Talking with Older Patients About Sensitive Subjects
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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.
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.
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.
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.
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.
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?"
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 health insurance.
Several resources may help patients pay for care. In addition, your State Health Insurance Assistance Program (SHIP) may help.
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.
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.
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.
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.
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 About Driving
1-877-342-2277 (español/línea gratis)
1-877-434-7598 (TTY/toll-free )
Federal Highway Administration
For More Information About Elder Abuse
Stop Medicare Fraud
For More Information About End of Life and Advance Directives
NHPCO offers educational resources, tools, and webinars for healthcare professionals on palliative care, including the Journal of Pain and Symptom Management.
For More Information About Financial Assistance
For More Information About Urinary Incontinence
For More Information About Long-Term Care
Nursing Home Compare
Centers for Medicare and Medicaid Services
U.S. Department of Veterans Affairs
For More Information About Mental Health
For More Information About Sexuality
Mayo Foundation for Medical Education and Research
For More Information About Substance Abuse
Updated: August 16, 2017