depression, but there is growing evidence that the methods of communication described in this review are important steps in improving the health care experiences and quality of life of older patients. Communication challenges in the medical visit Medical interactions with older patients almost inevitably include the pressures of time limitations that can affect the quality of care (Keeler et al 1982; Radecki et al 1988). Often because there is so much biomedical care to be delivered, primary care visits with older patients tend to include less health behavior counseling than do those with younger patients, and older patients tend to be given less information about their health issues. Research shows that older patients fail to discuss with their physicians as many as half of the potentially serious medical and psychosocial symptoms that they experience (Rost and Frankel 1993). Older patients often have difﬁculty raising important psychosocial concerns when the focus of their medical visit is on their already diagnosed chronic conditions. The over- whelming nature of dealing with multiple chronic health issues can lead to confusion and forgetting, particularly in the context of limited time. Sometimes patients’ intentions to bring up important concerns in the visit become derailed by all that needs to be accomplished and by their uncertainty of which are the most important issues to raise (Rost and Frankel 1993). Participation in the medical visit tends to be attenuated by patients’ age as well, and is particularly low in patients older than 75 (Kaplan et al 1996). Research has shown that some physicians make an extra effort with their older patients to be nonverbally responsive, egalitarian, non-dominant, close in interpersonal distance, supportive in back-channel communications (such as “hmm” and “uh-huh”), and share opportunities for communication with their older patients (Street and Buller 1988). Despite these positive ﬁndings, however, research evidence points to discrepancies between older and younger patients in decision-making in the medical interaction (Adelman et al 1991, 1992). Other differences between older and younger patients also exist. Younger patients in medical interactions receive more instruction about what is to be done during the visit and more guidance about the procedures of the physical examination than do older patients (Callahan et al 2000). Physicians tend to devote more of the older patients’ medical visit to history taking and question-asking about prior adherence Clinical Interventions in Aging 2007:2(3) Physician-patient communication with medications and recommended treatments (Callahan et al 2000). Presence of a third person Medical visits between older patients and their physicians sometimes involve another person who may be a caregiver, friend, or family member. When another person accompanies the older patient during the medical visit, the interaction becomes a triadic “physician-patient-other relationship”. Third party individuals are often necessary, particularly when the older patient becomes more physically and cognitively vulnerable and has difﬁculty understanding the discourse that takes place during the medical interaction. The third party can serve an important supportive function for the older patient (Silliman 1989; Greene and Adelman 2003). Third party persons, however, can also pose a challenge and complicate the interaction between an older patient and his or her physician, changing the dynamic of the interaction. When a third person is present, older patients raise fewer topics overall, are less expressive and responsive in the quality of their questioning and informativeness. They tend to be less assertive in triadic interactions than in dyadic interactions, and there is often less joint decision-making (Greene et al 1994b; Greene and Adelman 2003). On the other hand, if the third party person is present at the request of the patient to offer positive support to the patient and accurate information to the physician, their presence may enhance communication (Greene and Adelman 2003). Physicians also often report that under the right circumstances third party persons can be a positive inﬂuence on the medical interaction if all members of the interaction are aware of the complexities and subtleties of communication (Brown et al 1998). It is essential that physicians be prepared for the challenges of possible triadic interactions with their older patients. To enhance this process, physicians should endeavor to recognize the effects and inﬂuences of third party caregivers on patient comprehension and involvement, involve caregivers in the interaction process, recognize the needs and concerns of caregivers, and assure caregivers of their own availability as a source of information and assistance in the care of the older patient (Silliman 1989). Recommendations for clinical practice Communication between the older patient and his or her physician has a strong inﬂuence on older patients’ satisfaction, adherence, and other health-related outcomes (Coe et al 1984; Rost and Roter 1987; DiMatteo 2004b). 461