Mr C, a 72-year-old patient with type 2 diabetes, is brought to the emergency department comatose with a blood sugar of 29 mg/dL.  When seen in his primary care provider’s office the previous day, his blood sugar was 456 mg/dL; he was prescribed fast-acting insulin with meals in addition to an increase in his insulin glargine.

Every day, low health literacy results in patients’ misunderstanding the instructions of their clinicians, sometimes with very serious consequences. Mr C did not understand his clinician’s verbal and written instructions and took too much fast-acting insulin at breakfast.

An estimated 90 million people in the United States have low basic literacy skills, with the average adult reading at an eighth-grade level.1 Almost 20% of American adults cannot read and almost 30% do not read well, for a combined level of approximately 50% who have some difficulty reading at even a fifth-grade level.  This group of Americans with limited reading skills comprises several demographic groups, including older adults, Latinos, African Americans, American Indians, and Alaskan natives.1

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Health Literacy

This low basic literacy is combined with widespread illiteracy associated with health information.  Health literacy is multifaceted and includes printed literature, oral communication, and numeracy. Printed literature requires reading and writing ability, while oral literacy requires the ability to listen and speak.  Many older adults have vision and/or hearing loss that represent additional obstacles to health literacy. Numeracy — the ability to understand and use numbers — is especially important with respect to medication dosages.

Even people with high basic literacy skills can have low health literacy, and medical jargon can seem like a foreign language to many people.  The most widely used definition for health literacy is “the ability to obtain, process, and understand basic health information and services needed to make appropriate healthcare decisions and follow instructions for treatment.”2

Poor health literacy among Americans has been an area of focus for several federal agencies for more than a decade.  The Institute of Medicine first described the problem in a 2004 report titled, “Health Literacy: A Prescription to End Confusion.”3 The Joint Commission addressed the issue in a 2007 white paper titled, “What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety.”4  In 2010, the United States Department of Health and Human Services suggested solutions in its “National Action Plan to Improve Health Literacy” and included a health literacy goal to improve communication in the Healthy People 2010 10-year national health objectives.5,6 The objective has also been included in the Healthy People 2020 agenda for improving health among Americans.7 Despite publication of ample literature on health literacy since Ratzen and Parker2 first defined the issue, health literacy remains a widespread problem among older adults.

Why Does It Matter?

The Agency for Healthcare Research and Quality (AHRQ) reported that low health literacy is associated with more emergency department visits and hospital readmissions, less preventive care, and poor medication administration skills.8  Older adults with poor health literacy were found to have overall poorer health status and higher mortality than those who possessed adequate health literacy skills.8  In addition to poor patient outcomes, low health literacy is a financial burden on our healthcare system with costs reaching to $92 billion annually in the United States.9  A Veterans Health Administration study indicated that low health literacy was a significant factor in higher healthcare costs.10  Hitting closer to home, many payers are penalizing healthcare practitioners who have poor patient outcomes.

Older Adult Learning Theory

Before we can address best practices to overcome low health literacy, we need to understand how older adults learn and factors that could impede older adult learning.  Geragogy involves the principles of older adult learning theory. Factors affecting learning can be physical functions such as vision, hearing, and mobility.11,12  Increasing age can be associated with a decrease in vision and hearing, as well as slower psychomotor abilities.  Adjustments in teaching will need to be made when educating these patients. Cognitive factors need to be considered.  Older adults may have decreased short-term memory and a tendency to be distracted.11 Repetition is a key element in teaching the older adult.

