Talking With Your Older Patient A Clinician S Handbook

A CLINICIAN’S HANDBOOK
Talking
With
Your
Older
Patient
NAT I O NA L INS TITU TE O N AGING

NATIONAL I NS TI TUTES OF HEA LTH
DEPARTM EN T OF HEA LTH A ND HUMA N S ERV I CES

Understanding Older Patients
What was once called “bedside manner” and considered

a matter of etiquette and personal style has now been
the subject of a large number of empirical studies.
The results of these studies suggest that the interview
is integral to the process and outcomes of medical care.
“Tell me more about how you spend your days.”
Although she complains of her loneliness and long days in front

of the TV, Mrs. Klein refuses to participate in activities at the
community senior center. “I’m not playing bingo with a bunch
of old ladies,” she tells her doctor when he suggests she get out
more. “You’ve mentioned how much you love to garden,” her
doctor says. “The center has a garden club with a master gardener.
One of my other patients says she loves it.” “I don’t want to hang
around old people who have nothing better to do than compare
health problems,” she says. “Why not give it a try?” her doctor
asks. “You might find the members are pretty active gardeners.”
Six months later, when she sees the doctor again, Mrs. Klein
thanks him. She has joined the garden club and reports that the
members all have green thumbs as well as being quite lively
conversationalists. Better still, Mrs. Klein’s depressive symptoms
seem improved.
6 understanding older patients

chapter 2
Effective communication has practical benefits. It can:
l help prevent medical errors
l strengthen the patient-provider relationship
l make the most of limited interaction time
l lead to improved health outcomes
This chapter provides tips on how to communicate with older patients in

ways that are respectful and informative.
Use Proper Form of Address

Establish respect right away by using formal language. As one patient
said, “Don’t call me Edna, and I won’t call you Sonny.” You might ask
your patient about preferred forms of address and how she or he would
like to address you. Use Mr., Mrs., Ms., and so on. Avoid using familiar
terms, like “dear” and “hon,” which tend to sound patronizing. Be sure to
talk to your staff about the importance of being respectful to all of your
patients, especially those who are older and perhaps used to more formal
terms of address.
Make Older Patients Comfortable

Ask staff to make sure patients have a comfortable seat in the waiting
room and help with filling out forms if necessary. Be aware that older
patients may need to be escorted to and from exam rooms, offices, and the
waiting area. Staff should check on them often if they have to wait long in
the exam room.
Take a Few Moments to Establish Rapport

Introduce yourself clearly. Show from the start that you accept the patient
and want to hear his or her concerns. If you are a consultant in a hospital
setting, remember to explain your role or refresh the patient’s memory of it.
In the exam room, greet everyone and apologize for any delays. With new
patients, try a few comments to promote rapport: “Are you from this area?”
or “Do you have family nearby?” With established patients, friendly questions
about their families or activities can relieve stress.
understanding older patients 7

Try Not to Rush
Avoid hurrying older patients. Time spent discussing concerns will allow you
to gather important information and may lead to improved cooperation and
treatment adherence.
Feeling rushed leads people to believe that they are not being heard or
understood. Be aware of the patient’s own tendency to minimize complaints
or to worry that he or she is taking too much of your time.
Avoid Interrupting
One study found that doctors, on average, interrupt patients within the first
18 seconds of the initial interview. Once interrupted, a patient is less likely
to reveal all of his or her concerns. This means finding out what you need to
know may require another visit or some follow-up phone calls.
Older people may have trouble following rapid-fire questioning or torrents of

information. By speaking more slowly, you will give them time to process what
is being asked or said. If you tend to speak quickly, especially if your accent is
different from what your patients are used to hearing, try to slow down. This
gives them time to take in and better understand what you are saying.
Use Active Listening Skills

Face the patient, maintain eye contact, and when he or she is talking, use
frequent, brief responses, such as “okay,” “I see,” and “uh-huh.” Active
listening keeps the discussion focused and lets patients know you understand
their concerns.
Demonstrate Empathy
Watch for opportunities to respond to patients’ emotions, using phrases
such as “That sounds difficult” or “I’m sorry you’re facing this problem; I think
we can work on it together.” Studies show that empathy can be learned and
practiced and that it adds less than a minute to the patient interview. It also
has rewards in terms of patient satisfaction, understanding, and adherence
to treatment.

For more information on active listening, contact:
American Academy on Communication in Healthcare
16020 Swingley Ridge Road, Suite 300
Chesterfield, MO 63017
1-636-449-5080
www.aachonline.org
This professional organization aims to improve physician-patient relationships and
offers courses and publications on medical encounters and interviews.
Macy Initiative in Health Communication

Division of Primary Care
NYU School of Medicine
550 First Avenue
Old Bellevue, Room D401
New York, NY 10016
1-212-263-3071
http://macyinitiative.med.nyu.edu
This initiative was a collaborative effort of three medical schools to identify and define
critical communication skills needed by physicians. It developed competency-based
curricula for medical students.
New England Research Institutes (NERI)

9 Galen Street
Watertown, MA 02472
1-617-923-7747
www.neriscience.com
NERI has designed a CME-accredited CD-ROM, Communicating With Older Adults,
educating physicians on communication strategies to practice with older patients.
Avoid Jargon
Try not to assume that patients know medical terminology or a lot about
their disease. Introduce necessary information by first asking patients what
they know about their condition and building on that. Although some terms
seem commonplace—MRIs, CAT scans, stress tests, and so on—some older
patients may be unfamiliar with what each test really is. Check often to be
sure that your patient understands what you are saying. You may want to
spell or write down diagnoses or important terms to remember.

