History

Geriatric Essentials

• Unless corrected, sensory deficits, especially hearing deficits, may interfere with history-taking.
• Many disorders in the elderly manifest solely as functional decline.
• As part of the drug history, the patient or a family member should be asked to bring in the patient's prescription and OTC drugs at the initial visit and periodically thereafter.
• Health care practitioners must often interview caregivers to obtain the history of functionally dependent elderly patients.
• Frail elderly patients with complex conditions (eg, multiple disorders, use of several drugs) often require assessment by an interdisciplinary team.

Physicians often need to spend more time interviewing and evaluating elderly patients than younger patients. When elderly patients present with many nonspecific symptoms, structuring and focusing the interview may be difficult and require more time. Sensory deficits (eg, hearing or vision deficits), which are common among elderly people, can interfere with the interview. Elderly patients may underreport symptoms that they consider a part of normal aging (eg, dyspnea, hearing or vision deficits, problems with memory, incontinence, gait disturbance, constipation, dizziness, falls). However, no symptom should be attributed to normal aging unless a thorough evaluation is done and other causes have been eliminated.

In elderly patients, clinical features of disorders may differ from those in younger patients. Disorders may manifest solely as functional decline. In such cases, standard questions may not apply. For example, when asked about joint symptoms, patients with severe arthritis may not report pain, swelling, or stiffness, but if asked about changes in activities, they may report that they no longer take walks or no longer volunteer at the hospital. Questions about duration of functional decline (eg, "How long have you been unable to do your own shopping?") can elicit useful information. Identifying people when they have just started to have difficulty doing basic activities of daily living (ADLs) or instrumental ADLs may provide more opportunities for interventions to restore function or to prevent further decline and thus maintain independence.

Elderly patients with cognitive dysfunction may have difficulty recalling past illnesses, hospitalizations, operations, and drug use; a physician may have to obtain these data from an alternative source (eg, family members, home health aide, medical records). The main problem reported by the patient may differ from that reported by family members.

Frail elderly patients with complex conditions, especially patients who have multiple disorders or who take several drugs, often require assessment by an interdisciplinary team. Such a team typically consists of some combination of physician, nurse, pharmacist, nutritionist, physical therapist, occupational therapist, and social worker. Team members evaluate from their own perspectives, then meet to discuss their findings and develop a single treatment plan that considers the patient's functional status, resources, and the many potential interactions between different disorders and drugs.

Approach to the interview: A physician's knowledge of an elderly patient's everyday concerns, social circumstances, mental function, emotional state, and sense of well-being helps orient and guide the interview. Traditionally, physicians use the main problem reported by a patient as the focal point of the interview. However, this highly structured approach may be too limiting. Instead, asking patients to describe a typical day elicits information about their quality of life and mental and physical function. This approach is especially useful during the first meeting, whether in an office, a clinic, an emergency department, a hospital, or a nursing home. Allowing the patient to speak with pride about a long life, accomplishments, and things of personal importance establishes a rapport between the physician and patient. A good physician-patient relationship helps the physician communicate with family members and motivate the patient to adhere to a treatment regimen.

Often, a disorder can be detected based on verbal and nonverbal clues (eg, the way the story is told, tempo of speech, tone of voice, eye contact). An elderly patient may omit or deny symptoms of anxiety or depression but betray them by a lowered voice, subdued enthusiasm, or even tears. A patient's comments about sleep and appetite may reveal information about physical and mental health. A change in the fit of clothing or dentures may indicate weight gain or loss. Also important are the patient's personal hygiene and dress, the person who accompanies the patient, and the patient's preference about having that person talk during the interview.

Patients should be fully clothed during the interview. Dentures, eyeglasses, or hearing aids, if normally worn, should be worn to facilitate communication. To improve communication with a patient who has vision or hearing deficits, the interviewer should adjust lighting so that it is adequate without causing glare; the interviewer should move close to the patient, face the patient directly, and speak clearly and slowly to facilitate speechreading. Shouting at the patient does not help because age-related stiffening of the tympanic membrane and ear ossicles distorts high-volume sound. Headphone and amplifier sets are useful and inexpensive if amplification is needed and the patient does not have a hearing aid. If these devices are unavailable, the interviewer can insert the earpieces of a stethoscope into the patient's ears and try speaking into the bell of the stethoscope.

