Talking With 

Your Older Patient 

A Clinician’s Handbook 
Table of Contents 

Effective Communication for Effective Care.........................................................1
 

Considering Healthcare Perceptions.....................................................................3
 

Understanding Older Patients ................................................................................5
 

Obtaining the Medical History.............................................................................. 10
 

Encouraging Wellness............................................................................................. 15
 

Talking about Sensitive Subjects.........................................................................19
 

Supporting Patients with Chronic Conditions...................................................29
 

Breaking Bad News ..................................................................................................33
 

Working with Diverse Older Patients .................................................................36
 

Including Families and Caregivers.......................................................................39
 

Talking with Patients about Cognitive Problems ............................................42
 
 

Effective Communication 

for Effective Care 

Good communication is an important 

part of the healing process. Effective 

doctor-patient communication has 

research-proven 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 

file malpractice suits. 

Studies show that good communication is a 

teachable skill. Medical students who receive 

communication training improve dramatically 

in talking with, assessing, and building 

relationships with patients. Time management 

skills also improve. 

Interpersonal communication skills are 

considered so important that they are a core 

competency identified by the Accreditation 

Council on Graduate Medical Education and 

the American Board of Medical Specialties. 

Learning—and using—effective communication 

techniques may help you build more satisfying 

relationships with older patients and become 

even more skilled at managing their care. 

Effective Communication for Effective Care 1 
 

With older patients, communication can involve 

special issues. For example: 

•	 How can you effectively interact with 

patients facing multiple illnesses and/or 

hearing and vision impairments? 

•	 What’s the best way to approach sensitive 

topics, such as driving abilities or end of life? 

•	 Are there best practices to help older patients 

experiencing confusion or memory loss? 

With such questions in mind, the National 

Institute on Aging, part of the National 

Institutes of Health, developed Talking With 

Your Older Patient: A Clinician’s Handbook. 

This booklet is intended for use by a range of 

professionals who work directly with patients— 

physicians, physicians-in-training, nurse 

practitioners, nurses, physician assistants, and 

other healthcare professionals. The aim is to 

introduce and/or reinforce communication skills 

essential in caring for older patients and working 

with their families. This booklet offers practical 

techniques and approaches that can 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: 

•	 Stereotypes about aging and old age can lead 

patients and healthcare professionals alike to 

dismiss or minimize problems as an inevitable 

decline of aging. What we’re learning from 

research is that aging alone does not cause 

illness nor does it automatically mean having 

to live with pain and discomfort. 

•	 Many of this booklet’s suggestions may appear 

at first glance to be time-consuming; however, 

an initial investment of time can lead to longterm gains for clinicians and patients. You may 

get to know your patient’s life history over the 

course of several visits rather than trying to 

get it all in one session, for example. 

•	 Older patients are not all the same. You may 

see frail 60-year-olds and relatively healthy 

80-year-olds. Your patients probably are 

culturally diverse, with varying socioeconomic 

and educational backgrounds. Some are 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 healthcare needs and questions. 

For more information on working with older 

patients, contact: 

American Geriatrics Society 

1-212-308-1414 

info.amger@americangeriatrics.org 

www.americangeriatrics.org 

AGS has programs in patient care, research, 

professional and public education, and public policy. 

American Society on Aging 

1-800-537-9728 (toll-free) 

www.asaging.org/form/contact-us (email form) 

www.asaging.org 

ASA offers professional education, publications, and 

online information and training resources. 

Gerontological Society of America 

1-202-842-1275 

info@geron.org 

www.geron.org 

GSA is a nonprofit, professional organization 

whose members include researchers, educators, 

practitioners, and policymakers. 

National Institute on Aging 

1-800-222-2225 (toll-free) 

1-800-222-4225 (TTY/toll-free) 

niaic@nia.nih.gov 

www.nia.nih.gov 

NIA funds research on the science of aging and 

provides information and materials for the public 

and professionals. It is the lead Federal agency for 

Alzheimer’s disease research. 

NIHSeniorHealth 

www.nihseniorhealth.gov 

This senior-friendly website from the National 

Institute on Aging and the National Library of 

Medicine has health and wellness information for 

older adults. 

2	 Talking With Your Older Patient 
 

Considering

Healthcare Perceptions 

At a Glance 

•	 Avoid making assumptions about your older patients; they are diverse and will have different views 

of aging. 

•	 Remember: Most health problems are caused by disease, not normal aging. 

•	 Expect baby boomers to actively participate in their health care. 

•	 Ask about the patient’s priorities for care. 

Considering Healthcare Perceptions 3 
 

 

“This is one of the best times of my life...” 

Mrs. Hill, age 85, lives in a nursing home. Her adult children think it must 

be depressing, but they don’t know what else to do. One day, Mrs. Hill’s 

doctor asks her about life in the facility. 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. The best way to learn what is and is not 

acceptable is to communicate directly with patients and caregivers. For 

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

During the past century, the nature of old 

age has changed dramatically. In the 

early 1900s, average life expectancy 

at birth was about 49 years—today, it is nearly 

80 years. With longevity, however, comes the 

sobering news that older 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. 

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. Those with treatable 

symptoms may dismiss their problems as an 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Choosing a Doctor AgePage 

•	 Talking With Your Doctor: A Guide for Older 

People 

•	 Talking With Your Doctor Presentation Toolkit 

inevitable part of aging and not get medical 

care. As a result, they may 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 

were generally healthy and could bounce back 

quickly from an illness. Experts observe that 

baby boomers bring different expectations, 

experiences, and preferences to aging than 

did previous generations. For instance, some 

boomers will want to participate actively in 

their health care and work collaboratively with 

clinicians to determine what treatments might 

best work for them. They frequently go online 

to search for health information. 

Values about Health 

Consider starting an appointment with the 

following question: “What are your goals for 

your care?” Although clinicians typically focus 

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 want to make 

the most of their remaining years. Younger 

family members, who might have to make 

life-and-death decisions when an older person 

is incapacitated, may be unaware of the 

patient’s views and preferences. 

4	 Talking With Your Older Patient 
 

Understanding

Older Patients
 

At a Glance 

•	 Unless asked to do otherwise, address the patient by last name, using the title he or she prefers 

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

•	 Begin the appointment with a few friendly questions not directly related to health. 

•	 Don’t rush through your questions, and speak slowly when giving your health instructions. 

•	 Listen actively to your older patients and try not to interrupt; give them enough time to fully 

express their concerns. 

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

•	 Whenever possible, write down instructions or provide handouts about care. 

Understanding Older Patients 5 
 

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. 

Effective communication has practical 

benefits. It can: 

• Help prevent medical errors 

• Lead to improved health outcomes 

• Strengthen the patient-provider relationship 

• Make the most of limited interaction time 

Here are tips for communicating with older 

patients in ways that are respectful and 

effective for information exchange. 

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.” Use Mr., 

Mrs., Ms., and so on. Or, you might ask your 

patient about preferred forms of address and 

how she or he would like to address you. 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 your 

patients, especially those who are older and 

might be 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, 

restrooms, and the waiting area. Staff should 

check on them often if they have a long wait 

in the exam room. 

Take a Few Moments to 

Establish Rapport 

Introduce yourself clearly and do not speak too 

quickly. Show from the start that you accept the 

patient and want to hear his or her concerns. 

If you are 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 

returning patients, friendly questions about their 

families or activities can relieve stress. 

Try Not to Rush 

Older people may have trouble following rapidfire 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. 

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 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. 

If time is an issue, you might suggest that your 

patients prepare a list of their health concerns 

in advance of their appointments. That way they 

are prepared and you have a sense of everything 

they’d like to cover during your time together. 

The National Institute on Aging’s booklet Talking 

With Your Doctor: A Guide for Older People 

has additional tips for patients preparing for a 

doctor’s visit. 

6 Talking With Your Older Patient 
 

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. 

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 “uhhuh.” Active listening keeps the discussion 

focused and lets patients know you understand 

their concerns. 

Write Down Take-Away Points 

It can often be difficult for patients to 

remember everything discussed during an 

appointment about their condition and care. 

Older adults can especially benefit from having 

written notes to refer back to that summarize 

major points from the visit. Try to make these 

notes simple and clear, avoiding ambiguous and 

complicated language. For example, you might 

write, “Drink at least one 6-oz glass of water 

every 2 hours” instead of “Increase fluids.” 

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 clinical 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. 

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, CT 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 might ask the patient 

to repeat back the diagnosis or care plan in his 

or her own words—this can help with recall, 

as well. You may want to spell or write down 

diagnoses or important terms to remember. 

