Heath and Aging

Talking With Your Older Patient: A Clinician's Handbook

Talking About Sensitive Subjects

At a Glance

  • Introduce sensitive topics with the "common concern" approach: "Many of us have more trouble with..." or "Some people taking this medication have trouble with..."
  • Keep educational materials available and visible to encourage discussion; the National Institute on Aging offers free brochures and booklets about many sensitive topics.
  • Raise topics such as safe driving, long-term care, advance directives, and end-of-life care before they become urgent matters.

A man talks to a physician.Caring for an older patient requires discussing sensitive topics. Many older people have a "don't ask, don't tell" relationship with healthcare providers about certain problems, such as driving, urinary incontinence, or sexuality. Hidden health issues, such as memory loss or depression, are a challenge. Addressing problems related to safety and independence, such as giving up one's driver's license or moving to assisted living, also can be difficult.

You may feel awkward and tempted to avoid addressing some of these concerns because you don't know how to help patients solve the problem. The information here gives an overview of techniques for broaching sensitive subjects, as well as resources for more information or support.

Try to take a universal, non-threatening approach. Start by saying, "You are not alone, many people experience..." or "Some people taking this medication have trouble with..." Try: "I have to ask you a lot of questions, some that might seem silly. Please don't be offended..."

Another approach is to tell anecdotes about patients in similar circumstances as a way to ease your patient into the discussion. Of course, always maintain patient confidentiality to reassure the patient with whom you are talking that you won't disclose personal information about him or her.

Some patients avoid issues that they think are inappropriate to discuss with clinicians. One way to overcome this is to keep informative brochures and materials readily available in the waiting room. Organizations offering relevant resources are listed within each topic area. NIA also has free online and print publications, some of which are listed at the end of this chapter.

Driving

Recommending that a patient limit driving—or that a patient give up his or her driver's license—is one of the most difficult topics a doctor has to address. Driving is associated with independence and identity, and making the decision not to drive is very hard.

As with other difficult subjects, try to frame it as a common concern of many patients. Mention, for instance, that certain health conditions can lead to slowed reaction times and impaired vision. In addition, it may be harder to move the head to look back, quickly turn the steering wheel, or safely hit the brakes.

"Many people your age experience similar problems."

older manDuring a regular exam, Mr. Abayo, age 80, acknowledges that trouble with his shoulder started after he had a car accident. "Many of my patients are worried about being safe drivers," Dr. Carli says. "I know it can be hard to stop driving, but maybe your children can help you get around. I can also suggest some transportation services in the area." She gives Mr. Abayo a pamphlet on older drivers and the phone number of a local transportation resource.

When applicable, warn patients about medications that may make them sleepy or impair judgment. Also, a device such as an automatic defibrillator or pacemaker might cause irregular heartbeats or dizziness that can make driving dangerous.

Ask the patient about any car accidents. You might ask if she or he has thought about alternative transportation methods if driving is no longer an option. Your local Area Agency on Aging may be able to help patients find alternative methods of transportation. Contact the Eldercare Locator at 1-800-677-1116 for your Area Agency on Aging.

For more information on safe driving, contact:

AAA Senior Driving
1-202-638-5944
publicaffairs@national.aaa.com
www.seniordriving.aaa.com

This website has links to help seniors evaluate their driving abilities, improve their driving skills, know the licensing laws in their states, and even find transportation services in their community.

AARP
1-888-687-2277 (toll-free)
1-877-342-2277 (español/línea gratis)
1-877-434-7598 (TTY/toll-free )
member@aarp.org
www.aarp.org/home-garden/transportation/driver_safety

The AARP Driver Safety Program offers classes to help motorists over the age of 50 improve their driving skills.

American Geriatrics Society
1-212-308-1414
info.amger@americangeriatrics.org
www.americangeriatrics.org

AGS has programs in patient care, research, professional and public education, and public policy. Among its resources is the Physician’s Guide to Assessing and Counseling Older Drivers.

Eldercare Locator
1-800-677-1116
www.eldercare.gov

The Eldercare Locator offers referrals to and information on services for seniors by geographic location.

Federal Highway Administration
1-804-775-3381
http://safety.fhwa.dot.gov/older_users/

The FHA website links to a variety of resources that promote older driver safety.

