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Medical Interviewing and the Doctor-Patient Relationship
B. Liptzin, MD
Tufts University School of Medicine
Talking with the Elderly
The elderly population is growing rapidly. In the years to come, given the fact that older patients consume more health care than younger patients, physicians will be spending more and more time caring for this population of patients. As with all populations of patients, their concerns are unique and require both special knowledge and special approaches in order to facilitate a successful and rewarding encounter.
By the end of this lecture, you will be able to:
Describe some of the unique needs of the elderly population (hearing problems, cognitive impairment, etc.) and how to meet them.
Recognize that older persons have had long and diverse life experiences.
Recognize that older persons may stir up feelings in you that you need to be aware of for their effect on the interview.
Recognize the significance of the Mental Status Exam.
Specific competencies students are expected to perform within the context of practice after this lecture.
Treat the elderly with respect and patience.
Identify unique developmental characteristics of an older adult.
Adjust interviews to accommodate patients’ physical limitations, such as hearing impairment or poor mobility.
Introduce the mini-mental status exam into history taking.
Who are the elderly?
By 2020, there will be approximately 7.3 million people over the age of 85, making this the fastest growing population. Older patients have had long and diverse life experience and therefore have unique needs. They often have extensive medical histories, which may require the adaptation of interviewing styles and techniques. When interviewing a 90-year-old patient, they will likely have a more complicated history than a 9-year-old.
Since the elderly age group spans several decades, there are many definitions of the term elderly. Geriatricians commonly divide this group into categories: young-old (65-74), middle-old (75-84), and old-old (85+). It is difficult to make generalizations about the elderly because there is so much heterogeneity in this age group. You may have a patient in his or her sixties with many health problems and a 90-year-old who is very active and healthy. Because of the variability in the elderly age group, it is important to enter each interview without biases or preconceptions.
Common biases about the elderly
It is important to be aware of the many biases people have about the elderly in order to avoid making assumptions regarding your patients. Go into each interview with an open mind.
What does it mean to "Age"?
When we consider what it means to “Age,” we need to separate out normal aging from what happens as a result of disuse and disease. Every person will age in a different way and at a different rate. Some of the external signs of aging that make a person appear older include: hair loss, graying, wrinkling, and the sagging of subcutaneous tissue.
While there are physical changes that occur with aging, there are also changes in our relationships, career, and values. At varying ages people may become grandparents, experience the death of friends and family, and enter retirement. Individuals may also experience physical restrictions, health problems, and will begin to think about death. It is important to be aware and sensitive to the fact that loss is a common occurrence late in life. Individuals may experience decreased wealth, strength, physical ability, sexual opportunities, intimacy, and sense of the future.
Normal aging is accompanied by many physiologic changes. These changes will have implications for interviewing patients in this age group.
As we get older the lens of our eye becomes less elastic and we experience poor accommodation for near vision. Usually around age 40, people will need reading glasses and almost everyone will need them by the age of 55. When you interview an elderly patient make sure they have their glasses available and use large print if you are giving written directions or tasks.
High frequency pitches and certain sounds (s, z, sh, ch) become harder to hear with normal aging. Hearing problems are worsened in noisy surroundings, so try to conduct interviews in a quiet environment. If a patient uses a hearing aid, make sure that they are wearing the aid and that it is properly adjusted before beginning the interview. Sit close, look the patient in the eye, and make sure to speak slowly and clearly throughout the interview. Since high frequency tones are often where the hearing loss occurs, use your lowest voice and do not shout. If the patient is still having trouble hearing you, consider writing the questions down.
There has been no evidence of decline in selective attention in normal aging, but there is some decrease in divided attention. Understanding that there is a decrease in divided attention will improve your ability to interview older patients. Attempt to minimize distractions by blocking out external stimuli in the room during an interview.