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

Although she complains of loneliness and long days in front of the 

television, Mrs. Lopez refuses to participate in activities at the 

community senior center. “I don’t want to hang around old people 

who have nothing better to do than compare health problems,” 

she tells her doctor. “Why not give it a try?” her doctor asks. “You 

might find members who share many of your same interests, 

including your love of gardening.” Six months later, when she sees 

the doctor again, Mrs. Lopez thanks her. She has joined the garden 

club and reports that the members all have green thumbs and are lively conversationalists. 

Better still, Mrs. Lopez’s depressive symptoms seem improved. 

Understanding Older Patients 7 
 

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. 

Be Careful about Language 

Some words may have different meanings to 

older patients than to you or your peers. Words 

may also have different connotations based on 

cultural or ethnic background. For example, 

the word “dementia” may connote insanity, and 

the word “cancer” may be considered a death 

sentence. Although you cannot anticipate every 

generational and cultural/ethnic 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.” 

Low literacy or inability to read also may be a 

problem. Reading materials written at an easy 

reading level can help. 

Ensure Understanding 

Conclude the visit by making sure the patient 

understands: 

• What is the main health issue 

• What he or she needs to do 

• Why it is important to act 

Compensating for Hearing Deficits 

Age-related hearing loss is common. About one quarter of people between the ages of 65 and 75, 

and half of those over the age of 75 have disabling hearing loss. Here are a few tips to make it 

easier to communicate with a person who has lost some hearing: 

• 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. 

• 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. 

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

• Face the person directly, at eye level, so that he or she can lip-read or pick up visual clues. 

• Keep your hands away from your face while talking, as this can hinder lip-reading ability. 

• Be aware that background noises, such as whirring computers and office equipment, can mask 

what is being said. 

• 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 (for 

example, “five, six” instead of “fifty-six”). Be especially careful with letters that sound alike (for 

example, m and n, and b, c, d, e, t, and v). 

• Keep a notepad handy so you can write what you are saying. Write out diagnoses and other 

important terms. 

• 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. 

8 Talking With Your Older Patient 
 

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: 

• Make sure there is adequate lighting, including sufficient light on your face. Try to minimize glare. 

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

• Make sure that handwritten instructions are clear. 

• If your patient has trouble reading, consider alternatives such as recording instructions, providing 

large pictures or diagrams, or using aids such as specially configured pillboxes. 

• When using printed materials, make sure the type is large enough and the typeface is easy to read. 

The following print size (14 pt) works well: 

“This size is readable.” 

One way to do this is the “teach-back 

method”—ask patients to say what they 

understand from the visit. Also, ask about any 

potential issues that might keep the patient 

from carrying out the treatment plan. 

For more information on effective 

communication approaches, contact: 

Agency for Healthcare Research and Quality 

1-301-427-1104 

https://info.ahrq.gov/app/ask (email form) 

www.ahrq.gov 

AHRQ produces evidence to make health care safer, 

higher quality, more accessible, equitable, and 

affordable. 

American Academy on Communication 

in Healthcare 

1-859-514-9211 

info@aachonline.org 

www.aachonline.org 

This professional organization aims to improve 

physician-patient relationships and offers courses and 

publications on medical encounters and interviews. 

Centers for Disease Control and Prevention 

www.cdc.gov/healthliteracy 

This website features resources for supporting the 

health literacy needs of your patients, including tips 

for developing plain language materials. 

Partnership for Clear Health Communication 

National Patient Safety Foundation 

1-617-391-9900 

info@npsf.org 

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. 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Aging and Your Eyes AgePage 

•	 Hearing Loss AgePage 

•	 Hospitalization Happens: A Guide to Hospital 

Visits for Individuals with Memory Loss 

•	 Making Your Printed Health Materials Senior 

Friendly 

•	 Talking With Your Doctor: A Guide for Older 

People 

Understanding Older Patients 9 
 

Obtaining the

Medical History 

At a Glance 

•	 Obtain basic information before the visit. 

•	 Ask patients to bring in written lists of concerns and all medications, including over-the-counter 

and alternative or complementary remedies. 

•	 Use family history to gain insight into an older patient’s social situation and disease risk. 

•	 Discuss activities of daily living and be alert to changes. 

•	 Ask about living arrangements, transportation, and lifestyle to help devise appropriate interventions. 

10 Talking With Your Older Patient 
 

When patients are older, obtaining a 

good history—including information 

on social circumstances and 

lifestyle in addition to medical and family 

history—is crucial to good health care. 

The varied needs of older patients may 

require different interviewing techniques. 

The following guidelines can help you 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 healthcare 

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. 

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: 

•	 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. 

•	 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. 

•	 Sit and face the patient at eye level. Use 

active listening skills, responding with brief 

comments such as “I see” and “okay.” 

•	 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. 

•	 Try to use open-ended questions that 

encourage a more comprehensive response. 

If the patient has trouble with responding, 

be prepared with yes-or-no or simplechoice questions. 

•	 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 and can build trust. 

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. 

Allowing uninterrupted time to express concerns 

enables your patient 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. Sometimes, 

an older patient will seek medical care because 

of family members’ or caregivers’ concerns. 

Obtaining the Medical History 11 
 

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. 

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, such as internists, 

cardiologists, urologists, or rheumatologists. 

Remember to ask about any alternative 

treatments, such as dietary supplements, 

complementary remedies, or teas that the 

patient might be using. Remind patients that it 

is important for you to know all the over-thecounter medicines, such as pain relievers or 

eye drops, they use. 

Suggest that patients bring a list of all of their 

medications—prescriptions, over-the-counter 

medicines, vitamins, supplements, herbal 

medicines, topicals, liquids, injectibles, and 

inhalants—along with how much and how 

frequently they take each medicine. Or, you 

could suggest that they bring everything with 

them in a bag. 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 

Understanding an older patient’s usual 

level of functioning and knowing 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, bathing, and dressing and 

more complex instrumental activities of daily 

living (IADLs) such as cooking, shopping, and 

managing finances. There are standardized ADL 

12 Talking With Your Older Patient 
 

“Any new issues at home affecting your treatment?” 

The health team is puzzled. 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 because of shortness of breath. A home care 

nurse 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. 

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 doctor-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 is also crucial. If you are 

aware of your patient’s living arrangements or 

his or 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 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 if the patient thinks 

he or she can “afford to get sick,” in view of 

family responsibilities. 

House calls by a healthcare 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 

during the interview: “Do you use oil or gas 

heat? Do you have steep stairs to navigate? Do 

you 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. 

Obtaining the Medical History 13 
 

Also, be sure to ask if anything has changed 

since the last visit. For instance, you’ll want to 

find out if your patient still has the same living 

arrangements or experienced some type of loss. 

For more information on obtaining a medical 

history, contact: 

American Academy of Family Physicians 

1-800-274-2237 (toll-free) 

contactcenter@aafp.org 

www.aafp.org 

AAFP offers information on patient care, including 

clinical recommendations for geriatric care. 

American Geriatrics Society 

1-212-308-1414 

info.amger@americangeriatrics.org 

www.americangeriatrics.org 

AGS has programs in patient care, research, 

professional and public education, and public policy. 

American Occupational Therapy Association 

1-301-652-6611 

praota@aota.org 

www.aota.org 

AOTA educates the public and advances occupational 

therapy by providing resources, setting standards, and 

serving as an advocate to improve health care. It has 

information pertinent to activities of daily living. 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Dietary Supplements AgePage 

•	 Home Safety for People with Alzheimer’s 

Disease 

•	 Medicines: Use Them Safely AgePage 

•	 Safe Use of Medicines 

•	 Talking With Your Doctor: A Guide for 

Older People 

•	 There’s No Place Like Home—For Growing Old 

14 Talking With Your Older Patient 
 

Encouraging

Wellness 

At a Glance 

•	 Talk with your older patients about the value of exercise and physical activity. 

•	 Encourage patients to be physically active or exercise; the National Institute on Aging’s Go4Life® 

campaign can help. 

•	 Talk with your older patients about their eating habits. 

•	 Consider having older patients keep a food diary to help ensure they are getting needed nutrients. 

Encouraging Wellness 15 
“I’d like you to exercise regularly. Just start low and go slow.” 

Mr. Gupta has a list of excuses for why he couldn’t follow Dr. Lipton’s 

exercise recommendation, like exercise is for young people and 

equipment costs too much. After listening empathetically, Dr. Lipton 

explains that physical activity is good for people of all ages and that 

being sedentary is far more dangerous than exercising. He suggests 

that Mr. Gupta start by walking for 10 minutes at a time and build up 

to 150 minutes of physical activity each week. The only equipment he 

will need is a pair of comfortable walking shoes. 

Exercise and Physical Activity 

Exercise has proven benefits for older people. 

It reduces risk of cardiovascular disease, 

hypertension, type 2 diabetes, osteoporosis, 

obesity, colon cancer, and breast cancer. 

It also decreases the risk of falls and 

fall-related injuries. 

