REVIEW ARTICLE

ASPECTS OF CLINICAL COMMUNICATION IN PRIMARY HEALTH CARE FOR OLDER ADULTS: A SCOPING REVIEW

Rogério Sampaio de Oliveira1, Ítalo Emanoel de Sousa Chaves2, Antônio Germane Alves Pinto3, Roberto Wagner Júnior Freire de Freitas1, Maria Rosilene Cândido Moreira2, Maria de Fátima Antero Sousa Machado1

1 Oswaldo Cruz Foundation Ceará, Eusébio, Ceará, Brazil

2 University of Cariri, Barbalha, Ceará, Brazil

3 Regional University of Cariri, Crato, Ceará, Brazil

ABSTRACT

Objective: To identify, in scientific literature, the aspects of clinical communication (CC) employed by primary health care (PHC) professionals when caring for older adults. Method: This scoping review was conducted following the JBI methodology and the PRISMA-ScR checklist. Searches were performed in January 2024 in the LILACS, Web of Science, Scopus, Google Scholar databases, and the Brazilian Digital Library of Theses and Dissertations. Primary studies addressing CC with older adults conducted by PHC professionals were included. Study selection and data extraction were performed using the Rayyan software. Extracted data were organized into a chart containing the following items: authors, year, country, objective, method, participants, main findings, and limitations. The results and conclusions were analyzed using similarity analysis with the IRaMuTeQ software. Results: A total of 20 studies were analyzed, including 16 qualitative and 4 quantitative studies, published between 1999 and 2022, predominantly from Brazil and the United States. The similarity analysis highlighted the terms “patient,” “communication,” “physician,” “nurse,” and “consultation,” which helped identify the core elements of the studies. Major barriers to CC included the use of technical language and the omission of specific topics during consultations. Key facilitators were active listening and the use of supportive technologies. Conclusion: CC with older adults in PHC presents relevant barriers and facilitators. These findings underscore the need for continuous training of health professionals in communication skills to improve the quality of care.

Descriptors: Health Communication; Older Adults; Primary Health Care.

INTRODUCTION

Communication is a shared process of meaning-making, characterized by a dialogical relationship between human consciousnesses within their context of existence(1). It is an essential element of the human condition, enabling the expression of intercommunication and intersubjectivity within dialogical interaction spaces(2). This process may occur directly, when there is physical proximity between interlocutors, or indirectly, even in the absence of such proximity(3-4).

When it occurs between health professionals, patients, family members, or caregivers, this process is referred to as clinical communication (CC)(3,5). CC involves the exchange of information mediated by interpersonal connections, including therapeutic encounters, interactions through communication technologies, and dialogues with family members(3,6).

Once established, CC serves multiple purposes, such as initiating and maintaining a therapeutic relationship, gathering relevant information about individuals within their care processes, making shared decisions, developing therapeutic plans, and providing patient support(3,6). This approach fosters person-centered care(7).

However, studies report several challenges faced by health professionals in practicing CC, including limitations in patient reception, failure to consider the individual’s uniqueness, weak relationship-building, and the persistence of hierarchical dynamics in communication processes. Additionally, communication breakdowns are frequently reported, compromising the quality of care(8-9).

There is also evidence of gaps in CC education, with a disproportionate focus on pathological conditions and insufficient investment in developing communication skills for engaging with individuals experiencing illness(7). Primary health care (PHC) represents a strategic setting for promoting comprehensive care for the older population. It plays a key role in the training and professional practice of health workers, particularly those involved in the Family Health Strategy (FHS), by reinforcing the centrality of person-centered care(10).

Accordingly, this review aims to identify, in scientific literature, the aspects of CC applied by PHC professionals in the care of older adults.

METHOD

This is a scoping review conducted based on the PCC framework, which guides the development of the review question considering: Population (P) – PHC professionals; Concept (C) – CC; and Context (C) – health care for older adults. The guiding review question was: How do PHC professionals engage in CC when caring for older adults?

The review followed the methodological framework proposed by the JBI for scoping reviews (11) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Extension for Scoping Reviews (PRISMA-ScR) checklist(12) to ensure methodological transparency and scientific rigor(13). The process was structured into nine stages: (1) defining the objective and research question; (2) developing eligibility criteria; (3) establishing the approach for searching, selecting, extracting, and presenting evidence; (4) conducting the search; (5) selecting the evidence; (6) extracting data; (7) analyzing the evidence; (8) presenting the results; and (9) synthesizing the evidence.

The review protocol was developed following the Template for Scoping Review Protocols(14) and registered on the Open Science Framework (OSF) under the code https://osf.io/n95wy(15).

Search strategy

Search was conducted between January 11 and 22, 2024, in LILACS, Web of Science, and Scopus databases. To retrieve gray literature, Google Scholar and the Brazilian Digital Library of Theses and Dissertations (BDTD) were also used. The search strategy was developed by combining the terms primary health care professionals, communication, and elderly, resulting in the final strategies presented in Figure 1.

