October 1999 Bulletin

Communicating with elderly depends on listening skills

By Sandra Lee Breisch

Ever been caught in a communication snafu with your aging patients? Don't spend enough time with them to determine their chief complaint and/or any hidden problems? Are your treatment plans and/or surgical procedures often misunderstood?

Here are some communication tips from geriatric experts that'll enhance medical care for your patients:

"Good communication often depends on good listening skills for both parties involved," explains Elton Strauss, MD, chief of orthopaedic trauma and reconstructive surgery, department of orthopaedic surgery, Mount Sinai Medical Center, New York. "It also means taking more time with the patient and being very patient with them," he says.

"Schedule elderly patients earlier in the morning because they tend to get tired. Later in the day, your practice tends to get busier and you've less time to talk to them. Also, try to have a nurse with them to help them get undressed and dressed. But be sure to talk or consult with them after the examination is over in the privacy of an office setting."

Communicate face-to-face with the individual, especially if the patient has a physical impairment such as a hearing or vision loss, says Myron Miller, MD, director of the division of geriatric medicine, Sinai Hospital, Baltimore. It's not unusual for a physician in a hospital setting to be off to the side or in a shadow or where there's a lot of competing sound, he notes.

Not sure if your aging patient has any physical impairments, cognitive or mild dementia problems? "You can simply ask the individual directly, 'Do you have an impairment?'" suggests Dr. Miller. "Or, if there's a family member around, inquire if there are any kinds of impediments in communications."

To test a patient's cognitive ability, try using a three-item recall screening, suggests Jane F. Potter, MD, chief, geriatrics and gerontology, University of Nebraska Medical Center and chair of American Geriatric Society's clinical practice committee. "Tell the patient you're giving them three things to remember: an apple, a table and a penny," she explains. "Say, 'I want you to repeat those three things.' If they didn't quite hear, keep saying it until they do hear all three.

Then, do some distracting activity such as continuing to talk to the patient about their orthopaedic problem. Two to three minutes later, ask the patient to recall all three items-not necessarily in order and without prompting. If they don't recall all three items, you've got to worry that this is a person who has an abnormal learning ability and/or cognitive impairment."

How can you be sure if the patient understands your treatment plan and/or surgical procedure? It's often difficult to know because the rate of learning new information is slowed particularly after age 70 and 75, Dr. Potter says.

"Older folk's noncompliance with their physician's verbal or written instructions is unintentional and often due to a misunderstanding," she explains. But providing visual information-clearly written instructions, educational brochures or videos-will bolster their memory.

Determining hidden medical problems unrelated to orthopaedic care is a challenge, but it can be done. Although many orthopaedists have multidisciplinary teams in place with social workers, geriatricians, psychiatrists, therapists who can weed out those problems, physicians located in rural areas often don't have such luxuries. Their nurse is usually their best and only resource because they usually perform part of the patient's intake service.

So, have your nurse ask a new and/or current patient to bring in their "drug bag," with both prescription and non-prescription drugs in hand. "Their drug bag will show you how many doctors they've been seeing for a multitude of health problems," notes Dr. Potter. "But remember, it's not a list of medicines you're asking for-but the actual medication," she stresses.

Is the individual capable of making his/her own medical decisions? If not, find out who is the authorized spokesperson for that individual. "The law lays out the progression to follow: a spouse, next of kin, some friends, neighbors or persons designated by the legal system such as a guardian," explains Dr.Miller.

What about a patient's right to privacy?

"I usually call a family member,"explains Dr. Strauss. "I always tell the patient I'm going to do this because of the legal problem with the right to privacy. And that patient has the right to privacy because if that patient says, 'Look, I don't want my daughter to know about this,' and I think the patient is coherent enough, I don't call the daughter. But I always give them the option of my speaking to their family-not so much for the surgery, but what's going to happen after they get discharged from the hospital."

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