Talking With Your Older Patient

Transcription

1 A CLINICIAN S HANDBOOK Taking With Your Oder Patient NATIONAL INSTITUTE ON AGING NATIONAL INSTITUTES OF HEALTH DEPARTMENT OF HEALTH AND HUMAN SERVICES

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3 Contents Foreword 1 1. Considering Heath Care Perceptions I m unti I ook in the mirror. 2. Understanding Oder Patients Te me more about how you spend your days. 3. Obtaining the Medica History What brings you here today? 4. Encouraging Weness I d ike you to try this exercise routine. 5. Taking About Sensitive Subjects Many peope your age experience simiar probems. 6. Supporting Patients With Chronic Conditions Let s discuss iving with Breaking Bad News I wish I had better news. 8. Working With Diverse Oder Patients Cutura differences, not divides. 9. Incuding Famiies and Caregivers What woud you ike your famiy to know? 10. Taking With Patients About Cognitive Probems You mentioned having troube with your memory. 11. Keeping the Door Open Effective Communication Pubications At-a-Gance Services At-a-Gance Tear-Off Card

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5 Foreword Good communication is an important part of the heaing process. Studies find that effective physician-patient communication has specific benefits: patients are more ikey to adhere to treatment and have better outcomes, they express greater satisfaction with their treatment, and they are ess ikey to bring mapractice suits. Research aso shows that good communication is a teachabe ski. Medica students who receive communication training improve dramaticay, not ony in communicating with patients, but aso in assessing and buiding reationships with them. Time management skis aso get better. Interpersona and communication skis are now a core competency identified by the Accreditation Counci on Graduate Medica Education (ACGME) and the American Board of Medica Speciaties (ABMS). Learning effective communication techniques and using them may hep you buid more satisfying reationships with oder patients and become even more skied at managing their care. Communicating with oder patients invoves specia issues. For exampe: How can you effectivey interact with patients facing mutipe inesses and/or hearing and vision impairments? What s the best way to approach sensitive topics such as driving privieges or assisted iving? Are there ways to hep oder patients who are experiencing confusion or memory oss? With questions ike these in mind, the Nationa Institute on Aging (NIA), part of the Nationa Institutes of Heath, deveoped this booket. foreword 1

6 Athough referring to cinicians throughout the text, this booket is intended for use by a range of professionas deaing directy with patients physicians, physicians-in-training, nurse practitioners, nurses, physician assistants, and other heath care professionas. The aim is to introduce and/or reinforce communication skis essentia in caring for oder patients and their famiies. Taking With Your Oder Patient: A Cinician s Handbook offers practica techniques and approaches to hep with diagnosis, promote treatment adherence, make more efficient use of cinicians time, and increase patient and provider satisfaction. Three points are important to remember: Stereotypes about aging and od age can ead patients and heath professionas aike to dismiss or minimize probems as an inevitabe part of aging. What we re earning from research is that aging aone does not cause iness and that growing oder does not automaticay mean having to ive with pain and discomfort. Many of this booket s suggestions may, at first gance, appear to be time-consuming, especiay given the time constraints of most cinicians. However, an initia investment of time can ead to ong-term gains for physicians and patients. Time-intensive practices need not be inefficient. You may get to know your oder patient s ife history over the course of severa visits rather than trying to get it a in one session. Oder patients are diverse and unique, just ike your younger patients. You may see frai 60-year-ods and reativey heathy 80-year-ods. Your patients may be cuturay diverse. Some may be quite active whie others may be sedentary. The techniques offered here encourage you to view a oder peope as individuas who have a wide range of heath care needs and questions. Many physicians, nurses, researchers, and other heath care professionas were generous in providing information and advice on making this edition of the Cinician s Handbook usefu. The Institute is gratefu for their thoughtfu contributions. Richard J. Hodes, M.D., Director Nationa Institute on Aging Nationa Institutes of Heath 2 foreword

7 chapter 1 Considering Heath Care Perceptions The best way to earn what is and is not acceptabe is to communicate directy with patients and caregivers. I m unti I ook in the mirror. Mrs. Hi is an 85-year-od nursing home resident. She has ived in a faciity since advanced heart disease made it impossibe for her to ive independenty. Her adut chidren fee that ife in a nursing home must be a nightmare. They want to do something, but they don t know what. Moving her to one of their homes isn t an option; visiting her makes them fee depressed. One day, her doctor chats with Mrs. Hi about ife in the home. She tes him that this is one of the best times of her ife peope prepare and deiver her meas, she has a comfortabe room with a view of the gardens, and the pace is very peacefu. Mrs. Hi is quite happy and has no desire to move. For Mrs. Hi, a ife her chidren find unacceptabe is, in fact, just fine with her. What seems intoerabe to a 40-year-od may actuay be preferred by a 90-year-od. In the past century, the nature of od age has changed dramaticay. In the eary 1900s, the average ife expectancy was about 49 years today, it is neary 80 years. With ongevity, however, comes the sobering news that oder considering heath care perceptions 3