A mental status examination may be necessary early in the interview to determine the patient's reliability; this examination should be conducted tactfully so that the patient does not become embarrassed, offended, or defensive.

Some patients prefer to have a relative or caregiver present; however, unless mental status is impaired, patients should also be interviewed alone to encourage the discussion of personal matters. Physicians often also need to speak with a relative or caregiver. Relatives and caregivers, who may be interviewed with the patient or separately according to need, often give a different perspective on function, mental status, and emotional state.

The physician should not invite a relative or caregiver to be present without asking the patient's permission because doing so implies that the patient is incapable of providing a complete history. Asking the patient to wait outside while a relative or caregiver is interviewed may have the same effect. The physician can avoid this problem by explaining that separate interviews are usual and intended to make sure that all the needed information is obtained. During the caregiver's interview, the patient should be kept usefully occupied (eg, filling out a standardized questionnaire to evaluate mood, cognition, or general quality of life; being interviewed by another member of the interdisciplinary team about such issues as whether help needed for daily activities is available).

Medical history: When asking patients about their past medical history, a physician should ask about disorders that used to be more common (eg, rheumatic fever, poliomyelitis) and about outdated treatments (eg, pneumothorax therapy for TB, mercury for syphilis). A history of immunizations (eg, tetanus, influenza, pneumococcus), adverse reactions to immunizations, and skin test results for TB is needed. If the patient recalls having surgery but does not remember the procedure or its purpose, surgical records should be obtained if possible.

Questions designed to systematically review each body area or system are asked to check for other disorders and common problems that patients may have forgotten to mention (see Table 3-1).

Drug history: The drug history should be recorded; a flow sheet is often useful. A copy should be given to the patient or caregiver. The drug history includes the drugs used, dose, dosing schedule, prescriber, and reason for prescribing the drugs. Topical drugs must be included, partly because they may be absorbed systemically; eg, -blocker eyedrops for treating glaucoma can have cardiovascular and pulmonary effects that may be comparable to those of -blockers taken po or given IV. OTC drugs must be included. Their overuse can have serious consequences (eg, diarrhea due to laxative use, salicylism due to aspirin use, GI or renal toxicity due to NSAID use), and their use may affect drug prescriptions (eg, when OTC acetaminophen is taken, the amount of prescribed analgesics that contain acetaminophen must be limited). Dietary supplements and medicinal herb preparations must also be included because many can interact adversely with prescription and OTC drugs; for example, ginkgo biloba extract taken with NSAIDs or warfarin increases risk of spontaneous bleeding. Also, the precise nature of any drug allergies should be determined.

The patient or a family member should be asked to bring in all of the patient's prescription and OTC drugs, dietary supplements, and medicinal herb preparations at the initial visit and periodically thereafter. However, the patient's possession of current prescription drugs does not guarantee the patient's adherence to the treatment regimen. Counting the number of tablets in each vial during the first and subsequent visits may be necessary. If someone other than the patient administers the drugs, that person is interviewed.

Patients should demonstrate their ability to read labels (often printed in small type) and open containers (especially the child-resistant type). Patients should also demonstrate their ability to recognize drugs, which may be difficult to differentiate if patients put the drugs into one container.

Alcohol, tobacco, and recreational drug use history: Tobacco and alcohol use are recorded. Patients who smoke should be counseled to stop. They should also be warned against smoking in bed because elderly people are more likely to fall asleep while doing so. Patients should be checked for signs of alcohol use disorders, which are underdiagnosed in elderly people. Such signs include confusion, anger, hostility, alcohol odor on the breath, impaired balance and gait, tremors, peripheral neuropathy, and nutritional deficiencies. Screening questionnaires (eg, CAGE questionnaire) and questions about quantity and frequency of alcohol consumption are effective means for identifying patients with an alcohol use disorder. Questions about use of other recreational drugs or substances of abuse are appropriate.

