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Obtaining the Medical History
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When patients are older, obtaining
a good history-of current concerns, family health experience, medications,
and social situation-is crucial to sound health care. But doing so
poses special challenges. The following ideas can aid in obtaining
appropriate information with minimal strain on both you and the patient.
Although these suggestions
may appear time-consuming, many of them involve a one-shot investment
of time and can be performed by a variety of health care professionals
in an office or home setting. You may also find it works best to
schedule several short visits rather than trying to cover all these
subjects at once.
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General Suggestions
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The varied nature and needs
of older patients call for flexibility in interviewing. Here are some
measures to consider.
 If
feasible, gather preliminary data before the session. Request previous
medical records, have the patient or family complete a questionnaire
at home or in the waiting room, or obtain information from the patient
by telephone. Structure questionnaires for easy reading by using
large enough type and providing enough space between items. If questionnaires
are to be filled out in the waiting room, keep them relatively short..
Try
to avoid making the patient tell his or her story more than once-first
to a nurse and then to you. This can be tiring, especially if the
patient has limited energy.
Be
willing to depart from the usual interview structure. You might
understand the patient's condition more quickly if you elicit his
or her past medical history immediately after the chief compliant,
before obtaining a complete evaluation of the present illness.
In
the review of systems, remember to ask about often overlooked problems,
such as difficulty sleeping, incontinence, falling, depression,
dizziness, or loss of energy.
Pace
the interview. An older patient may need extra time to formulate
answers. Resist the tendency to interrupt prematurely.
If
the patient has trouble coping with open-ended questions, make greater
use of yes-or-no or simple choice questions.
Remember
that the interview itself can be therapeutic. Although for you the
patient is one of many, for the patient you may be one of the most
important individuals in his or her life. The patient's chance to
express concerns and to receive your attention can itself prove
therapeutic.
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Current Concerns
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Although younger patients often
have well-defined chief complaints reflecting classic presentation
of single diseases, older patients tend to have multiple chronic conditions
and show vague, atypical presentations of disorders. Thinking in terms
of current concerns rather than a chief complaint may be more appropriate.
Following are some considerations to keep in mind.
Research
shows that shortly after asking a patient his or her chief concerns,
physicians commonly interrupt and turn to other matters. Try to
resist this tendency and give the patient enough time to answer
your questions.
If
a patient has ongoing problems that were discussed in previous visits,
the temptation exists to begin by asking about them. Starting an
interview with past concerns may leave the patient's .current concerns
unarticulated until the end of the allotted time. Try beginning
with general questions such as "How can I help you most at this
visit?" or "What's been happening?"
Encourage
the patient and his or her caregivers to bring a list of their main
concerns and questions to help ensure that these issues are discussed.
Sometimes
an older patient will see a physician because of concerns of family
members or caregivers. Find out whose concern led to the visit.
Even
if a patient's chief concern is not the problem that is medically
most important, you must deal with that concern. For example, an
older patient may see you about a minor foot problem and be found
to have dangerously high blood pressure or cognitive impairment.
Only if the foot problem is addressed is the patient likely to follow
your recommendations regarding blood pressure control or mental
status testing.
Symptoms
in older people tend to be nonspecific, but the rate at which the
symptoms develop can indicate whether an acute problem exists. Therefore,
determine how fast the patient's condition has been changing.
Sometimes
a patient is not comfortable enough to express a concern, such as
the death of a close relative or friend, until the end of an interview.
To give such patients an opening, end with a question such as "Is
there anything else you'd like to discuss?"
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Medications
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Side effects, interactions,
and misuse of medications can lead to complications causing morbidity
in older people. It is crucial to find out what medications older
patients are using and how often they are taken. Older people often
take many medications prescribed by several different doctors, e.g.,
general internists, cardiologists, urologists, or rheumatologists.
Ask
the patient to bring all the medications he or she is taking, both
prescription and over-the-counter, to your office. A good approach
is to have the patient put everything in a brown bag and bring it
to each visit..
Find
out about the patient's habits of taking each medication. Ask what
each one is for.
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Family History
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Even if the patient has passed
the age at which many conditions with familial components typically
appear, the family history can be of considerable value. It still
indicates the patient's likelihood of developing some diseases, and
it provides information on the health of relatives who care for the
patient or who might do so in the future.
The
family history can offer a window of opportunity to explore the
patient's experiences, perceptions, and attitudes regarding diseases
and death. For example, a patient may say "I never want to be in
a nursing home like my mother." Be alert for openings to discuss
issues such as advance directives.
It
is important to obtain sufficient information not only on previous
generations and siblings but also on children and grandchildren.
If a patient needs long-term care at some point, you will know what
support may be available from family members.
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Life History
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If you expect to continue caring
for an older patient, obtaining a life history is an excellent investment
of time. Obtaining such a history aids greatly in understanding the
patient. It also strengthens the clinician-patient relationship by
showing your interest in the patient as a person. Two suggestions:
Use
simple statements such as "Are you originally from this area?" to
start a patient telling his or her life story.
Be
alert for information on the patient's relationships with others,
thoughts about families or coworkers, typical responses to stress,
and attitudes toward aging, illness, occupation, and death. Such
information can help you interpret later reports by the patient
and can help you make appropriate recommendations.
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Functional Status
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Knowing an older patient's
usual level of functioning, and learning of recent changes in it,
are basic to providing appropriate health care. You should remember:
The
ability to perform basic activities of daily living (ADLs) both
reflects and affects a patient's health. It also influences which
treatment regimens are suitable. Depending on the patient's status,
ask about ADLs such as eating, bathing, and dressing and more complex
instrumental activities of daily living (IADLs) such as cooking,
shopping, and managing finances.
Sudden
changes in ADLs or IADLs are valuable diagnostic clues. In older
people, serious conditions such as infections and infractions often
produce a decline in functional ability or confusion rather than
symptoms such as fever or pain. If an older person stops eating,
becomes confused or incontinent, or stops getting out of bed, look
for underlying medical problems. Keep in mind the possibility the
problem may be acute.
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Social History
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The social history also is
crucial. If you are aware of the patient's living arrangements or
access to transportation, you are much more likely to devise realistic,
appropriate interventions.
Ask
about type of dwelling, neighborhood safety, eating habits, tobacco
and alcohol use, typical daily activities, work, education, and
financial situation. It also helps to find out who lives with or
nearby the patient.
Determine
if the patient is a caregiver. Many older women care for spouses,
elderly parents, or grandchildren. A patient's willingness to report
symptoms sometimes depends on whether they think they can "afford
to get sick."
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Home Visits
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A picture of the patient in
his or her usual surroundings can be worth hours of interviewing.
Thus, a home visit is often an excellent investment of time. However,
make sure the patient understands the purpose of the visit. Here are
some pointers.
Remember
to observe the patient's environment, mode of functioning, and interaction
with others in the household. Your findings may aid greatly in diagnosis
or treatment planning.
If
the patient offers to get you something to eat or drink, accept;
how the patient proceeds can be very informative. A glimpse into
the refrigerator may provide a wealth of information.
If
you cannot readily conduct a home visit yourself, consider sending
a member of your staff. Nurses, social workers, and a range of other
health care professionals can call on patients.
If
a home visit isn't possible, ask your patient to describe a typical
day.
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