Working with older adult simulated patients (SPs) to deliver effective geriatric simulations

By Nemat Alsaba (@talk2nemat), Lisa Sokoloff(@BaycrestSLP1) and Cathy Smith (@csmith_toronto)

As the population of older adults continues to grow globally, there is a need for simulation-based education to train healthcare professionals involved in their care. As simulation educators, we need to ensure that both our simulation faculty and older simulated patents (SPs) have the right tools and support to deliver effective geriatric-focused simulation activities. (Smith et al., 2020)  While most research involving SPs focuses on learner outcomes, few studies have considered SPs’ needs, experiences, and perceptions. (Schelgel & Smith, 2019)  

Imagine ….

You have been asked to run a geriatric simulation scenario for your hospital. The scenario involves recognizing and responding to delirium in an older person. You are excited to run this simulation, with a real ‘SP’ rather than a manikin, as you know they can provide great authenticity and engagement.  When you arrive to prepare for the simulation you do not see an older simulated patient. Instead, you see a 20-year-old who will be wearing a wig and carrying a cane to play the role as the SP for the scenario. When you express surprise, the simulation educator says to you “Don’t worry!  This SP is an excellent actor and is wearing a wig to look old. They also give good feedback!”

The educator tells you that the last time they recruited an older SP, the SP forgot and showed up 30 minutes late. Also, during the scenario, a “time-out” was called to stop and debrief with the learners, but the SP just kept going.  This has made the educator reluctant to work with older SPs. 

Why is this an issue?

Simulation educators may not understand the rationale for working with an age-appropriate simulated patient. Choosing a younger SP to portray an older person may lack authenticity, and carries the potential for bias and ageism. There is a risk that the younger SP will play the role in a stereotypical manner, e.g., with a grey-haired wig and using a cane, affecting the mannerisms that they think exemplify an older adult.  This can be disrespectful; not all older adults have grey hair or are frail!  An older adult SP will portray the role with their life history as a reference and will embody their own physical, cognitive, and sensory challenges authentically.  For example, the older SP may have a mild hearing loss that would be difficult to replicate by a younger SP but that may have a significant effect on the simulation scenario and the learning outcome. 

What works?

The educator described above may not have been aware of some simple strategies that could have made the experience with the older SP more successful. If the simulation educator had the right tools to work with and engage older SPs the learners would have benefitted from a more authentic, respectful, and engaging simulation. (Lewis et al., 2017) We need to make a shift in our mindset when designing and delivering geriatric simulation and attempt to remove bias and stereotypes.

Understanding the normal physiological changes with aging is the first step toward making that mindset shift, and will help address unique considerations required when working with older SPs. (Lewis et al., 2017,  Nestel & Bearman, 2014). 

What are the physiological changes to consider when working with older SP?

“Age is just a number!”. We should differentiate between chronological aging (number of years person lived so far) and biological aging (loss of tissue and organ to function efficiently and to repair itself).(Chalise, 2019) There are SPs well into their 90’s who work in geriatric simulation programs and still contribute greatly to the simulation community!

Meet Helen, a 90 year old SP working with Baycrest Simulation program
(photo used with her permission)

In translating knowledge of physiological aging into a successful approach when working with and supporting older SPs, we offer a framework to guide simulation educators. In considering cognitive, physical and sensory changes, the framework provides practical advice for strategies before, during and after simulation activities (Table 1).

Table 1 Tips and practical strategies when working with Older SPs (click to zoom in)

Adapted from Smith CM, Sokoloff LG, Alsaba N. Collaborative framework for working with older simulated participants (SP). BMJ Simulation and Technology Enhanced Learning Published Online First: 16 June 2020. doi: 10.1136/bmjstel-2020-000613 (Smith et al., 2020

Let’s think back to the educator who noted that the older SP was late and didn’t stop for timeouts. Reflecting on the framework, ‘Knowing Your SP’ is extremely important.  Understanding that some older adults may have some memory loss, perhaps the educator could have contacted the SP shortly before the session to ensure they were aware of the day, time, location, etc.  If the SP had any degree of hearing loss, a system could have been in place to accommodate for lip reading – if the SP wasn’t facing the learner, they may not have heard or “seen” the learner call the timeout. After the simulation, a short debrief may have suggested scenario re-design or a better match of simulated patient to different scenario.

Finally, these are our 3 top take home messages

  • Be aware of bias and ageism as these can affect the quality and authenticity of simulation designed to improve the care of older adults
  • Understanding physiological aging helps in providing support needed for any cognitive, sensory, or physical changes an older simulated patient might require
  • Using a framework pre, during and post simulation can support older SPs


About the authors:

Dr Nemat Alsaba MBBS, FACEM: Emergency physician at Gold Coast University Hospital and Deputy Director of Bond Simulation program with Special interest in Geriatric emergency Medicine and working with SP (@talk2nemat)

Lisa Sokoloff, MS, CCC-SLP: Manager, Training & Simulation at Baycrest; Speech-language pathologist with interest in immersive, experiential learning (@BaycrestSLP1)

Cathy Smith, PhD, CHSE: Interprofessional and Simulation Educator, Training & Simulation at Baycrest; Educator with a focus on integrating simulation methodology into health care education (@csmith_toronto)

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