Communicating With Geriatric Patients

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1 Communicating With Geriatric Patients

2 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

3 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. Communication ski is 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

4 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

5 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

6 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

7 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 4 Let oder patients know that you wecome their questions and participation. 4 Encourage oder aduts to voice their concerns. 4 Be aert to barriers to communication about symptoms, such as fears about oss of independence or costs of diagnostic tests. 4 Expect those in the baby boom generation to be more active participants in their heath care. considering heath care perceptions 5

8 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

9 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

10 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

11 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 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 Patients, 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

12 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 as many as haf of those over the age of 75, have a hearing oss. 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

13 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 132 MASS MoCA Way North Adams, 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

14 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 4 Address the patient by ast name, using the tite the patient prefers (Mr., Ms., Mrs., etc.). 4 Begin the interview with a few friendy questions not directy reated to heath. 4 Don t rush, and try not to interrupt; speak sowy and give oder patients a few extra minutes to tak about their concerns. 4 Use active istening skis. 4 Avoid jargon, use common anguage, and ask if carification is needed, such as writing something down. 4 Ask the patient to say what he or she understands about the probem and what needs to be done. 12 understanding oder patients

15 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

16 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

17 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

18 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

19 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

20 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 4 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. 4 Use the famiy history to gain insight into an oder patient s socia situation as we as his or her risk of disease. 4 Tak about the activities of daiy iving and be aert to changes. 4 Ask about iving arrangements, transportation, and ifestye to hep in devising appropriate interventions. 18 obtaining the medica history

21 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

22 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 Exercise and Physica Activity: Your Everyday Guide from the Nationa Institute on Aging, NIA s free book showing oder aduts how to start and stick with a safe, effective exercise program. 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

23 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 4 Tak to your oder patients about the importance of exercise and physica activity. Staying active can benefit oder peope in many ways. 4 Encourage your patients to get a free copy of Exercise and Physica Activity: Your Everyday Guide from the Nationa Institute on Aging. 4 Tak to your oder patients about their eating habits. 4 Consider having your oder patients keep a food diary, if necessary, to make sure they are getting the correct nutrients. 22 encouraging weness

24 chapter 5 Taking About Sensitive Subjects Caring for an oder patient requires discussing sensitive topics. You may be tempted to avoid these discussions, 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

25 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

26 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 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 1700 Diagona Road, Suite 625 Aexandria, VA (to-free) This group provides resources for competing advance directives, incuding inks to each State s advance directive forms. taking about sensitive subjects 25

27 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

28 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 1700 Diagona Road, Suite 625 Aexandria, VA (to-free) 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

29 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 Maryand Avenue, NE, Suite 112 Washington, DC (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

30 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

31 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) 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

32 For more information on spirituaity, contact: Association of Professiona Chapains 1701 East Woodfied Road, Suite 400 Schaumburg, IL The Association is an interfaith professiona society providing education, research, and certification for its members and web inks to many chapaincy organizations. George Washington University Institute for Spirituaity & Heath 2300 K Street, NW, Suite 313 Washington, DC The Institute recognizes spiritua dimensions of heath. Its work focuses on bringing increased attention to the spiritua needs of patients, famiies, and heath care professionas. Cinicians have found that very direct and simpe questions are the best way to broach this subject. You might start, for instance, by asking, What has heped you to dea with chaenges in the past? Substance Abuse Acoho and drug abuse are major pubic heath probems, even for oder aduts. Sometimes peope can become dependent on acoho or other drugs as they confront the chaenges of aging, even if they did not have a probem when younger. Because baby boomers have a higher rate of ifetime substance abuse than did their parents, the number of peope in this age group needing treatment is ikey to grow. For more information on substance abuse, contact: Nationa Cearinghouse for Acoho & Drug Information (NCADI) P.O. Box 2345 Rockvie, MD (to-free) NCADI, funded by the Substance Abuse and Menta Heath Services Administration, is a one-stop resource for information on substance abuse prevention and addiction treatment. taking about sensitive subjects 33

33 Chidbirth, infection, certain medications, and some inesses are exampes. Incontinence may go untreated because patients are embarrassed to mention it. Be sure to ask specificay about the probem. Try the some peope approach: When some peope cough or sneeze, they eak urine. Have you had this probem? You may want to expain that incontinence can often be significanty improved through badder training; medication and surgery can aso be effective treatments for certain types of incontinence. In Summary 4 Introduce sensitive topics with the common concern approach: As we age, many of us have more troube with... or Some peope taking this medication have troube with... 4 Keep educationa materias avaiabe and visibe to encourage discussion. 4 Raise topics such as safe driving, ong-term care, advance care directives, and end-of-ife care eary, before they become urgent matters. taking about sensitive subjects 35

