminds me of, I don’t know if you’ve heard the concept of universal design, but for people with mobility challenges, the idea that we put up handrails and have gradually sloped ramps are not just for people with disabilities, but it’s actually good for all of us because it makes it easier. So that’s kind of what that reminds me of is like, at baseline, knowing all of those things when you’re communicating with someone is just a good practice.

Claire Shaw:

Yes, you should always assess, are you understanding me? That should be universal across a patient with dementia or a patient without dementia.

Lauren Lavin:

Absolutely. So caregivers reduce elders speak. What are the positive outcomes that you see?

Claire Shaw:

Yeah. So with people with dementia specifically, we focus a lot on that behavior. So we do see that in our clinical trials, when elders speak is reduced, rejection of care is then reduced. If you’re talking about the older adult population in general, we know from our research that older adults do find the elders speak attributes as more patronizing and disrespectful. So with any older adult that they would just feel more cared for and more heard and seen in a conversation without elders speak.

Lauren Lavin:

Yeah, that makes sense. And then do you have any tips for family members that interact with someone with dementia regularly in order how to communicate effectively for them?

Claire Shaw:

Yeah. So for family members, I tend not to focus too much on elders speak when I’m actually giving tips for a family member how to communicate because all relationships are complicated and especially for a family member, if you’re talking about two spouses that have been married for 50 years, their pattern of communication is going to be based on 50 years of communication.

But when they hear elders speak in the healthcare setting, I think it is important to speak up and advocate for how they think their loved one would want to be talked to. And so simply saying, “You can just call her Jane.” Or if they’re using words like tummy or jammies, you can say like, “Oh, it’s actually her abdomen.” Just simple correcting, but I don’t ever want family members to think that it is coming from a place of disrespect. That doesn’t mean they should let it go, but typically we know people who are doing this are really just trying to show they care.

Lauren Lavin:

Yeah. I think that’s a good point to emphasize. So what are the implications for your work on training programs and policy in nursing homes and how do you get that across to all of these people?

Claire Shaw:

Yeah. So we have some well funded studies right now in nursing homes nationally trying to really educate nursing home nurses, janitorial aids, dietary staff on elder speak and its consequences. We have an online training program called Chatto and then I’m really working to also get this information into hospitals right now so we can improve hospitalizations for people with dementia.

Lauren Lavin:

So is it a standard part of training or is that something you’re working towards?

Claire Shaw:

It is not a standard part of training. So thankfully, dementia care is becoming a more standard part of training in general, educating on what dementia is, what communication deficits look like and other behavioral approaches. And so people are becoming more aware of this concept as a way to prevent behaviors, but currently it’s not a well known enough concept to have it being the standard of training anywhere.

Lauren Lavin:

Hopefully in the future though, right?

Claire Shaw:

Yeah. That’s the goal.

Lauren Lavin:

So as we wrap this up, what do you want caregivers, families, or students to remember from the work that you do in this area?

Claire Shaw:

So what I think it’s most important to remember is that it’s progress, not perfection. People tend to speak a certain way and we find that some people are 0% elder speak users, so they’ll hear this and they will say, “I never do that.” And honestly, that could be very true. We find that some people never talk like this. And then there’s me. I’m someone who just falls into it quite naturally when I’m providing care. And so it’s just to try to remind yourself that we just try a little different each time. Every patient’s going to respond differently. So if you’re having these challenging behaviors, try a different approach, try a different way to communicate and see if it helps.

Lauren Lavin:

Yeah. I like that you said it’s progress, not perfection, and it’s a constant practice. The awareness is the first step, and then you can take some smaller steps to get to a spot where you’re better off.

Claire Shaw:

Yep.

Lauren Lavin:

Well, thank you so much for chatting with me today. This was a really great conversation. I hope our listeners learn more about dementia and elders speak and hopefully can apply it to some of their own areas of research and just interaction with the world.

Claire Shaw:

Yes, absolutely.

Lauren Lavin:

Thank you.

Claire Shaw:

Yes, thank you.

Lauren Lavin:

That’s it for our episode this week. A big thank you to Dr. Claire Shaw for joining us and sharing her insight on dementia care and communication. Today we learned how small changes in language, like avoiding elders speak and speaking to older adults with the same respect we offer anyone else can make a big difference in how care is received. Dr. Shaw’s research reminds us that empathy, awareness, and progress, not perfection, are at the heart of quality care. This episode was hosted and written by Lauren Lavin and editing produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook.

Our podcast is available on Spotify, Apple Podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues, friends, or anyone interested in public health. Have a suggestion for our team? You can reach us at cph-gradambassador@uiowa.edu. This episode is brought to you by the University of Iowa College of Public Health. Until next week, stay healthy, stay curious, and take care.