8 peope may ive for years with one or more chronic, potentiay disabing conditions. This means they wi have an ongoing need for medica services. No singe characteristic describes an oder patient. Each person has a different view of what it means to be od. A 68-year-od woman with an active consuting business is ikey to dea with a visit to the doctor quite differenty from her frai 88-year-od aunt who rarey ventures beyond her neighborhood. The perspectives that foow are common among oder peope and important to consider when taking with oder patients. Views of Physicians and Cinicians In the past, oder peope have hed doctors in high esteem and treated them with deference. This view may change over time as aging baby boomers are ikey to take a more egaitarian and active approach to their own heath care. Today, many oder peope don t want to waste the doctor s time with concerns they think the cinician wi deem unimportant. Patients sometimes worry that if they compain too much about minor issues, they won t be taken seriousy ater on. Or, they are afraid of the diagnosis or treatment. They may worry that the physician wi recommend surgery or suggest costy diagnostic tests or medications. Some patients do not ask questions for fear of seeming to chaenge the cinician. On the other hand, some oder peope, having ampe time and interest, wi bring popuar medica artices to the attention of their providers. This kind of active patient participation can provide an opportunity for communication. Views of Aging Ageism can work both ways. Doctors can make assumptions about their oder patients. Oder peope may unwittingy assume the stereotypes of od age. Expectations regarding heath diminish with age, sometimes reaisticay, but often not. Oder peope with treatabe symptoms may dismiss their probems as an inevitabe part of aging and not get medica care. As a resut, they may 4 considering heath care perceptions

9 suffer needess discomfort and disabiity. Some may not even seek treatment for serious conditions. The process of aging may be troubing for oder aduts. It can be especiay hard for peope who once bounced back quicky from an iness or were generay heathy. Experts observe that baby boomers bring different expectations, experiences, and preferences to aging than did previous generations. For instance, some boomers are ikey to want to participate activey in heath care treatments and decisions. They may aso search the Internet for heath information. Vaues About Heath Athough physicians typicay focus primariy on diagnosing and treating disease, oder peope generay care most about maintaining the quaity of their ives. They are not necessariy preoccupied with death. In fact, many oder peope are reativey accepting of the prospect of death and seek chiefy to make the most of their remaining years. Younger famiy members, who commony must make ife-and-death decisions when an oder person is incapacitated, may be unaware of the patient s views and preferences. In Summary Let oder patients know that you wecome their questions and participation. Encourage oder aduts to voice their concerns. Be aert to barriers to communication about symptoms, such as fears about oss of independence or costs of diagnostic tests. Expect those in the baby boom generation to be more active participants in their heath care. considering heath care perceptions 5

10 Understanding Oder Patients What was once caed bedside manner and considered a matter of etiquette and persona stye has now been the subject of a arge number of empirica studies. The resuts of these studies suggest that the interview is integra to the process and outcomes of medica care. Te me more about how you spend your days. Athough she compains of her oneiness and ong days in front of the TV, Mrs. Kein refuses to participate in activities at the community senior center. I m not paying bingo with a bunch of od adies, she tes her doctor when he suggests she get out more. You ve mentioned how much you ove to garden, her doctor says. The center has a garden cub with a master gardener. One of my other patients says she oves it. I don t want to hang around od peope who have nothing better to do than compare heath probems, she says. Why not give it a try? her doctor asks. You might find the members are pretty active gardeners. Six months ater, when she sees the doctor again, Mrs. Kein thanks him. She has joined the garden cub and reports that the members a have green thumbs as we as being quite ivey conversationaists. Better sti, Mrs. Kein s depressive symptoms seem improved. 6 understanding oder patients

11 chapter 2 Effective communication has practica benefits. It can: hep prevent medica errors strengthen the patient-provider reationship make the most of imited interaction time ead to improved heath outcomes This chapter provides tips on how to communicate with oder patients in ways that are respectfu and informative. Use Proper Form of Address Estabish respect right away by using forma anguage. As one patient said, Don t ca me Edna, and I won t ca you Sonny. You might ask your patient about preferred forms of address and how she or he woud ike to address you. Use Mr., Mrs., Ms., and so on. Avoid using famiiar terms, ike dear and hon, which tend to sound patronizing. Be sure to tak to your staff about the importance of being respectfu to a of your patients, especiay those who are oder and perhaps used to more forma terms of address. Make Oder Patients Comfortabe Ask staff to make sure patients have a comfortabe seat in the waiting room and hep with fiing out forms if necessary. Be aware that oder patients may need to be escorted to and from exam rooms, offices, and the waiting area. Staff shoud check on them often if they have to wait ong in the exam room. Take a Few Moments to Estabish Rapport Introduce yoursef ceary. Show from the start that you accept the patient and want to hear his or her concerns. If you are a consutant in a hospita setting, remember to expain your roe or refresh the patient s memory of it. In the exam room, greet everyone and apoogize for any deays. With new patients, try a few comments to promote rapport: Are you from this area? or Do you have famiy nearby? With estabished patients, friendy questions about their famiies or activities can reieve stress. understanding oder patients 7