Figure 1 – Search strategy used in this scoping review. Barbalha, Ceará, Brazil, 2024

Eligibility criteria

Studies were included based on the criteria established using the PCC framework:
Population – primary studies involving health professionals working in PHC; Concept – studies addressing CC, considering different forms of interaction between health professionals, patients, and individuals in their surroundings(6); Context – studies conducted within the scope of PHC focused on the care of older adults.

Study selection from sources of evidence

Study selection was carried out using Rayyan software (CQRI Systems)(16). Two independent review authors conducted the removal of duplicates, title and abstract screening, and eligibility assessment. In cases of disagreement, a third reviewer was consulted to reach a final decision. Studies included in the screening phase proceeded to data extraction.

Data extraction

Information related to study identification, participant characteristics, and main findings was extracted and organized in a summary table. Each study was coded with the letter “T” followed by a sequential number.

Methodological quality assessment of the studies was not performed, as the objective of a scoping review is to map concepts and available evidence without critically appraising the quality of the included data.

The conclusions of the included studies composed the textual corpus analyzed using the IRaMuTeQ software (version 0.7 alpha 2), which enables multidimensional analyses based on the vocabulary used in the texts(17). Among the available tools, similarity analysis was applied to identify co-occurrences and connections between words, supporting the understanding of the investigated phenomenon and informing the discussion of the results.

RESULTS

A total of 1,594 records were initially identified in the databases, along with 28 records from gray literature, resulting in 1,622 documents overall. The study selection process is illustrated in Figure 2.

Figure 2 – Flowchart of the study selection process for this scoping review. Barbalha, Ceará, Brazil, 2024

Of the 20 studies included(18-37), 16 employed a qualitative approach and four a quantitative approach. Most studies were conducted in Brazil (43%) and the United States (14%).

A predominance of studies focused on characterizing CC between health professionals and older adults was observed(19-21,25-28,31-36). One study(23) examined the types of messages physicians sent to older patients through virtual platforms, while another(35) analyzed the factors influencing CC between nurses and family members of older adults.

Two studies(27,30) assessed the quality of CC from the perspectives of physicians and patients; one study(32) explored the quality of CC between nurses and older adults with hypertension; another(34) examined communication mediated by metaphors; and one study(31) investigated the quality of questions posed by physicians during consultations with older adults.

The main characteristics of the included studies are presented in Figure 3.

Figure 3 – Characteristics of the studies included on clinical communication by PHC professionals in the care of older adults. Barbalha, Ceará, Brazil, 2024

The similarity analysis generated a maximum tree representing the main findings and conclusions of the included studies, organized into one central community and three peripheral communities (Figure 4).

Figure 4 – Maximum tree from the similarity analysis of the textual corpus on clinical communication by PHC professionals in the care of older adults. Barbalha, Ceará, Brazil, 2024

The central community (represented in green) highlights the relationship between the terms “patient”, “physician”, and “communication”, with an emphasis on the topics “medication”, “polypharmacy”, and “violence” within the family context. This community encompasses elements that reflect ambiguities in CC conducted by physicians. Facilitating factors include providing specific information about medications and emphasizing the importance of correct use by family members(34). On the other hand, failing to address sensitive topics — such as family violence(20), polypharmacy and its impact on older adults’ health(26), and sexuality in old age(32) — was identified as a communication barrier. The use of technical language during consultations also emerged as a limiting factor for CC(23).

The peripheral pink community groups the terms “nurse” and “health”, whose connections reflect the role of nurses and the communication strategies adopted in the “care” and “attention” provided within the FHS. This community highlights the nurse’s role in the communication process with older adults, their family members, and caregivers. Facilitating factors identified include the professional’s educational level(18), the use of active listening(21), and adapting language to the needs of interlocutors(36). However, the need for further training in the care of older adults with mental disorders, especially depression(37), was also noted.

The purple community groups the terms “communication” and “difficulty”, highlighting that the “understanding” of topics such as “medication” may be affected by the “aging” process. This community reveals that medical consultations often emphasize technical guidance regarding medication use(34), directed both at older adults and their caregivers or family members. This focus acts as a barrier to CC, as it tends to limit the discussion of other relevant topics or prevent deeper engagement. Furthermore, physicians may not adequately assess whether older patients fully understand their instructions(27), sometimes attributing comprehension difficulties to the aging process. As a result, communication becomes restricted to medication-centered explanations.

The blue community addresses “email” “consultation” as a strategy to improve “access” to medical guidance for older adults. This community highlights the use of email consultations and virtual messages as potential facilitators of CC. However, in some cases, the use of email consultations became excessive and inappropriate, leading to dissatisfaction among physicians(33). Additionally, virtual messages were often limited in communication quality, lacking supportive and empathetic language from professionals(23).