National Association of Area Agencies on Aging
1-202-872-0888
info@n4a.org
www.n4a.org

This membership association provides brochures for older people, professional resources, and training opportunities through its website.

National Highway Traffic Safety Administration
1-800-934-8517 (toll-free)
1-800-424-9153 (TTY/toll-free)
NCSAWeb@dot.gov
www.nhtsa.gov/Senior-Drivers

NHTSA offers resources for people who may be concerned about an older driver, including a booklet on talking about driver safety.

Elder Abuse and Neglect

Be alert to the signs and symptoms of elder abuse. If you notice that a patient delays seeking treatment or offers improbable explanations for injuries, for example, you may want to bring up your concerns. The laws in most States require healthcare professionals to report suspected abuse or neglect.

Older people caught in an abusive situation are not likely to say what is happening to them for fear of reprisal or because of diminished cognitive abilities. If you suspect abuse, ask about it in a constructive, compassionate tone.

If the patient lives with a family caregiver, you might start by saying that caregiver responsibilities can cause a lot of stress. Stress sometimes may cause caregivers to lose their temper. You can assist by recommending a support group or alternative arrangements, such as respite care. Give the patient opportunities to bring up this concern, but if necessary, raise the issue yourself.

If a family member or other caregiver accompanies the patient to an appointment, you might ask the companion to step out of the exam room during part of the visit so that you can express your concern.

For more information on elder abuse, contact:

National Center on Elder Abuse
1-855-500-3537 (toll-free)
ncea@med.usc.edu
www.ncea.aoa.gov

Directed by the Administration for Community Living, NCEA works with healthcare and social service practitioners, policy makers, the justice system, researchers, advocates, and families. Its website includes training resources and webinars.

National Committee for the Prevention of Elder Abuse
1-202-464-9481
info@preventelderabuse.org
www.preventelderabuse.org/elderabuse

NCPEA offers information and materials on abuse and neglect, including resources for healthcare professionals on elder abuse prevention.

Stop Medicare Fraud
1-800-447-8477 (toll-free)
1-800-377-4950 (TTY/toll-free)
www.stopmedicarefraud.gov

Hosted by the U.S. Department of Health and Human Services and U.S. Department of Justice, this website has information and resources about how to identify, prevent, and report fraud. The site includes a section for healthcare providers.

U.S. Department of Justice
1-202-514-2000
elder.justice@usdoj.gov
www.justice.gov/elderjustice

This website has information on how to report elder abuse and financial exploitation, as well as resources to help healthcare professionals prevent elder abuse and resources to help people who have been abused, neglected, or exploited.

End of Life and Advance Directives

Many older people have thought about the prospect of their own death and are willing to discuss their wishes regarding end-of-life care. You can help ease some of the discomfort simply by being open and willing to talk about dying and related issues or concerns.

You may feel uncomfortable raising the issue, fearing that patients will assume the end is near. But, in fact, this conversation is best begun well before end-of-life care is appropriate. It may be helpful to talk about a patient's thoughts, values, and desires related to end-of-life care early in your relationship, perhaps when first discussing medical and family history.

Let your patients know that advance care planning is a part of good health care. You can say that, increasingly, people realize the importance of making plans while they are still healthy. You can let them know that these plans can be revised and updated over time or as their health changes.

With a healthy patient, an advance care planning discussion can be relatively brief. Encourage your patients to share the type of care they would choose to have at the end of life, rather than what they don't want. Suggest they discuss end-of-life decisions with family members and other important people in their lives.

Be sure to put a copy of the signed living will, durable power of attorney for health care, or other documents discussing do not resuscitate orders, organ/tissue donation, dialysis, and blood transfusions in the medical record. Too often, forms are completed but cannot be found when needed. Many organizations now photocopy the forms on neon-colored paper, which is easy to spot in the medical record.

Considering End of Life

If your patient is in the early stages of an illness, it's important to assess whether or not the underlying process is reversible. It's also a good time to discuss how the illness is likely to progress. If your patient is in the early stages of a cognitive problem, it is especially important to discuss advance directives.

Of course, it is not always easy to determine who is close to death; even experienced clinicians find that difficult to predict. If you have already talked with your patient about end-of-life concerns, it still can be hard to know the right time to re-introduce this issue.