12 Try Not to Rush Avoid hurrying oder patients. Time spent discussing concerns wi aow you to gather important information and may ead to improved cooperation and treatment adherence. Feeing rushed eads peope to beieve that they are not being heard or understood. Be aware of the patient s own tendency to minimize compaints or to worry that he or she is taking too much of your time. Avoid Interrupting One study found that doctors, on average, interrupt patients within the first 18 seconds of the initia interview. Once interrupted, a patient is ess ikey to revea a of his or her concerns. This means finding out what you need to know may require another visit or some foow-up phone cas. Oder peope may have troube foowing rapid-fire questioning or torrents of information. By speaking more sowy, you wi give them time to process what is being asked or said. If you tend to speak quicky, especiay if your accent is different from what your patients are used to hearing, try to sow down. This gives them time to take in and better understand what you are saying. Use Active Listening Skis Face the patient, maintain eye contact, and when he or she is taking, use frequent, brief responses, such as okay, I see, and uh-huh. Active istening keeps the discussion focused and ets patients know you understand their concerns. Demonstrate Empathy Watch for opportunities to respond to patients emotions, using phrases such as That sounds difficut or I m sorry you re facing this probem; I think we can work on it together. Studies show that empathy can be earned and practiced and that it adds ess than a minute to the patient interview. It aso has rewards in terms of patient satisfaction, understanding, and adherence to treatment. 8 understanding oder patients

13 For more information on active istening, contact: American Academy on Communication in Heathcare Swingey Ridge Road, Suite 300 Chesterfied, MO This professiona organization aims to improve physician-patient reationships and offers courses and pubications on medica encounters and interviews. Macy Initiative in Heath Communication Division of Primary Care NYU Schoo of Medicine 550 First Avenue Od Beevue, Room D401 New York, NY This initiative was a coaborative effort of three medica schoos to identify and define critica communication skis needed by physicians. It deveoped competency-based curricua for medica students. New Engand Research Institutes (NERI) 9 Gaen Street Watertown, MA NERI has designed a CME-accredited CD-ROM, Communicating With Oder Aduts, educating physicians on communication strategies to practice with oder patients. Avoid Jargon Try not to assume that patients know medica terminoogy or a ot about their disease. Introduce necessary information by first asking patients what they know about their condition and buiding on that. Athough some terms seem commonpace MRIs, CAT scans, stress tests, and so on some oder patients may be unfamiiar with what each test reay is. Check often to be sure that your patient understands what you are saying. You may want to spe or write down diagnoses or important terms to remember. understanding oder patients 9

14 Reduce Barriers to Communication Oder aduts often have sensory impairments that can affect communication. Vision and hearing probems need to be treated and accounted for in communication. Ask oder patients when they ast had vision and hearing exams. Compensating for Hearing Deficits Age-reated hearing oss is common. About one-third of peope between the ages of 65 and 75, and neary haf of those over the age of 75, have a hearing impairment. Here are a few tips to make it easier to communicate with a person who has ost some hearing: Make sure your patient can hear you. Ask if the patient has a working hearing aid. Look at the auditory cana for the presence of excess earwax. Tak sowy and ceary in a norma tone. Shouting or speaking in a raised voice actuay distorts anguage sounds and can give the impression of anger. Avoid using a high-pitched voice; it is hard to hear. Face the person directy, at eye eve, so that he or she can ip-read or pick up visua cues. Keep your hands away from your face whie taking, as this can hinder ipreading abiity. Be aware that background noises, such as whirring computers and office equipment, can mask what is being said. If your patient has difficuty with etters and numbers, give a context for them. For instance, say, m as in Mary, two as in twins, or b as in boy. Say each number separatey (e.g., five, six instead of fifty-six ). Be especiay carefu with etters that sound aike (e.g., m and n, and b, c, d, e, t, and v). Keep a note pad handy so you can write what you are saying. Write out diagnoses and other important terms. Te your patient when you are changing the subject. Give cues such as pausing briefy, speaking a bit more oudy, gesturing toward what wi be discussed, genty touching the patient, or asking a question. 10 understanding oder patients

15 Compensating for Visua Deficits Visua disorders become more common as peope age. Here are some things you can do to hep manage the difficuties caused by visua deficits: Make sure there is adequate ighting, incuding sufficient ight on your face. Try to minimize gare. Check that your patient has brought and is wearing eyegasses, if needed. Make sure that handwritten instructions are cear. When using printed materias, make sure the type is arge enough and the typeface is easy to read. The foowing print size works we: This size is readabe. If your patient has troube reading, consider aternatives such as tape recording instructions, providing arge pictures or diagrams, or using aids such as speciay configured piboxes. Be Carefu About Language Some words may have different meanings to oder patients than to you or your peers. For exampe, the word dementia may connote insanity, and the word cancer may be considered a death sentence. Athough you cannot anticipate every generationa difference in anguage use, being aware of the possibiity may hep you to communicate more ceary. Use simpe, common anguage, and ask if carification is needed. Offer to repeat or reword the information: I know this is compex; I do my best to expain, but et me know if you have any questions or just want me to go over it again. For more information on ow iteracy, contact: Partnership for Cear Heath Communication Nationa Patient Safety Foundation 268 Summer Street, 6th Foor Boston, MA This nationa coaition addresses issues reated to ow heath iteracy and its effect on outcomes. Its Ask Me 3 campaign has materias for physicians offices, incuding patient handouts, to promote good communication. understanding oder patients 11

