Talking With Your Older Patients
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Doctor-patient communication is an essential, though sometimes challenging, aspect of the health care process. The following suggestions can help you work with older patients to optimize care and make the most of your time and resources.
Tips for communicating with older patients
Effective communication can help build satisfying relationships with older patients to best manage their care. It can strengthen the patient-provider relationship, lead to improved health outcomes, help prevent medical errors, and make the most of limited interaction time.
Interpersonal communication skills are considered so important that they are a core competency identified by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties.
These key communication tips can help facilitate successful interactions with all of your patients, including older adults:
- Speak to the patient as a fellow adult. Having physical, sensory, or cognitive impairments does not lessen the maturity of an adult patient. Those who are older might be used to more formal terms of address. Establish respect right away by using formal language as a default (such as Mr. or Ms.) and avoiding familiar terms, such as “dear,” which could be perceived as disrespectful. You or your staff can also ask patients how they prefer to be addressed.
- Make older patients comfortable. Ask staff to ensure patients have a comfortable seat in the waiting room and, if necessary, help with filling out forms. Staff should check on them often if they have a long wait before they are seen. Patients with impaired mobility may need to be escorted to and from exam rooms, offices, restrooms, and the waiting area. They may require assistance with climbing on to the exam table or removing clothing or shoes.
- Avoid hurrying older patients. Be mindful if you are feeling impatient with an older person’s pace. Some people may have trouble following rapid-fire questioning or torrents of information. Try speaking more slowly to give them time to process what is being asked or said, and don’t interrupt. Once interrupted, a patient is less likely to reveal all of their concerns. If time is an issue, you might suggest that your patients prepare a list of their health concerns in advance of appointments.
- Speak plainly. Do not assume that patients know medical terminology. Use simple, common language and ask if clarification is needed. Check to be sure your patient understands the health issue, what they need to do, and why it is important to act.
- Address the patient face-to-face. Don’t talk to patients with your back turned or while typing. Many people with hearing impairment understand better when they can read lips as well as listen. Watching a patient’s body language can also help you know whether they understand what you’re saying.
- Write down or print out takeaway points. It can often be difficult for patients to remember everything discussed during an appointment. Older adults with more than one medical condition or health concern benefit especially from having clear and specific written notes or printed handouts. That way, they have information to review later about their health conditions, treatments, and other major points from visits.
- Recognize that people from different backgrounds may have different expectations. Be sensitive to cultural differences that can affect communication with your patients. When needed, provide professional translation services and written materials in different languages.
Compensating for hearing deficits
Age-related hearing loss is common: About one-third of older adults have hearing loss, and the chance of developing hearing loss increases with age. Here are a few tips to make it easier to communicate with a person who may have difficulty hearing:
- Make sure your patient can hear you. Ask if the patient has a working hearing aid, look at the auditory canal for excess earwax, and be aware of background noises, such as whirring computers and office equipment.
- Talk clearly and in a normal tone. Shouting or speaking in a raised voice distorts language sounds and can give the impression of anger, and a high-pitched voice can be hard to hear.
- Face the person directly, at eye level, so that they can lip read or pick up visual clues.
- Indicate to your patient when you are changing the subject, such as by pausing briefly, speaking a bit louder, gesturing toward what will be discussed, gently touching the patient, or asking a question.
- Keep a notepad handy so you can write down important points, such as diagnoses, treatments, and important terms.
- Use amplification devices if they are available in your clinic or hospital.
- If your patient has difficulty hearing the difference between certain letters and numbers, give context for them. For instance, “m as in Mary” or “five, six” instead of “56.” Be especially careful with letters that sound alike.
Compensating for visual deficits
Visual disorders become more common as people age. Here are some things you can do to help manage the difficulties in communication that can result from visual deficits:
- Make sure there is adequate lighting, including sufficient light on your face. Try to minimize glare.
- Check that your patient has brought and is wearing eyeglasses or contact lenses, if needed.
- Make sure that handwritten instructions are clear. When using printed materials, make sure the type is large enough (at least 14-point font) and the typeface is easy to read.
- If your patient has trouble reading because of low vision, consider providing alternatives, such as audio instructions, large pictures or diagrams, and large pillboxes with raised markings.
Families and caregivers as part of the health care team
Family members and other informal caregivers play a significant role in the lives of their loved ones. They may provide transportation and accompany an older adult to medical appointments. In many cases, they act as facilitators to help the patient express concerns and can reinforce the information you give. But first, to protect and honor patient privacy, check with the patient by asking how they see the companion’s role in the appointment.
It is important to keep the patient involved in their own health care and conversation. Whenever possible, try to sit so that you can address both the patient and companion face-to-face. Be mindful not to direct your remarks only to the companion.
