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Exploring Sensitive Topics
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Caring for an older patient
requires discussing sensitive topics. Such discussions are sometimes
more uncomfortable for the physician than for the patient. Some patients
avoid mentioning their concerns because they think the physician would
not want to discuss them. One way to show patients that sensitive
issues are appropriate to address is to keep brochures and fact-sheets
on these subjects in your waiting room.
The resources that follow
represent a sampling of the kinds of information available. Refer
to the NIA's Resource Directory for Older People (see
"Many People Believe..." for ordering information) for a more
comprehensive list.
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Sexuality
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An understanding, accepting
attitude and a sensitivity to verbal and other cues promote a comfortable,
helpful discussion of sexuality. Depending on indications earlier
in the interview, you may decide to approach the subject directly
(for example, "Are you satisfied with your sex life?") or more obliquely,
with allusions to changes that sometimes occur in marriage. Cues from
the patient can then be followed up. You might note that many patients
have a given concern, then wait for a response. Also effective are
anecdotes about a person in a similar situation, or raising the issue
in the context of physical findings (for example, "Some people taking
this medication have trouble...Have you experienced anything like
that?")..Don't assume that an older patient is no longer sexually
active, does not care about sex, or necessarily is heterosexual.
More information about sexuality
is available from:
Sex Information & Education
Council of the United States
130 West 42nd Street, Suite 2500
New York, NY 10036
1-212-819-9770
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Urinary Incontinence
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About 10 million Americans,
including 15 to 30 percent of community-dwelling people over age 65
and at least one-half of nursing home residents, have some significant
degree of urinary incontinence. Often, this problem can be substantially
alleviated through behavioral techniques such as bladder training.
Incontinence often goes untreated
because the patient is embarrassed to mention it. You should ask
specifically about the problem. Many physicians have found that
the "some people" approach (for example, "when some people cough
or sneeze, they tend to leak urine...") works well. Further information
about urinary incontinence is available from:
National Institute on Aging
Information Center
P.O. Box 8057
Gaithersburg, MD 20898-8057
1-800-222-2225/TTY 1-800-222-4225
(880 instead of 800 if you are calling from outside the US)
Help for Incontinent People
P.O. Box 544
Union, SC 29379
1-800-252-3337 (1-800-BLADDER)
(880 instead of 800 if you are calling from outside the US)
The Simon Foundation
P.O. Box 815
Wilmette, IL 60091
1-800-237-4666
(880 instead of 800 if you are calling from outside the US)
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Elder Abuse
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An estimated one million or
more older Americans each year are the victims of physical, psychological,
or other forms of abuse. Embarrassment and fear of reprisal are some
reasons patients may not tell their physicians about this problem.
Clues that elder abuse may be occurring include:
 Delay
in seeking treatment for injuries, improbable explanations of injuries,
or major inconsistencies between patient's and caregiver's accounts
of how the patient was injured.
Repeated
injuries, suspicious-looking injuries, or signs of physical neglect.
Changes
in the patient's behavior when the caregiver enters or leaves the
room.
Risk
factors such as substance abuse by a caregiver, a history of family
violence, or exceptional stress on the caregiver.
If a patient appears to be
at high risk, or if you suspect abuse or neglect, you should raise
the possibility with the patient alone first. An opening to discuss
the situation can be provided, for example, by noting that the caregiver
is under the sort of stress that can make someone lose his or her
temper.
If appropriate, you can help
caregivers obtain the support needed to function appropriately or
help them arrange for the patient to move to a new setting. As in
discussing other sensitive topics, an understanding, constructive
tone is needed. More information about elder abuse is available
from:
National Aging Resource
Center on Elder Abuse
810 First Street NE, Suite 500
Washington, DC 20002
1-202-682-2470
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Depression
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Although depression is by no
means an inevitable part of aging, depressive symptoms and illness
are common in older people and often can be treated. Signs of depression
often go unrecognized. People who are depressed lack hope and may
feel that reporting symptoms would be futile. And, because of the
lingering stigma associated with mental illness and psychiatric treatment,
some older people do not mention such problems. If clinicians are
relatively unwilling to listen to older people or believe that depression
is simply a part of old age, the signs of depression are likely to
be missed.
The patient's current and
social history often provide clues that depression may be present.
Look for aches and pains that just won't go away, irritability,
problems with eating and weight, tiredness or lack of energy, or
expressions of feeling "empty," sad, or anxious. Gently ask how
the patient is doing and be direct in asking about sadness, tiredness,
or episodes of crying. Try to ease fears about being evaluated by
noting that a readily remediable cause may be found, such as a side
effect of medications. If the patient is reluctant to be evaluated,
relatives or friends of the patient may be able to provide reassurance.
More information about depression in older people is available from:
NIMH Depression Awareness,
Recognition & Treatment Program
5600 Fishers Lane, Room 7C02
Rockville, MD 20857
1-800-421-4211
(880 instead of 800 if you are calling from outside the US)
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Long-Term Care
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Although only 5 percent of
the older population reside in nursing homes at any one time, about
43 percent of all people eventually spend some time in such a facility.
Discussing the possibility of long-term care is often an important
part of working with older patients. The topic should be explored
with patients and caregivers early, so they can look into home care,
daycare programs, nursing homes, or other options, well before the
need arises.
You can begin talking about
long-term care when discussing the course and management of the
patient's medical problems. More information about long-term care
is available from:
Administration on Aging
330 Independence Avenue SW
Washington, DC 20201
1-202-619-0641
American Association of
Retired Persons
601 E Street NW
Washington, DC 20049
1-202-434-2277
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Death and Terminal Care
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Most older people have thought
about the prospect of their death and want to discuss their wishes
regarding terminal care. The opportunity to express these wishes can
be provided at an appropriate time early in the physician-patient
relationship, when the patient's values and history are being explored.
Explain to the patient that because of new technologies and medical
findings, great strides have been made in relieving pain, and it has
become easier to manage the dying process. It may also be appropriate
to bring up the issue of terminal care when meeting with family members
and solicit their views on hospice care or advance directives.
You should make clear a willingness
to resume the discussion about death and dying at other times and
should keep alert for cues that the patient may want to talk about
this again. Work with patients directly on advance directives and
living wills to help ensure that they receive the type of care they
want. These documents should be revised and updated based on patients'
changing needs or desires. More information about terminal care
is available from:
National Hospice Organization
1901 N. Moore Street, Suite 901
Arlington, VA 22209
1-800-658-8898
(880 instead of 800 if you are calling from outside the US)
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Cognitive Impairment
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A major cause of cognitive
impairment is Alzheimer's disease. For specific suggestions about
communicating with patients with this illness, see page 29. However,
many other disorders can cause similar memory loss, confusion, or
related symptoms; for example, strokesÑabout 72 percent of stroke
victims are age 65 or older. More information about strokes is available
from:
National Stroke Association
8480 East Orchard Road, Suite 1000
Englewood, CO 80111-5015
1-800-367-1990
(880 instead of 800 if you are calling from outside the US)
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