National Institute on aging

National institutes of health

Department of health and human services

Your 

Older 

Patient

Talking

 With

A CLI N ICIA N ’ S HA NDB OO K

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Tear-Off Card

 Foreword

 1. Considering Health Care Perceptions

“I’m 30 . . . until I look in the mirror.”

 2. Understanding Older Patients

“Tell me more about how you spend your days.”

 3. Obtaining the Medical History

“What brings you here today?”

 4. Encouraging Wellness

“I’d like you to try this exercise routine.”

 5. Talking About Sensitive Subjects

“Many people your age experience similar problems.”

 6. Supporting Patients With Chronic Conditions

“Let’s discuss living with . . .”

 7. Breaking Bad News

“I wish I had better news.”

 8. Working With Diverse Older Patients

“Cultural differences, not divides.”

 9. Including Families and Caregivers

“What would you like your family to know?”

 10. Talking With Patients About Cognitive Problems

“You mentioned having trouble with your memory.”

 11. Keeping the Door Open

“Effective Communication”

 Publications At-a-Glance

 Services At-a-Glance

Contents

Foreword

Good communication is an important part of 

the healing process. 

Studies find that effective physician-patient communication has specific 

benefits: patients are more likely to adhere to treatment and have better 

outcomes, they express greater satisfaction with their treatment, and they 

are less likely to bring malpractice suits.

Research also shows that good communication is a teachable skill. Medical 

students who receive communication training improve dramatically, 

not only in communicating with patients, but also in assessing and 

building relationships with them. Time management skills also get 

better. Communication skill is now a core competency identified by the 

Accreditation Council on Graduate Medical Education (ACGME) and the 

American Board of Medical Specialties (ABMS). 

Learning effective communication techniques—and using them—may help 

you build more satisfying relationships with older patients and become even 

more skilled at managing their care.

Communicating with older patients involves special issues. For example:

l How can you effectively interact with patients facing multiple illnesses 

and/or hearing and vision impairments? 

l What’s the best way to approach sensitive topics such as driving privileges 

or assisted living? 

l Are there ways to help older patients who are experiencing confusion or 

memory loss? 

With questions like these in mind, the National Institute on Aging (NIA), 

part of the National Institutes of Health, developed this booklet.

foreword 1
Although referring to clinicians throughout the text, this booklet is intended 

for use by a range of professionals dealing directly with patients—physicians, 

physicians-in-training, nurse practitioners, nurses, physician assistants, and 

other health care professionals. The aim is to introduce and/or reinforce 

communication skills essential in caring for older patients and their families. 

Talking With Your Older Patient: A Clinician’s Handbook offers practical 

techniques and approaches to help with diagnosis, promote treatment 

adherence, make more efficient use of clinicians’ time, and increase patient 

and provider satisfaction.

Three points are important to remember: 

l Stereotypes about aging and old age can lead patients and health 

professionals alike to dismiss or minimize problems as an inevitable part 

of aging. What we’re learning from research is that aging alone does not 

cause illness and that growing older does not automatically mean having 

to live with pain and discomfort. 

l Many of this booklet’s suggestions may, at first glance, appear to be 

time-consuming, especially given the time constraints of most clinicians. 

However, an initial investment of time can lead to long-term gains for 

physicians and patients. Time-intensive practices need not be inefficient. 

You may get to know your older patient’s life history over the course of 

several visits rather than trying to get it all in one session.

l Older patients are diverse and unique, just like your younger patients. 

You may see frail 60-year-olds and relatively healthy 80-year-olds. Your 

patients may be culturally diverse. Some may be quite active while others 

may be sedentary. The techniques offered here encourage you to view all 

older people as individuals who have a wide range of health care needs 

and questions.

Many physicians, nurses, researchers, and other health care professionals 

were generous in providing information and advice on making this edition of 

the Clinician’s Handbook useful. The Institute is grateful for their thoughtful 

contributions.

Richard J. Hodes, M.D., Director

National Institute on Aging

National Institutes of Health

2 foreword
considering health care perceptions 3

Considering Health Care Perceptions 

The best way to learn what is and is not acceptable is to 

communicate directly with patients and caregivers.

“I’m 30 . . . until I look in the mirror.”

Mrs. Hill is an 85-year-old nursing home resident. She has lived 

in a facility since advanced heart disease made it impossible for 

her to live independently. Her adult children feel that life in a 

nursing home must be a nightmare. They want to do something, 

but they don’t know what. Moving her to one of their homes isn’t 

an option; visiting her makes them feel depressed. One day, her 

doctor chats with Mrs. Hill about life in the home. She tells him 

that this is one of the best times of her life—people prepare and 

deliver her meals, she has a comfortable room with a view of the 

gardens, and the place is very peaceful. Mrs. Hill is quite happy 

and has no desire to move.

For Mrs. Hill, a life her children find unacceptable is, in fact, just fine with 

her. What seems intolerable to a 40-year-old may actually be preferred by a 

90-year-old. 

In the past century, the nature of old age has changed dramatically. In the 

early 1900s, the average life expectancy was about 49 years—today, it is 

nearly 80 years. With longevity, however, comes the sobering news that older 

chapter 1
4 considering health care perceptions

people may live for years with one or more chronic, potentially disabling 

conditions. This means they will have an ongoing need for medical services.

No single characteristic describes an older patient. Each person has a 

different view of what it means to be old. A 68-year-old woman with an 

active consulting business is likely to deal with a visit to the doctor quite 

differently from her frail 88-year-old aunt who rarely ventures beyond her 

neighborhood.

The perspectives that follow are common among older people—and 

important to consider when talking with older patients.

Views of Physicians and Clinicians 

In the past, older people have held doctors in high esteem and treated them 

with deference. This view may change over time as aging baby boomers are 

likely to take a more egalitarian and active approach to their own health care. 

Today, many older people don’t want to “waste the doctor’s time” with 

concerns they think the clinician will deem unimportant. Patients 

sometimes worry that if they complain too much about minor issues, they 

won’t be taken seriously later on. Or, they are afraid of the diagnosis or 

treatment. They may worry that the physician will recommend surgery or 

suggest costly diagnostic tests or medications.

Some patients do not ask questions for fear of seeming to challenge the 

clinician. On the other hand, some older people, having ample time 

and interest, will bring popular medical articles to the attention of 

their providers. This kind of active patient participation can provide an 

opportunity for communication.

Views of Aging

Ageism can work both ways. Doctors can make assumptions about their older 

patients. Older people may unwittingly assume the stereotypes of old age. 

Expectations regarding health diminish with age, sometimes realistically, but 

often not. Older people with treatable symptoms may dismiss their problems 

as an inevitable part of aging and not get medical care. As a result, they may 
In Summary

considering health care perceptions 5

suffer needless discomfort and disability. Some may not even seek treatment 

for serious conditions. 

The process of aging may be troubling for older adults. It can be especially 

hard for people who once bounced back quickly from an illness or were 

generally healthy. Experts observe that baby boomers bring different 

expectations, experiences, and preferences to aging than did previous 

generations. For instance, some boomers are likely to want to participate 

actively in health care treatments and decisions. They may also search the 

Internet for health information.

Values About Health

Although physicians typically focus primarily on diagnosing and treating 

disease, older people generally care most about maintaining the quality of 

their lives. They are not necessarily preoccupied with death. In fact, many 

older people are relatively accepting of the prospect of death and seek chiefly 

to make the most of their remaining years. Younger family members, who 

commonly must make life-and-death decisions when an older person is 

incapacitated, may be unaware of the patient’s views and preferences.

4 Let older patients know that you welcome their questions and 

participation.

4 Encourage older adults to voice their concerns.

4 Be alert to barriers to communication about symptoms, such as fears 

about loss of independence or costs of diagnostic tests.

4 Expect those in the baby boom generation to be more active 

participants in their health care.
6 understanding older patients

Understanding Older Patients

What was once called “bedside manner” and considered 

a matter of etiquette and personal style has now been 

the subject of a large number of empirical studies. 

The results of these studies suggest that the interview 

is integral to the process and outcomes of medical care.

“Tell me more about how you spend your days.”

Although she complains of her loneliness and long days in front 

of the TV, Mrs. Klein refuses to participate in activities at the 

community senior center. “I’m not playing bingo with a bunch 

of old ladies,” she tells her doctor when he suggests she get out 

more. “You’ve mentioned how much you love to garden,” her 

doctor says. “The center has a garden club with a master gardener. 

One of my other patients says she loves it.” “I don’t want to hang 

around old people who have nothing better to do than compare 

health problems,” she says. “Why not give it a try?” her doctor 

asks. “You might find the members are pretty active gardeners.” 

Six months later, when she sees the doctor again, Mrs. Klein 

thanks him. She has joined the garden club and reports that the 

members all have green thumbs as well as being quite lively 

conversationalists. Better still, Mrs. Klein’s depressive symptoms 

seem improved.
understanding older patients 7

Effective communication has practical benefits. It can:

l help prevent medical errors 

l strengthen the patient-provider relationship 

l make the most of limited interaction time 

l lead to improved health outcomes

This chapter provides tips on how to communicate with older patients in 

ways that are respectful and informative.

Use Proper Form of Address 

Establish respect right away by using formal language. As one patient 

said, “Don’t call me Edna, and I won’t call you Sonny.” You might ask 

your patient about preferred forms of address and how she or he would 

like to address you. Use Mr., Mrs., Ms., and so on. Avoid using familiar 

terms, like “dear” and “hon,” which tend to sound patronizing. Be sure to 

talk to your staff about the importance of being respectful to all of your 

patients, especially those who are older and perhaps used to more formal 

terms of address.

Make Older Patients Comfortable

Ask staff to make sure patients have a comfortable seat in the waiting 

room and help with filling out forms if necessary. Be aware that older 

patients may need to be escorted to and from exam rooms, offices, and the 

waiting area. Staff should check on them often if they have to wait long in 

the exam room. 

Take a Few Moments to Establish Rapport

Introduce yourself clearly. Show from the start that you accept the patient 

and want to hear his or her concerns. If you are a consultant in a hospital 

setting, remember to explain your role or refresh the patient’s memory of it.

In the exam room, greet everyone and apologize for any delays. With new 

patients, try a few comments to promote rapport: “Are you from this area?”

or “Do you have family nearby?” With established patients, friendly questions 

about their families or activities can relieve stress.

chapter 2
8 understanding older patients

Try Not to Rush

Avoid hurrying older patients. Time spent discussing concerns will allow you 

to gather important information and may lead to improved cooperation and 

treatment adherence.

Feeling rushed leads people to believe that they are not being heard or 

understood. Be aware of the patient’s own tendency to minimize complaints 

or to worry that he or she is taking too much of your time.

Avoid Interrupting

One study found that doctors, on average, interrupt patients within the first 

18 seconds of the initial interview. Once interrupted, a patient is less likely 

to reveal all of his or her concerns. This means finding out what you need to 

know may require another visit or some follow-up phone calls. 

