When patients are older, obtaining a good history—including information on social circumstances and lifestyle as well as medical and family history—is crucial to sound health care.
"What brings you here today?"
Mr. Symonds has advanced lung disease and usually manages well with home oxygen. But, he's been admitted to the emergency room three times in as many weeks, unable to breathe. The health team is puzzled because Mr. Symonds is taking his medications on schedule and, he says, using the oxygen. Finally, a home care nurse is sent to the Symonds' house. She discovers that because of this winter's bitter cold, Mr. Symonds has been running a kerosene heater in his kitchen. He does not use the oxygen and heater at the same time for fear of fire.
The varied needs of older patients may require different interviewing techniques. The following guidelines can help you to obtain a thorough history of current and past concerns, family history, medications, and socioeconomic situation. These suggestions are less time-consuming than they may appear. Some involve a single investment of time. Other health care professionals in the office or home may assist in gathering the information. You may want to get a detailed life and medical history as an ongoing part of older patients' office visits and use each visit to add to and update information.
You may need to be especially flexible when obtaining the medical history of older patients. Here are some strategies to make efficient use of your time and theirs:
- If feasible, try to gather preliminary data before the session. Request previous medical records or, if there is time, mail forms that the patient or a family member can complete at home. Try to structure questionnaires for easy reading by using large type and providing enough space between items for people to respond. Questionnaires to fill out in the waiting room should be brief.
- Try to have the patient tell his or her story only once, not to another staff member and then again to you. For older patients who are ill, this process can be very tiring.
- Sit and face the patient at eye level. Use active listening skills, responding with brief comments such as "I see" and "okay."
- Be willing to depart from the usual interview structure. You might understand the patient's condition more quickly if you elicit his or her past medical history immediately after the chief complaint, before making a complete evaluation of the present illness.
- If the patient has trouble with open-ended questions, make greater use of yes-or-no or simple choice questions.
- Remember that the interview itself can be beneficial. Although you see many patients every day, you may be the only person your patient is socially engaged with that day. Your attention is important. Giving your patient a chance to express concerns to an interested person can be therapeutic.
Elicit Current Concerns
Older patients tend to have multiple chronic conditions. They may have vague complaints or atypical presentations. Thinking in terms of current concerns rather than a chief complaint may be helpful. You might start the session by asking your patient to talk about his or her major concern, "Tell me, what is bothering you the most?"
Resist the Tendency to Interrupt
Give the patient time to answer your questions. Giving someone uninterrupted time to express concerns enables him or her to be more open and complete.
Ask, "Is there anything else?" This question, which you may have to repeat several times, helps to get all of the patient's concerns on the table at the beginning of the visit.
The main concern may not be the first one mentioned, especially if it is a sensitive subject. If there are too many concerns to address in one visit, you can plan with the patient to address some now and some next time.
Encourage the patient and his or her caregivers to bring a written list of concerns and questions. Sometimes an older patient will seek medical care because of concerns of family members or caregivers.
Ask About Medications
Side effects, interactions, and misuse of medications can lead to major complications in older people. It is crucial to find out which prescription and over-the-counter medications older patients are using and how often. Older people often take many medications prescribed by several different doctors, e.g., internists, cardiologists, urologists, or rheumatologists. Sometimes they take prescriptions intended for other household members.
Remember to ask about any alternative treatments, such as dietary supplements, homeopathic remedies, or teas that the patient might be using. Remind patients that it is important for you to know what over-the-counter medicines, such as pain relievers or eye drops, they use.
Ask patients to bring all medications, both prescription and over-the-counter, to your office. A good approach is to have the patient put everything he or she takes in a brown bag and bring it to each visit. Find out about the patient's habits for taking each medication, and check to be sure that he or she is using it as directed.
Check to see if the patient has (or needs) a medical alert ID bracelet or necklace. There are several sources, including MedicAlert Foundation International, www.medicalert.org .
Obtain a Thorough Family History
The family history is valuable, in part because it gives you an opportunity to explore the patient's experiences, perceptions, and attitudes regarding illness and death. For example, a patient may say, "I never want to be in a nursing home like my mother." Be alert for openings to discuss issues such as advance directives.
The family history not only indicates the patient's likelihood of developing some diseases but also provides information on the health of relatives who care for the patient or who might do so in the future.
Knowing the family structure will help you to know what support may be available from family members, if needed.
Ask About Functional Status
Knowing an older patient's usual level of functioning and learning about any recent significant changes are fundamental to providing appropriate health care. They also influence which treatment regimens are suitable. The ability to perform basic activities of daily living (ADLs) reflects and affects a patient's health. Depending on the patient's status, ask about ADLs such as eating, bathing, and dressing and more complex instrumental activities of daily living (IADLs) such as cooking, shopping, and managing finances. There are standardized ADL assessments that can be done quickly and in the office.
Sudden changes in ADLs or IADLs are valuable diagnostic clues. If your older patient stops eating, becomes confused or incontinent, or stops getting out of bed, look for underlying medical problems. Keep in mind the possibility that the problem may be acute.
Consider a Life History
If you plan to continue caring for an older patient, consider taking time to learn about his or her life. A life history is an excellent investment. It helps to understand the patient. It also strengthens the clinician-patient relationship by showing your interest in the patient as a person.
Be alert for information about the patient's relationships with others, thoughts about family members or coworkers, typical responses to stress, and attitudes toward aging, illness, work, and death. This information may help you interpret the patient's concerns and make appropriate recommendations.
Obtain a Social History
The social history also is crucial. If you are aware of your patient's living arrangements or his/her access to transportation, you are much more likely to devise realistic, appropriate interventions. Ask about where he or she lives; neighborhood safety; eating habits; tobacco, drug, and alcohol use; typical daily activities; and work, education, and financial situations. It also helps to find out who lives with or near the patient.
Understanding a person's life and daily routine can help you to understand how your patient's lifestyle might affect his or her health care. To this end, determine if the patient is an informal caregiver for others. Many older people care for spouses, elderly parents, or grandchildren. A patient's willingness to report symptoms sometimes depends on whether the patient thinks he or she can "afford to get sick," in view of family responsibilities.
House calls by a health care professional are an excellent way to find out about a patient's home life. If that's not possible, try to learn some details about the patient's home life: "Do you use oil or gas heat? Have steep stairs to navigate? Own a pet? Can you get to the grocery store or pharmacy on your own? Are you friendly with anyone in the neighborhood?" Learning about your patient's home life will help you understand aspects of his or her illness and may improve adherence to treatment.
- Obtain basic information before the visit. Encourage patients to bring in written lists of concerns as well as all medication, including over-the-counter and alternative or homeopathic remedies.
- Use the family history to gain insight into an older patient's social situation as well as his or her risk of disease.
- Talk about the activities of daily living and be alert to changes.
- Ask about living arrangements, transportation, and lifestyle to help in devising appropriate interventions.