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: 

•	 Whenever appropriate, let them know 

that regular physical activity—including 

endurance, muscle-strengthening, balance, 

and flexibility exercises—is essential for 

healthy aging. 

•	 Help patients set realistic goals and develop 

an exercise plan. 

•	 Write an exercise prescription, and make it 

specific, including type, frequency, intensity, 

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

•	 Refer patients to community resources, such 

as mall-walking groups and senior center 

fitness classes. 

•	 Talk to them about Go4Life, NIA’s exercise 

and physical activity campaign. It has 

exercises, motivational tips, virtual coaches, 

shared stories, and free materials to help 

older adults start exercising and keep going. 

Visit www.nia.nih.gov/Go4Life. 

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, 

16 Talking With Your Older Patient 
 

including calcium, vitamin D, and vitamins B6 

and B12, increases after age 50. 

Try these strategies to encourage healthy diets: 

•	 Emphasize that good nutrition can have an 

impact on well-being and independence. 

•	 If needed, suggest liquid nutrition supplements, 

but emphasize the benefits of solid foods. 

•	 If needed, suggest multivitamins that fulfill 

100 percent of the recommended daily 

amounts of vitamins and minerals for older 

people, but not megadoses. 

•	 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 the Eldercare 

Locator at 1-800-677-1116 for your Area Agency 

on Aging. 

•	 Suggest NIA’s online resource, What’s On Your 

Plate? Smart Food Choices for Healthy Aging. 

Too Old to Exercise? Studies Say No! 

• Together, exercise and lifestyle changes, such as becoming more active and eating healthy food, 

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. 

• In another study, moderate exercise was effective at reducing stress and sleep problems in older 

women caring for a family member with dementia. 

• Older people who exercise moderately are able to fall asleep quickly, sleep for longer periods, and get 

better quality of sleep. 

• Researchers also found that exercise, which can improve balance, reduced falls among older people 

by 33 percent. 

• Walking and strength-building exercises by people with knee osteoarthritis help reduce pain and 

maintain function and quality of life. 

Encouraging Wellness 17 
 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Everyday Exercises from the National 

Institute on Aging at NIH (DVD) 

•	 Exercise & Physical Activity: Your Everyday 

Guide from the National Institute on Aging 

at NIH 

•	 Exercise and Physical Activity: Getting Fit 

for Life AgePage 

•	 Falls and Fractures AgePage 

•	 Healthy Eating After 50 AgePage 

•	 Participating in Activities You Enjoy— 

More Than Just Fun and Games 

•	 What’s On Your Plate? Smart Food Choices 

for Healthy Aging 

•	 Workout to Go: A Sample Exercise Routine 

from the National Institute on Aging at NIH 

For more information on exercise, nutrition, 

and older people, contact: 

Centers for Disease Control and Prevention 

1-800-232-4636 (toll-free) 

1-888-232-6348 (TTY/toll-free) 

cdcinfo@cdc.gov 

Healthy Aging: www.cdc.gov/aging 

Nutrition, Physical Activity, and Obesity: 

www.cdc.gov/nccdphp/dnpao 

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 health and prevent 

and control chronic diseases. 

Department of Agriculture 

Food and Nutrition Information Center 

National Agricultural Library 

1-301-504-5414 

FNIC@ars.usda.gov 

https://fnic.nal.usda.gov 

The website provides more than 2,000 links to 

current, reliable nutrition resources. 

National Institute on Aging 

Go4Life® Exercise and Physical Activity Campaign 

1-800-222-2225 (toll-free) 

1-800-222-4225 (TTY/toll-free) 

niaic@nia.nih.gov 

www.nia.nih.gov/Go4Life 

NIA’s Go4Life campaign has free online and 

print materials in English and Spanish to show 

older adults how to start and maintain a safe, 

effective exercise routine that includes endurance, 

flexibility, balance, and strength-training. NIA also 

offers information about how to make smart food 

choices for healthy aging. 

National Resource Center on Nutrition, 

Physical Activity and Aging 

Florida International University 

1-305-348-1517 

nutritionandaging@fiu.edu 

http://nutritionandaging.fiu.edu 

The Center helps to develop and implement nutrition 

programs for a variety of settings. One such program 

is YouCan! Steps to Healthier Aging. 

18 Talking With Your Older Patient 
 

Talking about

Sensitive Subjects 

At a Glance 

•	 Introduce sensitive topics with the “common concern” approach: “Many of us have more 

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

•	 Keep educational materials available and visible to encourage discussion; the National Institute 

on Aging offers free brochures and booklets about many sensitive topics. 

•	 Raise topics such as safe driving, long-term care, advance directives, and end-of-life care 

before they become urgent matters. 

Talking about Sensitive Subjects 19 
 

 

 

Caring for an older patient requires 

discussing sensitive topics. Many older 

people have a “don’t ask, don’t tell” 

relationship with healthcare providers about 

certain problems, 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 and tempted to avoid 

addressing some of these concerns because 

you don’t know how to help patients solve the 

problem. The information here gives an overview 

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, “You are not alone, many people 

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 maintain patient confidentiality to 

reassure the patient with whom you are talking 

that you won’t disclose personal information 

about him or her. 

Some patients avoid issues that they think are 

inappropriate to discuss with clinicians. One 

way to overcome this is to keep informative 

brochures and materials readily available in the 

waiting room. Organizations offering relevant 

resources are listed within each topic area. NIA 

also has free online and print publications, some 

of which are listed at the end of this chapter. 

Driving 

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. Driving is associated with 

independence and identity, and making the 

decision not to drive is very hard. 

As with other difficult subjects, try to frame 

it as a common concern of many patients. 

Mention, for instance, that certain health 

conditions 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. 

When applicable, 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. 

Ask the patient about any car accidents. You might 

ask if she or he has thought about alternative 

transportation methods if driving is no longer an 

option. Your local Area Agency on Aging may be 

able to help patients find alternative methods 

of transportation. Contact the Eldercare Locator 

at 1-800-677-1116 for your Area Agency on Aging. 

20 Talking With Your Older Patient 
 

“Many people your age experience similar problems.” 

During a regular exam, Mr. Abayo, age 80, acknowledges that 

trouble with his shoulder started after he had a car accident. 

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

Dr. Carli says. “I know it can be hard to stop driving, but maybe 

your children can help you get around. I can also suggest some 

transportation services in the area.” She gives Mr. Abayo a 

pamphlet on older drivers and the phone number of a local 

transportation resource. 

For more information on safe driving, contact: 

AAA Senior Driving 

1-202-638-5944 

publicaffairs@national.aaa.com 

www.seniordriving.aaa.com 

This website has links to help seniors evaluate their 

driving abilities, improve their driving skills, know 

the licensing laws in their states, and even find 

transportation services in their community. 

AARP 

1-888-687-2277 (toll-free) 

1-877-342-2277 (español/línea gratis) 

1-877-434-7598 (TTY/toll-free ) 

member@aarp.org 

www.aarp.org/home-garden/transportation/driver_ 

safety 

The AARP Driver Safety Program offers classes to 

help motorists over the age of 50 improve their 

driving skills. 

American Geriatrics Society 

1-212-308-1414 

info.amger@americangeriatrics.org 

www.americangeriatrics.org 

AGS has programs in patient care, research, 

professional and public education, and public 

policy. Among its resources is the Physician’s Guide 

to Assessing and Counseling Older Drivers. 

Eldercare Locator 

1-800-677-1116 

www.eldercare.gov 

The Eldercare Locator offers referrals to 

and information on services for seniors by 

geographic location. 

Federal Highway Administration 

1-804-775-3381 

http://safety.fhwa.dot.gov/older_users/ 

The FHA website links to a variety of resources that 

promote older driver safety. 

National Association of Area Agencies on Aging 

1-202-872-0888 

info@n4a.org 

www.n4a.org 

This membership association provides brochures for 

older people, professional resources, and training 

opportunities through its website. 

National Highway Traffic Safety Administration 

1-800-934-8517 (toll-free) 

1-800-424-9153 (TTY/toll-free) 

NCSAWeb@dot.gov 

www.nhtsa.gov/Senior-Drivers 

NHTSA offers resources for people who may be 

concerned about an older driver, including a booklet 

on talking about driver safety. 

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 healthcare professionals 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 

Talking about Sensitive Subjects 21 
 

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. 

If a family member or other caregiver 

accompanies the patient to an appointment, 

you might ask the companion to step out of the 

exam room during part of the visit so that you 

can express your concern. 

For more information on elder abuse, contact: 

National Center on Elder Abuse 

1-855-500-3537 (toll-free) 

ncea@med.usc.edu 

www.ncea.aoa.gov 

Directed by the Administration for Community Living, 

NCEA works with healthcare and social service 

practitioners, policy makers, the justice system, 

researchers, advocates, and families. Its website 

includes training resources and webinars. 

