Communication Commentary: Enhancing Communication With Aging Patients
“The most important thing in communication is to hear what isn’t being said”.Peter Drucker
The communication process is nuanced and complex, with many opportunities for miscommunication and missed communication. This process may be further complicated when communication is with an aging individual. Individuals over the age of 65 visit their doctor more often and, in contrast to generally held notions, are generally more heterogeneous than younger people (1). Their wide range of life experiences and cultural backgrounds often influence their “perception of illness, willingness to adhere to medical regimens and ability to communicate effectively with health care providers” (2). Communication can also be hindered by the normal aging process. Frequent correlates of aging are sensory loss (especially of hearing), memory decline, slower reaction and information processing times, and a diminishing power and influence over their own lives (3). At a time when older patients have the greatest need to communicate effectively with their doctors, physiological and life changes often make it most difficult.
Clinical vignette
“Hi Mom,” a colleague piped loudly into her cell phone in the staff office. “How was your visit to the doctor?” There was a pause, then, “Didn’t you ask?” Another pause. “Yes, it sounds like he did talk fast. What is the name of the medication?” Another pause. “Did he say what it was for?” “Didn’t he tell you why you needed to go for an MRI? Which part of the body is the MRI for?” … “No, I don’t think it sounds like cancer.” … “Would you like me to call him and get more information?” “Do you have his number?” “Ok, I’ll call you back after I talk with him.” My colleague sighed heavily as she hung up the phone. I glanced over inquisitively.
“My mother has been complaining of a cough and she finally went to the doctor. It seems that an MRI was ordered and she is being prescribed a medication, but my mother, who is a pretty sharp lady even at 85, is really confused about what the doctor said, what medicine he prescribed, and what it is for. She has decided she must have cancer and is really upset. Why can’t doctors just explain things better? It seems that my mother practically needs an interpreter to understand the ‘medicalese’ the doctors speak when she goes to an appointment. I can’t always get away to go with her. Doctors should slow down when they talk. Or write down what they say.” I smiled sympathetically. I had had the same experience with my dad. “Do you think we do that with OUR patients?” my colleague suddenly blurted, the shocking thought of this possibility startling her and me.
The quality of the interpersonal communication between a patient and his/her health care providers plays a major role in patient health outcomes (3). An empirical link has been established between patients’ satisfaction with their physicians’ communication style and their adherence to prescribed treatment (4). Effective physician-patient communication is associated with increased psychological well-being and better biomedical outcomes (3, 5). Likewise, poor physician-patient communication can lead to negative consequences, such as patient dissatisfaction, doctor shopping, poor adherence to medical recommendations, and malpractice litigation (6). Positive physician–patient communication is especially important with an older patient, due to physical, cognitive, and psychological factors unique to the geriatric population. For example, elderly patients often present with more complicated medical conditions. This may complicate accurate psychiatric diagnosis and increases the potential for adverse medication interactions and side effects.
The physical signs of aging, including hearing, visual, and cognitive impairments, may act as a barrier to effective physician–patient communication. Psychological intergenerational differences complicate the physician–patient interaction even further. For instance, elderly patients tend to demonstrate respect for their physicians by being more passive in their interactions with them (7). This may lead to a reluctance of elderly patients to request clarification and written information. Personal topics may be less likely to be broached (8).
Research on doctor–patient communication indicates that physicians’ speech to elderly patients is, unfortunately, often characterized by a dismissive patronizing communication style (9, 10). As effective communication is a crucial skill for all physicians working with an aging population, an instrument for assessing interactions between doctors and their elderly patients has been recently developed. This instrument, Assessment of Doctor-Elderly Patient Transactions (ADEPT), may be utilized by training programs, clinics, office practices, and academicians to help teach and assess the effectiveness of communication skills with geriatric patients (11).
Robinson, White, and Houchins (1) have postulated that making a physical and emotional connection is key to effective doctor-patient communication, especially with geriatric patients, and they have written practical recommendations for enhancing therapeutic rapport.
