Elderspeak: the language of ageism in healthcare

Scene: A long-term care facility. A nurse is helping an older resident with dementia as she takes a shower.

Nurse: “There we go, sweetie, just lift your arm up a little bit for me. We’ll get you all cleaned up in no time, won’t we?”

Resident (swatting away the nurse’s hand):“Get outta here—I don’t want your help!”

This fictional scenario exemplifies the nature of elderspeak, or babytalk to older adults, and the typical context in which it occurs—used by younger caregivers providing care to older adults. The example also illustrates a potential side-effect of elderspeak: resistance to care by persons living with dementia.

The past 40 years have seen a growing awareness of elderspeak, its characteristics, antecedents, and consequences. But research efforts have been limited by a lack of coherence. The concept, historically referred to as baby-talk, secondary baby-talk, infantilization, patronization, and over-accommodation, has been studied using a range of experimental paradigms by ethnographers, psycholinguists, and healthcare professionals. Upon reviewing four decades of elderspeak research, we propose a new and comprehensive definition of elderspeak that aims to capture its core attributes, its primary antecedents, and its potential consequences:

Elderspeak is a form of communication over-accommodation used with older adults that:

• is evidenced by inappropriately juvenile lexical choices and/or exaggerated prosody;
• arises from implicit ageist stereotypes;
• carries goals of expressing care, exerting control, and/or facilitating comprehension; and
• may lead to negative self-perceptions in older adults and challenging behaviors in persons with dementia.

To elaborate, elderspeak is comprised of modifications in both linguistic and paralinguistic domains. Examples of linguistic attributes, including childish terms, diminutives, simplified sentences, and tag questions, have been reported globally. For example, in German nursing homes, staff urged residents to “wash the little bottom” while assisting with bathing. Staff in Swedish nursing homes administered medication with the phrase “here comes little pills on the spoon here.” In Singapore care homes, staff equated residents to children, saying “just like little kids, we should only play after finishing our homework.” The hallmark paralinguistic feature of elderspeak is a change in prosody, including excessive pitch modulation and a sing-song intonation that matches the tone and pattern of communication in nursery schools.

Elderspeak is often produced with the goal of appearing caring while also exerting control. Care interactions recorded in a South African nursing home documented a nurse instructing a resident to “move up, be a darling.” Similarly, a carer in an adult day center in the US was observed telling a resident, “Sweetie, you need to sit down until I’m finished.” In healthcare settings, control by staff may be required in order to achieve health goals, especially for frail older adults. When staff want to soften their controlling directives, they may adopt excessively “caring” language. Issues arise when the language is perceived negatively. Cognitively intact older adults generally perceive elderspeak to be patronizing and infantilizing, and believe that those who use elderspeak are less respectful, nurturing, and competent. Even more concerning, elderspeak has been demonstrated to double the probability of resistiveness to care by nursing home residents with dementia. When elderspeak is reduced by nursing home staff, resistiveness declines, which also reduces the need for chemical restraints.

Why, then, do care providers use elderspeak if it is perceived as patronizing and elicits potentially harmful behaviors in persons with dementia? The answer lies in the ubiquitous ageism embedded in societal views of older adults. Although often implicit, the message typically portrayed in the media is that elders are as incompetent and dependent as children. The emergence of the baby-boomers as senior citizens has begun to change this picture. But positive portrayals of aging tend to set a lofty standard of “successful aging” enacted by improbably young and attractive older adults, with the implication that anything else constitutes unsuccessful aging.

Although the examples of elderspeak cited here occurred in healthcare contexts, it is important to note that elderspeak extends beyond healthcare settings. Children as young as seven years old have been found to adopt attributes of elderspeak when speaking to older adults. By adulthood, age-related stereotypes are so thoroughly entrenched that even the most considerate caregivers may be susceptible to implicit ageism. Thus, behaviors stemming from ageism are common in healthcare, and elderspeak is an example of how communication that is meant to be caring can actually come across as prejudiced to older adults. To combat elderspeak, a systemic shift in our attitudes toward older adults is needed. In the shorter term, intervention through policy change and education can help reduce the implicit bias of ageism that leads to elderspeak.