Nutrition history: The type, quantity, and frequency of food eaten are determined. People who eat <= 2 meals a day are at risk of undernutrition. Any special diets (eg, low-salt, low-carbohydrate) or self-prescribed fad diets are noted. Intake of dietary fiber and prescribed or OTC vitamins is recorded. Asking about weight loss and change of fit in clothing is also important. The amount of money a patient has to spend on food, accessibility of food stores, and access to suitable kitchen facilities should be determined. The variety and freshness of foods is also important; many elderly people are limited to bread products and canned foods.

The patient's ability to eat (eg, to chew and swallow) is evaluated. It may be impaired by xerostomia, which is common among elderly people. Decreased taste or smell may reduce the pleasure of eating, so patients may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients who are worried about urinary incontinence may reduce their fluid intake; as a result, they may eat less food.

Mental health history: Mental health problems may not be detected as easily in elderly patients as in younger patients. Insomnia, changes in sleep patterns, constipation, cognitive dysfunction, anorexia, weight loss, fatigue, preoccupation with bodily functions, and increased alcohol consumption are common symptoms. The patient should be asked about delusions and hallucinations, past mental health care (including psychotherapy, institutionalization, and electroconvulsive therapy), use of psychoactive drugs, and recent changes in circumstances.

Sadness, hopelessness, and crying episodes may indicate depression. Many circumstances (eg, recent loss of a loved one, including a pet; hearing loss; a change in residence or living situation; loss of independence) may contribute to depression. Irritability may be the primary affective symptom of depression, or patients may present with cognitive dysfunction. Patients' spiritual and religious preferences, including their personal interpretation of aging, declining health, and death, are clarified.

Functional status: Evaluating the patient's functional status is part of comprehensive geriatric assessment. The evaluation is done to find out whether patients can function independently, need some help with basic or instrumental ADLs, or need total assistance. Patients may be asked open-ended questions about their ability to do activities or be asked to fill out a standardized assessment instrument with questions about specific basic and instrumental ADLs (eg, Katz ADL Scale, Lawton IADL Scale).

Social history: Social history includes evaluation of the patient's living arrangements, possibly best done by visiting the home. The number of rooms, number and type of phones, presence of smoke and carbon monoxide detectors, and condition of plumbing and heating system are determined, as is the availability of elevators, stairs, and air conditioning. Home safety evaluations can identify home features that can lead to falls (eg, poor lighting, slippery bathtubs, unanchored rugs), and solutions can be suggested.

Having the patient describe a typical day, including activities such as reading, television viewing, work, exercise, hobbies, and interactions with others, provides valuable information. The patient is asked about the frequency and nature of social contacts (eg, friends, senior citizens' groups), family visits, and religious or spiritual participation. The patient should also be asked about driving and availability of other forms of transportation.

Caregivers and support systems (eg, church, senior citizens' groups, friends, neighbors) that are available to the patient are identified. The ability of family members to help the patient (eg, their employment status, their health, traveling time to the patient''s home) is determined. The patient's attitude toward family members and their attitude toward the patient (including their level of interest in helping and willingness to help) are explored. Drug abuse and patient abuse by the caregiver should be considered when appropriate.

The patient's marital status is noted. Questions about sexual practices and satisfaction must be sensitive and tactful but thorough. The number and sex of sex partners are determined, and risk of sexually transmitted diseases is evaluated. Many sexually active elderly people do not know about safe sex practices.

The patient should be asked about educational level, jobs held, known exposures to radioactivity or asbestos, and current and past hobbies. Economic difficulties due to retirement, a fixed income, or death of a spouse or partner are discussed. Financial or health problems may result in loss of a home, social status, or independence. The patient should be asked about past relationships with physicians; a longtime relationship with a physician may have been lost because the physician retired or died or because the patient relocated.

The patient's wishes regarding measures for prolonging life must be documented. The patient is asked what provisions for surrogate decision making have been made in case the patient becomes incapacitated, and if none have been made, the patient is encouraged make them.

This topic was last updated June 2006.