16 Low iteracy or inabiity to read aso may be a probem. Reading materias written at an easy reading eve may hep. Ensure Understanding Concude the visit by making sure the patient understands: what the main heath issue is what he or she needs to do about it why it is important to do it One way to do this is the teach-back method ask patients to say what they understand from the visit. Aso, ask if there is anything that might keep the patient from carrying out the treatment pan. In Summary Address the patient by ast name, using the tite the patient prefers (Mr., Ms., Mrs., etc.). Begin the interview with a few friendy questions not directy reated to heath. Don t rush, and try not to interrupt; speak sowy, and give oder patients a few extra minutes to tak about their concerns. Use active istening skis. Avoid jargon, use common anguage, and ask if carification is needed, such as writing something down. Ask the patient to say what he or she understands about the probem and what needs to be done. 12 understanding oder patients

17 chapter 3 Obtaining the Medica History When patients are oder, obtaining a good history incuding information on socia circumstances and ifestye as we as medica and famiy history is crucia to sound heath care. What brings you here today? Mr. Symonds has advanced ung disease and usuay manages we with home oxygen. But, he s been admitted to the emergency room three times in as many weeks, unabe to breathe. The heath team is puzzed because Mr. Symonds is taking his medications on schedue and, he says, using the oxygen. Finay, a home care nurse is sent to the Symonds house. She discovers that because of this winter s bitter cod, Mr. Symonds has been running a kerosene heater in his kitchen. He does not use the oxygen and heater at the same time for fear of fire. The varied needs of oder patients may require different interviewing techniques. The foowing guideines can hep you to obtain a thorough history of current and past concerns, famiy history, medications, and socioeconomic situation. These suggestions are ess time-consuming than they may appear. Some invove a singe investment of time. Other heath care professionas in the office or home may assist in gathering the information. You may want to get a detaied ife and medica history as an ongoing part of oder patients office visits and use each visit to add to and update information. obtaining the medica history 13

18 Genera Suggestions You may need to be especiay fexibe when obtaining the medica history of oder patients. Here are some strategies to make efficient use of your time and theirs: If feasibe, try to gather preiminary data before the session. Request previous medica records or, if there is time, mai forms that the patient or a famiy member can compete at home. Try to structure questionnaires for easy reading by using arge type and providing enough space between items for peope to respond. Questionnaires to fi out in the waiting room shoud be brief. Try to have the patient te his or her story ony once, not to another staff member and then again to you. For oder patients who are i, this process can be very tiring. Sit and face the patient at eye eve. Use active istening skis, responding with brief comments such as I see and okay. Be wiing to depart from the usua interview structure. You might understand the patient s condition more quicky if you eicit his or her past medica history immediatey after the chief compaint, before making a compete evauation of the present iness. If the patient has troube with open-ended questions, make greater use of yes-or-no or simpe choice questions. Remember that the interview itsef can be beneficia. Athough you see many patients every day, you may be the ony person your patient is sociay engaged with that day. Your attention is important. Giving your patient a chance to express concerns to an interested person can be therapeutic. 14 obtaining the medica history

19 Eicit Current Concerns Oder patients tend to have mutipe chronic conditions. They may have vague compaints or atypica presentations. Thinking in terms of current concerns rather than a chief compaint may be hepfu. You might start the session by asking your patient to tak about his or her major concern, Te me, what is bothering you the most? Resist the Tendency to Interrupt Give the patient time to answer your questions. Giving someone uninterrupted time to express concerns enabes him or her to be more open and compete. Probe Ask, Is there anything ese? This question, which you may have to repeat severa times, heps to get a of the patient s concerns on the tabe at the beginning of the visit. The main concern may not be the first one mentioned, especiay if it is a sensitive subject. If there are too many concerns to address in one visit, you can pan with the patient to address some now and some next time. Encourage the patient and his or her caregivers to bring a written ist of concerns and questions. Sometimes an oder patient wi seek medica care because of concerns of famiy members or caregivers. Ask About Medications Side effects, interactions, and misuse of medications can ead to major compications in oder peope. It is crucia to find out which prescription and over-the-counter medications oder patients are using and how often. Oder peope often take many medications prescribed by severa different doctors, e.g., internists, cardioogists, uroogists, or rheumatoogists. Sometimes they take prescriptions intended for other househod members. obtaining the medica history 15