34 Supporting Patients With Chronic Conditions Case managers can pay an important roe in educating patients and famiies and can connect them with appropriate community resources and services. Let s discuss iving with... Four years ago, Mrs. Smoey suffered a stroke. Athough she takes her pis just ike the doctor ordered, she has not been abe to quit smoking. Now she has emphysema and may soon need oxygen. Dr. Nguyen thinks she shoud participate in a disease management program at a oca hospita that wi give her the information she needs to manage on her own. It coud hep you prevent the probems you ve had with shortness of breath, the doctor expains. And you might earn some tips about how to manage your day so that you have some more energy. She offers to hep Mrs. Smoey schedue her first appointment. Approximatey 80 percent of oder aduts have at east one chronic disease, and of those, 50 percent have at east two chronic conditions. For many oder peope, coping with mutipe chronic conditions is a rea chaenge. Learning to manage a variety of treatments whie maintaining quaity of ife can be probematic. Peope with chronic conditions may have different 36 supporting patients with chronic conditions

35 chapter 6 needs, but they aso share common chaenges with other oder aduts, such as paying for care or navigating the compexities of the heath care system. Try to start by appreciating that peope iving with chronic disease are often iving with oss the oss of physica function, independence, or genera we-being. Empathize with patients who fee angry, sad, ost, or bewidered. Ask, Is it hard for you to ive with these probems? From there you can refer patients to community resources that may meet their needs or, when avaiabe, recommend a disease management program or case managers in the community. Educating the Patient Most oder patients want to understand their medica conditions and are interested in earning how to manage them. Likewise, famiy members and other caregivers want this information. Physicians typicay underestimate how much patients want to know and overestimate how ong they spend giving information to patients. Devoting more attention to educating patients may seem ike a uxury, but in the ong run it can improve patients adherence to treatment, increase patients we-being, and save you time. The foowing tips can hep you inform patients and their caregivers about medica conditions and their treatment. Doctors advice generay receives greatest credence, so the doctor shoud introduce treatment pans. Other medica team members have an important roe, incuding buiding on the origina instructions. Let your patient know you wecome questions. Indicate whom on your staff he or she can ca to have questions answered ater. Remember that some patients won t ask questions even if they want more information. Be aware of this tendency and think about making information avaiabe even if it is not requested. Provide information through more than one channe. In addition to taking to the patient, you can use fact sheets, drawings, modes, videotapes, or audiotapes. In many cases, referras to websites and support groups can be hepfu. supporting patients with chronic conditions 37

36 Encourage the patient or caregiver to take notes. It s hepfu to offer a pad and penci. Active invovement in recording information may promote your patient s retention and adherence. Repeat key points about the heath probem and treatment at every office visit. Check that the patient and his or her caregivers understand what you say. One good approach is to ask that they repeat the main message in their own words. Provide encouragement. Ca attention to strengths and ideas for improvement. Remember to provide continued reinforcement for new treatment or ifestye changes. Expaining Diagnoses Cear expanations of diagnoses are critica. Uncertainty about a heath probem can be upsetting. When patients do not understand their medica conditions, they tend not to foow the treatment pans. In expaining diagnoses, it is hepfu to begin by finding out what the patient beieves is wrong, what the patient thinks wi happen, and how much more he or she wants to know. Based on the patient s responses, you can correct any misconceptions and provide appropriate types of information. Discussing Treatment Some oder patients may refuse treatment because they do not understand what it invoves or how it wi improve their heath. In some cases, they may be frightened about side effects or have misinformation from friends and reatives with simiar heath probems. They may aso be concerned about the cost of the treatment. Treatment can invove ifestye changes (such as diet and exercise) as we as medication. Make sure you deveop and communicate treatment pans with the patient s input and consent. Te the patient what to expect from the treatment, incuding recommended ifestye change, what degree of improvement is reaistic, and when he or she may start to fee better. 38 supporting patients with chronic conditions

37 Keep medication pans as simpe and straightforward as possibe. For exampe, minimize the number of doses per day. Taior the pan to the patient s situation and ifestye, and try to reduce disruption to the patient s routine. Indicate the purpose of each medication. Make it cear which medications must be taken and on what schedue. It is hepfu to say which drugs the patient shoud take ony when having particuar symptoms. After proposing a treatment pan, check with the patient about its feasibiity and acceptabiity. Work through what the patient fees may be obstaces to maintaining the pan. Try to resove any misunderstandings. For exampe, make it cear that a referra to another doctor does not mean you are abandoning the patient. Provide ora and written instructions. Do not assume that a of your patients are abe to read. Make sure the print is arge enough for the patient to read. Encourage your patient and his or her caregivers to take an active roe in discovering how to manage chronic probems. Think in terms of joint probem soving or coaborative care. Such an approach can increase the patient s satisfaction whie decreasing demands on your time. In Summary 4 The physician shoud provide key information and advice for greatest impact; other team members can buid on that. 4 To expain diagnoses, start by asking the patient what he or she understands and how much more he or she wants to know. 4 After proposing a treatment pan, check with the patient on feasibiity and acceptabiity; confirm that the patient understands the pan. 4 Encourage the patient and caregivers to take an active roe in managing a chronic probem. supporting patients with chronic conditions 39

