Taking an accurate history in older patients
Taking a history in older patients can be a challenge. In the fifth part of our series, Dr Shaun O’Keeffe gives some advice
Taking a history in older patients can be a challenge. In the fifth part of our series, Dr Shaun O'Keeffe gives some advice
Taking an adequate history from an older person may be time-consuming for both clinician and patient. The reasons, although not unique to older people, are more common with advancing age.
Problems with communication
Older people are often described as ‘poor historians' but the historian is the person who writes the history, not the one who provides the facts. A ‘poor historian' or someone who seems ‘vague' or ‘uncooperative' may not hear what the doctor is asking or may not understand what is being asked. Causes of incomprehension include cognitive impairment, aphasia, depression and poorly formulated questions, such as those that are too long or contain technical jargon. It is always worthwhile ensuring that the patient's hearing aid is functioning and that their dentures are in place before trying to elicit a history.
Just as practitioners need to guard against negative stereotypes of ageing, older people themselves may share the same attitudes. They may fail to mention or downplay symptoms they attribute to old age, with remarks such as: ‘What can you expect at my age?' Special sensitivity is required in exploring topics such as finances, elder abuse and continence.
Clarifying what the patient means is important when they use medical terms or report on previous consultations or diagnoses. ‘Constipation' may be misused by those who grew up with a firm belief that the bowels should move each day. ‘Dizziness' may refer to problems ranging from vertigo and orthostatic dizziness to ataxia or leg weakness.
A knowledge of the local vernacular can be useful in interpreting many phrases. It is helpful to listen for the phrase ‘I must have...' since it suggests uncertainty; for example, the patient with a fall who says ‘I must have slipped', and denies loss of consciousness, may have had a syncopal attack.
Confirmation of the patient's story is often needed when there is a possibility that it may be unreliable. An independent account of the temporal course of cognitive decline is helpful in distinguishing those with delirium from those with dementia. Details of the impact of cognitive impairment on basic and advanced activities of daily living (ADLs) and of associated behavioural and sleep problems are also important in this group.
Complexity of illness in old age
It is not surprising that those with an extensive history of multiple medical conditions may have difficulty in recalling the details in an organised manner. Maintaining a problem list, mapping the chronology of each complaint and of the response to treatment, and asking the patient to highlight the most significant current problem (‘What's the most important thing I could do for you today?'), irrespective of the reported reason for attendance, are often helpful.
The non-classical presentation of acute illness is a further complicating factor, so in someone with acute confusion or incontinence, it is necessary to consider the causes rather than just focusing on the presenting complaint.
An essential part of the assessment of older people is to establish how patients are functioning and how their level of function has changed. Assessing functional status helps to define the impact of illness on the older person's life. A recent decline in the ability to walk or to self-care is as good a predictor of outcome as age or traditional measures of illness severity1.
The basic ADLs relate to the personal care tasks of feeding, washing, dressing, getting in and out of bed and moving about on a level surface, getting to and from the toilet and continence management.
‘Instrumental' ADLs are tasks such as shopping, laundry, cleaning, cooking a main meal and handling personal administrative tasks. A helpful practical approach is to ask the patient to take you through a typical day – how they get out of bed, dress, what they have for breakfast and so on – and to assess how this may have changed as a result of recent illness.
Part of the functional assessment involves asking about the amount of help provided to patients and the extent to which such help is essential.
This may be informal, such as family visits and assistance with shopping, or formal, such as home help, meals on wheels or attendance at a day centre.
No assessment is complete without evaluating the medications patients have been prescribed, those they are actually taking (including over-the-counter products) and the effectiveness – or otherwise – of them.
Polypharmacy, arbitrarily defined as taking five or more drugs, occurs in the UK in 10% of the community-dwelling population aged over 65 in the UK, rising to 15% in those aged over 752. Rates are much higher in those in long-term care.
Use of complex multidrug regimens increases the likelihood of non-compliance or errors and of adverse drug effects and drug interactions.
But with an ageing of the population, the lowered threshold for instituting preventive measures such as lowering blood pressure and cholesterol, and the development of new treatments, polypharmacy is inevitable for some patients. Nevertheless, there is considerable evidence of overprescribing among older people with use of ineffective or unduly toxic medications or use of one drug to treat the side-effects of another3.
It is often possible to simplify the prescription using once-daily medications and fixed-dose combination pills when possible and by encouraging use of a pill box to organise the week's medications.
Presence of family or carers at assessments
Family members often accompany the older person on a visit to the doctor and may want to sit in on the clinical consultation. This is usually with the benign intention of supporting the patient, ensuring that all complaints are reported and to assist with the management plan.
This is often helpful but there is the potential for the family member's perspective and preferences to dominate the conversation. There are times when the patient's and the family's interests are divergent as, for example, when a frail older person prefers to live at risk at home and the family would prefer that they enter a nursing home.
It is important that the patient's privacy and autonomy are respected and that the degree to which the family is involved in the interview or informed about the outcome is negotiated with the patient.
The clinician should always have a period alone with the patient to ascertain their preferences in this regard and to allow discussion on topics such as abuse and continence.
Emphasis on the need to maintain the confidentiality and autonomy of the patient is not to deny that carers for those with physical or cognitive problems may often find their role physically, emotionally and financially draining and that stress and depression are common problems among carers.
Abuse of the patient can also occur if adequate support is not provided. Physicians should ask carers about depression and stress, and carers may need to be provided with education, encouragement and practical advice.
Dr Shaun O'Keeffe is a consultant geriatrician at Galway University Hospital
This is an extract from Managing Older People in Primary Care, a practical guide for clinicians involved in the day-to-day care of older people in the community. With most chapters co-authored by a specialist and a GP, it provides an indispensable resource, including tips on differential diagnosis and summaries of the existing evidence base, and guidelines on treatment. For more details and to order your copy at a 20% discount visit www.oup.com/uk/isbn9780199546589 and quote the promotion code PULSE
• Next week In the sixth and final article in this series, Dr O'Keeffe will look at the problems involved in physically examining an older person
Medication review for older patient