20 Remember to ask about any aternative treatments, such as dietary suppements, homeopathic remedies, or teas that the patient might be using. Remind patients that it is important for you to know what over-the-counter medicines, such as pain reievers or eye drops, they use. Ask patients to bring a medications, both prescription and over-thecounter, to your office. A good approach is to have the patient put everything he or she takes in a brown bag and bring it to each visit. Find out about the patient s habits for taking each medication, and check to be sure that he or she is using it as directed. Check to see if the patient has (or needs) a medica aert ID braceet or neckace. There are severa sources, incuding MedicAert Foundation Internationa, Obtain a Thorough Famiy History The famiy history is vauabe, in part because it gives you an opportunity to expore the patient s experiences, perceptions, and attitudes regarding iness and death. For exampe, a patient may say, I never want to be in a nursing home ike my mother. Be aert for openings to discuss issues such as advance directives. The famiy history not ony indicates the patient s ikeihood of deveoping some diseases but aso provides information on the heath of reatives who care for the patient or who might do so in the future. Knowing the famiy structure wi hep you to know what support may be avaiabe from famiy members, if needed. Ask About Functiona Status Knowing an oder patient s usua eve of functioning and earning about any recent significant changes are fundamenta to providing appropriate heath care. They aso infuence which treatment regimens are suitabe. The abiity to perform basic activities of daiy iving (ADLs) refects and affects a patient s heath. Depending on the patient s status, ask about ADLs such as eating, 16 obtaining the medica history

21 bathing, and dressing and more compex instrumenta activities of daiy iving (IADLs) such as cooking, shopping, and managing finances. There are standardized ADL assessments that can be done quicky and in the office. Sudden changes in ADLs or IADLs are vauabe diagnostic cues. If your oder patient stops eating, becomes confused or incontinent, or stops getting out of bed, ook for underying medica probems. Keep in mind the possibiity that the probem may be acute. Consider a Life History If you pan to continue caring for an oder patient, consider taking time to earn about his or her ife. A ife history is an exceent investment. It heps to understand the patient. It aso strengthens the cinician-patient reationship by showing your interest in the patient as a person. Be aert for information about the patient s reationships with others, thoughts about famiy members or coworkers, typica responses to stress, and attitudes toward aging, iness, work, and death. This information may hep you interpret the patient s concerns and make appropriate recommendations. Obtain a Socia History The socia history aso is crucia. If you are aware of your patient s iving arrangements or his/her access to transportation, you are much more ikey to devise reaistic, appropriate interventions. Ask about where he or she ives; neighborhood safety; eating habits; tobacco, drug, and acoho use; typica daiy activities; and work, education, and financia situations. It aso heps to find out who ives with or near the patient. Understanding a person s ife and daiy routine can hep you to understand how your patient s ifestye might affect his or her heath care. To this end, determine if the patient is an informa caregiver for others. Many oder peope care for spouses, edery parents, or grandchidren. A patient s wiingness to report symptoms sometimes depends on whether the patient thinks he or she can afford to get sick, in view of famiy responsibiities. obtaining the medica history 17

22 House cas by a heath care professiona are an exceent way to find out about a patient s home ife. If that s not possibe, try to earn some detais about the patient s home ife: Do you use oi or gas heat? Have steep stairs to navigate? Own a pet? Can you get to the grocery store or pharmacy on your own? Are you friendy with anyone in the neighborhood? Learning about your patient s home ife wi hep you understand aspects of his or her iness and may improve adherence to treatment. In Summary Obtain basic information before the visit. Encourage patients to bring in written ists of concerns as we as a medication, incuding overthe-counter and aternative or homeopathic remedies. Use the famiy history to gain insight into an oder patient s socia situation as we as his or her risk of disease. Tak about the activities of daiy iving and be aert to changes. Ask about iving arrangements, transportation, and ifestye to hep in devising appropriate interventions. 18 obtaining the medica history

23 chapter 4 Encouraging Weness Peope of a ages can benefit from heathy habits such as reguar exercise and good nutrition. I d ike you to try this exercise routine. Just start ow and go sow. Mrs. Green is surprised when Dr. Lipton recommends that she exercise reguary. She responds with a ist of excuses: exercise is for young peope, it s not safe for peope over 65, it takes too much time, exercise equipment costs too much. Dr. Lipton istens empatheticay and then tes her that exercise and physica activity are good for peope of a ages and that being sedentary is far more dangerous than exercising. He expains that Mrs. Green can start ow and go sow by waking for 10 minutes at a time and buiding up to at east 30 minutes of physica activity on 5 days or more each week. At her next office visit, Mrs. Green says that she has more energy than she used to; in fact, she s ready to try a dance cass at her senior center. Exercise and Physica Activity Exercise has proven benefits for oder peope. It reduces risk of cardiovascuar disease, stroke, hypertension, type 2 diabetes, osteoporosis, obesity, coon cancer, and breast cancer. It aso decreases the risk of fas and fareated injuries. encouraging weness 19

24 Like the rest of us, oder peope may know that exercise is good for their heath, but they may not have the motivation or encouragement to do it. You can guide your patients by asking about their daiy activities and whether they engage in any kind of reguar exercise or physica activity. There are severa ways to encourage oder patients to exercise: Whenever appropriate, et them know that reguar physica activity incuding endurance, musce-strengthening, baance, and fexibiity exercises is essentia for heathy aging. Hep patients set reaistic goas and deveop an exercise pan. Write an exercise prescription, and make it specific, incuding type, frequency, intensity, and time; foow up to check progress and reevauate goas over time. Refer patients to community resources, such as ma-waking groups and senior center fitness casses. Te them about Go4Life TM, NIA s exercise and physica activity campaign. It has exercises, motivationa tips, and free materias to hep oder aduts start exercising and keep going. Check out Too Od to Exercise? Studies Say No! Together, exercise and ifestye changes such as becoming more active and heathy eating reduce the risk of diabetes in high-risk oder peope. In one study, ifestye changes ed to a 71 percent decrease in diabetes among peope 60 and oder. In another study, moderate exercise was effective at reducing stress and seep probems in oder women caring for a famiy member with dementia. Oder peope who exercise moderatey are abe to fa aseep quicky, seep for onger periods, and get better quaity of seep. Researchers aso found that exercise, which can improve baance, reduced fas among oder peope by 33 percent. Waking and strength-buiding exercises by peope with knee osteoarthritis hep reduce pain and maintain function and quaity of ife. 20 encouraging weness