38 Breaking Bad News Deivering bad news is never easy, but tested strategies can ease the process. I wish I had better news. Since Dr. Caas got Mrs. Larson s test resuts, he had been thinking about how to te her she has Parkinson s disease. Because he didn t want to fee pressured for time, Dr. Caas made sure Mrs. Larson had today s ast appointment. He knew she d have a ot of questions. Knowing that Mrs. Larson suspected something was seriousy wrong, Dr. Caas decided the best approach was to be gente, but direct. He reviewed her chart for detais, took a deep breath, and opened the exam room door... Knowing how to communicate bad news can hep you to make the process more bearabe for patients. The Education in Paiative and End-of-Life Care Project (EPEC), offers a modue, Communicating Bad News, that provides a practica approach. It indicates that breaking bad news in a compassionate yet direct way can hep physicians and patients. And, athough some of the advice may seem obvious, it may aso be the sort of thing that is easiy overooked. The first step is to prepare yoursef. Before meeting with the patient, think about what you want to say and make sure that you have a of the information you need. Be sure there is enough time, rather than trying to schedue it between other appointments. If possibe, ask your staff to hod cas and pages unti the appointment is over. 40 breaking bad news

39 chapter 7 You may fee more comfortabe by first finding out what the patient knows about his or her condition. You might ask questions such as, Have you been worried about your iness or symptoms? Next, you might spend a few moments finding out how much the patient reay wants to know. Depending on their cutura background, persona history, or medica status, peope may have different expectations and preferences for what they shoud be tod. You might ask the patient if he or she wants to hear the prognosis, for exampe, or woud prefer not to know. If a patient s famiy has reservations about having the patient know the prognosis, you might ask them about their concerns. Legay, of course, you are obigated to te the patient; however, you may negotiate some eements with the famiy. If you cannot resove it, an ethics consutation may be hepfu. When you are ready to share the bad news, try to be as straightforward as possibe, without speaking in a monotone or deivering a monoogue. Be positive, but avoid the natura temptation to minimize the seriousness of the diagnosis. Communications experts suggest that you not start by saying, I m sorry... Instead, try saying, I fee bad to have to te you... After you have expained the bad news, you can express genuine sadness whie reassuring the patient that you and others wi be there to hep. Of course, peope wi respond differenty to bad news; shock, anger, sorrow, despair, denia, bame, disbeief, and guit a are common reactions. In some cases, peope may simpy have to eave the office. Try to give the patient and famiy time and privacy to react. A good way to end this visit is to estabish a pan for next steps. This may incude gathering more information, ordering more tests, or preparing advance directives. Reassure the patient and famiy that you are not going to abandon them, regardess of referras to other heath care providers. Let them know how they can reach you and be sure to respond when they ca. In foow-up appointments or conversations, give the patient an opportunity to tak again about the situation. Ask if he or she has more questions or needs hep taking with famiy members or others about the diagnosis. Assess the patient s eve of emotiona distress and consider a referra to a menta heath provider. breaking bad news 41

40 The Language of Bad News: Phrases That Hep These phrases can hep you to be straightforward, yet compassionate: Deivering bad news I m afraid the news is not good. The biopsy showed you have coon cancer. Unfortunatey, there is no question about the resuts. You have emphysema. The report is back, and it s not as we had hoped. It confirms that you have the eary stages of Parkinson s disease. Responding to patient reactions I imagine this is difficut news. Does this news frighten you? I wish the news were different. Is there anyone you d ike me to ca? I try to hep you. I hep you te your chidren. Deaing with prognosis What are you expecting to happen? What woud you ike to have happen? How specific woud you ike me to be? What are your fears about what might happen? Adapted from: Emanue LL, von Gunten CF, Ferris FF, and Hauser, JM, eds. Modue 2: Communicating Bad News, The Education in Paiative and End-of-Life Care (EPEC) Curricuum: The EPEC Project, 1999, breaking bad news