National Committee for the Prevention of 

Elder Abuse 

1-202-464-9481 

info@preventelderabuse.org 

www.preventelderabuse.org/elderabuse 

NCPEA offers information and materials on abuse 

and neglect, including resources for healthcare 

professionals on elder abuse prevention. 

Stop Medicare Fraud 

1-800-447-8477 (toll-free) 

1-800-377-4950 (TTY/toll-free) 

www.stopmedicarefraud.gov 

Hosted by the U.S. Department of Health and Human 

Services and U.S. Department of Justice, this website 

has information and resources about how to identify, 

prevent, and report fraud. The site includes a section 

for healthcare providers. 

U.S. Department of Justice 

1-202-514-2000 

elder.justice@usdoj.gov 

www.justice.gov/elderjustice 

This website has information on how to report elder 

abuse and financial exploitation, as well as resources 

to help healthcare professionals prevent elder abuse 

and resources to help people who have been abused, 

neglected, or exploited. 

End of Life and Advance Directives 

Many 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 open and willing to talk about 

dying and related issues or concerns. 

You may feel uncomfortable raising the issue, 

fearing that patients will assume the end is near. 

But, in fact, this conversation is best begun well 

before end-of-life care is appropriate. It may 

be helpful to talk about a patient’s thoughts, 

values, and desires related to end-of-life care 

early in your relationship, perhaps when first 

discussing medical and family history. 

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. 

22 Talking With Your Older Patient 
 

With a healthy patient, an advance care planning 

discussion can be relatively brief. Encourage 

your patients to share the type of care they 

would choose to have at the end of life, rather 

than what they don’t want. Suggest they discuss 

end-of-life decisions with family members and 

other important people in their lives. 

Be sure to put a copy of the signed living will, 

durable power of attorney for health care, or 

other documents discussing do not resuscitate 

orders, organ/tissue donation, dialysis, and 

blood transfusions in the medical record. Too 

often, forms are completed but cannot be 

found when needed. Many organizations now 

photocopy the forms on neon-colored paper, 

which is easy to spot in the medical record. 

Considering End of Life 

If your patient is in the early stages of an 

illness, it’s important to assess whether or not 

the underlying process is reversible. It’s also a 

good time to discuss how the illness is likely to 

progress. If your patient is in the early stages of 

a cognitive problem, it is especially important 

to discuss advance directives. 

Of course, it is not always easy to determine 

who is close to death; even experienced 

clinicians find that difficult to predict. 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. 

Stay alert to cues that the patient may want to 

talk about this subject again. Some clinicians 

find it helpful to ask, “Would I be surprised 

if Mr. Flowers were to die this year?” If the 

answer is “no,” then it makes sense to address 

end-of-life concerns with the patient and family, 

including pain and symptom management, home 

health, and hospice care. You can offer to help 

patients review their advance directives. Include 

any updates in the patient’s medical record to 

ensure he or she receives desired care. 

For some older people, spirituality takes on new 

meaning as they age or face serious illness. How 

a patient views the afterlife can also sometimes 

help in framing the conversation about serious 

illness and end-of-life care. 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?” 

For more information on end-of-life care and 

advance directives, contact: 

Aging with Dignity 

1-888-594-7437 (toll-free) 

fivewishes@agingwithdignity.org 

www.agingwithdignity.org 

This organization provides an easy-to-read advance 

care planning document called Five Wishes. 

Education in Palliative and End-of-life Care 

Northwestern University 

Feinberg School of Medicine 

1-312-503-3732 

info@epec.net 

www.epec.net 

This group provides physicians the basic knowledge 

and skills needed to care for dying patients. 

National Hospice and Palliative Care Organization 

1-703-837-1500 

nhpco_info@nhpco.org 

www.nhpco.org 

NHPCO offers educational resources, tools, and 

webinars for healthcare professionals on palliative 

care, including the Journal of Pain and Symptom 

Management. 

NHPCO’s CaringInfo 

1-800-658-8898 (toll-free) 

caringinfo@nhpco.org 

www.caringinfo.org 

This website offers consumer-oriented resources 

related to end-of-life and palliative care, including 

guidance for completing advance directives and links 

to each State’s advance directive forms. Resources 

are also available in Spanish. 

Talking about Sensitive Subjects 23 
 

Financial Barriers 

Rising healthcare costs make it difficult for 

some people to follow treatment regimens. Your 

patients may be too embarrassed to mention 

financial concerns. Studies have shown that many 

clinicians also are reluctant to bring up costs. 

If possible, designate an administrative staff 

person who has good bedside manner to discuss 

money and payment questions. This person 

can also talk with your patient about changes 

in Medicare Part D prescription drug coverage 

plans and the Affordable Care Act. 

The resources in this section may be useful 

when you talk with your patients about their 

financial concerns. In addition, your State Health 

Insurance Assistance Program (SHIP) may help. 

For more information on financial assistance, 

contact: 

Benefits.gov 

This Federal website provides easy, online access 

to government benefit and assistance programs, 

including a “Benefit Finder.” 

Medicare Rights Center 

1-800-333-4114 (toll-free) 

info@medicarerights.org 

www.medicarerights.org 

The toll-free consumer hotline provides free 

counseling services about insurance choices, 

Medicare rights and protections, payment denials 

and appeals, complaints about care or treatment, 

and Medicare bills. 

National Council on Aging 

1-571-527-3900 

www.ncoa.org/get-involved/contact-us/email 

(email form) 

www.benefitscheckup.org 

The Council’s online resource offers a searchable list 

of programs that can help with healthcare costs. 

Partnership for Prescription Assistance 

www.pparx.org/about_us/contact_us (email form) 

www.pparx.org 

Many pharmaceutical companies offer reduced 

medication fees for patients who meet certain 

income requirements and other criteria. The 

website has a directory of prescription drug 

patient-assistance programs. 

State Health Insurance Assistance Programs 

1-877-839-2675 (toll-free) 

info@shiptacenter.org 

www.shiptacenter.org 

The SHIP program provides free, in-depth, one-onone insurance counseling and assistance to Medicare 

beneficiaries, their families, and caregivers. 

Incontinence 

More than half of women and more than 

one quarter of men age 65 and older report 

experiencing some urinary leakage. Several 

factors can contribute to incontinence. 

Childbirth, infection, certain medications, and 

some illnesses are examples. 

Additionally, people of any age can have 

a bowel control problem, though fecal 

incontinence is more frequent in older adults. 

Fecal incontinence has many causes, such as 

muscle damage or weakness, nerve damage, 

loss of stretch in the rectum, hemorrhoids, and 

rectal prolapse. 

24 Talking With Your Older Patient 
 

Incontinence may go untreated because 

patients are often embarrassed to mention 

it. Be sure to ask specifically about the 

problem. Try the “some people” approach. For 

example, you might say “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, for instance through bladder or 

bowel training, pelvic floor exercises and 

biofeedback, changes in diet and nutrition, as 

well as medication and surgery for certain types 

of incontinence. 

For more information on urinary incontinence, 

contact: 

National Institute of Diabetes and Digestive and 

Kidney Diseases 

1-800-860-8747 (toll-free) 

1-866-569-1162 (TTY/toll-free) 

healthinfo@niddk.nih.gov 

www.niddk.nih.gov 

Part of the National Institutes of Health, NIDDK has 

online publications about urinary incontinence and 

provides links to resources and support groups. 

The Simon Foundation for Continence 

1-800-237-4666 (toll-free) 

info@simonfoundation.org 

www.simonfoundation.org 

The Foundation provides information about cure, 

treatment, and management techniques for 

incontinence. 

Urology Care Foundation 

1-800-828-7866 (toll-free) 

info@urologycarefoundation.org 

www.urologyhealth.org 

The Foundation provides information on the 

prevention, detection, management, and cure of 

urologic diseases. 

Long-Term Care 

Long-term care includes informal caregiving, 

assisted living, home health services, adult 

day care, nursing homes, and communitybased 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. 

For more information on long-term care, 

contact: 

Eldercare Locator 

1-800-677-1116 (toll-free) 

www.eldercare.gov 

The Eldercare Locator offers referrals to 

and information on services for seniors by 

geographic location. 

Nursing Home Compare 

Centers for Medicare and Medicaid Services
 

1-800-633-4227 (toll-free)
 

1-877-486-2048 (TTY/toll-free)
 

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. 

U.S. Department of Veterans Affairs 

1-877-222-8387 (toll-free) 

www.va.gov/healthbenefits 

The Department provides information about VA 

health benefits for veterans who served in the active 

military, naval, or air service. 

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 

Talking about Sensitive Subjects 25 
 

to recognize when a patient is depressed and/ 

or suicidal. Many older patients who commit 

suicide saw 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, 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. 