DISCUSSION

The studies analyzed made it possible to map the main aspects of CC established by health professionals in the care of older adults. A relevant finding is the still limited number of studies conducted within the context of Brazilian PHC, suggesting that despite the importance of the topic, it remains underexplored in the country(38). On the other hand, most Brazilian studies included in this review were published in the past 5 years, indicating a growing interest in the subject. This trend may be associated with the incorporation of new educational guidelines in health-related academic programs as well as the strengthening of public policies focused on population aging in Brazil.

The similarity analysis highlighted the multifaceted nature of the communication process, revealing ambiguities that require critical reflection in PHC practice. In this context, the roles of physicians and nurses stand out, as their practices exhibit both facilitating elements and barriers to CC.

Caring for older adults involves interconnected dimensions — social, physical, and emotional — that require PHC professionals to recognize them and plan effective interventions(39). In addition to these aspects, it is essential to consider the individuality of older adults, including their beliefs, perceptions, life contexts, and the need for multidisciplinary care. Valuing these elements fosters the development of a strong bond between the healthcare team and the patient, strengthening trust and adherence to care(40), which contributes to overcoming barriers and enhancing communication-facilitating strategies.

Among the facilitating factors identified, some studies highlighted the use of tools and technologies aimed at improving CC between health professionals and older adults, demonstrating the potential of the PHC setting to strengthen these practices. Active listening, mentioned in one study, supports the expression of beliefs, fears, and concerns by older adults, encouraging their more proactive and participatory role in the care process(41).

The internet and virtual communication tools were also recognized as resources that contribute to health information access and interaction between older adults and health professionals. In this context, digital inclusion emerges as an important mechanism for promoting autonomy and quality of life while also strengthening the connection between users and health care teams(42-43).

On the other hand, some studies revealed that certain health-related topics are either underexplored or addressed in a limited manner by both professionals and older adults. These include family violence, sexuality, polypharmacy, and the content of the Older Adult Health Booklet, all of which represent barriers to CC in PHC practice.

Regarding family violence, one study(44) reported a prevalence of 30% among older adults, exceeding the average observed in several other studies conducted in Brazil. These data highlight how frequently different forms of violence occur within the family environment, reinforcing the importance of medical consultations as a strategic space to address this issue and enable older adults to report situations of abuse, contributing to the identification and management of this condition.

With respect to sexuality, one study(45) revealed a lack of knowledge and a low frequency in addressing this topic during consultations with older adults, emphasizing the need to develop strategies that support its incorporation into health professionals’ routine practice.

Regarding medication use and polypharmacy, one study(46) reported a prevalence of 57.7% among older adults receiving care in PHC units, reinforcing the need to expand the discussion of these topics during consultations, not only in terms of prescription but also guidance and follow-up.

In addition to these underexplored topics, one study(47) revealed a lack of awareness among health professionals regarding the Older Adult Health Booklet, highlighting the need for greater dissemination and strengthening of this knowledge. This tool plays a significant role not only in care planning and continuity but also as a record of the quality of care provided(48).

No scoping reviews were identified that specifically mapped studies on CC in the care of older adults within the context of PHC, which gives this work an original contribution to this field of research. However, some limitations are acknowledged, including the potential exclusion of unpublished studies or those not indexed in the selected databases, as well as the possibility of divergent interpretations of certain findings, which may limit the breadth of the reflections presented.

The following section presents effective communication practices recommended for PHC professionals in the care of older adults (Figure 5).

Figure 5 – Recommended practices for PHC professionals to improve clinical communication with older adults. Barbalha, Ceará, Brazil, 2024

CONCLUSION

Mapping CC practices carried out by PHC professionals in the care of older adults allowed for the identification of both barriers and facilitators that directly impact the effectiveness of this practice. Although some studies highlighted positive aspects, essential topics related to the health and quality of life of the older population were either insufficiently addressed or superficially explored in the communication processes described.

Based on these findings, there is a clear need to improve CC within PHC training processes, both in theoretical and practical settings, involving students, faculty, and preceptors from various health disciplines.

This review also highlights the importance of conducting further research to deepen the understanding of CC as practiced by PHC professionals in the care of older adults, with the aim of identifying additional facilitators and overcoming barriers beyond those mapped in this study.

It is therefore recommended that studies and educational initiatives be carried out with an emphasis on strengthening CC, with the aim of advancing knowledge on the subject and improving the quality of care provided in PHC.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 02-Jul-2024

Approved: 13-May-2025

Editors:

Rosimere Ferreira Santana (ORCID: 0000-0002-4593-3715)

Geilsa Soraia Cavalcanti Valente (ORCID: 0000-0003-4488-4912)

Graziele Ribeiro Bitencourt (ORCID: 0000-0002-9130-9307)

Corresponding author: Maria Rosilene Cândido Moreira (rosilene.moreira@ufca.edu.br)

Publisher:

Escola de Enfermagem Aurora de Afonso Costa – UFF

Rua Dr. Celestino, 74 – Centro, CEP: 24020-091 – Niterói, RJ, Brazil

Journal email: objn.cme@id.uff.br