41 Referring Patients to Cinica Trias Carefuy conducted cinica trias are the primary way researchers find out if a promising treatment is safe and effective. Patients who participate in cinica research can gain access to new treatments before they are widey avaiabe and hep others by contributing to medica research findings. Cinicians have an important roe in continuing to care for patients who participate in cinica trias. Most trias offer short-term treatments reated to a specific iness or condition. They do not provide extended or compete primary heath care. You wi continue your invovement in the patient s care but may need to communicate at times with your patient s cinica research team. By working with the research team, you can ensure that other medications or treatment needed by your patient wi not confict with the protoco. For information about federay and privatey supported cinica research, visit: In Summary 4 Prepare yoursef for deivering bad news aow enough time, and have cas hed. 4 Find out how much the patient understands and how much he or she wants to know about the prognosis. 4 Be straightforward and compassionate. 4 Give the patient time to react. 4 Estabish a pan for next steps; et the patient and famiy know you are not going to abandon them. 4 Give the patient an opportunity to continue the conversation in foow-up appointments or cas. breaking bad news 43

42 Working With Diverse Oder Patients Appreciating the richness of cutura and ethnic backgrounds among oder patients and providing interpretation for those with imited Engish can hep to promote good heath care. Cutura differences, not divides. Azeeza Houssani had been Dr. Smith s patient for severa years. She had aways carefuy foowed his instructions. So, Dr. Smith was surprised when Mrs. Houssani was not wiing to take her morning medication with food, as directed. He reminded her that these drugs were very hard on the stomach and coud cause her pain if taken without food. But Mrs. Houssani just shook her head. Rather than getting frustrated, Dr. Smith genty pursued her reasons. Mrs. Houssani expained that it was Ramadan and she coud not eat or drink from sunrise to sunset. Dr. Smith thought a bit and suggested that she find out if it s okay to take medicine with food during Ramadan there might be an exception for peope in her situation who need to take medicine. Understanding how different cutures view heath care heps you to taior questions and treatment pans to the patient s needs. Athough you cannot become an expert in the norms and traditions of every cuture, being sensitive to genera differences can strengthen your reationship with your patients. 44 working with diverse oder patients

43 chapter 8 Each cuture has its own rues about body anguage and interpretations of hand gestures. Some cutures point with the entire hand, because pointing with a finger is extremey rude behavior. For some cutures, direct eye contact is considered disrespectfu. Unti you are sure about a patient s background, you might opt for a conservative approach. And, if you aren t certain about a patient s preferences, ask. The use of aternative medicines, herba treatments, and fok remedies is common in many cutures. Be sure to ask your patient if he or she takes vitamins, herba treatments, dietary suppements, or other aternative or compementary medicines. Aso, in order to hep buid a trusting reationship, be respectfu of native heaers on whom your patient may aso rey. Oder immigrants or non-native Engish speakers may need a medica interpreter. Amost 18 percent of the U.S. popuation speaks a anguage other than Engish at home, according to the Census Bureau. Among oder peope, 2.3 miion report not speaking Engish or not speaking it very we. Federa poicies require cinicians and heath care providers who receive Federa funds, such as Medicare payments, to make interpretive services avaiabe to peope with imited Engish. Many cinicians rey on patients famiy members or on the ad hoc services of biingua staff members, but experts strongy discourage this practice and recommend the use of trained medica interpreters. Famiy members or office staff may be unabe to interpret medica terminoogy, may inadvertenty misinterpret information, or may find it difficut to reay bad news. Athough a patient may choose to have a famiy member transate, the patient shoud be offered access to a professiona interpreter. working with diverse oder patients 45

44 When working with non-native Engish-speaking patients, be sure to ask which anguage they prefer to speak and whether or not they read and write Engish (and, if not, which anguage they do read). Whenever possibe, offer patients appropriate transations of written materia or refer them to biingua resources. If transations are not avaiabe, ask the medica interpreter to transate medica documents. Finding a Medica Interpreter A number of States have associations and foundations that can hep with ocating, and in some cases provide funding for, medica interpreters. Some State Medicaid offices offer reimbursement for medica interpretation services. A web search can ocate State organizations and oca services. Or you can contact: Nationa Counci on Interpreting in Heath Care 5505 Connecticut Avenue, NW, #119 Washington, DC (fax) In Summary 4 Keep in mind that cutura differences have an impact on how patients view doctors and medicine. 4 Ask about patients use of aternative and compementary medicines. 4 Use a professiona medica interpreter rather than famiy members or untrained staff. 4 Provide written materias in the patient s primary anguage. working with diverse oder patients 47