For more information on mental health, 

contact: 

American Association for Geriatric Psychiatry 

1-703-556-9222 

main@aagponline.org 

www.aagponline.org 

The Association promotes the mental health and wellbeing of older people and works to improve the care 

of those with late-life mental disorders. 

National Institute of Mental Health 

1-866-615-6464 (toll-free) 

1-866-415-8051 (TTY/toll-free) 

nimhinfo@nih.gov 

www.nimh.nih.gov 

Part of the National Institutes of Health, NIMH funds 

and conducts mental health research and distributes 

information to health professionals and the public. 

Substance Abuse and Mental Health Services 

Administration 

1-877-726-4727 (toll-free) 

1-800-487-4889 (TTY/toll-free) 

samhsainfo@samhsa.hhs.gov 

www.samhsa.gov 

www.findtreatment.samhsa.gov 

SAMHSA leads public health efforts to advance 

behavioral health and reduce the impact of substance 

abuse and mental illness on America’s communities. 

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 

heterosexual, no longer sexually active, or does 

not care about sex. 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, you might 

approach it 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 lives 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 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 has unprotected sex can 

be at risk of sexually transmitted diseases. 

For more information on sexuality, contact: 

AIDSinfo 

1-800-448-0440 (toll-free; weekdays, 1-4 p.m. ET) 

1-888-480-3739 (TTY/toll-free) 

ContactUs@aidsinfo.nih.gov 

www.aidsinfo.nih.gov 

A service of the U.S. Department of Health and 

Human Services, AIDSinfo offers information on HIV/ 

AIDS treatment, prevention, and research. 

26 Talking With Your Older Patient 
 

 

Centers for Disease Control and Prevention 

1-800-232-4636 (toll-free) 

1-888-232-6348 (TTY/toll-free) 

NPIN-info@cdc.gov 

www.cdc.gov/hiv/risk/age/olderamericans 

http://npin.cdc.gov 

CDC provides statistics and other information 

about HIV/AIDS and older people. CDC’s National 

Prevention Information Network connects public 

health professionals with trusted information about 

sexual health. 

Mayo Foundation for Medical Education 

and Research 

www.mayoclinic.com/health/sexual-health/ 

HA00035 

This website has articles about sexual health and 

sexuality for adults age 50 and older. 

National Institute of Allergy and Infectious 

Diseases 

1-866-284-4107 (toll-free) 

1-800-877-8339 (TTY/toll-free) 

ocpostoffice@niaid.nih.gov 

www.niaid.nih.gov 

Part of the National Institutes of Health, NIAID 

provides information about many sexually transmitted 

diseases. 

Services & Advocacy for Gay, Lesbian, Bisexual & 

Transgender Elders 

1-212-741-2247 

info@sageusa.org 

www.sageusa.org 

SAGE offers services and programs to LGBT older 

people. The organization also trains aging providers 

and LGBT organizations on the best ways to support 

LGBT older people in long-term care settings. 

Sexuality Information and Education Council 

of the United States 

1-202-265-2405 

admin@siecus.org 

www.siecus.org 

The Council provides education and information about 

sexuality and sexual and reproductive health. 

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. 

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. 

For more information on substance abuse, 

contact: 

National Institute on Alcohol Abuse and Alcoholism 

1-888-696-4222 (toll-free) 

niaaaweb-r@exchange.nih.gov 

www.niaaa.nih.gov 

Part of the National Institutes of Health, NIAAA 

supports and conducts research on the impact of 

alcohol use on human health and well-being, and is 

the largest funder of alcohol research in the world. 

National Institute on Drug Abuse 

1-301-443-1124 

www.drugabuse.gov/about-nida/contact-nida 

(email form) 

www.drugabuse.gov 

Part of the National Institutes of Health, NIDA 

supports and conducts research on the science of 

drug abuse and addiction. NIDA also offers drug abuse 

screening tools, publications, and other information 

resources. 

Substance Abuse and Mental Health Services 

Administration 

1-877-726-4727 (toll-free) 

1-800-487-4889 (TTY/toll-free) 

webmaster@samhsa.hhs.gov 

www.samhsa.gov 

www.findtreatment.samhsa.gov 

SAMHSA leads public health efforts to advance 

behavioral health and reduce the impact of substance 

abuse and mental illness on America’s communities. 

Talking about Sensitive Subjects 27 
 

Related Publications 

NIA has free health and aging materials in English 

and Spanish. Some are easy-to-read publications. 

You can download or order copies online at 

www.nia.nih.gov/health. 

Driving 

•	 Driving Safety: Alzheimer’s Caregiving Tips 

•	 Older Drivers AgePage 

Elder Abuse and Neglect 

•	 Beware of Health Scams AgePage 

•	 Crime and Older People AgePage 

•	 Elder Abuse AgePage 

End of Life and Advance Directives 

•	 Advance Care Planning 

•	 End-of-Life Care: Alzheimer’s Caregiving Tips 

•	 End of Life: Helping With Comfort and Care 

•	 Getting Your Affairs in Order AgePage 

•	 Legal and Financial Planning for People with 

Alzheimer’s Disease 

Financial Barriers 

•	 Getting Your Affairs in Order AgePage 

•	 Legal and Financial Planning for People with 

Alzheimer’s Disease 

•	 Money Problems: Alzheimer’s Caregiving Tips 

Incontinence 

•	 Incontinence: Alzheimer’s Caregiving Tips 

•	 Urinary Incontinence AgePage 

Long-Term Care 

•	 Caring for a Person with Alzheimer’s Disease: 

Your Easy-to-Use Guide from the National 

Institute on Aging 

•	 Nursing Homes: Making the Right Choice 

AgePage 

•	 So Far Away: Twenty Questions and Answers 

for Long Distance Caregiving 

Mental Health 

•	 Caring for Yourself: Alzheimer’s Caregiving Tips 

•	 Mourning the Death of a Spouse AgePage 

Sexuality 

•	 Changes in Intimacy and Sexuality: Alzheimer’s 

Caregiving Tips 

•	 HIV, AIDS, and Older People AgePage 

•	 Sexuality in Later Life AgePage 

Substance Abuse 

•	 Alcohol Use in Older People AgePage 

•	 Older Adults and Alcohol: You Can Get Help 

•	 Smoking: It’s Never Too Late to Stop AgePage 

Also visit www.nihseniorhealth.gov, a 

senior-friendly website from NIA and the 

National Library of Medicine that has health 

and wellness information for older adults. 

28 Talking With Your Older Patient 
 

Supporting Patients with

Chronic Conditions 

At a Glance 

•	 Let your patient know you understand that living with a chronic condition can be difficult. 

•	 Work as a team with all of your patient’s care providers to explain and manage chronic conditions. 

•	 Start by asking the patient what he or she understands about the diagnosis and how much more he 

or she wants to know. 

•	 Make sure the patient understands, accepts, and can follow the prescribed treatment plan. 

•	 Consider referring the patient to a clinical research trial. 

Supporting Patients with Chronic Conditions 29 
 

 

Approximately 85 percent of older 

adults have at least one chronic health 

condition, and 60 percent have at 

least two chronic conditions, according to the 

Centers for Disease Control and Prevention. 

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 needs, but they also share common 

challenges with other older adults, such as 

paying for care or navigating the complexities 

of the healthcare system. 

Clinicians can play an important role in 

educating patients and families about chronic 

health conditions and can connect them with 

appropriate community resources and services. 

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 

and their caregivers 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: 

• 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. 

• Let your patient know you welcome 

questions. Provide the name of someone on 

your staff whom the patient can call to have 

questions answered later. 

•	 Remember, 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. 

• 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. 

•	 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. 

30 Talking With Your Older Patient 
 

“Let’s discuss living with...” 

Mrs. Smoley has diabetes and heart disease. Although she takes 

her medicine as prescribed by the doctor, she has not been able 

to quit smoking. She recently was diagnosed with emphysema 

and needs oxygen. Dr. Nguyen suggests that Mrs. Smoley 

participate in a disease management program at a local hospital. 

“It could help you quit smoking,” the doctor explains. “And you 

might learn some tips about how to manage your day so that you 

have some more energy.” 

•	 Repeat key points about the health problem 

and treatment at every office visit. 

• 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. 

• 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 

Referring Patients to Clinical Trials 

Carefully conducted clinical trials are the primary way we learn 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 maintain their primary 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. 

However, you 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. 

Also visit the Recruiting Older Adults into Research (ROAR) Toolkit page at www.nia.nih.gov/health/ 

publication/roar-toolkit for more resources. 

Supporting Patients with Chronic Conditions 31 
 

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 changes, what 

degree of improvement is realistic, and when 

he or she may start to feel better. 

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. They may not be medical. For instance, 

transportation might be an issue. 