Elliot identified the following principles of older adult learning11:

  • “Approach the older adult in a way that communicates respect, acceptance, and support.  Create a learning environment in which the patient can feel comfortable when expressing what is and is not understood.”
  • “Schedule teaching session in mid-morning when energy levels are usually highest for the older adult. Conduct several brief sessions over different days rather than one long session, which may cause fatigue.”
  • “Provide more time for the older adult to process new information.”
  • “Link new knowledge to past experiences.  Reminiscing helps the older adult reconnect with lived experiences.”
  • “Keep the content practical and relevant to the older adult’s daily activities, social structure, and physical function.  Older adults tend to be more motivated when the information is perceived as a way to address a current problem.”
  • “Minimize distractions.”
  • “Speak slowly, but not so slowly that the patient becomes bored or distracted.”
  • “Use terminology that is familiar to the older adult.”
  • “Give older adults written material that reinforces the major points of teaching.  Use a large font.”
  • “Use visuals that portray older adults in a positive manner.”
  • “Encourage patients to keep written information easily accessible such as near a phone, bed table, or on the refrigerator.”
  • “Use concrete terms and avoid abstract terminology.”
  • “Encourage older adults to be actively involved in their teaching.”
  • “Encourage family members to actively participate in the educational sessions.”

Many of the principles of geragogy are also recommendations for low health literacy, which are discussed later in this article.

Include Family Members. As Jones, Treiber, and Jones state, “it takes a village” to assist a patient who has low health literacy.13  Not only do the various members of the healthcare team serve in important roles in the process, the family also plays a key role in overcoming low health literacy.  The patient’s spouse can assist in reinforcing patient education and adherence to treatment regimens. Ideally, a family member who has a higher level of basic and health literacy should be recruited, but realistically this may be difficult to accomplish.

Slow Down. Communication can be greatly improved simply by speaking more slowly, as older adults have slower processing speeds.14 If rushed, older adults can feel frustrated and exhibit unwillingness to learn due to fear of shame or failure.11 Although time is often limited during patient visits, which makes it difficult to slow down, the additional time allocated may contribute to better patient outcomes.

Use Plain, Nonmedical Language.  Clinicians can improve patient understanding by adopting simple speech patterns, such as using words with no more than 2 syllables (Table).  Communication with patients with low health literacy can be improved by asking colleagues to listen to patient encounters and give feedback, or by role playing with nonmedical friends and family members.

Show or Draw Pictures. Simple pictures can be used to help patients better recall important health information.  The pictures do not need to be detailed, although the use of color can make them more appealing to the eye.  In a pilot study of a narrative- and pictured-based health literacy intervention for older adults, pictures were found to be appealing and comprehensible.15

Limit the Volume of Information at Each Encounter. As older adults may have difficulty multitasking and dividing their attention, each encounter should be limited to 1 or 2 key pieces of important information.11 Practitioners may overwhelm patients with information during a single encounter, which can lead to confusion and poor understanding.  Patients with low health literacy may benefit from longer appointments, more frequent visits, or both.

Teach Back. Instructing patients to repeat back the information provided can serve to confirm their understanding.  If the patient repeats information incorrectly, the clinician can clarify the information to ensure patient comprehension.  The following is an example of a dialogue using the teach-back method:

Clinician:  The sugar in your blood is high, so I want you to take 1 more unit of your insulin glargine every 2 days until your morning blood sugar is 80 to 110.  I want to make sure you understand what I just said, so can you tell me what you’re going to do?

Mr C:  I’m going to take 1 extra unit of insulin glargine every 2 days until my blood sugar is 80 to 110.

Clinician:  That’s correct.  Once you have a morning blood sugar between 80 and 110, don’t increase your insulin glargine anymore.  Keep taking the same dose of insulin glargine you took to reach 80 to 110. So, how much insulin glargine will you take once your blood sugar is between 80 and 110?

Mr C:  Once my blood sugar is 80 to 110, I won’t increase my insulin glargine anymore.  I’ll keep taking the last dose of insulin glargine that I had been taking.

Create a Shame-Free Environment. The American Medical Association (AMA) created a video with actual patients who had low health literacy to demonstrate a woman describing her experience with a physician she consulted about her abnormal menses.  She went to the hospital and signed consent for surgery, but she did not realize until her 6-week postoperative visit that her procedure was a hysterectomy. The patient said she had been too ashamed to tell the physician and the admitting office that she didn’t read well, so she didn’t fully understand the papers she signed.  A body part was removed, which was never her intention, as a result of her low health literacy. As the woman’s experience shows, if patients feel shamed, they are less likely to ask questions. A shame-free environment allows patients to ask important and clarifying questions about their healthcare. Clinicians can create such an environment by developing rapport with patients and approaching them with a demeanor of acceptance that encourages them to ask questions.