You might ask the companion to step out of the exam room during part of the visit so you can raise sensitive topics and provide the patient some private time if they wish to discuss personal matters. For example, if you’re conducting a test of a patient’s cognitive abilities, you might ask the companion to step out so they can’t answer questions or cover for the patient’s cognitive lapses.
Some patients may ask that you contact their long-distance caregivers to discuss conditions or treatment plans. Make sure these patients fill out any necessary paperwork giving permission for you to speak with specific family members or friends if they are not present at the appointment.
Families may want to make decisions for a loved one. Adult children especially may want to step in for a parent who has cognitive impairment. If a family member has been named the health care agent or proxy, under some circumstances they have the legal authority to make care decisions. However, without this authority, the patient is responsible for making their own choices. When necessary, set clear boundaries with family members and encourage others to respect them.
Consider caregivers as “hidden patients”
Family caregivers face many emotional, financial, and physical challenges. They often provide help with household chores, transportation, and personal care, in addition to juggling their own jobs and families. Many also give medications, injections, and other treatments and may need advice or guidance on how to provide such medical care.
Caregivers often have their own health issues to manage as well. For example, they tend to have a higher risk of physical and mental health issues, sleep problems, and chronic conditions such as high blood pressure. It makes sense to view informal caregivers as “hidden patients” and to be alert for signs of illness, stress, and burnout. The long-term demands of caregiving tax the health of the caregiver and can also lead to unintentional elder abuse. Advise caregivers to talk with their own health care providers if they need help.
Caregivers may find it hard to make time for themselves, and your support and praise can help to sustain them. Encourage them to seek respite care so they can take a break to recharge. Colleagues such as social workers and other interdisciplinary team members may be able to recommend resources for caregivers.
Obtaining a thorough history
Obtaining a complete medical history — including current and past concerns, lifestyle, and family history — is crucial to good health care.
You may need to be especially flexible when obtaining the medical history of older patients. When possible, have the patient tell their story only once, even if other health care professionals in the office or home would typically assist in gathering the information. The process of providing their history to another staff member and then again to you can be tiring for patients.
Open-ended questions encourage a more comprehensive response, but yes-or-no or simple-choice questions may be helpful if the patient has trouble responding. Also be sure to ask if anything in a person’s health, medications, or lifestyle has changed since their last visit. 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.
Here are some strategies for obtaining a thorough history:
- Gather preliminary data. If feasible, request previous medical records or ask the patient or a family member to complete forms and worksheets at home or online prior to the appointment. Try to structure questionnaires for easy reading by using large type (at least 14-point font) and providing enough space between items for thorough responses. Keep any questionnaires meant to be filled out in the waiting room as brief as possible.
- Elicit current concerns. Older patients tend to have multiple chronic conditions. You might start the session by asking your patient to talk about their main concern. For example, “What brings you in today?” or “What is bothering you the most?”
- Ask prompting questions. The main concern may not be the first one mentioned, especially if it is a sensitive topic. Asking, for example, “Is there anything else?”, which you may have to ask more than once, helps to get all of the patient’s concerns on the table at the beginning of the visit. If there are too many concerns to address in one visit, plan with the patient to address some now and others next time. Encourage the patient (and their caregivers) to bring a written list of concerns and questions to a follow-up appointment.
- Discuss medications. Older people often take many medications prescribed by several different doctors and some drug interactions can lead to major complications. Suggest that patients bring a list of all of their prescription medications, over-the-counter drugs, vitamins, and dietary supplements, including the dosage and frequency of each. Or suggest that they bring everything with them in a bag. Check to ensure the patient is using each medication as directed.
- Ask about family history. The family history not only indicates the patient’s likelihood of developing some diseases but also provides information about the health of relatives who care for the patient or who might do so in the future. Knowing the family structure will help you evaluate what support may be available from family members.
- Ask about functional status. The ability to perform basic activities of daily living (ADLs) reflects and affects a patient’s health. There are standardized ADL assessments that can be done quickly in the office. Understanding an older patient’s usual level of functioning and learning about any recent significant changes are fundamental to providing appropriate health care.
- Consider a patient’s life and social history. Ask about where they live, who else lives in the home or nearby, neighborhood safety, their driving status, and access to transportation. Determine eating habits, assess their mood, and ask about tobacco, drug, and alcohol use. Factor in typical daily activities and work, education, and financial situations. Understanding a person’s life and daily routine can help you to understand how your patient’s lifestyle might affect their health care and to devise realistic, appropriate interventions.
Discussing medical conditions and treatments
Approximately 85% of older adults have at least one chronic health condition, and 60% have at least two chronic conditions. Clinicians can play an important role in educating patients and families about chronic health conditions and can connect them with appropriate community resources and services.