Older people may have trouble following rapid-fire questioning or torrents of 

information. By speaking more slowly, you will give them time to process what 

is being asked or said. If you tend to speak quickly, especially if your accent is 

different from what your patients are used to hearing, try to slow down. This 

gives them time to take in and better understand what you are saying.

Use Active Listening Skills

Face the patient, maintain eye contact, and when he or she is talking, use 

frequent, brief responses, such as “okay,” “I see,” and “uh-huh.” Active 

listening keeps the discussion focused and lets patients know you understand 

their concerns.

Demonstrate Empathy

Watch for opportunities to respond to patients’ emotions, using phrases 

such as “That sounds difficult” or “I’m sorry you’re facing this problem; I think 

we can work on it together.” Studies show that empathy can be learned and 

practiced and that it adds less than a minute to the patient interview. It also 

has rewards in terms of patient satisfaction, understanding, and adherence 

to treatment.
For more information on active listening, contact:

American Academy on Communication in Healthcare

16020 Swingley Ridge Road, Suite 300

Chesterfield, MO 63017

636-449-5080

www.aachonline.org

This professional organization aims to improve physician-patient relationships and 

offers courses and publications on medical encounters and interviews.

Macy Initiative in Health Communication

Division of Primary Care

NYU School of Medicine

550 First Avenue

New York, NY 10016

212-263-3071

http://macyinitiative.med.nyu.edu

This initiative was a collaborative effort of three medical schools to identify and define 

critical communication skills needed by physicians. It developed competency-based 

curricula for medical students.

New England Research Institutes (NERI) 

9 Galen Street

Watertown, MA 02472

617-923-7747

www.neriscience.com

NERI has designed a CME-accredited CD-ROM, Communicating With Older Patients, 

educating physicians on communication strategies to practice with older patients.

understanding older patients 9

Avoid Jargon

Try not to assume that patients know medical terminology or a lot about 

their disease. Introduce necessary information by first asking patients what 

they know about their condition and building on that. Although some terms 

seem commonplace—MRIs, CAT scans, stress tests, and so on—some older 

patients may be unfamiliar with what each test really is. Check often to be 

sure that your patient understands what you are saying. You may want to 

spell or write down diagnoses or important terms to remember.
10 understanding older patients

Reduce Barriers to Communication

Older adults often have sensory impairments that can affect 

communication. Vision and hearing problems need to be treated and 

accounted for in communication. Ask older patients when they last 

had vision and hearing exams.

Compensating for Hearing Deficits

Age-related hearing loss is common. About one-third of people between the ages 

of 65 and 75, and as many as half of those over the age of 75, have a hearing loss. 

Here are a few tips to make it easier to communicate with a person who has lost 

some hearing:

l Make sure your patient can hear you. Ask if the patient has a working hearing 

aid. Look at the auditory canal for the presence of excess earwax. 

l Talk slowly and clearly in a normal tone. Shouting or speaking in a raised voice 

actually distorts language sounds and can give the impression of anger. 

l Avoid using a high-pitched voice; it is hard to hear. 

l Face the person directly, at eye level, so that he or she can lip-read or pick up 

visual clues. 

l Keep your hands away from your face while talking, as this can hinder lipreading ability. 

l Be aware that background noises, such as whirring computers and office 

equipment, can mask what is being said. 

l If your patient has difficulty with letters and numbers, give a context for them. 

For instance, say, “‘m’ as in Mary, ‘two’ as in twins, or ‘b’ as in boy.” Say each 

number separately, (e.g., “five, six” instead of “fifty-six”). Be especially careful 

with letters that sound alike (e.g., m and n, and b, c, d, e, t, and v). 

l Keep a note pad handy so you can write what you are saying. Write out 

diagnoses and other important terms.

l Tell your patient when you are changing the subject. Give clues such as pausing 

briefly, speaking a bit more loudly, gesturing toward what will be discussed, 

gently touching the patient, or asking a question.
understanding older patients 11

Compensating for Visual Deficits

Visual disorders become more common as people age. Here are some things you 

can do to help manage the difficulties caused by visual deficits:

l Make sure there is adequate lighting, including sufficient light on your face. Try 

to minimize glare. 

l Check that your patient has brought and is wearing eyeglasses, if needed. 

l Make sure that handwritten instructions are clear. 

l When using printed materials, make sure the type is large enough and the 

typeface is easy to read. The following print size works well:

“This size is readable.”

l If your patient has trouble reading, consider alternatives such as tape recording 

instructions, providing large pictures or diagrams, or using aids such as 

specially configured pillboxes.

Be Careful About Language

Some words may have different 

meanings to older patients than to you 

or your peers. For example, the word 

“dementia” may connote insanity, and 

the word “cancer” may be considered 

a death sentence. Although you 

cannot anticipate every generational 

difference in language use, being 

aware of the possibility may help you 

to communicate more clearly. Use 

simple, common language and ask if 

clarification is needed. Offer to repeat 

or reword the information: “I know this 

is complex; I’ll do my best to explain, but 

let me know if you have any questions or 

just want me to go over it again.”

For more information on 

low literacy, contact:

Partnership for Clear Health 

Communication

National Patient Safety Foundation

132 MASS MoCA Way

North Adams, MA 01247

413-663-8900

www.npsf.org/askme3

This national coalition addresses issues 

related to low health literacy and its effect 

on outcomes. Its “Ask Me 3” campaign has 

materials for physicians’ offices, including 

patient handouts, to promote good 

communication.
In Summary

12 understanding older patients

Low literacy or inability to read also may be a problem. Reading materials 

written at an easy reading level may help. 

Ensure Understanding

Conclude the visit by making sure the patient understands: 

l what the main health issue is 

l what he or she needs to do about it 

l why it is important to do it 

One way to do this is the “teach-back method”—ask patients to say what 

they understand from the visit. Also, ask if there is anything that 

might keep the patient from carrying out the treatment plan.

4 Address the patient by last name, using the title the patient prefers 

(Mr., Ms., Mrs., etc.).

4 Begin the interview with a few friendly questions not directly related 

to health.

4 Don’t rush, and try not to interrupt; speak slowly and give older 

patients a few extra minutes to talk about their concerns.

4 Use active listening skills.

4 Avoid jargon, use common language, and ask if clarification is needed, 

such as writing something down.

4 Ask the patient to say what he or she understands about the problem 

and what needs to be done.
obtaining the medical history 13

Obtaining the Medical History

When patients are older, obtaining a good history—including 

information on social circumstances and lifestyle as well as 

medical and family history—is crucial to sound health care.

“What brings you here today?”

Mr. Symonds has advanced lung disease and usually manages well 

with home oxygen. But, he’s been admitted to the emergency 

room three times in as many weeks, unable to breathe. The health 

team is puzzled because Mr. Symonds is taking his medications 

on schedule and, he says, using the oxygen. Finally, a home care 

nurse is sent to the Symonds’ house. She discovers that because of 

this winter’s bitter cold, Mr. Symonds has been running a kerosene 

heater in his kitchen. He does not use the oxygen and heater at 

the same time for fear of fire. 

The varied needs of older patients may require different interviewing 

techniques. The following guidelines can help you to obtain a thorough history 

of current and past concerns, family history, medications, and socioeconomic 

situation. These suggestions are less time-consuming than they may appear. 

Some involve a single investment of time. Other health care professionals in 

the office or home may assist in gathering the information. You may want 

to get a detailed life and medical history as an ongoing part of older patients’ 

office visits and use each visit to add to and update information.

chapter 3
14 obtaining the medical history

General Suggestions

You may need to be especially flexible when obtaining the medical history 

of older patients. Here are some strategies to make efficient use of your time 

and theirs:

l If feasible, try to gather preliminary data before the session. Request 

previous medical records, or if there is time, mail forms that the 

patient or a family member can complete at home. Try to structure 

questionnaires for easy reading by using large type and providing 

enough space between items for people to respond. Questionnaires 

to fill out in the waiting room should be brief. 

l Try to have the patient tell his or her story only once, not to another staff 

member and then again to you. For older patients who are ill, this process 

can be very tiring. 

l Sit and face the patient at eye level. Use active listening skills, responding 

with brief comments such as “I see” and “okay.”

l Be willing to depart from the usual interview structure. You might 

understand the patient’s condition more quickly if you elicit his or 

her past medical history immediately after the chief complaint, before 

making a complete evaluation of the present illness. 

l If the patient has trouble with open-ended questions, make greater use of 

yes-or-no or simple choice questions. 

l Remember that the interview itself can be beneficial. Although you see 

many patients every day, you may be the only person your patient is 

socially engaged with that day. Your attention is important. Giving your 

patient a chance to express concerns to an interested person can be 

therapeutic.
obtaining the medical history 15

Elicit Current Concerns

Older patients tend to have multiple chronic conditions. They may have 

vague complaints or atypical presentations. Thinking in terms of current 

concerns rather than a chief complaint may be helpful. You might start the 

session by asking your patient to talk about his or her major concern, 

“Tell me, what is bothering you the most?”

Resist the Tendency to Interrupt

Give the patient time to answer your questions. Giving someone 

uninterrupted time to express concerns enables him or her to be more open 

and complete. 

Probe

Ask, “Is there anything else?” This question, which you may have to repeat 

several times, helps to get all of the patient’s concerns on the table at the 

beginning of the visit. 

The main concern may not be the first one mentioned, especially if it is a 

sensitive subject. If there are too many concerns to address in one visit, you 

can plan with the patient to address some now and some next time. 

Encourage the patient and his or her caregivers to bring a written list of 

concerns and questions. Sometimes an older patient will seek medical care 

because of concerns of family members or caregivers. 

Ask About Medications

Side effects, interactions, and misuse of medications can lead to major 

complications in older people. It is crucial to find out which prescription and 

over-the-counter medications older patients are using and how often. Older 

people often take many medications prescribed by several different doctors, 

e.g., internists, cardiologists, urologists, or rheumatologists. Sometimes they 

take prescriptions intended for other household members.
16 obtaining the medical history

Remember to ask about any alternative treatments, such as dietary 

supplements, homeopathic remedies, or teas that the patient might be using. 

Remind patients that it is important for you to know what over-the-counter 

medicines, such as pain relievers or eye drops, they use. 

Ask patients to bring all medications, both prescription and over-thecounter, to your office. A good approach is to have the patient put everything 

he or she takes in a brown bag and bring it to each visit. Find out about the 

patient’s habits for taking each medication, and check to be sure that he or 

she is using it as directed. 

Check to see if the patient has (or needs) a medical alert ID bracelet or 

necklace. There are several sources, including MedicAlert Foundation 

International, www.medicalert.org.

Obtain a Thorough Family History

The family history is valuable, in part because it gives you an opportunity 

to explore the patient’s experiences, perceptions, and attitudes regarding 

illness and death. For example, a patient may say, “I never want to be in a 

nursing home like my mother.” Be alert for openings to discuss issues such 

as advance directives.