Educate Staff. Clinicians should prioritize education on health literacy for the entire office staff.  Many resources are available to assist in staff education about this important topic.

Use Printed Material. When selecting or creating printed patient education materials, the most effective tools for patients with low health literacy limit information to 1 or 2 objectives and use plain language, primarily 1- or 2-syllable words, bullet points, pictures, readable fonts, and more empty space on the page.16  A 12- to 14-point font size is recommended for the general population; however, a larger font size is recommended for older adults due to potential visual disturbances.11  Black font is recommended because it is much easier for the older adult to see than other font colors such as red.  Although patient education materials should be written at a third- to fifth-grade level, many are often written at higher levels.17 To ensure that written material is at an appropriate level for most patients, clinicians can use the numerous online resources available.   

Technology and the Older Adult

Clinicians should exhibit caution when using electronic methods to deliver patient education to the older adult.  Only 42% of the US population between the ages of 55 and 74 years are regular users of computer technology.18 This gap increases with age, and women are less likely than men to have computer skills.  A 2014 Pew Report states that “seniors remain unattached from online and mobile life — 41% do not use the internet at all, 53% do not have broadband access at home, and 23% do not use cell phones.”19 Although technology use among older adults is increasing, they remain slower to adopt new products or innovations.


Older adults may have multiple medical conditions, and effective control of these conditions often begins with overcoming low health literacy.  Using the recommended strategies, clinicians can improve patient communication in their day-to-day practice — particularly with older adults and other patients with lower health literacy — potentially decreasing healthcare costs and improving patient outcomes through more effective communication.

Gwenn Scott RN, DNP, CNS, FNP-BC, is an assistant professor in the School of Nursing Master’s Program at the University of Texas Medical Branch in Galveston.


  1. Hersh L, Salzman B, Snyderman D. Health literacy in primary care practice. Am Fam Physician. 2015;92(2):118-124.
  2. Ratzan SC, Parker RM. Health literacy. National Library of Medicine website. Published 2000. Accessed October 1, 2018.
  3. Health literacy: a prescription to end confusion. Institute of Medicine website. Published April 8, 2004. Accessed October 9, 2018.
  4. What did the doctor say? Improving health literacy to protect patient safety. The Joint Commission website. Published February 27, 2007. Accessed October 9, 2018.
  5. National action plan to improve health literacy. Office of Disease Prevention and Health Promotion website. Published 2010. Accessed October 9, 2018.
  6. Healthy People 2010. Centers for Disease Control and Prevention website. Published October, 2011. Accessed October 9, 2018.
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  11. Elliot RW.  Educating older adults with chronic kidney disease.  Nephrol Nurs J.  2014;41(5):522-526.
  12. Osorio AR.  The learning of the elderly and the profile of the adult educator.  Convergence. 2008;41(2-3):155-172.
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  14. Kobayashi LC, Wardle J, Wolf MS, von Wagner C.  Aging and functional health literacy: a systematic review and meta-analysis. J Gerontol Series B:  Psychol Sci Social Sci. 2016;71(3):445-457.
  15. Koops JR, Winter AF, Reijneveld SA, Hoeks JC, Jansen CJ.  Development of a communication intervention for older adults with limited health literacy: photo stories to support doctor-patient communication.  J Health Commun. 2016;21(sup2):69-82.
  16. Weiss BD. How to bridge the health literacy gap. Fam Pract Manag. 2014;21(1):14-18.
  17. Bailey SC, Fang G, Annis IE, O’Conor R, Paasche-Orlow MK, Wolf MS. Health literacy and 30-day hospital readmission after acute myocardial infarction. BMJ Open. 2015;5(6):e006975.
  18. Schmidt-Hertha B, Krasovec SJ, Formosa M (eds). Learning Across Generations in Europe. Rotterdam: Sense Publications; 2014.
  19. Smith A. Older adults and technology use. Pew Research Center Internet & Technology website. Published 2014. Accessed October 9, 2018.

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This article originally appeared on Clinical Advisor