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. 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Fatigue: More Than Just Being Tired AgePage 

•	 Kidney Disease: A Silent Problem AgePage 

•	 Medicines: Use Them Safely AgePage 

•	 Pain: You Can Get Help AgePage 

•	 Safe Use of Medicines 

•	 Understanding Lung Problems—Make Each
	

Breath Healthy AgePage
 

Also visit www.nihseniorhealth.gov, 

a senior-friendly website from NIA and
	

the National Library of Medicine that
 

has health and wellness information for
 

older adults.
 

32 Talking With Your Older Patient 
 

Breaking

Bad News
 

At a Glance 

• Prepare yourself—allow enough time and have calls held. 

• Assess how much the patient understands and wants to know about the prognosis. 

• Be straightforward and compassionate. 

• Give the patient time to react. 

• Provide opportunities to continue the conversation in follow-up appointments or calls. 

Breaking Bad News 33 
 

Delivering bad news is never easy, but 

tested strategies can ease the process. 

Knowing how to communicate bad 

news can also help you make the process more 

bearable for patients. For instance, try to break 

bad news in a compassionate yet direct way. 

Prepare yourself. Before meeting with the 

patient, think about what you want to say 

and make sure you have all of the information 

you need. Be sure you have enough time to 

carefully explain the diagnosis and allow for 

questions, rather than trying to squeeze it 

between other appointments. If possible, ask 

The Language of Bad News: 

Phrases That Help 

These phrases can help you to be 

straightforward, yet compassionate: 

Delivering bad news 

• “I’m afraid the news is not good. The biopsy 

showed you have colon cancer.” 

• “Unfortunately, there is no question about 

the results. You have emphysema.” 

• “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 

• “I imagine this is difficult news.” 

• “Does this news frighten you?” 

• “I wish the news were different.” 

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

• “I’ll try to help you.” 

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

Dealing with prognosis 

• “What are you expecting to happen?” 

• “What would you like to have happen?” 

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

• “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. 

your staff to hold calls and pages until the 

appointment is over. Find 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?” 

Spend a few moments finding out how much the 

patient really wants to know. People may have 

different expectations and preferences for how 

much they are told about their prognosis and 

what they 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, 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. 

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 or offer false hope. 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. 

Give the patient and family time—and privacy— 

to react. 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. 

End the visit by establishing a plan for next steps. 

This may include gathering more information, 

ordering more tests, or preparing advance 

directives. Offer to write down important 

points of your discussion. Reassure the patient 

and family that you are not going to abandon 

them, regardless of referrals to other healthcare 

providers. Let them know how they can reach 

you—and be sure to respond when they call. 

34 Talking With Your Older Patient 
 

“I wish I had better news.” 

Dr. Callas has been thinking about how to tell Mrs. Larson 

she has Parkinson’s disease. He doesn’t want to feel 

pressured for time, so Dr. Callas makes sure Mrs. Larson has 

the last appointment of the day. Knowing that Mrs. Larson 

suspects something is seriously wrong, Dr. Callas decides 

the best approach is to be gentle, but direct. He reviews 

her chart for details, takes a deep breath, and opens the 

exam room door... 

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 and 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. 

For more information on breaking bad news, 

contact: 

American Counseling Association 

1-800-347-6647 (toll-free) 

webmaster@counseling.org 

www.counseling.org 

This not-for-profit professional organization has 

resources to help inform patients and families of 

bad news. 

Clinical Trials and You 

1-301-496-4000 

1-301-402-9612 (TTY) 

www.nih.gov/health/clinicaltrials 

This website from the National Institutes of Health 

explains the importance of participating in clinical 

trials and includes a list of registries, personal 

stories, resources for trial sites, and resources 

specifically for healthcare providers on referring 

patients to clinical trials. 

Education in Palliative and End-of-life Care 

Northwestern University 

Feinberg School of Medicine 

1-312-503-3732 

info@epec.net 

www.epec.net 

EPEC provides physicians the basic knowledge and 

skills needed to care for dying patients, including 

information about how to communicate bad news. 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Advance Care Planning 

•	 Clinical Trials and Older People 

•	 End of Life: Helping With Comfort and Care 

•	 End-of-Life Care: Alzheimer’s Caregiving Tips 

•	 Getting Your Affairs in Order AgePage 

•	 Legal and Financial Planning for People with 

Alzheimer’s Disease 

•	 Participating in Alzheimer’s Research:
	

For Yourself and Future Generations
 

Breaking Bad News 35 
 

Working with Diverse

Older Patients 

At a Glance 

•	 Keep in mind that cultural differences may affect a patient’s view of doctors and medicine. 

•	 Ask about your patient’s use of alternative and complementary medicines. 

•	 If you do not speak the same language as your patient, use a professional medical interpreter 

rather than family members or untrained staff. 

•	 Provide written materials in the patient’s primary language. 

36 Talking With Your Older Patient 
 

Appreciating the richness of cultural, 

religious, and ethnic backgrounds 

among older patients and providing 

interpretation for those with limited English 

can help to promote good health care. 

When you understand how different cultures 

view health care, you are better able 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. 

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. 

Using an Interpreter 

When working with patients who don’t speak 

English as a first language, be sure to ask which 

language they prefer to speak and if they can 

read English (if not, ask which language they 

read). Approximately 20 percent of the U.S. 

population speaks a language other than English 

at home, according to the Census Bureau. 

Some older immigrants or non-native English 

speakers may need a medical interpreter. 

Federal policies require clinicians and healthcare 

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 and 

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. 

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. Some of the resources listed in the “For 

more information” section can help you locate 

State organizations and local services. 

Whenever possible, offer patients appropriate 

translations of written material or refer them 

to bilingual resources. The National Institute 

on Aging, for example, provides a number of 

resources in both English and Spanish, as well 

as links to resources in other languages. If 

translations are not available, ask the medical 

interpreter to translate medical documents. 

Working with Diverse Older Patients 37 
 

“Tell me about your traditions...”
 

Mrs. Houssani has been Dr. Smith’s patient for several years and 

always carefully follows her instructions. So, Dr. Smith is surprised 

when Mrs. Houssani is not willing to take her morning medication 

with food, as directed. Dr. Smith gently pursues her reasons. 

Mrs. Houssani explains that it is Ramadan and she cannot eat or 

drink from sunrise to sunset. Dr. Smith determines it would be safe 

to adjust Mrs. Houssani’s medication schedule so that she can take 

her morning pills before sunrise during the month of fasting. 

For more information on working with patients 

with diverse cultural backgrounds, contact: 

Limited English Proficiency: A Federal 

Interagency Website 

www.lep.gov 

This website provides information, tools, and 

technical assistance to Federal agencies, recipients 

of Federal funds, users of Federal programs and 

federally assisted programs, and other stakeholders. 

Management Sciences for Health 

1-617-250-9500 

erc@msh.org 

http://erc.msh.org 

This organization publishes The Provider’s Guide 

to Quality & Culture. The guide offers materials 

for healthcare providers who work with diverse 

populations, including information about common 

beliefs and practices. 

National Board of Certification for 

Medical Interpreters 

1-765-633-2378 

staff@certifiedmedicalinterpreters.org 

www.certifiedmedicalinterpreters.org 

This organization runs a nationally recognized 

and validated certification program for medical 

interpreters. Their registry lists more than 1,400 

certified medical interpreters. 

National Council on Interpreting in Health Care 

info@NCIHC.org 

www.ncihc.org 

The Council is a multidisciplinary organization whose 

mission is to promote and enhance language access in 

health care in the United States. 

National Library of Medicine 

MedlinePlus 

www.medlineplus.gov 

www.medlineplus.gov/spanish 

MedlinePlus, a website from the National Institutes 

of Health, features consumer information in English, 

Spanish, and other languages on a variety of health 

topics, as well as drugs and treatment options. It also 

has videos and other tools. 

U.S. Department of Health and Human Services 

Office of Minority Health 

1-800-444-6472 (toll-free) 

1-301-251-1432 (TTY) 

info@minorityhealth.hhs.gov 

www.minorityhealth.hhs.gov 

This Federal office works to develop health policies 

and programs that help to eliminate racial and ethnic 

disparities in health. 

Related Publications 

NIA’s Spanish-language website at 

www.nia.nih.gov/espanol has free publications 

about health, aging, Alzheimer’s disease, and 

memory issues. 

NIA also offers online access to other nonEnglish health and wellness publications and 

information from the National Institutes of 

Health at www.nia.nih.gov/health/resources/ 

looking-non-english-health-information. 

Publications available in Chinese, Korean, 

Vietnamese, and other languages cover topics 

such as diabetes, arthritis, osteoporosis, 

exercise, heart health, and more. 

38 Talking With Your Older Patient 
 

Including Families

and Caregivers 

At a Glance 

•	 Ask the patient how he or she would like to include family members or companions in medical 

encounters. 

•	 Address the patient—avoid talking only to the family member or companion. 

•	 Make it clear that the patient should make medical decisions unless legal authority has been 

granted to someone else. 