Stay alert to cues that the patient may want to talk about this subject again. Some clinicians find it helpful to ask, "Would I be surprised if Mr. Flowers were to die this year?" If the answer is "no," then it makes sense to address end-of-life concerns with the patient and family, including pain and symptom management, home health, and hospice care. You can offer to help patients review their advance directives. Include any updates in the patient's medical record to ensure he or she receives desired care.

For some older people, spirituality takes on new meaning as they age or face serious illness. How a patient views the afterlife can also sometimes help in framing the conversation about serious illness and end-of-life care. Clinicians have found that very direct and simple questions are the best way to broach this subject. You might start, for instance, by asking, "What has helped you to deal with challenges in the past?"

For more information on end-of-life care and advance directives, contact:

Aging with Dignity
1-888-594-7437 (toll-free)
fivewishes@agingwithdignity.org
www.agingwithdignity.org

This organization provides an easy-to-read advance care planning document called Five Wishes.

Education in Palliative and End-of-life Care
Northwestern University Feinberg School of Medicine
1-312-503-3732
info@epec.net
www.epec.net

This group provides physicians the basic knowledge and skills needed to care for dying patients.

National Hospice and Palliative Care Organization
1-703-837-1500
nhpco_info@nhpco.org
www.nhpco.org

NHPCO offers educational resources, tools, and webinars for healthcare professionals on palliative care, including the Journal of Pain and Symptom Management.

NHPCO's CaringInfo
1-800-658-8898 (toll-free)
caringinfo@nhpco.org
www.caringinfo.org

This website offers consumer-oriented resources related to end-of-life and palliative care, including guidance for completing advance directives and links to each State's advance directive forms. Resources are also available in Spanish.

Financial Barriers

Rising healthcare costs make it difficult for some people to follow treatment regimens. Your patients may be too embarrassed to mention financial concerns. Studies have shown that many clinicians also are reluctant to bring up costs.

If possible, designate an administrative staff person who has good bedside manner to discuss money and payment questions. This person can also talk with your patient about changes in Medicare Part D prescription drug coverage plans and the Affordable Care Act.

The resources in this section may be useful when you talk with your patients about their financial concerns. In addition, your State Health Insurance Assistance Program (SHIP) may help.

For more information on financial assistance, contact:

Benefits.gov

This Federal website provides easy, online access to government benefit and assistance programs, including a "Benefit Finder."

Medicare Rights Center
1-800-333-4114 (toll-free)
info@medicarerights.org
www.medicarerights.org

The toll-free consumer hotline provides free counseling services about insurance choices, Medicare rights and protections, payment denials and appeals, complaints about care or treatment, and Medicare bills.

National Council on Aging
1-571-527-3900
www.ncoa.org/get-involved/contact-us/email (email form)
www.benefitscheckup.org

The Council’s online resource offers a searchable list of programs that can help with healthcare costs.

Partnership for Prescription Assistance
www.pparx.org/about_us/contact_us (email form)
www.pparx.org

Many pharmaceutical companies offer reduced medication fees for patients who meet certain income requirements and other criteria. The website has a directory of prescription drug patient-assistance programs.

State Health Insurance Assistance Programs
1-877-839-2675 (toll-free)
info@shiptacenter.org
www.shiptacenter.org

The SHIP program provides free, in-depth, one-on-one insurance counseling and assistance to Medicare beneficiaries, their families, and caregivers.

Incontinence

More than half of women and more than one quarter of men age 65 and older report experiencing some urinary leakage. Several factors can contribute to incontinence. Childbirth, infection, certain medications, and some illnesses are examples.

Additionally, people of any age can have a bowel control problem, though fecal incontinence is more frequent in older adults. Fecal incontinence has many causes, such as muscle damage or weakness, nerve damage, loss of stretch in the rectum, hemorrhoids, and rectal prolapse.

Incontinence may go untreated because patients are often embarrassed to mention it. Be sure to ask specifically about the problem. Try the "some people" approach. For example, you might say "When some people cough or sneeze, they leak urine. Have you had this problem?" You may want to explain that incontinence can often be significantly improved, for instance through bladder or bowel training, pelvic floor exercises and biofeedback, changes in diet and nutrition, as well as medication and surgery for certain types of incontinence.