25 For more information on exercise, nutrition, and oder peope, contact: Centers for Disease Contro and Prevention (CDC) 1600 Cifton Road Atanta, Georgia (to-free) (TTY/to-free) Heathy Aging: Nutrition, Physica Activity, and Obesity: The CDC has resources on nutrition and physica activity for oder aduts. The Division of Nutrition, Physica Activity, and Obesity addresses how heathy eating habits and exercise can improve the pubic s heath and prevent and contro chronic diseases. Department of Agricuture Food and Nutrition Information Center (FNIC) Nationa Agricutura Library Batimore Avenue, Room 105 Betsvie, MD The FNIC website provides over 2,000 inks to current and reiabe nutrition resources. Nationa Institute on Aging (NIA) Information Center P.O. Box 8057 Gaithersburg, MD (to-free) (TTY/to-free) NIA has free onine and print materias to show oder aduts how to start and maintain a safe, effective program of endurance, fexibiity, baance, and strength-training exercises. Nationa Resource Center on Nutrition, Physica Activity & Aging Forida Internationa University OE 200 Miami, FL A group serving nutrition programs funded by the Oder Americans Act, the Center aims to increase food and nutrition services in home- and community-based socia, heath, and ongterm-care systems serving oder aduts. Link to the program Eat Better & Move More. encouraging weness 21

26 Nutrition Oder patients may deveop poor eating habits for many reasons. These can range from a decreased sense of sme and taste to teeth probems or depression. Oder peope may aso have difficuty getting to a supermarket or standing ong enough to cook a mea. And athough energy needs may decrease with age, the need for certain vitamins and mineras, incuding cacium, vitamin D, and vitamins B 6 and B 12, increases after age 50. Try these strategies to encourage heathy diets: Emphasize that good nutrition can have an impact on we-being and independence. If needed, suggest iquid nutrition suppements, but emphasize the benefits of soid foods. If needed, suggest mutivitamins that fufi 100 percent of the recommended daiy amounts of vitamins and mineras for oder peope, but not megadoses. Offer a referra to a nutrition services program, such as Meas on Whees. Programs in your area are provided by the oca Area Agency on Aging or Triba Senior Services. Contact Edercare Locator at for your Area Agency on Aging. In Summary Tak to your oder patients about the importance of exercise and physica activity. Staying active can benefit oder peope in many ways. Encourage your patients to get a free copy of Exercise and Physica Activity: Your Everyday Guide from the Nationa Institute on Aging. Tak to your oder patients about their eating habits. Consider having your oder patients keep a food diary, if necessary, to make sure they are getting the correct nutrients. 22 encouraging weness

27 chapter 5 Taking About Sensitive Subjects Caring for an oder patient requires discus ing sensitive topics. You may be tempted to avoid these discus ions, but there are hepfu techniques to get you started and resources to hep. Many peope your age experience simiar probems. At age 80, Mr. Abayo was proud of his independence and abiity to get around. But, when he came to see Dr. Cari for a reguar exam, he acknowedged that the troube with his shouder had started after he coided with another car at a four-way stop sign. Many of my patients are worried about being safe drivers, Dr. Cari said. After the exam, she spoke with Mr. Abayo and his son in her office. She tod them that a ot of her oder patients had decided to rey on famiy and friends for transportation. She gave Mr. Abayo a pamphet on oder drivers and the number of a oca transportation resource that might be hepfu. Many oder peope have a don t ask, don t te reationship with heath care providers about some probems, especiay those reated to sensitive subjects, such as driving, urinary incontinence, or sexuaity. Hidden heath issues, such as memory oss or depression, are a chaenge. Addressing probems reated to safety and independence, such as giving up one s driver s icense or moving to assisted iving, aso can be difficut. You may fee awkward addressing some of these concerns because you don t know how to hep patients sove the probem. This chapter gives an overview taking about sensitive subjects 23