•	 Be alert to family caregivers’ own health needs, including signs of stress. 

Including Families and Caregivers 39 
 

Family and informal caregivers play a 

significant role in the lives of their loved 

ones. They also play an important role in 

how the healthcare system functions. 

By communicating effectively with all the 

individuals involved in your patient’s care, 

you can both help the patient and make more 

efficient use of your time and resources. 

Informal caregivers are able, for example, to 

be knowledgeable “informants.” They can also 

help to reinforce the information you give or 

the treatment you prescribe. 

Ask about the Caregiver’s Role 

To protect and honor patient privacy, be sure 

to ask the patient how he or she sees the 

companion’s role. In many cases, that person 

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. 

You might ask the companion to step out of 

the exam room during part of the visit so you 

can raise sensitive issues while protecting 

the patient’s privacy. For instance, the best 

time to conduct a “mini-mental” test is when 

the companion is not present, so that he or 

she cannot answer questions or cover for the 

patient’s cognitive lapses. 

Keep the Patient Involved 

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 triangle and can address 

both the patient and companion face-to-face. 

Be careful not to direct your remarks to the 

companion. This will help you 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 

impairment. If a family member has been 

named the healthcare 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. 

When necessary, set clear boundaries with 

family members, and encourage others to 

respect them. 

Some patients may ask that you contact their 

long-distance caregivers to discuss conditions or 

treatment plans. Make sure these patients fill 

out any necessary paperwork giving permission 

for you to speak with specific family or friends. 

Consider Caregivers to Be 

“Hidden Patients” 

Family caregivers face many emotional, 

financial, and physical challenges. They 

often provide help with household chores, 

transportation, and personal care, in addition 

to juggling their own jobs and families. Many 

also give medications, injections, and medical 

treatments to the person for whom they care 

(and may need advice or guidance on how to 

provide such medical care). 

Caregivers often have their own health issues 

to manage. Sometimes, the patient will 

outlive his or her caregiver. It makes sense to 

view informal caregivers as “hidden patients” 

and be alert for signs of illness and stress. 

Caregiver burnout can lead to negative health 

events. It can also sometimes give way to 

elder abuse. 

Caregivers may find it hard to make time for 

themselves. Encourage them to seek respite 

care so they can recharge and take a break. 

And remember, your encouragement and 

praise can help to sustain a caregiver. 

40 Talking With Your Older Patient 
 

“What would you like your family to know?” 

Mr. Patrick admitted to Dr. Hwang that he has trouble 

remembering much of what she said about managing his 

condition. Dr. Hwang wonders if it might be helpful for 

someone to accompany Mr. Patrick to his next appointment. 

Mr. Patrick isn’t sure. He is concerned his daughter, who 

often assists with his care, won’t let him speak for himself. 

He also doesn’t want his daughter to know about some 

personal issues. Dr. Hwang assures him that she will keep 

Mr. Patrick involved in the conversation and that they will have some private time to 

discuss any personal matters. 

For more information on working with families 

and caregivers, contact: 

Administration for Community Living 

1-202-401-4634 

aclinfo@acl.hhs.gov 

www.acl.gov 

The Administration on Aging, part of ACL, provides 

funding and community-based services for programs 

that serve older adults. 

American Geriatrics Society 

1-212-308-1414 

info.amger@americangeriatrics.org 

www.americangeriatrics.org 

The organization has programs in patient care, 

research, professional and public education, and 

public policy. Among its resources is a free Caregiver 

Health Self-Assessment Questionnaire, available in 

English and Spanish. 

Caregiver Action Network 

1-202-454-3970 

info@caregiveraction.org 

www.caregiveraction.org 

This Network supports family caregivers and offers 

education, information, and referrals. 

Eldercare Locator 

1-800-677-1116 (toll-free) 

www.eldercare.gov 

The Eldercare Locator offers referrals to 

and information on services for seniors by 

geographic location. 

Family Caregiver Alliance 

1-800-445-8106 (toll-free) 

www.caregiver.org/professional-inquiry-form 

(email form for health professionals) 

www.caregiver.org 

The Alliance offers programs to provide information 

to and support for caregivers. 

National Alliance for Caregiving 

1-301-718-8444 

info@caregiving.org 

www.caregiving.org 

The National Alliance offers support and resources for 

the public and professionals. 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Caring for a Person with Alzheimer’s Disease: 

Your Easy-to-Use Guide from the National 

Institute on Aging 

•	 Long-Distance Caregiving—A Family Affair 

•	 Long-Distance Caregiving—Getting Started 

•	 So Far Away: Twenty Questions and Answers 

About Long-Distance Caregiving 

Including Families and Caregivers 41 
 

Talking with Patients

about Cognitive Problems 

At a Glance 

•	 Use a short screening tool to assess cognitive function; if the screening suggests a problem, 

conduct further evaluation and/or refer the patient to a specialist. 

•	 Reassure the patient if there is no serious mental decline. 

•	 Ask permission to be in touch with a family member or friend who can be a care partner; make a 

note of that person in the medical record. 

•	 Offer information and referrals to supportive services and resources, and possibly suggest clinical 

research participation. 

•	 Be alert to caregivers’ needs for information, resources, and respite. 

42 Talking With Your Older Patient 
 

Primary care clinicians often have longestablished relationships with their 

patients and are in an ideal position to 

observe potential signs of a cognitive problem. 

And, when patients are worried about changes 

in their memory or thinking, they often bring 

that concern to their primary care doctor first. 

It is important to take these concerns seriously 

and to assess the patient as early as possible to 

determine the potential cause of impairment. 

The National Institute on Aging’s publication 

titled Assessing Cognitive Impairment in Older 

Patients: A Quick Guide for Primary Care 

Physicians (available at www.nia.nih.gov/ 

alzheimers) can help healthcare providers to 

talk with patients and caregivers about their 

concerns, assessment, and diagnosis. 

Cognitive Impairment 

As a person gets older, changes in the brain 

can affect memory and cognition. The extent 

of these changes varies from person to person. 

Your patients may be worried about their 

memory, and many may fear dementia disorders 

such as Alzheimer’s disease. 

It is important not to ignore changes in an older 

person’s memory or personality, or assume it’s 

just a normal part of aging. Whether memory 

and cognition problems are reported by the 

patient or a family member or observed by you, 

the issues should be noted in the patient’s chart 

and followed up with screening and assessment. 

Not all cognitive problems are caused by 

Alzheimer’s disease. There are a variety of 

other possible causes such as side effects from 

medications, metabolic and/or endocrine 

changes, delirium caused by other illnesses, 

or untreated depression. Some of these causes 

can be temporary and reversed with proper 

treatment. Other causes of cognitive problems, 

such as dementia, cannot be reversed, but 

symptoms can be treated for a period of time 

and families can be prepared for the future. 

Some older people have mild cognitive 

impairment (MCI). People with MCI have more 

memory problems than normal for their age, 

but their symptoms do not interfere with their 

everyday lives. Older people with MCI are at 

greater risk for developing Alzheimer’s, but 

not all of them do. Some may even go back to 

normal cognition. 

Determining When to Screen 

for Cognitive Impairment 

Older adults, particularly those who express 

concerns about their memory or show signs 

of a cognitive problem, should be screened. 

An assessment is actually a required part of 

the Medicare Annual Wellness Visit. While 

screening is not enough to diagnose a cognitive 

impairment like dementia, it is an important 

first step and may uncover problems that are 

reversible or treatable. 

The Dementia Screening Indicator is a basic 

risk assessment tool that can help guide your 

decision about screening. In general, you should 

screen for cognitive impairment if: 

•	 the patient, relative, or caregiver expresses 

concern about changes in the patient’s 

memory or thinking 

•	 you observe a potential issue 

•	 there is a medical history of type 2 diabetes, 

stroke, depression, or another health issue 

that increases risk for cognitive issues 

•	 the patient is age 80 or older 

Talking with Your Patient 

about Screening 

If your patient has immediate concerns about 

being diagnosed with Alzheimer’s disease or 

another dementia, explain that the issue may not 

be Alzheimer’s disease and reiterate that some 

problems with memory and thinking are treatable. 

Talking with Patients about Cognitive Problems 43 
 

“You mentioned having trouble with your memory.” 

Mr. Jones had always been a meticulously organized man. But 

during his last doctor’s appointment he appeared somewhat 

disheveled and had problems answering many of Dr. Ross’s 

questions. Mr. Jones asked Dr. Ross to repeat himself several times 

and had trouble recalling certain, common words. Mrs. Jones 

expressed concern about her husband getting disoriented in the 

neighborhood they had lived in for 50 years. Dr. Ross knows it’s 

time to find out what is causing Mr. Jones’s memory problems. 