Communication tips with aging patients (1, 12)
1.
Allow extra time for older patients. Older patients often require additional time to express their symptoms and feelings, to ask questions, and to take in the information they need from their psychiatrist. Plan for the extra time and be sure that the patient has the opportunity to express him/herself and to feel heard.
2.
3.
Listen carefully to what is said, and what is not. Many patients have a difficult time expressing their needs, and this may be most true with older patients. Listening, and asking for clarification, ensures optimal understanding and helps patients talk about important, but more difficult topics
4.
Speak slowly, clearly, and simply. Avoid “medicalese.”
5.
Share difficult information with a support group in place. For example, sharing information about dementing processes and how this affects the patient, caretakers, and other supports should be done with those supports in place and providing practical information for optimizing patient functioning and providing supports for caregivers
6.
Summarize the most important points, and ensure accuracy with the patient. Summarize frequently and ask patients to summarize as well, to be sure that bilateral communication was successful.
7.
Ask if there are questions. Solicit questions or other pertinent information that the patient has not mentioned. The elderly patient may not spontaneously volunteer this information
8.
Review recommendations and follow-up plans—verbally and in writing. Again, clearly and in lay language. You may wish to make 2 copies—one for the patient and one for a caretaker or family member.
References
1.
Robinson TE, White GL, Houchins JC: Improving communication with older patients: tips from the literature. Fam Pract Manag 2006; 13:73–78
2.
Halter JB: The challenge of communicating health information to elderly patients: a view from geriatric medicine, in Processing of Medical Information in Aging Patients: Cognitive and Human Factors Perspectives. Edited by, Park DC, Morrell RW, Shifren K, Mahwah NJ, Lawrence Erlbaum Assoc, 1999
3.
Ambady N, Koo J, Rosenthal R, Winograd CH: Physical therapists’ nonverbal communication predicts geriatric patients’ health outcomes. Psychol Aging 2002; 17:443–452
4.
Kaplan SH, Greenfield S, Ware JE: Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27(Suppl):S110–S127
5.
Bensing J: Doctor-patient communication and the quality of care. Soc Sci Med 1991; 32:1301–1310
6.
Lepper HS, Martin LR, DiMatteo MR: A model of nonverbal exchange in physician-patient expectations for patient involvement. J Nonverbal Behav 1995; 19:207–222
7.
Beisecker AE, Beisecker TD: Patient information-seeking behaviors when communicating with doctors. Med Care 1990; 28:19–28
8.
German PS, Shapiro S, Skinner EA, VonKorff M, Klein LE, Turner RW, et al.: Detection and management of mental health problems of older patients by primary care providers. JAMA 1987; 257:489–493
9.
Greene MG, Adelman R, Charon R, Hoffman S: Ageism in the medical encounter: an exploratory study of the doctor-elderly patient relationship. Lang Commun 1986; 6:113–124
10.
Adelman RD, Greene MG, Ory MG: Communication between older patients and their physicians. Clin Geriatr Med 2000; 16
11.
Teresi JA, Ramirez M, Ocepek-Welikson K, Cook MA: The development and psychometric analyses of ADEPT: an instrument for assessing the interactions between doctors and their elderly patients. Ann Behav Med 2005; 30:225–242
12.
Grossberg GT, Christensen DD, Griffith PA, Kerwin DR, Hunt G, Hall EJ: The art of sharing the diagnosis and management of Alzheimer’s disease with patients and caregivers: recommendations of an expert consensus panel. Primary Care Companion to the Journal of Clinical Psychiatry 2010; 12(1): PCC.09cs00833
Information & Authors
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Published online: 1 January 2013
Published in print: Winter 2013
Authors
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Author Information and CME Disclosure
Dorothy Stubbe, M.D., Associate Professor and Program Director, Yale University School of Medicine Child Study Center, New Haven, CT.
Dr. Stubbe reports no competing interests.
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