Reduce Barriers to Communication
Older adults often have sensory impairments that can affect
communication. Vision and hearing problems need to be treated and
accounted for in communication. Ask older patients when they last
had vision and hearing exams.
Compensating for Hearing Deficits
Age-related hearing loss is common. About one-third of people between the ages of
65 and 75, and nearly half of those over the age of 75, have a hearing impairment.
Here are a few tips to make it easier to communicate with a person who has lost
some hearing:
l Make sure your patient can hear you. Ask if the patient has a working hearing
aid. Look at the auditory canal for the presence of excess earwax.
l Talk slowly and clearly in a normal tone. Shouting or speaking in a raised voice
actually distorts language sounds and can give the impression of anger.
l Avoid using a high-pitched voice; it is hard to hear.
l Face the person directly, at eye level, so that he or she can lip-read or pick up
visual clues.
l Keep your hands away from your face while talking, as this can hinder lip-
reading ability.
l Be aware that background noises, such as whirring computers and office

equipment, can mask what is being said.
l If your patient has difficulty with letters and numbers, give a context for them.
For instance, say, “‘m’ as in Mary, ‘two’ as in twins, or ‘b’ as in boy.” Say each
number separately (e.g., “five, six” instead of “fifty-six”). Be especially careful
with letters that sound alike (e.g., m and n, and b, c, d, e, t, and v).
l Keep a note pad handy so you can write what you are saying. Write out
diagnoses and other important terms.
l Tell your patient when you are changing the subject. Give clues such as pausing
briefly, speaking a bit more loudly, gesturing toward what will be discussed,
gently touching the patient, or asking a question.

Compensating for Visual Deficits
Visual disorders become more common as people age. Here are some things you
can do to help manage the difficulties caused by visual deficits:
l Make sure there is adequate lighting, including sufficient light on your face. Try
to minimize glare.
l Check that your patient has brought and is wearing eyeglasses, if needed.
l Make sure that handwritten instructions are clear.
l When using printed materials, make sure the type is large enough and the
typeface is easy to read. The following print size works well:
“This size is readable.”

l If your patient has trouble reading, consider alternatives such as tape recording
instructions, providing large pictures or diagrams, or using aids such as
specially configured pillboxes.
Be Careful About Language

Some words may have different
meanings to older patients than to you
For more information on
or your peers. For example, the word low literacy, contact:
“dementia” may connote insanity, and Partnership for Clear Health
the word “cancer” may be considered Communication
a death sentence. Although you National Patient Safety Foundation
cannot anticipate every generational 268 Summer Street, 6th Floor
Boston, MA 02210
difference in language use, being
1-617-391-9900
aware of the possibility may help you www.npsf.org/askme3
to communicate more clearly. Use
This national coalition addresses issues
simple, common language, and ask if related to low health literacy and its effect
clarification is needed. Offer to repeat on outcomes. Its “Ask Me 3” campaign has
or reword the information: “I know this materials for physicians’ offices, including
patient handouts, to promote good
is complex; I’ll do my best to explain, but
communication.
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 may help.
Ensure Understanding
Conclude the visit by making sure the patient understands:
l what the main health issue is
l what he or she needs to do about it
l why it is important to do it
One way to do this is the “teach-back method”—ask patients to say what

they understand from the visit. Also, ask if there is anything that
might keep the patient from carrying out the treatment plan.
In Summary
✔ Address the patient by last name, using the title the patient prefers
(Mr., Ms., Mrs., etc.).
✔ Begin the interview with a few friendly questions not directly related
to health.
✔ Don’t rush, and try not to interrupt; speak slowly, and give older
patients a few extra minutes to talk about their concerns.
✔ Use active listening skills.
✔ Avoid jargon, use common language, and ask if clarification is needed,

such as writing something down.
✔ Ask the patient to say what he or she understands about the problem
and what needs to be done.

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A CLINICIAN’S HANDBOOK

NAT I O NA L INS TITU TE O N AGING

DEPARTM EN T OF HEA LTH A ND HUMA N S ERV I CES

What was once called “bedside manner” and considered

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

Although she complains of her loneliness and long days in front

6 understanding older patients

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

Use Proper Form of Address

Make Older Patients Comfortable

Take a Few Moments to Establish Rapport

understanding older patients 7

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

Use Active Listening Skills

8 understanding older patients

Macy Initiative in Health Communication

New England Research Institutes (NERI)

understanding older patients 9

Compensating for Hearing Deficits

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

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

10 understanding older patients

l Make sure that handwritten instructions are clear.

“This size is readable.”

Be Careful About Language

understanding older patients 11

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

✔ Use active listening skills.

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

12 understanding older patients

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