The family history not only indicates the patient’s likelihood of developing 

some diseases but also provides information on the health of relatives who 

care for the patient or who might do so in the future.

Knowing the family structure will help you to know what support may be 

available from family members, if needed.

Ask About Functional Status

Knowing an older patient’s usual level of functioning and learning about any 

recent significant changes are fundamental to providing appropriate health 

care. They also influence which treatment regimens are suitable. The ability to 

perform basic activities of daily living (ADLs) reflects and affects a patient’s 

health. Depending on the patient’s status, ask about ADLs such as eating, 
obtaining the medical history 17

bathing, and dressing and more complex instrumental activities of daily 

living (IADLs) such as cooking, shopping, and managing finances. There are 

standardized ADL assessments that can be done quickly and in the office.

Sudden changes in ADLs or IADLs are valuable diagnostic clues. If your older 

patient stops eating, becomes confused or incontinent, or stops getting out 

of bed, look for underlying medical problems. Keep in mind the possibility 

that the problem may be acute.

Consider a Life History

If you plan to continue caring for an older patient, consider taking time 

to learn about his or her life. A life history is an excellent investment. 

It helps to understand the patient. It also strengthens the clinician-patient 

relationship by showing your interest in the patient as a person.

Be alert for information about the patient’s relationships with others, 

thoughts about family members or coworkers, typical responses to stress, 

and attitudes toward aging, illness, work, and death. This information 

may help you interpret the patient’s concerns and make appropriate 

recommendations.

Obtain a Social History

The social history also is crucial. If you are aware of your patient’s living 

arrangements or his/her access to transportation, you are much more likely 

to devise realistic, appropriate interventions. Ask about where he or she lives; 

neighborhood safety; eating habits; tobacco, drug, and alcohol use; typical 

daily activities; and work, education, and financial situations. It also helps to 

find out who lives with or near the patient.

Understanding a person’s life and daily routine can help you to understand 

how your patient’s lifestyle might affect his or her health care. To this 

end, determine if the patient is an informal caregiver for others. Many 

older people care for spouses, elderly parents, or grandchildren. A patient’s 

willingness to report symptoms sometimes depends on whether the patient 

thinks he or she can “afford to get sick,” in view of family responsibilities.
In Summary

18 obtaining the medical history

House calls by a health care professional are an excellent way to find out 

about a patient’s home life. If that’s not possible, try to learn some details 

about the patient’s home life: “Do you use oil or gas heat? Have steep stairs 

to navigate? Own a pet? Can you get to the grocery store or pharmacy on your 

own? Are you friendly with anyone in the neighborhood?” Learning about your 

patient’s home life will help you understand aspects of his or her illness and 

may improve adherence to treatment.

4 Obtain basic information before the visit. Encourage patients to bring 

in written lists of concerns as well as all medication, including overthe-counter and alternative or homeopathic remedies.

4 Use the family history to gain insight into an older patient’s social 

situation as well as his or her risk of disease.

4 Talk about the activities of daily living and be alert to changes.

4 Ask about living arrangements, transportation, and lifestyle to help in 

devising appropriate interventions.
encouraging wellness 19

Encouraging Wellness

People of all ages can benefit from healthy habits such as 

regular exercise and good nutrition.

“I’d like you to try this exercise routine. 

Just start low and go slow.”

Mrs. Green is surprised when Dr. Lipton recommends that she 

exercise regularly. She responds with a list of excuses: exercise 

is for young people, it’s not safe for people over 65, it takes too 

much time, exercise equipment costs too much. Dr. Lipton listens 

empathetically and then tells her that exercise and physical 

activity are good for people of all ages and that being sedentary 

is far more dangerous than exercising. He explains that Mrs. Green 

can “start low and go slow” by walking for 10 minutes at a time 

and building up to at least 30 minutes of physical activity on 

5 days or more each week. At her next office visit, Mrs. Green 

says that she has more energy than she used to; in fact, she’s 

ready to try a dance class at her senior center.

Exercise and Physical Activity

Exercise has proven benefits for older people. It reduces risk of cardiovascular 

disease, stroke, hypertension, type 2 diabetes, osteoporosis, obesity, colon 

cancer, and breast cancer. It also decreases the risk of falls and fallrelated injuries.

chapter 4
20 encouraging wellness

Like the rest of us, older people may know that exercise is good for their 

health, but they may not have the motivation or encouragement to do it. You 

can guide your patients by asking about their daily activities and whether 

they engage in any kind of regular exercise or physical activity.

There are several ways to encourage older patients to exercise:

l Whenever appropriate, let them know that regular physical activity—

including endurance, muscle-strengthening, balance, and flexibility 

exercises—is essential for healthy aging. 

l Help patients set realistic goals and develop an exercise plan.

l Write an exercise prescription, and make it specific, including type, 

frequency, intensity, and time; follow up to check progress and reevaluate goals over time.

l Refer patients to community resources, such as mall-walking groups and 

senior center fitness classes. 

l Tell them about Exercise and Physical Activity: Your Everyday Guide from 

the National Institute on Aging, NIA’s free book showing older adults how 

to start and stick with a safe, effective exercise program. 

Too Old to Exercise? Studies Say ‘No!’

l Together, exercise and lifestyle changes such as becoming more active and 

healthy eating reduce the risk of diabetes in high-risk older people. In one 

study, lifestyle changes led to a 71 percent decrease in diabetes among people 

60 and older. 

l In another study, moderate exercise was effective at reducing stress and sleep 

problems in older women caring for a family member with dementia. 

l Older people who exercise moderately are able to fall asleep quickly, sleep for 

longer periods, and get better quality of sleep. 

l Researchers also found that exercise, which can improve balance, reduced falls 

among older people by 33 percent. 

l Walking and strength-building exercises by people with knee osteoarthritis help 

reduce pain and maintain function and quality of life.
encouraging wellness 21

For more information on exercise, nutrition, and 

older people, contact:

Centers for Disease Control and Prevention (CDC)

1600 Clifton Road

Atlanta, Georgia 30333

800-232-4636 (toll-free)

800-232-6348 (TTY/toll-free)

Healthy Aging: www.cdc.gov/aging/index.htm

Physical Activity: www.cdc.gov/nccdphp/dnpa/index.htm

The CDC has resources on nutrition and physical activity for older adults. The Division of 

Nutrition, Physical Activity, and Obesity addresses how healthy eating habits and exercise can 

improve the public’s health and prevent and control chronic diseases.

Department of Agriculture 

Food and Nutrition Information Center (FNIC) 

National Agricultural Library

10301 Baltimore Avenue, Room 105

Beltsville, MD 20705

www.nal.usda.gov/fnic

The FNIC website provides over 2,000 links to current and reliable nutrition resources.

National Institute on Aging (NIA) 

Information Center

P.O. Box 8057

Gaithersburg, MD 20898-8057

800-222-2225 (toll-free)

800-222-4225 (TTY/toll-free)

www.nia.nih.gov/HealthInformation

Exercise and Physical Activity: Your Everyday Guide from the National Institute on Aging, 

www.nia.nih.gov/Exercise, shows older adults how to start and maintain a safe, effective 

program of stretching, balance, and strength-training exercises. 

National Resource Center on Nutrition, Physical Activity & Aging

Florida International University

University Park OE 200

Miami, FL 33199

305-348-1517

nutritionandaging.fiu.edu

A group serving nutrition programs funded by the Older Americans Act, the Center aims to 

increase food and nutrition services in home- and community-based social, health, and longterm-care systems serving older adults. Link to the program “Eat Better & Move More.”
22 encouraging wellness

In Summary

Nutrition

Older patients may develop poor eating habits for many reasons. These 

can range from a decreased sense of smell and taste to teeth problems or 

depression. Older people may also have difficulty getting to a supermarket 

or standing long enough to cook a meal. And although energy needs may 

decrease with age, the need for certain vitamins and minerals, including 

calcium, vitamin D, and vitamins B6 and B12, increases after age 50. 

Try these strategies to encourage healthy diets:

l Emphasize that good nutrition can have an impact on well-being and 

independence.

l If needed, suggest liquid nutrition supplements, but emphasize the 

benefits of solid foods.

l If needed, suggest multivitamins that fulfill 100 percent of the 

recommended daily amounts of vitamins and minerals for older people, 

but not megadoses. 

l Offer a referral to a nutrition services program, such as Meals on Wheels. 

Programs in your area are provided by the local Area Agency on Aging 

or Tribal Senior Services. Contact Eldercare Locator at 800-677-1116 for 

your Area Agency on Aging.

4 Talk to your older patients about the importance of exercise and 

physical activity. Staying active can benefit older people in many ways.

4 Encourage your patients to get a free copy of Exercise and Physical 

Activity: Your Everyday Guide from the National Institute on Aging.

4 Talk to your older patients about their eating habits.

4 Consider having your older patients keep a food diary, if necessary, to 

make sure they are getting the correct nutrients.
talking about sensitive subjects 23

Talking About Sensitive Subjects

Caring for an older patient requires discussing sensitive topics. 

You may be tempted to avoid these discussions, but there are 

helpful techniques to get you started and resources to help.

“Many people your age experience similar problems.”

At age 80, Mr. Abayo was proud of his independence and ability 

to get around. But, when he came to see Dr. Carli for a regular 

exam, he acknowledged that the trouble with his shoulder had 

started after he collided with another car at a four-way stop sign. 

“Many of my patients are worried about being safe drivers,” 

Dr. Carli said. After the exam, she spoke with Mr. Abayo and his 

son in her office. She told them that a lot of her older patients 

had decided to rely on family and friends for transportation. 

She gave Mr. Abayo a pamphlet on older drivers and the number 

of a local transportation resource that might be helpful.

Many older people have a “don’t ask, don’t tell” relationship with health 

care providers about some problems, especially those related to sensitive 

subjects, such as driving, urinary incontinence, or sexuality. Hidden health 

issues, such as memory loss or depression, are a challenge. Addressing 

problems related to safety and independence, such as giving up one’s driver’s 

license or moving to assisted living, also can be difficult. 

You may feel awkward addressing some of these concerns because you don’t 

know how to help patients solve the problem. This chapter gives an overview 

chapter 5
24 talking about sensitive subjects

of techniques for broaching sensitive subjects, as well as resources for more 

information or support.

Try to take a universal, non-threatening approach. Start by saying, “Many people 

your age experience . . .” or “Some people taking this medication have trouble with 

. . .” Try: “I have to ask you a lot of questions, some that might seem silly. Please 

don’t be offended . . .” Another approach is to tell anecdotes about patients in 

similar circumstances as a way to ease your patient into the discussion, of 

course always maintaining patient confidentiality to reassure the patient you 

are talking to that you won’t disclose personal information about him or her.