As we age, we get slower. Specifically, there is a decrease in reaction time, motor speed, perceptual processing, and our ability to recall information. Make sure that you give the person adequate time to respond during an interview. Whether it is because of poor hearing or slower mental processing, it may take a person longer to respond to questions, but does not mean they don’t know the answer. A decrease in motor speed means that the elderly person may be less mobile. Falls are common among the elderly, so it is important to ask about any history of falls or the use of assistive walking devices.
Helpful questions to ask:
Have you ever had any falls?
Are you afraid of falling?
Do you use any devices to assist you while walking?
Before the age of 80, there is little generalized decline in overall cognitive functioning. Before this time, however, there is a normal decline in speech, free recall, divided attention, and problem-solving abilities. Although the above cognitive changes are normal with aging, a thorough cognitive assessment is important in order to rule out disease.
While there are normal cognitive changes that occur with age, dementia and other forms of cognitive decline are not an inevitable part of aging. Dementia is the progressive decline in memory, higher cortical functioning, and personality. Only 5% of persons over the age of 65 have serious cognitive impairment and 10-15% have mild cognitive impairment. It is not until over the age of 95 that the prevalence of serious cognitive impairment rises to ~50%. An interview may be very futile if you are trying to gather information from a patient with cognitive impairment. To avoid frustration, quickly assess cognitive function at the beginning of an interview. Don’t assume that an older person is demented before beginning your interview.
One way to assess this is by asking: Can you tell me why you are here?
If they answer that they are waiting to get a haircut, it may be futile to go through a detailed medical history. If the patient is cognitively impaired, get information from collateral sources such as friends, family, or medical records. Always remember to treat the patient with respect and avoid overloading them with questions they can’t answer. Repeating questions over and over isn’t going to help the situation; it will only lead to frustration by both you and the patient. Another way to assess the cognitive state of the patient is by using the Mini Mental Status Exam, which you will learn about later in the year.
Maintenance of sexual interest is normal in healthy older men and women. While the interest may not change, there are some functional changes that do occur. Older men will experience slower sexual response, decreased erection, decrease in seminal fluid volume, and decreased excitatory pressure as part of the normal aging process. Impotence, however, is not a part of the normal male aging process. Impotence may result from disease, drugs, or psychological problems and can often be treated. It is important to recognize that your beliefs about how sexual an elderly person is, may affect your willingness to help or listen to their concerns about sex. In older women, delay and decrease in vaginal secretions, shorter orgasmic phase, and possible painful spastic contractions of the uterus, are all normal changes associated with aging. For women, the availability of partner is typically the most important factor in deciding the sexual activity of the woman. In our society, men tend to die at a younger age and because of this, women often spend the last years of their life without a sexual partner
Discussing sex with the elderly.
Discussing sex tends to be an uncomfortable or difficult topic for younger people to discuss with older individuals. The elderly can be very sexually active; so do not make assumptions about the sexual activity of an individual based on age. There are many reasons why a person’s sexual activity may change; moral, physical, social, and cultural factors may influence sexual activity so it is important to consider all of these. As young doctors you need to give each patient an opportunity to discuss these topics even it makes you uncomfortable.
The process of growing old: What are the issues an older person may be thinking about?
The wide variety of changes experienced in late life will effect what a person thinks about on a daily basis. As doctors it is important that we recognize what this age group may be concerned about and assist them in achieving the best possible quality of life. Some individuals may worry about the things they can no longer do anymore. Alteration of relationships with parents, young adult children, and a maturing spouse may be a central component of an older person’s concerns. Other people must consider career accomplishments and come to terms with the fact that all personal goals may not be reached.
During your interviews, give the person a chance to discuss what’s on his or her mind. If you sit down with an older person do not assume that they are out of the work force and you don’t need to ask about their career. To ensure you are not asking questions based on previous notions of the elderly, ask many of the same questions that you would ask a 40-year-old. Don’t assume that an old person is sick, frail, and cognitively impaired, but instead invite them to share their thoughts with you. If you find that a person is thinking only about things they can no longer do, encourage them to focus on the things they are still able to do.
