Working with your older patient: a clinician's handbook

Educating the Patient

Most older patients are eager to understand their medical conditions and want to learn how to manage them. Likewise, family members and other caregivers want such information. Commonly, however, patients and caregivers feel that insufficient information has been supplied. Research indicates that physicians typically underestimate how much patients want to know and overestimate how long they spend giving information to patients. Devoting more attention to educating patients may seem like a luxury, but in the long run it can improve patients' adherence to treatment, increase patients' well-being, and save the physician's time.

General Suggestions

The following general measures can help you inform patients and their caregivers about medical conditions and their treatment.  Identify and discuss lifestyle factors such as diet and exercise that can facilitate or impede the patient's health.  Although other members of the medical team can play key roles in educating patients and caregivers, what the physician says generally receives greatest credence. Therefore, begin by providing the main information and advice yourself. Other team members may then build on what you say..  Some patients refrain from asking questions even if they want more information. Be aware of this tendency and make information available even if it is not requested.  Encourage the patient to ask questions. Indicate who in addition to yourself can answer questions that arise later.  Provide information through more than one channel. In addition to giving information orally, use or supply materials such as factsheets, drawings, models, videotapes, or audiotapes.  Encourage the patient or caregiver to take notes and be ready to offer a pad and pencil. Active involvement in recording information may promote retention and compliance.  Repeat key points, both within a given visit and at later visits.  Present information in a way that is easy to understand. Avoid medical jargon, use simple everyday language, break the information into small parts, and use analogies or examples. Avoid overloading the patient with too much information at once.  Check whether 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 praise and encouragement when appropriate. Call attention to strengths that can be built on. Remember to provide continued reinforcement for new treatment or lifestyle changes.

Explaining Diagnoses

Receiving clear explanations of diagnoses is critical. When patients do not understand their medical conditions, they tend not to follow the treatment plans. Uncertainty about what is wrong can be disturbing. In explaining diagnoses, it is helpful to begin by finding out what the patient believes is wrong, what the patient sees as its implications, and how much more the patient wants to know.. You can use these responses as a starting point for gently correcting misconceptions (for example, "Many people believe ... but actually we are learning that ...") and providing appropriate amounts and types of information.

Discussing Treatment

Most treatment refusals by older patients result from the patients' feeling that they have received insufficient information. Remember that treatment can involve lifestyle changes (such as diet and exercise) as well as medication. Make sure you develop and communicate treatment plans carefully.  Be certain that the patient agrees with the goal or outcome of the treatment plan.  Keep the treatment plan as simple and straightforward as possible. For example, minimize the number of doses per day. Tailor the plan to the patient's situation and lifestyle, and try to reduce disruption to the patient's routine.  After proposing a treatment plan, check with the patient about its feasibility and acceptability, and resolve any misunderstandings. For example, make it clear that a referral to another doctor does not mean you are abandoning the patient. If appropriate, revise the plan.  Tell the patient what to expect from treatment or recommended lifestyle change, what improvement is realistic, and when he or she should start to feel better.  Unless literacy is a problem, provide written instructions. Make sure the print is large enough for the patient to read.  Indicate the purpose of each medication or other treatment.  Make it clear which medications must be taken regularly and which ones the patient may choose to take only when having symptoms..  Encourage the patient and his or her caregivers to take an active role in discovering how to manage chronic problems. Think in terms of joint problem-solving or collaborative care. Such an approach can increase both the patient's and his or her caregivers' satisfaction while decreasing demands on your time.

Recommending Resources

Many organizations and government agencies provide health related information and services to older people and their caregivers. You can order these publications for the office library so they will be on hand to help your patients and conserve your time. Often a lack of ready information about other resources keeps physicians from referring patients to appropriate organizations or agencies. In part to address this problem, the NIA makes available the Resource Directory for Older People. This directory contains names, addresses, and telephone numbers of more than 200 organizations offering health information, self-help programs, consumer advice, and other assistance. The NIA also publishes Who? What? Where? Resources for Women's Health & Aging, a directory providing an overview of the major health and lifestyle issues affecting older women and including selected readings and referral organizations. You may also find the Institute's Age Page series to be of use. These are factsheets with practical information on more than 40 topics of concern to older people. They are printed in large type and can readily be copied for distribution. Free copies of these publications are available by contacting: National Institute on Aging Information Center P.O. Box 8057 Gaithersburg, MD 20898-8057 1-800-222-2225/TTY1-800-222-4225 (880 instead of 800 if you are calling from outside the US)