Some patients avoid issues that they think are inappropriate for their own 

clinicians. One way to overcome this is to keep informative brochures and 

materials readily available in the waiting room. Along with each topic listed 

alphabetically below is a sampling of resources. Although the lists are not 

exhaustive, they are a starting point for locating useful information and 

referrals.

Advance Directives

Advance directives, including “living wills,” can help you honor individual 

end-of-life preferences and desires. You may feel uncomfortable raising the 

issue, fearing that patients will assume the end is near. But, in fact, this is a 

conversation that is best begun well before end-of-life care is appropriate. Let 

your patients know that advance care planning is a part of good health care. 

You can say that, increasingly, people realize the importance of making plans 

while they are still healthy. You can let them know that these plans can be 

revised and updated over time or as their health changes.

An advance care planning discussion can take about 5 minutes with a 

healthy patient:

l Talk about the steps your patient would want you to take in the event of 

certain conditions or eventualities. 

l Discuss the meaning of a health care proxy and how to select one. 

l Give the patient the materials to review, complete, and return at the next 

visit. In some cases, the patient may want help completing the form. 
talking about sensitive subjects 25

l Ask the patient to bring a copy of the completed form at the next visit for 

you to keep. If appropriate, share the plan with family members. 

l Revise any advance directives based on the patient’s changing health 

and preferences.

Be sure to put a copy of the completed form in the medical record. Too 

often, forms are completed, but when needed, they cannot be found. Many 

organizations now photocopy the forms on neon-colored paper, which is 

easy to spot in the medical record. 

If your patient is in the early stages of an illness, it’s important for you to 

assess whether or not the underlying process is reversible. It’s also a good 

time to discuss how the illness is likely to play out. If your patient is in 

the early stages of a cognitive problem, it is especially important to discuss 

advance directives. 

For more information on advance directives, contact:

Aging With Dignity

P.O. Box 1661

Tallahassee, FL 32302-1661

888-594-7437 (toll-free) 

www.agingwithdignity.org

This group provides an easy-to-read advance care planning document called Five Wishes.

Institute for Healthcare Advancement

501 South Idaho Street, Suite 300

La Habra, CA 90631

800-434-4633

www.iha4health.org

A simplified advance directive form written at a fifth-grade reading level in English, Spanish, 

Chinese, and Vietnamese can be downloaded for free.

National Hospice and Palliative Care Organization

1700 Diagonal Road, Suite 625

Alexandria, VA 22314

800-658-8898 (toll-free)

www.caringinfo.org

This group provides resources for completing advance directives, including links to each 

State’s advance directive forms. 
26 talking about sensitive subjects

Driving Safety

Recommending that a patient limit driving—or that a patient give up his 

or her driver’s license—is one of the most difficult topics a doctor has to 

address. Because driving is associated with independence and identity, 

making the decision not to drive is very hard.

For more information on safe driving, contact:

AAA Foundation for Traffic Safety

607 14th Street, NW, Suite 210

Washington, DC 20005

202-638-5744

www.seniordrivers.org

AARP

601 E Street, NW

Washington, DC 20049

202-434-2277

800-424-3410 (toll-free)

www.aarp.org/families/driver_safety

The AARP Driver Safety Program offers classes to help motorists over the age of 50 

improve their driving skills.

American Association of Motor Vehicle Administrators

4301 Wilson Boulevard, Suite 400

Arlington, VA 22203

703-522-4200

www.granddriver.info

The American Association of Motor Vehicle Administrators sponsors this program 

designed to educate aging drivers and their caregivers.

American Medical Association (AMA) 

www.ama-assn.org/ama/pub/category/10791.html

The AMA offers guidance for physicians to address problems about driving and older 

adults. For details, download the Physician’s Guide to Assessing and Counseling Older 

Drivers from the website.
talking about sensitive subjects 27

As with other difficult subjects, try to frame it as a common concern of older 

patients. Mention, for instance, that aging can lead to slowed reaction times 

and impaired vision. In addition, it may be harder to move the head to look 

back, quickly turn the steering wheel, or safely hit the brakes. Ask the patient 

about any car accidents. When necessary, warn patients about medications 

that may make them sleepy or impair judgment. Also, a device such as an 

automatic defibrillator or pacemaker might cause irregular heartbeats or 

dizziness that can make driving dangerous. You might ask if she or he has 

thought about alternative transportation methods if driving is no longer 

an option.

Elder Abuse and Neglect

Be alert to the signs and 

symptoms of elder abuse. If 

you notice that a patient delays 

seeking treatment or offers 

improbable explanations for 

injuries, for example, you may 

want to bring up your concerns. 

The laws in most States require 

helping professionals, such as 

doctors and nurses, to report 

suspected abuse or neglect.

Older people caught in an abusive situation are not likely to say what is 

happening to them for fear of reprisal or because of diminished cognitive 

abilities. If you suspect abuse, ask about it in a constructive, compassionate 

tone. If the patient lives with a family caregiver, you might start by saying that 

caregiver responsibilities can cause a lot of stress. Stress sometimes may cause 

caregivers to lose their temper. You can assist by recommending a support 

group or alternative arrangements (such as respite care). Give the patient 

opportunities to bring up this concern, but if necessary, raise the 

issue yourself.

For more information on 

elder abuse, contact:

National Center on Elder Abuse

Center for Community Research and Services

University of Delaware

297 Graham Hall

Newark, DE 19716

302-831-3525

www.ncea.aoa.gov

This consortium of organizations provides 

information about and conducts research 

on elder abuse. 
28 talking about sensitive subjects

End-of-Life Care

Most older people have thought about the prospect of their own death and 

are willing to discuss their wishes regarding end-of-life care. You can help 

ease some of the discomfort simply by being willing to talk about dying and 

by being open to discussions about these important issues and concerns. It 

may be helpful to do this early in your relationship with the patient when 

discussing medical and family history. Stay alert to cues that the patient may 

want to talk about this subject again. Encourage the patient to discuss endof-life decisions early with family members and to consider a living will. 

Of course, it is not always easy to determine who is close to death; even 

experienced clinicians find that prognostication can be difficult. Even if you 

have already talked with your patient about end-of-life concerns, it still can 

be hard to know the right time to re-introduce this issue. Some clinicians 

find it helpful to ask themselves, “Would I be surprised if Mr. Flowers were 

to die this year?” If the answer is “no,” then it makes sense to start working 

with the patient and family to address end-of-life concerns, pain and 

For more information on end-of-life care, contact:

Education in Palliative and End-of-life Care (EPEC) 

Northwestern University, Feinberg School of Medicine

750 North Lake Shore Drive, Suite 601

Chicago, IL 60611

312-503-5868

www.epec.net

EPEC provides physicians the basic knowledge and skills needed to care for 

dying patients.

National Hospice and Palliative Care Organization

1700 Diagonal Road, Suite 625

Alexandria, VA 22314

703-837-1500

800-658-8898 (toll-free)

www.nhpco.org

NHPCO links to care organizations and the consumer website, www.caringinfo.org.
talking about sensitive subjects 29

symptom management, home health, and hospice care. You can offer to 

help patients review their advance directives. Include these updates in your 

medical records to ensure that patients receive the care they want.

Financial Barriers

Rising health care costs make it difficult for some people to follow treatment 

regimens. Your patients may be too embarrassed to mention their financial 

concerns. Studies have shown that many clinicians also are reluctant to 

bring up costs. If possible, designate an administrative staff person with a 

good bedside manner to discuss money and payment questions. This person 

can also talk with your patient about changes in Medicare and the Part D 

prescription drug coverage plans. 

For more information on financial assistance, contact:

Medicare Rights Center

520 Eighth Avenue, North Wing, 3rd Floor

New York, NY 10018

212-869-3850

110 Maryland Avenue, NE, Suite 112

Washington, DC 20002

202-544-5561

800-333-4114 (toll-free)

www.medicarerights.org

The toll-free consumer hotline provides free counseling services about Medicare, including the 

prescription drug benefit.

National Council on Aging

www.benefitscheckup.org

The Council’s online resource offers a searchable list of programs that can help with health 

care costs.

Partnership for Prescription Assistance 

888-477-2669 (toll-free)

www.pparx.org

Many pharmaceutical companies offer reduced medication fees for patients who meet income 

requirements and other criteria. The website has a directory of prescription drug patient 

assistance programs.
30 talking about sensitive subjects

The resources in this section may help when you talk with your patients 

about their financial concerns. In addition, your State Health Insurance 

Assistance Program (SHIP) may be helpful.

Long-Term Care

Long-term care includes informal caregiving, assisted living, home health 

services, adult day care, nursing homes, and community-based programs.

Early in your relationship with 

an older patient, you can begin 

to talk about the possibility that 

he or she may eventually require 

long-term care of some kind. By 

raising this topic, you are helping 

your patient think about what he 

or she might need in the future 

and how to plan for those needs. 

For instance, you might talk 

about what sort of assistance you 

think your patient will need, how 

soon in the future he or she will 

need the extra help, and where he 

or she might get this assistance. 

Mental Health

Despite many public campaigns to educate people about mental health and 

illness, there is still a stigma attached to mental health problems. Some older 

adults may find mental health issues difficult to discuss.

Such conversations, however, can be lifesavers. Primary care doctors have a 

key opportunity to recognize when a patient is depressed and/or suicidal. 

In fact, 70 percent of older patients who commit suicide have seen a primary 

care physician within the previous month. This makes it especially important 

for you to be alert to the signs and symptoms of depression.

As with other subjects, try a general approach to bringing up mental health 

concerns. For example, “A lot of us develop sleep problems as we get older, 

For more information on 

long-term care, contact:

Nursing Home Compare

www.medicare.gov/nhcompare/home.asp

Medicare provides an online resource 

with detailed information about the past 

performance of every Medicare- and 

Medicaid-certified nursing home in the country.

Eldercare Locator

800-677-1116 (toll-free)

www.eldercare.gov

The Eldercare Locator offers referrals to and 

information on services for seniors.
talking about sensitive subjects 31

but this can be a sign of depression, which sometimes we can treat.” Because 

older adults may have atypical symptoms, it is important to listen closely 

to what your patient has to say about trouble sleeping, lack of energy, and 

general aches and pains. It is easy to dismiss these as “just aging” and leave 

depression undiagnosed and therefore untreated.

Sexuality

An understanding, accepting attitude can help promote a more comfortable 

discussion of sexuality. Try to be sensitive to verbal and other cues. Don’t 

assume that an older patient is no longer sexually active, does not care about 

sex, or necessarily is heterosexual. In fact, research has found that a majority 

of older Americans are sexually active and view intimacy as an important 

part of life. 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. If appropriate, follow up on patient cues. You might note 

that patients sometimes have concerns about their sex life and then wait for 

a response. It is also effective to share anonymous anecdotes about a person 

in a similar situation or to raise the issue in the context of physical findings 

For more information on mental health, contact:

American Association for Geriatric Psychiatry

7910 Woodmont Avenue, Suite 1050

Bethesda, MD 20814-3004

301-654-7850

www.aagponline.org

The Association promotes the mental health and well-being of older people and works to 

improve the care of those with late-life mental disorders.