For more information on urinary incontinence, contact:

National Institute of Diabetes and Digestive and Kidney Diseases
1-800-860-8747 (toll-free)
1-866-569-1162 (TTY/toll-free)
healthinfo@niddk.nih.gov
www.niddk.nih.gov

Part of the National Institutes of Health, NIDDK has online publications about urinary incontinence and provides links to resources and support groups.

The Simon Foundation for Continence
1-800-237-4666 (toll-free)
info@simonfoundation.org
www.simonfoundation.org

The Foundation provides information about cure, treatment, and management techniques for incontinence.

Urology Care Foundation
1-800-828-7866 (toll-free)
info@urologycarefoundation.org
www.urologyhealth.org

The Foundation provides information on the prevention, detection, management, and cure of urologic diseases.

Long-Term Care

Long-term care includes informal caregiving, assisted living, home health services, adult day care, nursing homes, and community-based programs.

Early in your relationship with an older patient, you can begin to talk about the possibility that he or she may eventually require long-term care of some kind. By raising this topic, you are helping your patient think about what he or she might need in the future and how to plan for those needs. For instance, you might talk about what sort of assistance you think your patient will need, how soon in the future he or she will need the extra help, and where he or she might get this assistance.

For more information on long-term care, contact:

Eldercare Locator
1-800-677-1116 (toll-free)
www.eldercare.gov

The Eldercare Locator offers referrals to and information on services for seniors by geographic location.

Nursing Home Compare
Centers for Medicare and Medicaid Services
1-800-633-4227 (toll-free)
1-877-486-2048 (TTY/toll-free)
www.medicare.gov/nhcompare/home.asp

Medicare provides an online resource with detailed information about the past performance of every Medicare- and Medicaid-certified nursing home in the country.

U.S. Department of Veterans Affairs
1-877-222-8387 (toll-free)
www.va.gov/healthbenefits

The Department provides information about VA health benefits for veterans who served in the active military, naval, or air service.

Mental Health

Despite many public campaigns to educate people about mental health and illness, there is still a stigma attached to mental health problems. Some older adults may find mental health issues difficult to discuss.

Such conversations, however, can be lifesavers. Primary care doctors have a key opportunity to recognize when a patient is depressed and/or suicidal. Many older patients who commit suicide saw a primary care physician within the previous month. This makes it especially important for you to be alert to the signs and symptoms of depression.

As with other subjects, try a general approach to bringing up mental health concerns. For example, "A lot of us develop sleep problems as we get older, but this can be a sign of depression, which sometimes we can treat." Because older adults may have atypical symptoms, it is important to listen closely to what your patient has to say about trouble sleeping, lack of energy, and general aches and pains. It is easy to dismiss these as "just aging" and leave depression undiagnosed and therefore untreated.

For more information on mental health, contact:

American Association for Geriatric Psychiatry
1-703-556-9222
main@aagponline.org
www.aagponline.org

The Association promotes the mental health and well-being of older people and works to improve the care of those with late-life mental disorders.

National Institute of Mental Health
1-866-615-6464 (toll-free)
1-866-415-8051 (TTY/toll-free)
nimhinfo@nih.gov
www.nimh.nih.gov

Part of the National Institutes of Health, NIMH funds and conducts mental health research and distributes information to health professionals and the public.

Substance Abuse and Mental Health Services Administration
1-877-726-4727 (toll-free)
1-800-487-4889 (TTY/toll-free)
samhsainfo@samhsa.hhs.gov
www.samhsa.gov
www.findtreatment.samhsa.gov

SAMHSA leads public health efforts to advance behavioral health and reduce the impact of substance abuse and mental illness on America's communities.

Sexuality

An understanding, accepting attitude can help promote a more comfortable discussion of sexuality. Try to be sensitive to verbal and other cues. Don't assume that an older patient is heterosexual, no longer sexually active, or does not care about sex. Research has found that a majority of older Americans are sexually active and view intimacy as an important part of life.

Depending on indications earlier in the interview, you may decide to approach the subject directly. For example, "Are you satisfied with your sex life?" Or, you might approach it more obliquely, with allusions to changes that sometimes occur in marriage. If appropriate, follow up on patient cues.

You might note that patients sometimes have concerns about their sex lives and then wait for a response. It is also effective to share anonymous anecdotes about a person in a similar situation or to raise the issue in the context of physical findings. For example, "Some people taking this medication have trouble... Have you experienced anything like that?"