45 Incuding Famiies and Caregivers By communicating effectivey with a the individuas invoved in your patient s care, you can hep him or her whie aso making efficient use of time and resources. What woud you ike your famiy to know? Dr. Hwang noticed that Mrs. Patrick wasn t getting her medication dosage quite right. Mrs. Patrick admitted that sometimes she does not remember everything prescribed for her to do. Dr. Hwang wondered if Mrs. Patrick shoud bring her daughter to her next appointment. Mrs. Patrick agreed, but at the foowing doctor visit she sti came aone. Dr. Hwang was puzzed. When he asked her about it, Mrs. Patrick said that she was concerned her daughter woudn t et her speak for hersef and that she has some persona issues she d ike to discuss with him that she doesn t want her daughter to know about. Dr. Hwang assured her that he woud keep her invoved in the conversation about her heath and that they coud have some private time to discuss any persona matters. Next time, Mrs. Patrick brought her daughter to the visit. Famiy and informa caregivers pay an important roe in the ives of their oved ones. They aso pay an increasingy important roe in how the heath care system functions. 48 incuding famiies and caregivers

46 chapter 9 Informa caregivers may be important informants. They can aso hep to reinforce the importance of information you give or the treatment you prescribe. To protect and honor patient privacy, be sure to check with the patient on how he or she sees the companion s roe. In many cases, the caregiver or companion can be a faciitator, heping the patient express concerns and reinforcing what you say. But it is best not to assume that a companion shoud be incuded in the medica encounter. First, check with the patient. Conducting the physica exam aone protects the patient s privacy and aows you to raise sensitive issues. For instance, the best time to conduct a mini-menta test is during a private exam, so that a famiy member cannot answer questions or cover for the patient s cognitive apses. When a companion is present, be aware of communication issues that arise in three-party interactions. Whenever possibe, try to sit so that you form a For more information on working with famiies and caregivers, contact: Administration on Aging (AoA) Washington, DC AoA provides funds and community-based services for programs that serve oder aduts. Edercare Locator (to-free) The Edercare Locator offers referras to information on services for seniors. Famiy Caregiver Aiance 180 Montgomery Street, Suite 1100 San Francisco, CA Nationa Aiance for Caregiving 4720 Montgomery Lane, 5th Foor Bethesda, MD The Nationa Aiance offers support and resources for the pubic and professionas. Nationa Famiy Caregivers Association Connecticut Avenue, #500 Kensington, MD (to-free) This Association supports famiy caregivers and offers education, information, and referras. The Aiance offers programs to provide information to and support for caregivers. incuding famiies and caregivers 49

47 triange and can address both the patient and companion face-to-face. Be carefu not to direct your remarks to the companion. By not faing into this trap, you can prevent the encounter from feeing ike a two against one match. Famiies may want to make decisions for a oved one. Adut chidren especiay may want to step in for a parent who has cognitive impairments. If a famiy member has been named the heath care agent or proxy, under some circumstances, he or she has the ega authority to make care decisions. However, without this authority, the patient is responsibe for making his or her own choices. Try to set cear boundaries with famiy members, and encourage others to respect them. Famiy caregivers face many emotiona, financia, and physica chaenges. They often provide hep with househod chores, transportation, and persona care. More than one-third aso give medications, injections, and medica treatments to the person for whom they care. It makes sense to view informa caregivers as hidden patients and be aert for signs of iness and stress. Caregivers may find it hard to make time for themseves. Encourage them to seek respite care so that they can recharge and take a break from the oved one. And remember, your encouragement and praise can hep to sustain a caregiver. In Summary 4 Check with the patient on how he or she woud ike any famiy members or companions to participate in the medica encounter. 4 Address the patient try to avoid taking ony to the famiy member or companion. 4 Make it cear that the patient shoud make his or her own decisions uness ega authority to do so has been granted to someone ese. 4 Be aert to famiy caregivers own heath needs, incuding signs of stress. 50 incuding famiies and caregivers

48 Taking With Patients About Cognitive Probems chapter 10 Communicating with a confused patient hods specia chaenges. Specific techniques can hep heath care providers to tak with patients and caregivers about a diagnosis. You mentioned having troube with your memory. Jonathan Jones had aways been a meticuousy organized man. His bis were paid on time; his car gas tank was aways at east haf fu. He coud be counted on to arrive sighty eary for every appointment. Dr. Ross knew a this because he d been taking care of the Jones famiy for neary 30 years. So when Mr. Jones missed two appointments in a row, Dr. Ross knew something was not right and caed him at home. The phone rang for quite a whie before Mr. Jones answered, Yes? Heo, Dr. Ross. Why are you caing? I don t have an appointment schedued with you. The conversation added to Dr. Ross s concerns. The doctor made a note on the chart it was time to broach the subject of memory oss with Mr. Jones. After so many years, this was going to be a hard discussion. taking with patients about cognitive probems 51

