Communicating Across Languages: Experiences of Spanish‐Speaking People With Dementia and Care Partners in the Emergency Department

People living with dementia (PLWD) often face challenges communicating in the emergency department (ED), where time pressures and workflow complexity can make conversations feel rushed and unidirectional, i.e., from care teams to patients and family [1]. Communication barriers may limit the engagement of PLWD and their care partners in medical decision-making. When PLWD speak a primary language other than English, language discordance with their care team introduces another layer of vulnerability because cognitive impairment may limit patients' ability to advocate for themselves. Prior qualitative work has shown that care partner advocacy is crucial for capturing ED staff's attention and simplifying communication for PLWD in the ED [2]. However, little is known about how PLWD and care partners experience communication across languages or how they perceive the use of certified interpreters [1]. To address this gap, we conducted qualitative interviews with PLWD and their care partners who spoke Spanish—representing the most commonly spoken non-English language in the United States—focusing on their experiences with language interpretation in the ED. This analysis is drawn from a larger qualitative study of PLWD and their care partners recruited from a public safety-net hospital system in the southeastern United States. The full study, reported in detail elsewhere following the Consolidated criteria for Reporting Qualitative Research [3], explored health priorities and experiences of communication during emergency department (ED) and hospital care [4]. For the present report, we focused on data related to communication across languages and use of interpretation services. The Baylor College of Medicine Institutional Review Board provided ethics approval (H-53024). The health system serves a low-income underinsured population which is over 50% Hispanic/Latino and 43% of whom speak Spanish as their primary language. It has > 155,000 annual visits across two EDs and has 24/7 Spanish language interpretation available by phone or in person. We used chart review to identify people with an established dementia diagnosis who had an ED visit in the prior month and recruited them and care partners by phone to participate in an interview about their experiences of ED care. A medical student trained in qualitative interviewing performed interviews in Spanish and English in person or by telephone, based on participant preference. As part of interview guide questions about experiences of communication, we asked specifically about experiences of language interpretation and challenges related to communicating across languages (Data S1). Interviews were professionally transcribed verbatim, and Spanish interviews were translated into English by a native Spanish speaker. Using an inductive thematic approach, two analysts independently coded transcripts for language-related content and met to resolve discrepancies through consensus. Quotations and summarized data were organized in a matrix to identify overarching themes. We performed 15 interviews with 14 PLWD and 33 care partners, all of whom identified as Hispanic. Most interviews were conducted in dyads or triads with patients and their care partners, and 14 of 15 were conducted in Spanish. All PLWD and 18 care partners spoke Spanish as their primary language, while one care partner was bilingual in English and Spanish. Interviews lasted an average of 87 min (range 47–119 min). Data collection and analysis proceeded concurrently, and thematic saturation—the point where no new findings emerge from participants' responses—was reached by the fifteenth interview. Two overarching themes emerged regarding communication across primary language in the emergency department: (1) certified interpreters eased social dynamics in communication; and (2) episodic certified interpreter use with communication gaps. My experience was perfect because they give me an interpreter. And the interpreter [explains] what I want to ask or what the doctors want to tell me. (Patient 108) Because we don't really speak the language, having an interpreter is always excellent. (Care partner 105) She talks a lot…The interpreter always says: ‘You have to speak in short, brief sentences.’ So, she doesn't like it. That's why she tells the doctor that she'd rather I interpret for her. I don't really like to interpret for her, precisely because of that. (Care partner 113) When there are a bunch of doctors talking to each other [in English], I don't like to interrupt them. (Care partner 104) Language is the hardest part. I'm embarrassed. I'm embarrassed they're going to say, ‘Here comes this silly rancher from over there [laughs].’ (Patient 105) So, [when the doctors spoke to us] they did bring a translator who is a person who is there all the time translating for patients… But for the rest of the time we were there, no, they never brought the interpreter to make my mom feel that they were interested in everything she was feeling. (Care partner 113) I was there battling and waving for them to understand me. There was a group of about 15 doctors when they were in the emergency room…And then there was one who I didn't know who spoke Spanish. I said to them, ‘Who's going to explain it to me? Who's going to understand me?’ because I was, you know [worried]. (Care partner 112) Nobody spoke Spanish, so they were obviously addressing her. But in other words, they were addressing me, but speaking about her. And I did the translation. (Care partner 113) In this study of Spanish-speaking PLWD and their care partners, participants emphasized that certified interpreter services were available and highly valued at critical junctures—such as an initial clinical assessment or updates on test results—but were often inaccessible during “in-between” periods. Other studies have similarly documented Spanish-speaking patients' limited access to certified interpreters outside of interactions with providers [5]. Even in a health system offering 24/7 certified interpreter coverage, these gaps created uncertainty and tension. For study participants, language barriers during the “in-between” periods compounded the discomfort of the ED environment and uncertainty about what was happening. Our findings also underscore the emotional and cognitive burden on care partners who are asked to translate for PLWD, on top of their caregiving duties and roles in healthcare decision-making. The challenges we identified are likely shared by speakers of other non-English languages and in EDs with limited availability of certified interpreters and bilingual staff. Our findings highlight two ongoing priorities in ED dementia research: understanding how system-level factors influence communication and how individual ED care team members can ensure high-quality communication [1]. Prior work shows that patients spend approximately 75% of their ED stay not interacting with providers [6], underscoring that communication failures are often rooted in system design rather than clinician intent. Certified interpreter use, therefore, should be reframed. Rather than viewing interpretation as a discrete service for isolated or episodic conversations, we must recognize it as one component of a continuous, person-centered approach to communicating with patients who speak non-English languages and live with cognitive impairment. Several practical strategies could help address these gaps. Systems-level solutions include ensuring visible signage or bedside instructions in commonly spoken languages explaining how to request a certified interpreter [7], incorporating certified bilingual staff into key frontline roles (e.g., registration, triage, nursing), and rooming PLWD in care areas with easy access to staff and call buttons. ED staff who are present throughout the department, such as sitters and technicians, could also be trained to facilitate calling certified interpreters during “in-between” moments. Table 1 expands on additional strategies, which align with recommendations from national quality and equity frameworks such as the Geriatric Emergency Department Accreditation program and the American Hospital Association Health Equity Roadmap. Facilitate staff and patient access to certified interpreters Speed dial to interpretation services on health system telephones Certified interpreter offices located in or near the ED Signage indicating how to contact certified interpreters Patient-initiated call button that connects to bilingual staff member Track requests and wait times for certified interpreters and use this to guide department staffing Use dementia-friendly communication practices [9, 10] for certified interpreters and staff working with certified interpreters Limit use of pronouns Use simple sentence structures Speak slowly Give enough time for the patient to speak Outside of the ED, care partner-oriented programs such as the Centers for Medicare and Medicaid Guiding an Improved Dementia Experience (GUIDE) Model could strengthen preparedness by equipping family members with information and skills to advocate effectively during ED visits [11]. For example, GUIDE coaches could help patients and caregivers understand episodic certified interpreter availability in the ED, encourage caregivers to accompany patients when possible, and equip them with cards or scripts for requesting certified interpreters and clarifying symptoms. Such preparation could reduce miscommunication and foster culturally sensitive care. Our study is limited to a single site and a Spanish-speaking patient population, but adds an important perspective on the intersection of language barriers and ED dementia care. Future research should test interventions that provide continuous language access for patients with cognitive impairment. Doing so may improve comprehension of care plans and inclusion of patients and care partners in decision-making, while mitigating the compounded vulnerabilities of language discordance and cognitive impairment faced by Spanish-speaking PLWD. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Data S1: Interview Guide. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.