Caring for the geriatric patient: The initial visit
Establish a healthy working relationship by making the patient the focus of attention.
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At a glance
- Tell patients to bring all their medications, including herbal supplements, vitamins, and OTC products, to every visit.
- The extent of social relationships is a powerful predictor of functional status and mortality for older patients.
- Ask about the medical history of the patient's spouse and children. This can reveal issues like caregiver stress.
- Mental status should be assessed formally and routinely in every geriatric patient.
Older people often present with complex medical problems that have been previously managed by multiple health-care providers, a long list of medications, and functional limitations. Moreover, many patients come to the office accompanied by others, including family members and home attendants. Taken together, these circumstances make an efficient yet thorough history and physical examination a challenge for the clinician. The goal of the first visit should be to gather as much information as possible about the patient's medical condition, functional status, and social situation in a timely manner. A thorough history and physical examination as laid out in a textbook might not be possible at the first visit. Instead, parts of the examination and less urgent issues can be addressed at subsequent visits. To increase the productivity of the first encounter, ask patients or their families to complete a previsit questionnaire. The responses provided can facilitate the first visit by focusing the discussion on the patient's concerns, while allowing the interviewer to obtain a thorough history and review of systems. An example of such a questionnaire is available online.
The environmentThe clinic setting should recognize common sensory and functional limitations of older patients. More than 50% of older adults suffer from presbycusis and may find background noises distracting. Arranging for some privacy, for example, by drawing the curtains or closing the doors can help the patient maintain focus. Older patients have difficulty hearing high-pitched voices, especially women's voices. Face the patient and speak in a low-pitched voice. Patients should be instructed to bring their hearing aids to every visit. Some clinicians carry amplifiers to be used if needed. If amplifiers are not available, putting the stethoscope's earpieces into the patient's ears and speaking into the instrument's diaphragm can serve as a hearing tool. Another way to amplify sound is to seat the patient in front of a wall; your voice will be reflected off the wall and amplified.
Proper lighting in the examination room helps the patient see the clinician's facial expressions and gestures, which is important to making patients feel comfortable. Providing aphasic patients with a pen and paper will also help with communication. Encourage patients who are unable to write to answer by nodding or shaking their head.
The encounterBegin with introductions. Older patients should be addressed by their title and last name (e.g., “Mr. Smith”) unless you are told to do otherwise. Even if the patient prefers that family members be present at the time of the interview, the clinician should find some time alone with the patient. This is important to screen for elder abuse or neglect, information that the patient might not volunteer spontaneously. Time with the patient alone can be achieved by asking the family to step out during the physical examination.
Making the patient the focus of attention during the interview will also provide the basis for a healthy clinician-patient relationship. Direct all questions to the patient. Make sure everyone understands that the patient should answer all the questions; his or her permission should be requested before questions are directed to others in the room. While protecting the patient's autonomy, take care not to minimize the significance of family members. Families can provide details about the patient's illness and social situation, assist with the treatment plan, and work as a team with the patient and the clinician in achieving the goals of medical care. Patients or caregivers should provide a detailed past medical and surgical history. This includes bringing along old medical records detailing previously administered vaccines and test results to be documented in the patient's chart (Figure 1) as well as a list of other health-care providers and their contact information. The role of family members is crucial to the care of patients with advanced dementia who cannot provide a meaningful and detailed history themselves. In such a situation, family members and caregivers should be asked to provide a detailed history of presenting illness and review of systems.