49 Cognitive Impairment Aging itsef can cause deficits in cognition that vary from person to person. Whie some oder peope show itte or no decrease in cognitive function, others may be very worried about their memory and may fear dementing disorders such as Azheimer s disease (AD). But, not a cognitive probems are caused by AD. Various inesses, both physica and menta, can cause temporary, reversibe cognitive impairment. Certain drug combinations can aso cause a probem. Identifying and working with oder aduts who have cognitive impairment are important for their safety and for the safety of others. Oder patients with cognitive impairment can deveop difficuties in remembering and correcty adhering to instructions about medications for their other heath probems. In addition, activities such as cooking and driving can become dangerous. Many patients with cognitive impairments experience behaviora changes. For instance, they may withdraw from or ose interest in activities, grow irritabe or uncharacteristicay angry when frustrated or tired, or become insensitive to other peope s feeings. During more advanced stages of cognitive impairment, peope may behave inappropriatey kicking, hitting, screaming, or cursing. Depending on the stage of the disease, you can suggest activities that your patient might sti enjoy for exampe, istening to music and perhaps dancing, paying games, gardening, or spending time with pets. Some of your oder patients may have a specific condition caed mid cognitive impairment (MCI). Peope with MCI have ongoing memory probems but do not have other osses associated with AD such as confusion, attention probems, or difficuty with anguage. Some peope s cognitive probems may not get worse for many years. Some peope with MCI may convert to AD over time. Research is ongoing to determine better which peope with MCI wi deveop AD. The suggestions in this section of the booket pertain specificay to effective communication with patients with cognitive impairments. Diagnosis Accurate diagnosis of AD or other cognitive probems can hep your oder patient and his or her famiy to pan for the future. Eary diagnosis offers the best chance to treat the symptoms of the disease, when possibe, and to 52 taking with patients about cognitive probems

50 discuss ways of positivey coping with the condition, incuding discussing care options. A reativey eary diagnosis aows patients to make financia pans, prepare advance directives, and express informed consent for research. Yet data suggest that ony a sma fraction of peope with AD are ever diagnosed. When patients are ony midy impaired, they can be adept at covering up what is happening to them. However, giving a few straightforward tests, using a medica history, and taking a famiy history from another famiy member can often te you if there are persistent or worsening probems. It is best to conduct tests or interviews with the patient aone so that famiy members or companions cannot prompt the patient. Information can aso be geaned from the patient s behavior on arriva in your office or from teephone interactions with staff. Famiy members who may contact you in advance or foowing the visit are aso a source of information, but keep in mind patient privacy concerns. Athough assessing an oder person s cognitive function is important, forma testing of menta status tends to provoke anxiety. If you are concerned about a patient s cognition, it might be best to eave any forma testing of menta status unti the atter part of the appointment either between the history and the physica examination or after the examination or to refer the patient to a neuropsychoogist for more detaied assessment of cognition. If you administer a cognitive status test, try to present it in the context of concerns the patient has expressed. Providing support and encouragement during the testing can decrease stress. There are imitations to any menta status test for exampe, the test resuts can refect eve of education, or the resuts may appear norma eary in the disease. The most commony used screen is the Mini-Menta State Examination. This test can be used to screen patients for cognitive impairment and can be administered in the primary care setting in about 10 minutes. A positive finding suggests the need for referra to a neuroogist or neuropsychoogist for a more detaied diagnosis. Cognitive impairment may refect a variety of conditions, some reversibe. In particuar, it is important to review your patient s medications to check for antichoinergic or other potentiay inappropriate medications. However, taking with patients about cognitive probems 53

51 since patients or caregivers may assume that the cause is Azheimer s disease, you may need to expain the need for a carefu history, aboratory tests, and physica examination to search for other conditions or issues. If your patient does have mid to moderate cognitive impairment, you might ask if there is someone who heps when he or she has troube remembering. If your patient says yes, you coud aso ask if it woud be a good idea for you to discuss the patient s treatment pans with the heper and keep his or her name in your notes for future reference. Make these arrangements eary, and check that the patient has given you forma authorization to incude the heper in the conversation about your patient s care. For more information on Azheimer s disease, contact: Azheimer s Association 225 North Michigan Avenue, Foor 17 Chicago, IL (to-free) This nationa vountary heath organization supports Azheimer s disease research and care and offers information and support to patients and famiies. It has oca chapters with community information incuding referras, support groups, and safety services. Azheimer s Disease Education and Referra (ADEAR) Center P.O. Box 8250 Siver Spring, MD (to-free) A service of NIA, ADEAR provides information, pubications, referras, a heath information database, and a cinica trias database for the pubic and for heath care professionas. Azheimer s Foundation of America 322 8th Avenue, 7th Foor New York, NY (to-free) The Foundation brings together groups around the country, incuding assisted iving organizations, community services agencies, State agencies, and others, to coaborate on education, resources, and program design and impementation for peope with AD, their caregivers, and famiies. 54 taking with patients about cognitive probems