National Institute of Mental Health (NIMH)

6001 Executive Boulevard, Room 8184, MSC 9663

Bethesda, MD 20892-9663

866-615-6464 (toll-free)

www.nimh.nih.gov

NIMH, part of the National Institutes of Health, funds and conducts mental health research 

and distributes information to health professionals and the public.
32 talking about sensitive subjects

(for example, “Some people taking this medication have trouble . . . 

Have you experienced anything like that?”). Don’t forget to talk with your 

patient about the importance of safe sex. For example, “It’s been a while 

since your husband died. If you are considering dating again, would you like to 

talk about how to have safe sex?” Any person, regardless of age, who is not 

in a long-term relationship with a faithful partner and has unprotected 

sex, is at risk of sexually transmitted disease.

Spirituality

For some older people, spirituality takes on new meaning as they age or 

face serious illness. By asking patients about their religious and spiritual 

practices, you can learn something about their health care choices and 

preferences. How a patient views the afterlife can sometimes help in framing 

the conversation.

For example, some patients feel that their fate is in the hands of a higher 

power, and this may prevent them from making treatment decisions. For 

patients who report suffering and distress about illness or end-of-life, a 

referral to a hospital or nursing home chaplain may be helpful.

For more information on sexuality, contact:

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

800-232-4636 (toll-free)

www.cdc.gov/hiv/topics/over50

Mayo Foundation for Medical Education and Research

Senior Health: Sex and Intimacy

www.mayoclinic.com/health/senior-health/HA00074

This website has articles about sexual health and sexuality for adults age 50 and older.

Sexuality Information and Education Council of the United States

130 West 42nd Street, Suite 350

New York, NY 10036-7802

212-819-9770

www.siecus.org/_data/global/images/new_expectations.pdf

This organization publishes New Expectations: Sexuality Education for Mid and Later Life.
talking about sensitive subjects 33

Clinicians have found that very direct and simple questions are the best way 

to broach this subject. You might start, for instance, by asking, “What has 

helped you to deal with challenges in the past?”

Substance Abuse

Alcohol and drug abuse are major 

public health problems, even for 

older adults. Sometimes people can 

become dependent on alcohol or 

other drugs as they confront the 

challenges of aging, even if they did 

not have a problem when younger. 

Because baby boomers have a higher 

rate of lifetime substance abuse 

than did their parents, the number 

of people in this age group needing 

treatment is likely to grow. 

For more information on spirituality, contact:

Association of Professional Chaplains

1701 East Woodfield Road, Suite 400

Schaumburg, IL 60173

847-240-1014

www.professionalchaplains.org

The Association is an interfaith professional society providing education, research, and 

certification for its members and web links to many chaplaincy organizations.

George Washington University Institute for Spirituality & Health

2300 K Street, NW, Suite 313

Washington, DC 20037-1898

202-994-6220

www.gwish.org

The Institute recognizes spiritual dimensions of health. Its work focuses on bringing 

increased attention to the spiritual needs of patients, families, and health care professionals. 

For more information 

on substance abuse, 

contact:

National Clearinghouse for 

Alcohol & Drug Information 

(NCADI)

P.O. Box 2345

Rockville, MD 20847-2345

800-729-6686 (toll-free)

www.health.org

NCADI, funded by the Substance Abuse and 

Mental Health Services Administration, is a 

one-stop resource for information on substance 

abuse prevention and addiction treatment.
34 talking about sensitive subjects

One approach you might try is to mention that some medical conditions can 

become more complicated as a result of alcohol and other drug use. Another 

point to make is that alcohol and other drugs can increase the side effects of 

medication, or even reduce the medicine’s effectiveness. From this starting 

point, you may find it easier to talk about alcohol or other drug use.

Urinary Incontinence

About 17 percent of men and 38 percent of women age 60 and older suffer 

from urinary incontinence. Several factors can contribute to incontinence. 

For more information on urinary incontinence contact:

American Foundation for Urologic Diseases

1000 Corporate Boulevard, Suite 410

Linthicum, MD 21090

866-746-4282 (toll-free) 

www.urologyhealth.org

The Foundation provides information on the prevention, detection, management, and cure 

of urologic diseases.

National Institute of Diabetes and Digestive and Kidney Diseases 

(NIDDK) 

3 Information Way

Bethesda, MD 20892-3580

800-891-5390 (toll-free)

www2.niddk.nih.gov

NIDDK, part of the National Institutes of Health, distributes publications on urinary 

incontinence and provides links to resources and support groups.

The Simon Foundation for Continence

P.O. Box 815

Wilmette, IL 60091

800-237-4666 (toll-free) 

www.simonfoundation.org

The Foundation provides information about cure, treatment, and management techniques 

for incontinence.
In Summary

talking about sensitive subjects 35

Childbirth, infection, certain medications, and some illnesses are 

examples. Incontinence may go untreated because patients are 

embarrassed to mention it. Be sure to ask specifically about the problem. 

Try the “some people” approach: “When some people cough or sneeze, 

they leak urine. Have you had this problem?” You may want to explain 

that incontinence can often be significantly improved through bladder 

training; medication and surgery can also be effective treatments for 

certain types of incontinence.

4 Introduce sensitive topics with the “common concern” approach: 

“As we age, many of us have more trouble with . . .” or “Some people 

taking this medication have trouble with . . .”

4 Keep educational materials available and visible to encourage 

discussion.

4 Raise topics such as safe driving, long-term care, advance 

care directives, and end-of-life care early, before they become 

urgent matters.
36 supporting patients with chronic conditions

Supporting Patients With 

Chronic Conditions

Case managers can play an important role in educating 

patients and families and can connect them with appropriate 

community resources and services.

“Let’s discuss living with . . .”

Four years ago, Mrs. Smoley suffered a stroke. Although she takes 

her pills just like the doctor ordered, she has not been able to quit 

smoking. Now she has emphysema and may soon need oxygen. 

Dr. Nguyen thinks she should participate in a disease management 

program at a local hospital that will give her the information 

she needs to manage on her own. “It could help you prevent 

the problems you’ve had with shortness of breath,” the doctor 

explains. “And you might learn some tips about how to manage 

your day so that you have some more energy.” She offers to help 

Mrs. Smoley schedule her first appointment.

Approximately 80 percent of older adults have at least one chronic disease, 

and of those, 50 percent have at least two chronic conditions. For many 

older people, coping with multiple chronic conditions is a real challenge. 

Learning to manage a variety of treatments while maintaining quality of 

life can be problematic. People with chronic conditions may have different 
supporting patients with chronic conditions 37

needs, but they also share common challenges with other older adults, such 

as paying for care or navigating the complexities of the health care system. 

Try to start by appreciating that people living with chronic disease are often 

living with loss—the loss of physical function, independence, or general 

well-being. Empathize with patients who feel angry, sad, lost, or bewildered. 

Ask, “Is it hard for you to live with these problems?” From there you can 

refer patients to community resources that may meet their needs or, when 

available, recommend a disease management program or case managers in 

the community.

Educating the Patient

Most older patients want to understand their medical conditions and are 

interested in learning how to manage them. Likewise, family members and 

other caregivers want this information. 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 you time. 

The following tips can help you inform patients and their caregivers about 

medical conditions and their treatment.

l Doctors’ advice generally receives greatest credence, so the doctor should 

introduce treatment plans. Other medical team members have an 

important role, including building on the original instructions. 

l Let your patient know you welcome questions. Indicate whom on your 

staff he or she can call to have questions answered later. 

l Remember that some patients won’t ask questions even if they want 

more information. Be aware of this tendency and think about making 

information available even if it is not requested. 

l Provide information through more than one channel. In addition 

to talking to the patient, you can use fact sheets, drawings, models, 

videotapes, or audiotapes. In many cases, referrals to websites and 

support groups can be helpful. 

chapter 6
38 supporting patients with chronic conditions

l Encourage the patient or caregiver to take notes. It’s helpful to offer a pad 

and pencil. Active involvement in recording information may promote 

your patient’s retention and adherence. 

l Repeat key points about the health problem and treatment at every 

office visit. 

l Check that 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. 

l Provide encouragement. Call attention to strengths and ideas for 

improvement. Remember to provide continued reinforcement for new 

treatment or lifestyle changes.

Explaining Diagnoses

Clear explanations of diagnoses are critical. Uncertainty about a health 

problem can be upsetting. When patients do not understand their medical 

conditions, they tend not to follow the treatment plans.

In explaining diagnoses, it is helpful to begin by finding out what the patient 

believes is wrong, what the patient thinks will happen, and how much more 

he or she wants to know. Based on the patient’s responses, you can correct 

any misconceptions and provide appropriate types of information.

Discussing Treatment

Some older patients may refuse treatment because they do not understand 

what it involves or how it will improve their health. In some cases, they may 

be frightened about side effects or have misinformation from friends and 

relatives with similar health problems. They may also be concerned about the 

cost of the treatment. 

Treatment can involve lifestyle changes (such as diet and exercise) as well 

as medication. Make sure you develop and communicate treatment plans 

with the patient’s input and consent. Tell the patient what to expect from 

the treatment, including recommended lifestyle change, what degree of 

improvement is realistic, and when he or she may start to feel better.
In Summary

supporting patients with chronic conditions 39

Keep medication plans 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. Indicate the purpose of each medication. Make it clear which 

medications must be taken and on what schedule. It is helpful to say which 

drugs the patient should take only when having particular symptoms.

After proposing a treatment plan, check with the patient about its feasibility 

and acceptability. Work through what the patient feels may be obstacles to 

maintaining the plan. Try to resolve any misunderstandings. For example, 

make it clear that a referral to another doctor does not mean you are 

abandoning the patient. Provide oral and written instructions. Do not assume 

that all of your patients are able to read. Make sure the print is large enough 

for the patient to read.

Encourage your 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 the 

patient’s satisfaction while decreasing demands on your time.

4 The physician should provide key information and advice for greatest 

impact; other team members can build on that.

4 To explain diagnoses, start by asking the patient what he or she 

understands and how much more he or she wants to know.

4 After proposing a treatment plan, check with the patient on feasibility 

and acceptability; confirm that the patient understands the plan.

4 Encourage the patient and caregivers to take an active role in 

managing a chronic problem.
40 breaking bad news

Breaking Bad News

Delivering bad news is never easy, but tested strategies 

can ease the process.

“I wish I had better news.”

Since Dr. Callas got Mrs. Larson’s test results, he had been thinking 

about how to tell her she has Parkinson’s disease. Because he 

didn’t want to feel pressured for time, Dr. Callas made sure 

Mrs. Larson had today’s last appointment. He knew she’d have a 

lot of questions. Knowing that Mrs. Larson suspected something 

was seriously wrong, Dr. Callas decided the best approach was to 

be gentle, but direct. He reviewed her chart for details, took a 

deep breath, and opened the exam room door . . .