You can also explain that an accurate diagnosis of 

Alzheimer’s disease or other cognitive problems 

can help your patient and his or her family to 

plan for the future. Early diagnosis offers the best 

chance to treat the symptoms, when possible, 

and to 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 clinical research. 

Patients and family are more likely to consider 

participating in research after talking to a 

doctor about what a clinical study involves, 

as well as the benefits and risks. There are 

clinical trials for people who have Alzheimer’s 

disease or MCI, those with a family history 

of Alzheimer’s, and healthy people with no 

memory problems or family history of the 

disease. You can learn more about what trials 

are available on the clinicaltrials.gov website, 

or use NIA’s clinical trials finder at 

www.nia.nih.gov/alzheimers/clinical-trials. 

Conducting a Screening in the 

Primary Care Setting 

You may worry that you don’t have time to 

screen your patients for cognitive issues. It 

usually takes 10 minutes or less for trained 

staff to initially assess a patient using readily 

available screening tools. 

You can use NIA’s Instruments to Detect 

Cognitive Impairment in Older Adults database at 

www.nia.nih.gov/research/cognitive-instrument 

to search for instruments that meet your 

needs. Many of these tools are brief and easy 

to administer. 

Cognitive impairment screening tools include 

the Ascertain Dementia 8 (AD8), Mini-Cog, and 

Informant Questionnaire on Cognitive Decline in 

the Elderly (IQCODE). Some of these tools are 

intended for use with the patient (i.e., Mini-Cog); 

others are designed to collect information from 

a caregiver, family member, or other companion 

(i.e., IQCODE); and some can be used both with 

the patient and informant (i.e., AD8). 

Because testing may provoke anxiety, it might 

be best to do any formal screening during the 

latter part of the appointment. Try to present 

the screening in the context of concerns the 

patient has expressed. Providing support 

and encouragement during the testing can 

decrease stress. 

The tests or interviews should be conducted 

with the patient alone so that family members 

or companions cannot prompt the patient. 

You may also glean information from your 

patient’s behavior in your office or from 

telephone interactions with staff. Family 

members who may contact you about the 

patient are another source of information, but 

44 Talking With Your Older Patient 
 

be sure to obtain the patient’s permission to 

speak with these individuals. 

You may want to invite the family member 

or close companion to come to the visit, and 

after the private patient screening, ask the 

person to contribute additional information. 

People who are mildly impaired often have 

strategies to compensate for their memory 

loss. Taking a family history from a relative is 

one way of determining if there are persistent 

or worsening memory problems. 

If the screening suggests the need for further 

evaluation, you can recommend that your 

patient see a specialist such as a neurologist, 

geriatric psychiatrist, or neuropsychologist 

for a more detailed diagnosis. Depending on 

your location, a local memory disorders clinic 

or Alzheimer’s Disease Center may also be an 

Communicating with a Confused Patient 

Working with patients who are cognitively impaired presents an ongoing communication challenge. 

For instance, they likely will have trouble following any instructions about their care, including how 

and when to take prescriptions. Make sure someone can closely monitor care management, and try to 

involve a care partner whenever possible. 

Here are some tips for effectively working with and communicating with cognitively impaired patients. 

• Try to address the patient directly, even if his or her cognitive capacity is diminished. 

• Gain the person’s attention. Sit in front of and at the same level as him or her and maintain 

eye contact. 

• Speak distinctly and at a natural rate of speed. Resist the temptation to speak loudly. 

• Help orient the patient. Explain (or re-explain) who you are and what you will be doing. 

• If possible, meet in surroundings familiar to the patient. Consider having a family member or other 

familiar person present at first. 

• Support and reassure the patient. Acknowledge when responses are correct. 

• If the patient gropes for a word, gently provide assistance. 

• Make it clear that the encounter is not a “test,” but rather a search for information to help 

the patient. 

• Use simple, direct wording. Present one question, instruction, or statement at a time. 

• If the patient hears you but does not understand you, rephrase your statement. 

• 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. 

• Remember that many older people have hearing or vision problems, which can add to their confusion. 

• Consider having someone call the patient to follow up on instructions after outpatient visits. 

• If the patient can read, provide written instructions and other background information about the 

problem and options for solutions. 

• Address potential issues of driving, getting lost, and home safety each time you see the patient. And, 

encourage regular physical activity, social activity, hobbies, and intellectual stimulation, as well as a 

healthy diet. Some studies link these approaches to the maintenance of cognitive function. 

Talking with Patients about Cognitive Problems 45 
 

option for referrals. You can provide comfort 

by reassuring the patient that you will still be 

involved in his or her medical care. 

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 an opportunity for you to start 

making financial and legal plans. It is best to 

do this 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. 

The American College of Physicians 

Foundation and Alzheimer’s Association have 

produced an 11-minute video, “Disclosing a 

Dementia Diagnosis,” that might be helpful. 

Written materials can also be helpful. NIA’s 

Alzheimer’s Disease Education and Referral 

Center has free tools and publications you can 

give to your patients. Local resources can be 

found using the Eldercare Locator. 

Following Up 

If possible, schedule additional time for the 

appointment so that you can listen and respond 

to the patient’s or caregiver’s concerns. The 

Alzheimer’s Association or other supportive 

organizations can provide information about 

planning, social services, and care. 

Ask the patient if there is a family member 

or friend who can help with medical, legal, 

and financial concerns going forward. Make 

these arrangements early, and assure that the 

patient has given you formal authorization to 

include the care partner in the conversation 

about your patient’s care. Keep that person’s 

name and contact information in your notes 

for future reference. 

Informing family members or others that 

the patient may have Alzheimer’s disease 

or any cognitive impairment may be done in 

a telephone conference or group meeting, 

which should be arranged with the consent 

of the patient. Let everyone know that 

you will continue to be available for care, 

information, guidance, and support. 

Consider how your practice can coordinate 

and integrate care for the person and family 

across the many specialists and services that 

will be involved. 

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 chapter titled 

“Including Families and Caregivers” has 

suggestions that can help. Here are some 

approaches that are especially useful: 

•	 Explain that much can be done to improve 

the patient’s quality of life. Measures such as 

modifications in daily routine and medications 

may help control symptoms. If appropriate, 

bring in a palliative care consultant to help 

the patient with symptom management. 

• Let caregivers know there is time to adapt. 

Decline is rarely rapid. Provide information 

about the consumer resources and services 

available from local organizations, as well as 

support groups. 

46 Talking With Your Older Patient 
 

•	 Help caregivers plan for the possibility that 

they eventually may need more help at home 

or may have to look into residential care. 

•	 Encourage 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. 

For more information on Alzheimer’s disease 

and other dementias, contact: 

Alzheimer’s Disease Education and Referral Center 

National Institute on Aging 

1-800-438-4380 (toll-free) 

1-800-222-4225 (TTY/toll-free) 

adear@nia.nih.gov 

www.nia.nih.gov/alzheimers 

www.nia.nih.gov/alzheimers/alzheimers-anddementia-resources-professionals 

A service of NIA, the ADEAR Center provides resources 

for healthcare professionals, as well as information, 

publications, referrals, and a clinical trials finder for 

patients, families, and caregivers. 

Alzheimer’s Association 

1-800-272-3900 (toll-free, 24/7) 

1-866-403-3073 (TTY/toll-free, 24/7) 

info@alz.org 

www.alz.org 

www.alz.org/health-care-professionals 

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 Foundation of America 

1-866-232-8484 (toll-free) 

info@alzfdn.org 

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 

Alzheimer’s disease, their caregivers, and families. 

Eldercare Locator 

1-800-677-1116 (toll-free) 

www.eldercare.gov 

The Eldercare Locator offers referrals to 

and information on services for seniors by 

geographic location. 

Related Publications 

NIA has free health and aging materials in 

English and Spanish. Some are easy-to-read 

publications. You can download or order copies 

online at www.nia.nih.gov/health. 

•	 Alzheimer’s Disease Fact Sheet 

•	 Caring for a Person with Alzheimer’s Disease: 

Your Easy-to-Use Guide from the National 

Institute on Aging 

•	 Forgetfulness: Knowing When to Ask for 

Help AgePage 

•	 Participating in Alzheimer’s Research:
	

For Yourself and Future Generations
 

•	 Preventing Alzheimer’s Disease: What Do 

We Know? 

•	 Understanding Alzheimer’s Disease:
	

What You Need to Know
 

•	 Understanding Memory Loss: What To Do 

When You Have Trouble Remembering 

NIA’s Alzheimer’s Disease Education and Referral 

(ADEAR) Center, www.nia.nih.gov/alzheimers, 

offers information and referrals to local and 

national resources. The ADEAR Center also has 

free clinical practice tools, training materials, 

and more resources for clinicians. 

Talking with Patients about Cognitive Problems 47 
48 Talking With Your Older Patient 

NIH Publication No. 16-7105
 

February 2016