52 Communicating With a Confused Patient Try to address the patient directy, even if his or her cognitive capacity is diminished. Gain the person s attention. Sit in front of him or her and maintain eye contact. Speak distincty and at a natura rate of speed. Resist the temptation to speak oudy. Hep orient the patient. Expain (or re-expain) who you are and what you wi be doing. If possibe, meet in surroundings famiiar to the patient. Consider having a famiy member or other famiiar person present at first. Support and reassure the patient. Acknowedge when responses are correct. If the patient gropes for a word, genty provide assistance. Make it cear that the encounter is not a test, but rather a search for information to hep the patient. Use simpe, direct wording. Present one question, instruction, or statement at a time. If the patient hears you but does not understand you, rephrase your statement. Athough open-ended questions are advisabe in most interview situations, patients with cognitive impairments often have difficuty coping with them. Consider using a yes-or-no or mutipe-choice format. Remember that many oder peope have hearing or vision probems, which can add to their confusion. Consider having someone ca the patient to foow up on instructions after outpatient visits. If the patient can read, provide written instructions and other background information about the probem and options for soutions. taking with patients about cognitive probems 55

53 Conveying Findings Some patients may prefer a cautious, reserved expanation. You might consider saying something ike, You have a memory disorder, and I beieve it wi get worse as time goes on. It s not your faut. It may not hep for you to try harder. Now is probaby a good time for you to start making financia and ega pans before your memory and thinking get worse. Some patients may prefer more precise anguage and appreciate it when a doctor uses specific words ike Azheimer s disease. If possibe, schedue additiona time for the appointment so that you can isten and respond to the patient s or caregiver s concerns. Aso, if possibe, offer to have a foow-up appointment to further discuss what to expect from the diagnosis. Regardess of how you present the diagnosis, providing written materias can make a big difference in heping your patient and his or her famiy know what to expect. The NIA s Azheimer s Disease Education and Referra (ADEAR) Center has free pubications you can incude in a patient/caregiver information packet. You might want to refer your patient to a neuroogist or neuropsychoogist for testing. The Azheimer s Association or other supportive organizations can provide assistance in panning, socia services, and care. Informing famiy members or others that the patient may have Azheimer s disease or any cognitive impairment may be done in a famiy conference or group meeting, which shoud be arranged with the consent of the patient. In some situations, a series of short visits may be more suitabe. You shoud make cear you wi continue to be avaiabe for care, information, guidance, and support. If you are unabe to provide a of these services, it woud make a tremendous difference if you coud refer the patient and famiy to a service organization. Working With Famiy Caregivers A famiy caregivers face chaenges, but these chaenges are compounded for peope caring for patients with Azheimer s disease and other dementias. The patient usuay decines sowy, over the course of severa years. This is an 56 taking with patients about cognitive probems

54 exhausting and disturbing experience for everyone. The foowing suggestions are especiay usefu for famiy caregivers in these situations: Persuade caregivers to get reguar respite, especiay when patients require constant attention. Ask if the caregiver, who is at considerabe risk for stress-reated disorders, is receiving adequate heath care. Expain that much can be done to improve the patient s quaity of ife. Measures, such as modifications in daiy routine and medications for anxiety, depression, or seep, may hep contro symptoms. Let the caregivers know there is time to adapt. Decine is rarey rapid. Provide information about the consumer resources and support services avaiabe from groups. Hep caregivers pan for the possibiity that they eventuay may need more hep at home or may have to ook into residentia care. In Summary 4 Using a simpe screen, such as the Mini-Menta State Examination, assess the patient s cognitive function when aone with him or her. Refer the patient to a speciaist (e.g., neuroogist or neuropsychoogist) for diagnosis of cognitive impairment. 4 Reassure the patient if there is no serious menta decine. 4 Decide how to tak about serious cognitive probems, depending on how much the patient wants to know and can understand. 4 Communicate with famiy members in a famiy conference, arranged with the patient s consent. 4 Suggest activities that the patient and famiy might sti enjoy. 4 Be aert to caregivers needs for information, resources, and respite. taking with patients about cognitive probems 57