Knowing how to communicate bad news can help you to make the process 

more bearable for patients. The Education in Palliative and End-of-Life Care 

Project (EPEC), www.epec.net, offers a module, “Communicating Bad News,” 

that provides a practical approach. It indicates that breaking bad news 

in a compassionate yet direct way can help physicians and patients. And, 

although some of the advice may seem obvious, it may also be the sort of 

thing that is easily overlooked. 

The first step is to prepare yourself. Before meeting with the patient, 

think about what you want to say and make sure that you have all of the 

information you need. Be sure there is enough time, rather than trying to 

schedule it between other appointments. If possible, ask your staff to hold 

calls and pages until the appointment is over.
breaking bad news 41

You may feel more comfortable by first finding out what the patient knows 

about his or her condition. You might ask questions such as, “Have you been 

worried about your illness or symptoms?”

Next, you might spend a few moments finding out how much the patient 

really wants to know. Depending on their cultural background, personal 

history, or medical status, people may have different expectations and 

preferences for what they should be told. You might ask the patient if he or 

she wants to hear the prognosis, for example, or would prefer not to know.

If a patient’s family has reservations about having the patient know the 

prognosis, you might ask them about their concerns. Legally, of course, you are 

obligated to tell the patient; however, you may negotiate some elements with 

the family. If you cannot resolve it, an ethics consultation may be helpful.

When you are ready to share the bad news, try to be as straightforward as 

possible, without speaking in a monotone or delivering a monologue. 

Be positive, but avoid the natural temptation to minimize the seriousness of 

the diagnosis. Communications experts suggest that you not start by saying, 

“I’m sorry . . .” Instead, try saying, “I feel bad to have to tell you . . .” After you 

have explained the bad news, you can express genuine sadness while 

reassuring the patient that you and others will be there to help.

Of course, people will respond differently to bad news; shock, anger, sorrow, 

despair, denial, blame, disbelief, and guilt all are common reactions. In some 

cases, people may simply have to leave the office. Try to give the patient and 

family time—and privacy—to react.

A good way to end this visit is to establish a plan for next steps. This may 

include gathering more information, ordering more tests, or preparing 

advance directives. Reassure the patient and family that you are not going 

to abandon them, regardless of referrals to other health care providers. Let 

them know how they can reach you—and be sure to respond when they call.

In follow-up appointments or conversations, give the patient an opportunity to 

talk again about the situation. Ask if he or she has more questions or needs help 

talking with family members or others about the diagnosis. Assess the patient’s 

level of emotional distress and consider a referral to a mental health provider.

chapter 7
42 breaking bad news

The Language of Bad News: Phrases That Help

These phrases can help you to be straightforward, yet compassionate:

Delivering bad news

l “I’m afraid the news is not good. The biopsy showed you have colon cancer.”

l “Unfortunately, there is no question about the results. You have emphysema.”

l “The report is back, and it’s not as we had hoped. It confirms that you have 

the early stages of Parkinson’s disease.”

Responding to patient reactions

l “I imagine this is difficult news.”

l “Does this news frighten you?”

l “I wish the news were different.”

l “Is there anyone you’d like me to call?”

l “I’ll try to help you.”

l “I’ll help you tell your children.” 

Dealing with prognosis

l “What are you expecting to happen?”

l “What would you like to have happen?”

l “How specific would you like me to be?”

l “What are your fears about what might happen?”

Adapted from: Emanuel LL, von Gunten CF, Ferris FF, and Hauser, JM, eds. “Module 2: 

Communicating Bad News,” The Education in Palliative and End-of-Life Care (EPEC) Curriculum: 

© The EPEC Project, 1999, 2003.
In Summary

breaking bad news 43

Referring Patients to Clinical Trials

Carefully conducted clinical trials are the primary way researchers find out if a 

promising treatment is safe and effective. Patients who participate in clinical 

research can gain access to new treatments before they are widely available 

and help others by contributing to medical research findings. Clinicians have an 

important role in continuing to care for patients who participate in clinical trials. 

Most trials offer short-term treatments related to a specific illness or condition. 

They do not provide extended or complete primary health care. You will continue 

your involvement in the patient’s care but may need to communicate at times with 

your patient’s clinical research team. By working with the research team, you can 

ensure that other medications or treatment needed by your patient will not conflict 

with the protocol.

For information about federally and privately supported clinical research, visit: 

www.clinicaltrials.gov

4 Prepare yourself for delivering bad news—allow enough time, 

and have calls held.

4 Find out how much the patient understands and how much he or 

she wants to know about the prognosis.

4 Be straightforward and compassionate.

4 Give the patient time to react.

4 Establish a plan for next steps; let the patient and family know you 

are not going to abandon them.

4 Give the patient an opportunity to continue the conversation in 

follow-up appointments or calls.
44 working with diverse older patients

Working With Diverse Older Patients

Appreciating the richness of cultural and ethnic backgrounds 

among older patients and providing interpretation for those 

with limited English can help to promote good health care.

“Cultural differences, not divides.”

Azeeza Houssani had been Dr. Smith’s patient for several years. 

She had always carefully followed his instructions. So, Dr. Smith 

was surprised when Mrs. Houssani was not willing to take her 

morning medication with food, as directed. He reminded her that 

these drugs were very hard on the stomach and could cause her 

pain if taken without food. But Mrs. Houssani just shook her head. 

Rather than getting frustrated, Dr. Smith gently pursued her 

reasons. Mrs. Houssani explained that it was Ramadan and she 

could not eat or drink from sunrise to sunset. Dr. Smith thought 

a bit and suggested that she find out if it’s okay to take medicine 

with food during Ramadan—there might be an exception for 

people in her situation who need to take medicine. 

Understanding how different cultures view health care helps you to tailor 

questions and treatment plans to the patient’s needs. Although you cannot 

become an expert in the norms and traditions of every culture, being sensitive 

to general differences can strengthen your relationship with your patients.
working with diverse older patients 45

Each culture has its own rules about body language and interpretations of 

hand gestures. Some cultures point with the entire hand, because pointing 

with a finger is extremely rude behavior. For some cultures, direct eye contact 

is considered disrespectful. Until you are sure about a patient’s background, 

you might opt for a conservative approach. And, if you aren’t certain about a 

patient’s preferences, ask.

The use of alternative medicines, herbal treatments, and folk remedies is 

common in many cultures. Be sure to ask your patient if he or she takes 

vitamins, herbal treatments, dietary supplements, or other alternative or 

complementary medicines. Also, in order to help build a trusting relationship, 

be respectful of native healers on whom your patient may also rely.

Older immigrants or non-native English speakers may need a medical 

interpreter. Almost 18 percent of the U.S. population speaks a language other 

than English at home, according to the Census Bureau. Among older people, 

2.3 million report not speaking English or not speaking it very well. Federal 

policies require clinicians and health care providers who receive Federal 

funds, such as Medicare payments, to make interpretive services available to 

people with limited English. 

Many clinicians rely on patients’ family members or on the ad hoc services 

of bilingual staff members, but experts strongly discourage this practice 

and recommend the use of trained medical interpreters. Family members 

or office staff may be unable to interpret medical terminology, may 

inadvertently misinterpret information, or may find it difficult to relay bad 

news. Although a patient may choose to have a family member translate, the 

patient should be offered access to a professional interpreter. 

chapter 8
46 working with diverse older patients

For more information on working with patients with 

diverse cultural backgrounds, contact:

Management Sciences for Health

784 Memorial Drive

Cambridge, MA 02139-4613

617-250-9500

http://erc.msh.org

This organization publishes The Provider’s Guide to Quality & Culture. The Guide offers 

materials for health care providers who work with diverse populations, including 

information about common beliefs and practices.

National Institute on Aging (NIA)

Information Center

P.O. Box 8057

Gaithersburg, MD 20898-8057

800-222-2225 (toll-free)

www.nia.nih.gov/Espanol 

The NIA Spanish-language website provides accurate, up-to-date information in Spanish on 

a variety of health issues of interest to seniors. The website offers free publications and links 

to other health-related Spanish-language resources. 

National Institutes of Health (NIH) 

www.salud.nih.gov

The NIH has a wealth of patient education materials—a wide variety of which are available 

in Spanish. Visit the website for a complete list of Spanish-language resources.

National Library of Medicine 

MedlinePlus 

www.medlineplus.gov/spanish

Office of Minority Health

P.O. Box 37337

Washington, DC 20013-7337

800-444-6472 (toll-free)

www.omhrc.gov

This Federal agency works to develop health policies and programs that help to eliminate 

racial and ethnic disparities in health.
In Summary

working with diverse older patients 47

When working with non-native English-speaking patients, be sure to ask 

which language they prefer to speak and whether or not they read and write 

English (and, if not, which language they do read). Whenever possible, 

offer patients appropriate translations of written material or refer them 

to bilingual resources. If translations are not available, ask the medical 

interpreter to translate medical documents.

Finding a Medical Interpreter

A number of States have associations and foundations that can help with locating, 

and in some cases provide funding for, medical interpreters. Some State Medicaid 

offices offer reimbursement for medical interpretation services. A web search can 

locate State organizations and local services. Or you can contact:

National Council on Interpreting in Health Care

5505 Connecticut Avenue, NW, #119

Washington, DC 20015-2601

518-459-3443 (fax)

www.ncihc.org

4 Keep in mind that cultural differences have an impact on how patients 

view doctors and medicine. 

4 Ask about patients’ use of alternative and complementary medicines.

4 Use a professional medical interpreter rather than family members or 

untrained staff.

4 Provide written materials in the patient’s primary language.
48 including families and caregivers

Including Families and Caregivers

By communicating effectively with all the individuals involved 

in your patient’s care, you can help him or her while also 

making efficient use of time and resources.

“What would you like your family to know?”

Dr. Hwang noticed that Mrs. Patrick wasn’t getting her medication 

dosage quite right. Mrs. Patrick admitted that sometimes she does 

not remember everything prescribed for her to do. Dr. Hwang 

wondered if Mrs. Patrick should bring her daughter to her next 

appointment. Mrs. Patrick agreed, but at the following doctor visit 

she still came alone. Dr. Hwang was puzzled. When he asked her 

about it, Mrs. Patrick said that she was concerned her daughter 

wouldn’t let her speak for herself and that she has some personal 

issues she’d like to discuss with him that she doesn’t want her 

daughter to know about. Dr. Hwang assured her that he would 

keep her involved in the conversation about her health and 

that they could have some private time to discuss any personal 

matters. Next time, Mrs. Patrick brought her daughter to the visit. 

Family and informal caregivers play an important role in the lives of their 

loved ones. They also play an increasingly important role in how the health 

care system functions. 
Informal caregivers may be important “informants.” They can also help to 

reinforce the importance of information you give or the treatment you prescribe.