Don't forget to talk with your patient about the importance of safe sex. For example, "It's been a while since your husband died. If you are considering dating again, would you like to talk about how to have safe sex?" Any person, regardless of age, who has unprotected sex can be at risk of sexually transmitted diseases.

For more information on sexuality, contact:

AIDSinfo
1-800-448-0440 (toll-free; weekdays, 1-4 p.m. ET)
1-888-480-3739 (TTY/toll-free)
ContactUs@aidsinfo.nih.gov
www.aidsinfo.nih.gov

A service of the U.S. Department of Health and Human Services, AIDSinfo offers information on HIV/AIDS treatment, prevention, and research.

Centers for Disease Control and Prevention
1-800-232-4636 (toll-free)
1-888-232-6348 (TTY/toll-free)
NPIN-info@cdc.gov
www.cdc.gov/hiv/risk/age/olderamericans
http://npin.cdc.gov

CDC provides statistics and other information about HIV/AIDS and older people. CDC’s National Prevention Information Network connects public health professionals with trusted information about sexual health.

Mayo Foundation for Medical Education and Research
www.mayoclinic.org/healthy-lifestyle/sexual-health/basics/sexual-health-basics/hlv-20049432

This website has articles about sexual health and sexuality for adults age 50 and older.

National Institute of Allergy and Infectious Diseases
1-866-284-4107 (toll-free)
1-800-877-8339 (TTY/toll-free)
ocpostoffice@niaid.nih.gov
www.niaid.nih.gov

Part of the National Institutes of Health, NIAID provides information about many sexually transmitted diseases.

Services & Advocacy for Gay, Lesbian, Bisexual & Transgender Elders
1-212-741-2247
info@sageusa.org
www.sageusa.org

SAGE offers services and programs to LGBT older people. The organization also trains aging providers and LGBT organizations on the best ways to support LGBT older people in long-term care settings.

Sexuality Information and Education Council of the United States
1-202-265-2405
admin@siecus.org
www.siecus.org

The Council provides education and information about sexuality and sexual and reproductive health.

Substance Abuse

Alcohol and drug abuse are major public health problems, even for older adults. Sometimes, people can become dependent on alcohol or other drugs as they confront the challenges of aging, even if they did not have a problem when younger. Because baby boomers have a higher rate of lifetime substance abuse than did their parents, the number of people in this age group needing treatment is likely to grow.

One approach you might try is to mention that some medical conditions can become more complicated as a result of alcohol and other drug use. Another point to make is that alcohol and other drugs can increase the side effects of medication, or even reduce the medicine's effectiveness. From this starting point, you may find it easier to talk about alcohol or other drug use.

For more information on substance abuse, contact:

National Institute on Alcohol Abuse and Alcoholism
1-888-696-4222 (toll-free)
niaaaweb-r@exchange.nih.gov
www.niaaa.nih.gov

Part of the National Institutes of Health, NIAAA supports and conducts research on the impact of alcohol use on human health and well-being, and is the largest funder of alcohol research in the world.

National Institute on Drug Abuse
1-301-443-1124
www.drugabuse.gov/about-nida/contact-nida (email form)
www.drugabuse.gov

Part of the National Institutes of Health, NIDA supports and conducts research on the science of drug abuse and addiction. NIDA also offers drug abuse screening tools, publications, and other information resources.

Substance Abuse and Mental Health Services Administration
1-877-726-4727 (toll-free)
1-800-487-4889 (TTY/toll-free)
webmaster@samhsa.hhs.gov
www.samhsa.gov
www.findtreatment.samhsa.gov

SAMHSA leads public health efforts to advance behavioral health and reduce the impact of substance abuse and mental illness on America's communities.

NIA has free health and aging materials in English and Spanish. Some are easy-to-read publications. You can download or order copies online at www.nia.nih.gov/health.

Driving

Elder Abuse and Neglect

End of Life and Advance Directives

Financial Barriers

Incontinence

Long-Term Care

Mental Health

Sexuality

Substance Abuse

Also visit www.nihseniorhealth.gov, a senior-friendly website from NIA and the National Library of Medicine that has health and wellness information for older adults.

 

Publication Date: April 2016
Page Last Updated: July 29, 2016