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Older Patients' Perspectives
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Older Americans are, if anything,
a heterogeneous group. They vary widely in cultural background, educational
level, economic status, health, and even chronological age. They bring
a diversity of views, attitudes, experiences, and expectations to
the medical encounter. A 68-year-old woman with an active consulting
business is likely to deal with a visit to the doctor quite differently,
and require a very different approach, than her frail 88-year-old
aunt who has rarely ventured beyond the ethnic neighborhood where
she has kept house all her adult life.
Nevertheless, the perspectives
briefly discussed below are common enough among older people, and
important enough to effective communication, that you should be
especially aware of them.
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Perceptions of Self
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Like most of us, older people
want to be viewed as individuals, not as stereotypical members of
an age group. They want others to realize they were not always their
current age, and may often feel "there's still a young person inside."
Many older people do not view themselves as "old" in the pejorative
sense, and they shun those safety measures and medical interventions
they perceive as "only for old folks."
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Views of Physicians
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Some older people respect or
even revere physicians. In general, because older people have mainly
known physicians who were paternalistic rather than egalitarian, they
expect a paternalistic approach. Many older people do not want to
"waste the doctor's time" with concerns they fear the physician will
deem unimportant, and they do not ask questions for fear of seeming
to challenge the clinician. On the other hand, some older people,
having ample time to read, will bring popular medical articles to
the attention of their physicians. Try to avoid seeing this behavior
as criticism.
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Cultural Diversity
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Some older members of ethnic
minorities may be less assimilated into mainstream American culture
than their younger counterparts. Paying special attention to the patient's
cultural or ethnic heritage can help you tailor questions or treatment
plans appropriately.
Older people whose native
language is not English may be self-conscious about their fluency
and could feel embarrassed when talking to physicians. Under the
strain of illness, communicating in English could be especially
difficult. An interpreter can help. Even if your older patients
have always spoken English, those who are uneducated or who use
regional dialects can be similarly uneasy.
Among many ethnic groups,
strong extended families typically care for the elders and may participate
in the patient's medical encounter. Understanding these cultural
norms can help you plan appropriate care for the patient and provide
support for family caregivers. The payoff may be better compliance.
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Views About Aging and Health
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Expectations regarding health
diminish with age. This change is sometimes realistic. Often, though,
older people with treatable symptoms dismiss problems as an inevitable
part of aging and therefore do not seek medical care. As a result,
they sometimes suffer needless discomfort and disabilityÑand fail
to receive treatment for serious conditions..
On the other hand, sometimes
older people are disappointed because they used to "get better"
or bounce back from an illness more quickly. They may feel frustrated
that it takes longer to get their energy back.
Older people often do not
report all their symptoms. This sometimes happens because they think
aches and pains are a normal part of aging or, in some cases, because
they are reluctant to "bother" the physician. It also can occur
when a patient does not want to be seen as a hypochondriac or finds
a topic (such as mental health, sexuality, or incontinence) embarrassing
to discuss.
Patients may also be afraid
of having their complaint dismissed or may worry that if they complain
too much about small issues, they won't be taken seriously later
on. Some older patients don't mention symptoms for fear of what
the diagnosis or treatment might be. They may worry that the physician
will recommend surgery, suggest costly diagnostic tests or medications,
or tell them to stop driving or give up living alone. Sometimes
they may feel a need to "save money for a rainier day."
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Values Regarding Health
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Although physicians typically
focus primarily on diagnosing and treating disease, older people generally
care most about maintaining the quality of their lives. Among their
greatest fears are losing mental function (for example, through Alzheimer's
disease), losing autonomy and independence, or being abandoned by
family members.
Older people are not necessarily
preoccupied with death. In fact, many older people have become relatively
comfortable with the prospect of death and seek chiefly to make
the most of their remaining years. Younger family members, who commonly
must make life-and-death decisions when an older person is incapacitated,
may be unaware of the patient's views about terminal care or may
disagree with what the patient wants. It's a good idea to discuss
the patient's wishes regarding this subject well before the information
is likely to be needed. Ask about living wills or if advance directives
have been prepared. It is also important to know if durable power
of attorney for health care exists.
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