To protect and honor patient privacy, be sure to check with the patient on 

how he or she sees the companion’s role. In many cases, the caregiver or 

companion can be a facilitator, helping the patient express concerns and 

reinforcing what you say. But it is best not to assume that a companion 

should be included in the medical encounter. First, check with the patient. 

Conducting the physical exam alone protects the patient’s privacy and 

allows you to raise sensitive issues. For instance, the best time to conduct a 

“mini-mental” test is during a private exam, so that a family member cannot 

answer questions or cover for the patient’s cognitive lapses.

When a companion is present, be aware of communication issues that arise 

in three-party interactions. Whenever possible, try to sit so that you form a 

including families and caregivers 49

chapter

Administration on Aging (AoA)

Washington, DC 20201

202-619-0724

www.aoa.gov

AoA provides funds and community-based 

services for programs that serve older adults.

Eldercare Locator

800-677-1116 (toll-free)

www.eldercare.gov

The Eldercare Locator offers referrals to 

information on services for seniors.

Family Caregiver Alliance

180 Montgomery Street, Suite 1100

San Francisco, CA 94104

415-434-3388

www.caregiver.org

The Alliance offers programs to provide 

information to and support for caregivers.

National Alliance for Caregiving

4720 Montgomery Lane, 5th Floor

Bethesda, MD 20814

www.caregiving.org

The National Alliance offers support and 

resources for the public and professionals.

National Family Caregivers 

Association

10400 Connecticut Avenue, #500

Kensington, MD 20895-3944

800-896-3650 (toll-free)

www.nfcacares.org

This Association supports family caregivers 

and offers education, information, and 

referrals.

9

For more information on working with families 

and caregivers, contact:
50 including families and caregivers

In Summary

triangle and can address both the patient and companion face-to-face. Be 

careful not to direct your remarks to the companion. By not falling into this 

trap, you can prevent the encounter from feeling like a “two against one” 

match. 

Families may want to make decisions for a loved one. Adult children 

especially may want to step in for a parent who has cognitive impairments. 

If a family member has been named the health care agent or proxy, under 

some circumstances, he or she has the legal authority to make care decisions. 

However, without this authority, the patient is responsible for making his 

or her own choices. Try to set clear boundaries with family members, and 

encourage others to respect them.

Family caregivers face many emotional, financial, and physical challenges. 

They often provide help with household chores, transportation, and personal 

care. More than one-third also give medications, injections, and medical 

treatments to the person for whom they care. It makes sense to view 

informal caregivers as “hidden patients” and be alert for signs of illness and 

stress. Caregivers may find it hard to make time for themselves. Encourage 

them to seek respite care so that they can recharge and take a break from 

the loved one. And remember, your encouragement and praise can help to 

sustain a caregiver.

4 Check with the patient on how he or she would like any family 

members or companions to participate in the medical encounter.

4 Address the patient—try to avoid talking only to the family member 

or companion.

4 Make it clear that the patient should make his or her own decisions 

unless legal authority to do so has been granted to someone else.

4 Be alert to family caregivers’ own health needs, including signs of stress.
talking with patients about cognitive problems 51

Talking With Patients About 

Cognitive Problems

Communicating with a confused patient holds special 

challenges. Specific techniques can help health care 

providers to talk with patients and caregivers about 

a diagnosis.

“You mentioned having trouble with your memory.”

Jonathan Jones had always been a meticulously organized man. 

His bills were paid on time; his car gas tank was always at least 

half full. He could be counted on to arrive slightly early for 

every appointment. Dr. Ross knew all this because he’d been 

taking care of the Jones family for nearly 30 years. So when 

Mr. Jones missed two appointments in a row, Dr. Ross knew 

something was not right and called him at home. The phone 

rang for quite a while before Mr. Jones answered, “Yes? Hello, 

Dr. Ross. Why are you calling? I don’t have an appointment 

scheduled with you.” The conversation added to Dr. Ross’s 

concerns. The doctor made a note on the chart—it was time to 

broach the subject of memory loss with Mr. Jones. After so many 

years, this was going to be a hard discussion.

chapter 10
52 talking with patients about cognitive problems

Cognitive Impairment 

Aging itself can cause deficits in cognition that vary from person to person. 

While some older people show little or no decrease in cognitive function, 

others may be very worried about their memory and may fear dementing 

disorders such as Alzheimer’s disease (AD). But, not all cognitive problems 

are caused by AD. Various illnesses, both physical and mental, can cause 

temporary, reversible cognitive impairment. Certain drug combinations can 

also cause a problem. 

Identifying and working with older adults who have cognitive impairment 

are important for their safety and for the safety of others. Older patients with 

cognitive impairment can develop difficulties in remembering and correctly 

adhering to instructions about medications for their other health problems. In 

addition, activities such as cooking and driving can become dangerous.

Many patients with cognitive impairments experience behavioral changes. 

For instance, they may withdraw from or lose interest in activities, grow 

irritable or uncharacteristically angry when frustrated or tired, or become 

insensitive to other people’s feelings. During more advanced stages of 

cognitive impairment, people may behave inappropriately—kicking, hitting, 

screaming, or cursing. Depending on the stage of the disease, you can suggest 

activities that your patient might still enjoy—for example, listening to music 

and perhaps dancing, playing games, gardening, or spending time with pets.

Some of your older patients may have a specific condition called mild cognitive 

impairment (MCI). People with MCI have ongoing memory problems but do 

not have other losses associated with AD such as confusion, attention problems, 

or difficulty with language. Some people’s cognitive problems may not get worse 

for many years. Some people with MCI may convert to AD over time. Research is 

ongoing to determine better which people with MCI will develop AD.

The suggestions in this section of the booklet pertain specifically to effective 

communication with patients with cognitive impairments.

Diagnosis 

Accurate diagnosis of AD or other cognitive problems can help your older 

patient and his or her family to plan for the future. Early diagnosis offers 

the best chance to treat the symptoms of the disease, when possible, and to 
talking with patients about cognitive problems 53

discuss ways of positively coping with the condition, including discussing 

care options. A relatively early diagnosis allows patients to make financial 

plans, prepare advance directives, and express informed consent for research. 

Yet data suggest that only a small fraction of people with AD are ever 

diagnosed. 

When patients are only mildly impaired, they can be adept at covering up 

what is happening to them. However, giving a few straightforward tests, 

using a medical history, and taking a family history from another family 

member can often tell you if there are persistent or worsening problems. 

It is best to conduct tests or interviews with the patient alone so that family 

members or companions cannot prompt the patient. Information can also 

be gleaned from the patient’s behavior on arrival in your office or from 

telephone interactions with staff. Family members who may contact you 

in advance or following the visit are also a source of information, but keep 

in mind patient privacy concerns. 

Although assessing an older person’s cognitive function is important, formal 

testing of mental status tends to provoke anxiety. If you are concerned about 

a patient’s cognition, it might be best to leave any formal testing of mental 

status until the latter part of the appointment—either between the history 

and the physical examination or after the examination—or to refer the 

patient to a neuropsychologist for more detailed assessment of cognition. 

If you administer a cognitive status test, try to present it in the context of 

concerns the patient has expressed. Providing support and encouragement 

during the testing can decrease stress.

There are limitations to any mental status test—for example, the test 

results can reflect level of education, or the results may appear normal 

early in the disease. The most commonly used screen is the Mini-Mental 

State Examination. This test can be used to screen patients for cognitive 

impairment and can be administered in the primary care setting in about 10 

minutes. A positive finding suggests the need for referral to a neurologist or 

neuropsychologist for a more detailed diagnosis.

Cognitive impairment may reflect a variety of conditions, some reversible. 

In particular, it is important to review your patient’s medications to check 

for anticholinergic or other potentially inappropriate medications. However, 
54 talking with patients about cognitive problems

since patients or caregivers may assume that the cause is Alzheimer’s disease, 

you may need to explain the need for a careful history, laboratory tests, and 

physical examination to search for other conditions or issues.

If your patient does have mild to moderate cognitive impairment, you might 

ask if there is someone who helps when he or she has trouble remembering. 

If your patient says yes, you could also ask if it would be a good idea for you 

to discuss the patient’s treatment plans with the helper and keep his or her 

name in your notes for future reference. Make these arrangements early, 

and check that the patient has given you formal authorization to include the 

helper in the conversation about your patient’s care. 

For more information on Alzheimer’s disease, contact:

Alzheimer’s Association

225 North Michigan Avenue, Floor 17

Chicago, IL 60601-7633

800-272-3900 (toll-free)

www.alz.org

This national voluntary health organization supports Alzheimer’s disease research and 

care and offers information and support to patients and families. It has local chapters with 

community information including referrals, support groups, and safety services. 

Alzheimer’s Disease Education and Referral (ADEAR) Center

P.O. Box 8250

Silver Spring, MD 20907-8250

800-438-4380 (toll-free)

www.nia.nih.gov/Alzheimers

A service of NIA, ADEAR provides information, publications, referrals, a health information 

database, and a clinical trials database for the public and for health care professionals.

Alzheimer’s Foundation of America

322 8th Avenue, 7th Floor

New York, NY 10001

866-232-8484 (toll-free)

www.alzfdn.org 

The Foundation brings together groups around the country, including assisted living 

organizations, community services agencies, State agencies, and others, to collaborate 

on education, resources, and program design and implementation for people with AD, 

their caregivers, and families. 
talking with patients about cognitive problems 55

Communicating With a Confused Patient

l Try to address the patient directly, even if his or her cognitive capacity is 

diminished. 

l Gain the person’s attention. Sit in front of him or her and maintain eye contact.

l Speak distinctly and at a natural rate of speed. Resist the temptation to 

speak loudly.

l Help orient the patient. Explain (or re-explain) who you are and what you will 

be doing. 

l If possible, meet in surroundings familiar to the patient. Consider having a 

family member or other familiar person present at first. 

l Support and reassure the patient. Acknowledge when responses are correct. 

l If the patient gropes for a word, gently provide assistance. 

l Make it clear that the encounter is not a “test,” but rather a search for 

information to help the patient. 

l Use simple, direct wording. Present one question, instruction, or statement 

at a time. 

l If the patient hears you but does not understand you, rephrase your statement. 

l Although open-ended questions are advisable in most interview situations, 

patients with cognitive impairments often have difficulty coping with them. 

Consider using a yes-or-no or multiple-choice format. 

l Remember that many older people have hearing or vision problems, which can 

add to their confusion. 

l Consider having someone call the patient to follow up on instructions after 

outpatient visits. 

l If the patient can read, provide written instructions and other background 

information about the problem and options for solutions. 
56 talking with patients about cognitive problems

Conveying Findings

Some patients may prefer a cautious, reserved explanation. You might 

consider saying something like, “You have a memory disorder, and I believe 

it will get worse as time goes on. It’s not your fault. It may not help for you to 

try harder. Now is probably a good time for you to start making financial and 

legal plans before your memory and thinking get worse.” Some patients may 

prefer more precise language and appreciate it when a doctor uses specific 

words like Alzheimer’s disease. If possible, schedule additional time for 

the appointment so that you can listen and respond to the patient’s or 

caregiver’s concerns. Also, if possible, offer to have a follow-up appointment 

to further discuss what to expect from the diagnosis. 

