Obtaining medical history may pose special challenges
As the U.S. population ages, clinicians are seeing more and more older patients and they are seeing them with greater frequency. In 1991, older people averaged eight visits to a physician a year. Some researchers anticipate the number of physician visits by the growing population of people age 65 to 74 will nearly double between 1980 and 2040.
According to the Academy's research report, Orthopaedic Practice in the U.S., 1994/1995, 25 percent of all patients treated by orthopaedic surgeons involved patients aged 65 and older. This group accounted for 13 percent of the U.S. population in 1994.
The National Institute on Aging has developed Working with Your Older Patient: A Clinician's Handbook, for physicians-in-training and other health care professions and for experienced clinicians. Following is an excerpt.
When patients are older, obtaining a good history of current concerns, family health experience, medications, and social situation is crucial to sound health care. But doing so poses special challenges. The following ideas can aid in obtaining appropriate information with minimal strain on both you and the patient.
Although these suggestions may appear time-consuming, many of them involve a one-shot investment of time and can be performed by a variety of health care professionals in an office or home setting. You may also find it works best to schedule several short visits rather than trying to cover all these subjects at once.
The varied nature and needs of older patients call for flexibility in interviewing. Here are some measures to consider.
If feasible, gather preliminary data before the session. Request previous medical records, have the patient or family complete a questionnaire at home or in the waiting room, or obtain information from the patient by telephone. Structure questionnaires for easy reading by using large enough type and providing enough space between items. If questionnaires are to be filled out in the waiting room, keep them relatively short.
Try to avoid making the patient tell his or her story more than once - first to a nurse and then to you. This can be tiring, especially if the patient has limited energy.
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 obtaining a complete evaluation of the present illness.
In the review of systems, remember to ask about often-overlooked problems, such as difficulty sleeping, incontinence, falling, depression, dizziness, or loss of energy.
Pace the interview. An older patient may need extra time to formulate answers. Resist the tendency to interrupt prematurely.
If the patient has trouble coping with open-ended questions, make greater use of yes-or-no or simple choice questions.
Remember that the interview itself can be therapeutic. Although for you the patient is one of many, for the patient you may be one of the most important individuals in his or her life. The patient's chance to express concerns and to receive your attention can itself prove therapeutic.
Although younger patients often have well-defined chief complaints reflecting classic presentation of single diseases, older patients tend to have multiple chronic conditions and show vague, atypical presentations of disorders. Thinking in terms of current concerns rather than a chief complaint may be more appropriate. Following are some considerations to keep in mind.
Research shows that shortly after asking a patient his or her chief concerns, physicians commonly interrupt and turn to other matters. Try to resist this tendency and give the patient enough time to answer your questions.
If a patient has ongoing problems that were discussed in previous visits, the temptation exists to begin by asking about them. Starting an interview with past concerns may leave the patient's current concerns unarticulated until the end of the allotted time. Try beginning with general questions such as "How can I help you most at this visit?" or "What's been happening?"
Encourage the patient and his or her caregivers to bring a list of their main concerns and questions to help ensure that these issues are discussed.
Sometimes an older patient will see a physician because of concerns of family members or caregivers. Find out whose concern led to the visit.
Even if a patient's chief concern is not the problem that is medically most important, you must deal with that concern. For example, an older patient may see you about a minor foot problem and be found to have dangerously high blood pressure or cognitive impairment. Only if the foot problem is addressed is the patient likely to follow your recommendations regarding blood pressure control or mental status testing.
Symptoms in older people tend to be nonspecific, but the rate at which the symptoms develop can indicate whether an acute problem exists. Therefore, determine how fast the patient's condition has been changing.
Sometimes a patient is not comfortable enough to express a concern, such as the death of a close relative or friend, until the end of an interview. To give such patients an opening, end with a question such as "Is there anything else you'd like to discuss?"
Side effects, interactions, and misuse of medications can lead to complications causing morbidity in older people. It is crucial to find out what medications older patients are using and how often they are taken. Older people often take many medications prescribed by several different doctors, e.g., general internists, cardiologists, urologists, or rheumatologists.
Ask the patient to bring all the medications he or she is taking, both prescription and over-the-counter, to your office. A good approach is to have the patient put everything in a brown bag and bring it to each visit.
Find out about the patient's habits of taking each medication. Ask what each one is for.
Knowing an older patient's usual level of functioning, and learning of recent changes in it, are basic to providing appropriate health care.
The ability to perform basic activities of daily living (ADL) both reflects and affects a patient's health. It also influences which treatment regimens are suitable. Depending on the patient's status, ask about ADLs such as eating, bathing, and dressing and more complex instrumental activities of daily living (IADL) such as cooking, shopping, and managing finances.
Sudden changes in ADLs or IADLs are valuable diagnostic clues. In older people, serious conditions such as infections and infarctions often produce a decline in functional ability or confusion rather than symptoms such as fever or pain. If an older person stops eating, becomes confused or incontinent, or stops getting out of bed, look for underlying medical problems. Keep in mind the possibility the problem may be acute.
To order a copy of Working With Your Older Patient: A Clinician's
Handbook, write to the National Institutes on Aging Information
Center, P.O. Box 8057, Gaithersburg, Md. 20898-8057 or call the
NIA Information Center at
Orthopaedic practice distribution by age of patient.
Source: American Academy of Orthopaedic Surgeons, research department