Most older patients want to understand their medical conditions and learn how to manage them. Likewise, family members and other caregivers can benefit from having this information. Physicians typically underestimate how much patients want to know and overestimate how long they spend giving information to patients. Devoting more attention to educating patients and their caregivers can improve patients’ adherence to treatment, increase patients’ well-being, and save you time in the long run.
Clear explanations of diagnoses are critical. Uncertainty about a health problem can be upsetting, and when patients do not understand their medical conditions, they are less likely to follow their treatment plans. It is helpful to begin by finding out what the patient understands about their condition, what they think will happen, and how much more they want to know. Based on the patient’s responses, you can correct any misconceptions and provide appropriate information.
Treatment plans need to involve patients’ input and consent. Ask about their goals and preferences for care and focus on what matters most to them. Check in with your patient about feasibility and acceptability throughout the process, thinking in terms of joint problem-solving and collaborative care. This approach can increase the patient’s satisfaction while reducing demands on your time.
Treatment might involve lifestyle changes, such as a more nutritious diet and regular exercise, as well as medication. Tailor the plan to the patient’s situation and lifestyle and try to reduce disruption to their routine. Keep medication plans as simple and straightforward as possible, indicating the purpose of each medication and when it should be taken. Tell the patient what to expect from the treatment.
These tips may help discussions about medical conditions and treatment plans:
- A doctor’s advice generally receives the greatest credence, so the doctor should introduce treatment plans. Other medical team members can help build on the doctor’s original instructions.
- Let your patients know that you welcome questions. Tell them how to follow up if they think of any additional questions later.
- Some patients won’t ask questions even if they want more information. Consider making information available even if it’s not explicitly requested.
- Offer information through more than one channel. In addition to talking with the patient, you can use fact sheets, drawings, models, or videos. In many cases, referrals to websites and support groups can be helpful.
- Encourage the patient or caregiver to take notes. It’s helpful to offer a pad and pencil. Active involvement in recording information may help your patient better retain information and adhere to the treatment plan.
- Repeat key points about the health problem and treatment plan at every office visit, providing oral and written instructions, and check that the patient and their caregiver understand the information.
- Provide encouragement and continued reinforcement for treatment or necessary lifestyle changes. Call attention to the patient’s strengths and offer ideas for improvement.
- Make it clear that a referral to another doctor, if needed, does not mean you are abandoning the patient.
Referring older patients to clinical trials
Clinical trials are the primary way we learn if a promising treatment is safe and effective. Patients who participate in clinical research help others by contributing to medical research. In some cases, they can also gain access to new treatments before they are widely available. However, participants may not know whether they are receiving the experimental treatment, a placebo, or standard care. Most clinical trials test short-term interventions related to a specific illness or condition. They are designed to test research hypotheses, not to provide regular health care.
For information about federally and privately funded clinical research, or to search for specific studies, visit ClinicalTrials.gov.
Confusion and cognitive problems
A patient may still seem confused despite your best efforts to communicate clearly. In those instances, work to:
- Support and reassure the patient, acknowledging when responses are correct or understood.
- Make it clear that the conversation is not a “test” but rather a search for information to help the patient.
- Consider having someone from your staff call the patient to follow up on instructions.
Cognitive impairment, however, is more than general confusion or normal cognitive aging. If you observe changes in an older patient’s cognition or memory, follow up with screening and diagnostic testing, as appropriate.
There are a variety of possible causes of cognitive problems, such as side effects from medications, metabolic and/or endocrine changes, delirium, or untreated depression. Some of these causes can be temporary and reversed with proper treatment. Other causes of cognitive problems, such as Alzheimer’s disease, are chronic conditions but may be treated with medications or nondrug therapies. Having an accurate diagnosis also can help families wanting to improve the person’s quality of life and better prepare for the future.
Caring for an older patient requires discussing sensitive topics related to safety, independence, and health. Older patients may be hesitant to bring up certain problems and other concerns such as:
- Advance care planning
- Elder abuse
- End of life
- Health care costs
- Long-term care
- Mental health issues, such as depression
- Sexuality and sexual health
- Social isolation and loneliness
- Substance use/misuse, including alcohol
- Urinary incontinence
There are techniques for broaching sensitive subjects that can help you successfully start the conversation. Try to take a universal, nonthreatening approach that frames the subject as a common concern of many older patients (such as, “Many people experience …” or “Some people taking this medication have trouble with...”). You can also share anecdotes about patients in similar circumstances, though always clearly maintaining patient confidentiality, to ease your patient into the discussion.
Some patients will still avoid issues that they think are inappropriate to discuss with clinicians. One way to overcome this hesitation is to keep informative brochures and materials readily available in the exam room and waiting areas.
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For more information about talking with your older patients
Gerontological Society of America
This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.
January 25, 2023