28 of techniques for broaching sensitive subjects, as we as resources for more information or support. Try to take a universa, non-threatening approach. Start by saying, Many peope your age experience... or Some peope taking this medication have troube with... Try: I have to ask you a ot of questions, some that might seem siy. Pease don t be offended... Another approach is to te anecdotes about patients in simiar circumstances as a way to ease your patient into the discussion, of course aways maintaining patient confidentiaity to reassure the patient you are taking to that you won t discose persona information about him or her. Some patients avoid issues that they think are inappropriate for their own cinicians. One way to overcome this is to keep informative brochures and materias readiy avaiabe in the waiting room. Aong with each topic isted aphabeticay beow is a samping of resources. Athough the ists are not exhaustive, they are a starting point for ocating usefu information and referras. Advance Directives Advance directives, incuding iving wis, can hep you honor individua end-of-ife preferences and desires. You may fee uncomfortabe raising the issue, fearing that patients wi assume the end is near. But, in fact, this is a conversation that is best begun we before end-of-ife care is appropriate. Let your patients know that advance care panning is a part of good heath care. You can say that, increasingy, peope reaize the importance of making pans whie they are sti heathy. You can et them know that these pans can be revised and updated over time or as their heath changes. An advance care panning discussion can take about 5 minutes with a heathy patient: Tak about the steps your patient woud want you to take in the event of certain conditions or eventuaities. Discuss the meaning of a heath care proxy and how to seect one. Give the patient the materias to review, compete, and return at the next visit. In some cases, the patient may want hep competing the form. 24 taking about sensitive subjects

29 Ask the patient to bring a copy of the competed form at the next visit for you to keep. If appropriate, share the pan with famiy members. Revise any advance directives based on the patient s changing heath and preferences. Be sure to put a copy of the competed form in the medica record. Too often, forms are competed, but when needed, they cannot be found. Many organizations now photocopy the forms on neon-coored paper, which is easy to spot in the medica record. If your patient is in the eary stages of an iness, it s important for you to assess whether or not the underying process is reversibe. It s aso a good time to discuss how the iness is ikey to pay out. If your patient is in the eary stages of a cognitive probem, it is especiay important to discuss advance directives. For more information on advance directives, contact: Aging With Dignity P.O. Box 1661 Taahassee, FL (to-free) This group provides an easy-to-read advance care panning document caed Five Wishes. Institute for Heathcare Advancement 501 South Idaho Street, Suite 300 La Habra, CA (to-free) A simpified advance directive form written at a fifth-grade reading eve in Engish, Spanish, Chinese, and Vietnamese can be downoaded for free. Nationa Hospice and Paiative Care Organization 1731 King Street, Suite 100 Aexandria, VA (to-free) (to-free, mutiingua hepine) This group provides resources for competing advance directives, incuding inks to each State s advance directive forms. taking about sensitive subjects 25

30 Driving Safety Recommending that a patient imit driving or that a patient give up his or her driver s icense is one of the most difficut topics a doctor has to address. Because driving is associated with independence and identity, making the decision not to drive is very hard. For more information on safe driving, contact: AAA Foundation for Traffic Safety th Street, NW, Suite 201 Washington, DC AARP 601 E Street, NW Washington, DC (to-free) The AARP Driver Safety Program offers casses to hep motorists over the age of 50 improve their driving skis. American Association of Motor Vehice Administrators 4301 Wison Bouevard, Suite 400 Arington, VA The American Association of Motor Vehice Administrators sponsors a program designed to educate aging drivers and their caregivers. American Medica Association (AMA) 5515 North State Street Chicago, IL (to-free) The AMA offers guidance for physicians to address probems about driving and oder aduts. For detais, downoad the Physician s Guide to Assessing and Counseing Oder Drivers from the website. 26 taking about sensitive subjects

31 As with other difficut subjects, try to frame it as a common concern of oder patients. Mention, for instance, that aging can ead to sowed reaction times and impaired vision. In addition, it may be harder to move the head to ook back, quicky turn the steering whee, or safey hit the brakes. Ask the patient about any car accidents. When necessary, warn patients about medications that may make them seepy or impair judgment. Aso, a device such as an automatic defibriator or pacemaker might cause irreguar heartbeats or dizziness that can make driving dangerous. You might ask if she or he has thought about aternative transportation methods if driving is no onger an option. Eder Abuse and Negect Be aert to the signs and symptoms of eder abuse. If you notice that a patient deays seeking treatment or offers improbabe expanations for injuries, for exampe, you may want to bring up your concerns. The aws in most States require heping professionas, such as doctors and nurses, to report suspected abuse or negect. For more information on eder abuse, contact: Nationa Center on Eder Abuse Center for Community Research and Services University of Deaware 297 Graham Ha Newark, DE This consortium of organizations provides information about and conducts research on eder abuse. Oder peope caught in an abusive situation are not ikey to say what is happening to them for fear of reprisa or because of diminished cognitive abiities. If you suspect abuse, ask about it in a constructive, compassionate tone. If the patient ives with a famiy caregiver, you might start by saying that caregiver responsibiities can cause a ot of stress. Stress sometimes may cause caregivers to ose their temper. You can assist by recommending a support group or aternative arrangements (such as respite care). Give the patient opportunities to bring up this concern, but if necessary, raise the issue yoursef. taking about sensitive subjects 27