55 Keeping the Door Open Effective Communication Advising an oder man about starting an exercise program... counseing a woman about the proper way to take her osteoporosis medication... discussing end-of-ife care options with the famiy of a ong-time oder patient who is dying. These are just some exampes of the compex and sensitive issues facing cinicians who treat oder peope. Heath care providers who communicate successfuy with oder patients may gain their trust and cooperation, enabing everyone to work as a team to hande physica and menta heath probems that might arise. Effective communication techniques, ike those discussed in this handbook, can save time, increase satisfaction for both patient and practitioner, and improve the provider s ski in managing the care of his or her patients. Ongoing communication is key to working effectivey with your oder patient. If a patient does not foow recommendations or starts missing appointments, expore whether or not a difficuty in communication has deveoped. Paying attention to communication increases the odds of greater heath for your patient and satisfaction for you both. 58 keeping the door open

56 Pubications at-a-gance The Nationa Institute on Aging offers free pubications you might use when taking with your oder patients. You can order singe or mutipe copies from: Nationa Institute on Aging Information Center P.O. Box 8057 Gaithersburg, MD (to-free) (TTY/to-free) Fact sheets, caed AgePages, are avaiabe on a variety of topics. The asterisk (*) indicates those aso avaiabe in Spanish. Diseases/Conditions Safety Weness Arthritis Advice* Cancer Facts for Peope Over 50* Diabetes in Oder Peope* Hearing Loss* High Bood Pressure* Osteoporosis* Prostate Probems* Shinges Stroke* Crime and Oder Peope* Fas and Fractures* Medicines: Use Them Safey* Oder Drivers* Onine Heath Information: Can You Trust It? A Good Night s Seep* Aging and Your Eyes* Concerned About Constipation?* Dietary Suppements Exercise and Physica Activity: Getting Fit for Life* Fu Get the Shot* Foot Care* Heathy Eating After 50 Hyperthermia* (continued on next page) 60 pubications at-a-gance

57 Weness (continued) Sensitive Subjects Hypothermia* Shots for Safety* Skin Care and Aging Smoking: It s Never too Late to Stop Taking Care of Your Teeth and Mouth* Acoho Use and Abuse* Beware of Heath Scams* Considering Surgery* Depression: Don t Let the Bues Hang Around* Forgetfuness: Knowing When to Ask for Hep* Getting Your Affairs in Order HIV, AIDS, and Oder Peope* Mourning the Death of a Spouse Nursing Homes: Making the Right Choice* Sexuaity in Later Life* Urinary Incontinence* More in-depth pubications are aso avaiabe. End of Life: Heping With Comfort and Care Exercise and Physica Activity: Your Everyday Guide from the Nationa Institute on Aging So Far Away: Twenty Questions for Long-Distance Caregivers Taking With Your Doctor: A Guide for Oder Peope There s No Pace Like Home for Growing Od: Tips from the Nationa Institute on Aging NIA s ADEAR Center has a wide variety of free pubications for patients with cognitive probems, their famiies, and caregivers, such as Understanding Azheimer s Disease and Caregiver Guide: Tips for Caregivers of Peope with Azheimer s Disease. To order, contact: Azheimer s Disease Education and Referra Center P.O. Box 8250 Siver Spring, MD (to-free) pubications at-a-gance 61

58 Services at-a-gance You want to hep your patients get the services they need. But you may not be sure where to find the right resource. This is a starting pace. We ve identified some of the most common concerns and isted a few nationa resources that might be hepfu. What s the Probem? Abuse/negect Caregiver assistance Caregiving Daiy iving assistance Financia assistance Heath information Househod assistance Nutrition Socia support Transportation Utiity costs What s a Soution? Mandatory reporting to adut protective services Respite care Adut day care, nursing home care Home heath aide Case manager or supportive community programs Free fact sheets, bookets, and web resources Homemaker assistant Meas on Whees or congregate mea sites Vounteer companions Medica transport benefits or other community programs Utiity subsidies Hepfu Resources Nationa Center on Eder Abuse For your State Adut Protective Services: Ca oca poice or 911, if serious situation Nationa Respite Locator Service (to-free) Nationa Adut Day Services Association (to-free) Nursing Home Compare service Edercare Locator (to-free) Nationa Counci on Aging To assess eigibiity: Nationa Institute on Aging Information Center (to-free) NIH SeniorHeath Nationa Institutes of Heath Nationa Library of Medicine Edercare Locator (to-free) Meas on Whees Association of America Edercare Locator (to-free) Nationa Association of Area Agencies on Aging Nationa Transit Hotine (to-free) Nationa Energy Assistance Referra Project (to-free) nationa institute on aging taking with your oder patient: a cinician s handbook #

59 "This course was deveoped from the pubic domain document: A Cinician s Handbook: Taking With Your Oder Patient U.S. Department of Heath and Human Services."

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