It is important to consider the cohort that each person belongs to and consider how this has affected his or her development and identity. Every cohort lives through a unique time in history. History often dictates the opportunities that were available to people and thus the life decisions that they made. For instance, the opportunities available to women 50 years ago are very different than they are today. When someone is coming to terms with and processing his or her life, be sensitive to what was going on in history at the time. Cultural and societal expectations change over time and these factors influence our development. It is important to be aware and respectful of choices that people make within the context of history.
Eric Erikson, a renowned psychologist, described the aging process as a series of stages from infancy to old age. Erikson believed that as we age, people are faced with various psychosocial crises and must develop qualities to conquer each stage. The final stage, which elderly patients must conquer, is ego identity. Erikson described this as the acceptance of one’s own life cycle as something unique and necessary. Some older people may have an increased awareness of time limitations and approaching death. It is important to assess their feelings and contentment with their own life. If an individual fails to progress in an earlier stage, this may affect his or her ability to accomplish ego identity later in life. Erikson believed that there is always hope to make changes in previous frameworks and progress further. It is never too late to make changes or improve the quality of life of a patient, no matter how old they may be. When you interview the elderly make sure to consider early life experiences in order to gain a more comprehensive understanding of their development and health.
It is common for the elderly to think about death and the amount of time they may have left. This consideration is significant when considering medical decisions and may affect their willingness to participate in treatments such as, chemotherapy, surgery, and dialysis. A patient may wonder how beneficial a treatment would be and whether the effort would be futile. When you speak with elderly patients make sure to ask them about their outlook on life and discuss advanced directives.
Helpful questions to ask:
When you think about the future, what concerns you most?
What do you think the future holds for you?
As you think about the future, what is most important to you?
Do you have a health care proxy?
Are you currently married or have you ever been? Can you tell me about your marriage?
Can you tell me about your family?
Do you work outside of the home?
Depression in the Elderly
Depressive symptoms are more common in the elderly than in younger persons, but clinical depression much less common. Depression in older women is two times more common than older men. Clinical depression needs to be distinguished from normal grief when you encounter a patient exhibiting depressive symptoms. Normal grief may be experienced after dealing with the death of loved one and can take 6-12 months to resolve. Depressive symptoms may also be due to systemic diseases, brain disorders, or medication side effects. An older person who is depressed may not report feeling depressed but may express physical symptoms, be irritable or suspicious, complain a lot, and be very demanding.
Clinical depression is treatable and it is NOT a normal part of getting old. It is important to identify depression in the elderly and treat it so they can continue to lead a full and happy life. The rate of successful suicide attempts in the elderly is twice as high as that of younger patients. It is important to recognize that your biases or expectations of behavior for an elderly person may affect the questions you ask and your ability to recognize and diagnose clinical depression. When interviewing an older patient listen carefully for evidence of sadness, pessimism, or hopelessness. Be alert to clues that the person no longer wants to live and if you are concerned about clinical depression or suicidal ideations, get psychiatric help for the person.
SIG-E-CAPS- this is a mnemonic used to help remember questions to screen for depression
Sleep: Have you had any changes in you sleep recently?
Interests: Have you dropped many of your activities or interests lately?
Guilt: Do you ever feel guilty? Do you feel worthless?
Energy: Tell me about your energy level.
Concentration: Do you have difficulty concentrating?
Appetite: Tell me about your appetite. How is it?
Psychomotor: Do you ever feel anxious? Lethargic?
Suicidal Ideations: Have you had any suicidal thoughts? Have you thought about hurting yourself?
Remembering these points:
Appreciate the elderly & be respectful
Be sensitive to life events and cultural differences
Slow down when you ask questions
Put instructions in writing if needed
Speak clearly and frankly
Cognitive assessment is important
Older persons have unique needs which require the interviewer to adapt
Don’t make assumptions
Use open-ended questions
LISTEN and accept them as people that have experience knowledge and foresight
Over the next several years you will be seeing many sick older patients in the hospital. Being sick in the hospital you may be interacting with them in their most irritable and vulnerable state, but remember to always be respectful and patient.