32 End-of-Life Care Most oder peope have thought about the prospect of their own death and are wiing to discuss their wishes regarding end-of-ife care. You can hep ease some of the discomfort simpy by being wiing to tak about dying and by being open to discussions about these important issues and concerns. It may be hepfu to do this eary in your reationship with the patient when discussing medica and famiy history. Stay aert to cues that the patient may want to tak about this subject again. Encourage the patient to discuss endof-ife decisions eary with famiy members and to consider a iving wi. For more information on end-of-ife care, contact: Education in Paiative and End-of-ife Care (EPEC) Northwestern University, Feinberg Schoo of Medicine 750 North Lake Shore Drive, Suite 601 Chicago, IL EPEC provides physicians the basic knowedge and skis needed to care for dying patients. Nationa Hospice and Paiative Care Organization 1731 King Street, Suite 100 Aexandria, VA (to-free) (to-free, mutiingua hepine) NHPCO inks to care organizations and the consumer website, Of course, it is not aways easy to determine who is cose to death; even experienced cinicians find that prognostication can be difficut. Even if you have aready taked with your patient about end-of-ife concerns, it sti can be hard to know the right time to re-introduce this issue. Some cinicians find it hepfu to ask themseves, Woud I be surprised if Mr. Fowers were to die this year? If the answer is no, then it makes sense to start working with the patient and famiy to address end-of-ife concerns, pain and 28 taking about sensitive subjects

33 symptom management, home heath, and hospice care. You can offer to hep patients review their advance directives. Incude these updates in your medica records to ensure that patients receive the care they want. Financia Barriers Rising heath care costs make it difficut for some peope to foow treatment regimens. Your patients may be too embarrassed to mention their financia concerns. Studies have shown that many cinicians aso are reuctant to bring up costs. If possibe, designate an administrative staff person with a good bedside manner to discuss money and payment questions. This person can aso tak with your patient about changes in Medicare and the Part D prescription drug coverage pans. For more information on financia assistance, contact: Medicare Rights Center 520 Eighth Avenue, North Wing, 3rd Foor New York, NY M Street, NW, Suite 100 Washington, DC Main number: (to-free) The to-free consumer hotine provides free counseing services about Medicare, incuding the prescription drug benefit. Nationa Counci on Aging The Counci s onine resource offers a searchabe ist of programs that can hep with heath care costs. Partnership for Prescription Assistance (to-free) Many pharmaceutica companies offer reduced medication fees for patients who meet income requirements and other criteria. The website has a directory of prescription drug patient assistance programs. taking about sensitive subjects 29

34 The resources in this section may hep when you tak with your patients about their financia concerns. In addition, your State Heath Insurance Assistance Program (SHIP) may be hepfu. Long-Term Care Long-term care incudes informa caregiving, assisted iving, home heath services, adut day care, nursing homes, and community-based programs. Eary in your reationship with an oder patient, you can begin to tak about the possibiity that he or she may eventuay require ong-term care of some kind. By raising this topic, you are heping your patient think about what he or she might need in the future and how to pan for those needs. For instance, you might tak about what sort of assistance you think your patient wi need, how soon in the future he or she wi need the extra hep, and where he or she might get this assistance. For more information on ong-term care, contact: Nursing Home Compare Medicare provides an onine resource with detaied information about the past performance of every Medicare- and Medicaid-certified nursing home in the country. Edercare Locator (to-free) The Edercare Locator offers referras to and information on services for seniors. Menta Heath Despite many pubic campaigns to educate peope about menta heath and iness, there is sti a stigma attached to menta heath probems. Some oder aduts may find menta heath issues difficut to discuss. Such conversations, however, can be ifesavers. Primary care doctors have a key opportunity to recognize when a patient is depressed and/or suicida. In fact, 70 percent of oder patients who commit suicide have seen a primary care physician within the previous month. This makes it especiay important for you to be aert to the signs and symptoms of depression. As with other subjects, try a genera approach to bringing up menta heath concerns. For exampe, A ot of us deveop seep probems as we get oder, 30 taking about sensitive subjects

35 For more information on menta heath, contact: American Association for Geriatric Psychiatry 7910 Woodmont Avenue, Suite 1050 Bethesda, MD The Association promotes the menta heath and we-being of oder peope and works to improve the care of those with ate-ife menta disorders. Nationa Institute of Menta Heath (NIMH) 6001 Executive Bouevard, Room 8184, MSC 9663 Bethesda, MD (to-free) (TTY/to-free) NIMH, part of the Nationa Institutes of Heath, funds and conducts menta heath research and distributes information to heath professionas and the pubic. but this can be a sign of depression, which sometimes we can treat. Because oder aduts may have atypica symptoms, it is important to isten cosey to what your patient has to say about troube seeping, ack of energy, and genera aches and pains. It is easy to dismiss these as just aging and eave depression undiagnosed and therefore untreated. Sexuaity An understanding, accepting attitude can hep promote a more comfortabe discussion of sexuaity. Try to be sensitive to verba and other cues. Don t assume that an oder patient is no onger sexuay active, does not care about sex, or necessariy is heterosexua. In fact, research has found that a majority of oder Americans are sexuay active and view intimacy as an important part of ife. Depending on indications earier in the interview, you may decide to approach the subject directy (for exampe, Are you satisfied with your sex ife? ) or more obiquey with ausions to changes that sometimes occur in marriage. If appropriate, foow up on patient cues. You might note that patients sometimes have concerns about their sex ife and then wait for a response. It is aso effective to share anonymous anecdotes about a person in a simiar situation or to raise the issue in the context of physica findings taking about sensitive subjects 31