Regardless of how you present the diagnosis, providing written materials 

can make a big difference in helping your patient and his or her family 

know what to expect. The NIA’s Alzheimer’s Disease Education and Referral 

(ADEAR) Center has free publications you can include in a patient/caregiver 

information packet. You might want to refer your patient to a neurologist 

or neuropsychologist for testing. The Alzheimer’s Association or other 

supportive organizations can provide assistance in planning, social services, 

and care. 

Informing family members or others that the patient may have Alzheimer’s 

disease or any cognitive impairment may be done in a family conference or 

group meeting, which should be arranged with the consent of the patient. 

In some situations, a series of short visits may be more suitable. You should 

make clear you will continue to be available for care, information, guidance, 

and support. If you are unable to provide all of these services, it would make 

a tremendous difference if you could refer the patient and family to a service 

organization.

Working With Family Caregivers

All family caregivers face challenges, but these challenges are compounded 

for people caring for patients with Alzheimer’s disease and other dementias. 

The patient usually declines slowly, over the course of several years. This is an 
talking with patients about cognitive problems 57

In Summary

exhausting and disturbing experience for everyone. The following suggestions 

are especially useful for family caregivers in these situations:

l Persuade caregivers to get regular respite, especially when patients require 

constant attention. Ask if the caregiver, who is at considerable risk for 

stress-related disorders, is receiving adequate health care.

l Explain that much can be done to improve the patient’s quality of life. 

Measures, such as modifications in daily routine and medications for 

anxiety, depression, or sleep, may help control symptoms. 

l Let the caregivers know there is time to adapt. Decline is rarely rapid. 

Provide information about the consumer resources and support services 

available from groups. 

l Help caregivers plan for the possibility that they eventually may need 

more help at home or may have to look into residential care. 

4 Using a simple screen, such as the Mini-Mental State Examination, 

assess the patient’s cognitive function when alone with him or her. 

Refer the patient to a specialist (e.g., neurologist or neuropsychologist) 

for diagnosis of cognitive impairment.

4 Reassure the patient if there is no serious mental decline.

4 Decide how to talk about serious cognitive problems, depending on 

how much the patient wants to know and can understand.

4 Communicate with family members in a family conference, arranged 

with the patient’s consent.

4 Suggest activities that the patient and family might still enjoy. 

4 Be alert to caregivers’ needs for information, resources, and respite.
58 keeping the door open

Keeping the Door Open

“Effective Communication”

Advising an older man about starting an exercise program . . . 

counseling a woman about the proper way to take her osteoporosis 

medication . . . discussing end-of-life care options with the 

family of a long-time older patient who is dying. These are just 

some examples of the complex and sensitive issues facing 

clinicians who treat older people. Health care providers who 

communicate successfully with older patients may gain their 

trust and cooperation, enabling everyone to work as a team to 

handle physical and mental health problems that might arise. 

Effective communication techniques, like those discussed in this 

handbook, can save time, increase satisfaction for both patient 

and practitioner, and improve the provider’s skill in managing 

the care of his or her patients.

Ongoing communication is key to working effectively with your older 

patient. If a patient does not follow recommendations or starts missing 

appointments, explore whether or not a difficulty in communication 

has developed. Paying attention to communication increases the odds of 

greater health for your patient and satisfaction for you both.
keeping the door open 59

National Institute on Aging (NIA)

Building 31, Room 5C27

31 Center Drive, MSC 2292

Bethesda, MD 20892

301-496-1752

www.nia.nih.gov

NIA funds research on the science of aging 

and provides information and materials 

for the public and for professionals. It is 

the primary Federal agency for Alzheimer’s 

disease research and education.

For NIA publications: 

National Institute on Aging 

Information Center

P.O. Box 8057

Gaithersburg, MD 20898-8097

800-222-2225 (toll-free)

800-222-4225 (TTY/toll-free)

www.nia.nih.gov/HealthInformation 

NIHSeniorHealth 

www.nihseniorhealth.gov

This is a senior-friendly website from the 

National Institute on Aging and the National 

Library of Medicine. This website has health 

information for older adults. Special features 

make it simple to use. For example, you can 

click on a button to have the text read out 

loud or to make the type larger.

For resources on working with older patients, contact:

chapter 10

American Geriatrics Society (AGS)

The Empire State Building

350 Fifth Avenue, Suite 801

New York, NY 10018

212-308-1414

www.americangeriatrics.org

AGS has programs in patient care, research, 

professional and public education, and public 

policy. The AGS website also offers many clinical 

resources, including:

l Geriatrics at Your Fingertips, a pocket-sized 

guide to caring for older patients

l The Geriatric Review Syllabus, featuring 

relevant online educational programs

American Medical Association (AMA)

515 North State Street

Chicago, IL 60610

www.ama-assn.org/ama/pub/category/4642.html 

The AMA has several ongoing initiatives to address a 

variety of aging issues.

Gerontological Society of America 

(GSA)

1030 15th Street, NW, Suite 250

Washington, DC 20005-1503

202-842-1275

www.geron.org

GSA is a non-profit, professional organization 

whose members include researchers, educators, 

practitioners, and policymakers.
60 publications at-a-glance

Fact sheets, called AgePages, are available on a variety of topics. 

The asterisk (*) indicates those also available in Spanish.

Diseases/Conditions •	 Arthritis Advice*

•	 Cancer Facts for People Over 50*

•	 Diabetes in Older People*

•	 Hearing Loss*

•	 High Blood Pressure*

•	 Osteoporosis*

•	 Prostate Problems*

•	 Shingles

•	 Stroke*

Safety •	 Crime and Older People*

•	 Falls and Fractures*

•	 Medicines: Use Them Safely*

•	 Older Drivers*

•	 Online Health Information: Can You Trust It?

Wellness •	 A Good Night’s Sleep*

•	 Aging and Your Eyes*

•	 Concerned About Constipation?*

•	 Dietary Supplements

•	 Exercise and Physical Activity: Getting Fit for Life*

•	 Flu—Get the Shot*

•	 Foot Care*

•	 Healthy Eating After 50	

•	 Hyperthermia*

The National Institute on Aging offers free 

publications you might use when talking 

with your older patients. You can order single or multiple copies from: 

National Institute on Aging Information Center

P.O. Box 8057

Gaithersburg, MD 20898-9057

800-222-2225 (toll-free)

800-222-4225 (TTY/toll-free)

www.nia.nih.gov/HealthInformation

Publications

at-a-glance

(continued on next page)
publications at-a-glance 61

Wellness (continued)	 •	 Hypothermia*

•	 Shots for Safety*

•	 Skin Care and Aging

•	 Smoking: It’s Never too Late to Stop

•	 Taking Care of Your Teeth and Mouth*

Sensitive Subjects	 •	 Alcohol Use and Abuse*

•	 Beware of Health Scams*

•	 Considering Surgery*

•	 Depression: Don’t Let the Blues Hang Around*

•	 Forgetfulness: Knowing When to Ask for Help*

•	 Getting Your Affairs in Order

•	 HIV, AIDS, and Older People*

•	 Mourning the Death of a Spouse

•	 Nursing Homes: Making the Right Choice*

•	 Sexuality in Later Life*

•	 Urinary Incontinence*

More in-depth publications are also available. 

•	 End of Life: Helping With Comfort and Care

•	 Exercise and Physical Activity: Your Everyday Guide

from the National Institute on Aging

•	 So Far Away: Twenty Questions for

Long-Distance Caregivers

•	 Talking With Your Doctor: A Guide for Older People

•	 There’s No Place Like Home—for Growing Old:

Tips from the National Institute on Aging

NIA’s ADEAR Center has a wide variety of free publications for patients with 

cognitive problems, their families, and caregivers, such as Understanding Alzheimer’s

Disease and Caregiver Guide: Tips for Caregivers of People with Alzheimer’s Disease. 

To order, contact:

Alzheimer’s Disease Education and Referral Center

P.O. Box 8250

Silver Spring, MD 20907-8250

800-438-4380 (toll-free)

www.nia.nih.gov/Alzheimers 

Suggestions

Please send comments, personal observations, 

practical experiences, or suggestions to:

Freddi Karp, Editor

Office of Communications and Public Liaison

National Institute on Aging

Building 31, Room 5C27

Bethesda, MD 20892

301-496-1752

karpf@nia.nih.gov

Contributors: Caroline McNeil, Freelance Writer; Karin Kolsky and Megan J. Homer, NIA Office of Communications 

and Public Liaison; Susan R. Farrer, JBS International, Inc. Design: Susan Spangler Design & Illustration
#

national institute on aging

october 2008
You want to help your patients get the services they need. But you 

may not be sure where to find the right resource. This is a starting 

place. We’ve identified some of the most common concerns and 

listed a few national resources that might be helpful.

#

What’s a Solution?

Mandatory reporting to adult 

protective services

Respite care

Adult day care, nursing home care

Home health aide

Case manager or supportive

community programs

Free fact sheets, booklets, and

web resources

Homemaker assistant

Meals on Wheels or congregate

meal sites

Volunteer companions

Medical transport benefits or other

community programs

Utility subsidies

Helpful Resources

National Center on Elder Abuse

For your State Adult Protective Services:

www.ncea.aoa.gov

Call local police or 911, if serious situation

National Respite Locator Service

800-773-5433 (toll-free)

www.respitelocator.org

National Adult Day Services Association

877-745-1440 (toll-free)

www.nadsa.org

Nursing Home Compare service

www.medicare.gov/nhcompare/home.asp

Eldercare Locator

800-677-1116 (toll-free)

www.eldercare.gov

National Council on Aging

To assess eligibility:

www.benefitscheckup.org

National Institute on Aging Information Center

800-222-2225 (toll-free)

www.nia.nih.gov/HealthInformation

NIH SeniorHealth

www.nihseniorhealth.gov

National Institutes of Health

National Library of Medicine

www.medlineplus.gov

Eldercare Locator

800-677-1116 (toll-free)

www.eldercare.gov

Meals on Wheels Association of America

703-548-5558

www.mowaa.org

Eldercare Locator

800-677-1116 (toll-free)

www.eldercare.gov

National Association of Area Agencies on Aging

202-872-0888

www.n4a.org

National Transit Hotline

800-527-8279 (toll-free)

National Energy Assistance Referral Project

866-674-6327 (toll-free)

http://liheap.ncat.org/referral.htm

What’s the Problem?

Abuse/neglect

Caregiver assistance

Caregiving

Daily living assistance

Financial assistance

Health information 

Household assistance

Nutrition

Social support

Transportation

Utility costs

Services

at-a-glance

national institute on aging talking with your older patient: a clinician’s handbook
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Institute on Aging

NIH Publication No. 08-7105

October 2008