Clinical Assessment of Older People

Consultation skills

There are certain skills that are key to any consultation, but some are more important with an older patient.

Arranging an appointment

For older patients, attending hospital may be more of a physical and emotional challenge, for which there is a need to feel well. Patients often decide not to attend clinic appointments because they feel ill
Hospital transport is often used. Morning appointments usually require a patient to be ready by 8:30am—daunting for someone who takes time to get going in the morning. Offer late morning or afternoon appointments, using early slots for patients who travel independently
When informing the patient about the appointment, make sure that instructions are clear. Patients with dementia should probably have appointments sent to carers who would ideally attend with them; visually impaired patients may need a large print letter or a telephone call
Remind the patient to bring both medication and prescription lists to their appointment. Muddled medications may indicate self-medication problems. Comparison of drugs and list helps to assess concordance
Establish who has requested the consultation—eg memory clinic appointments are often in response to family concerns, and the patient may not attend as they do not perceive or wish to face the problem
DH settings for consultation can be more relaxed, allowing the patient to recover over lunch before facing the trip home again
Are hospital attendances really necessary? Discuss with the GP, offering to discharge the patient to his/her care, but supported by open telephone access for advice and a hospital review on request
If all else fails, DVs may be useful

Rapport

Good rapport with the patient makes the interview easier, more productive and more enjoyable
Smart dress increases patient confidence, especially in older patients
Always introduce yourself—shake hands if it seems appropriate, and address formally (Mr/Mrs/Miss) unless invited to do otherwise
Be friendly but not patronizing or over familiar. Informal chat can break the ice, and show that you have time for and interest in the person
Older patients deserve and expect respect from (inevitably) younger doctors, but often have more respect for the medical profession
Patients are likely to have great faith in a trusted GP than in a young junior met for the first time. When asked what is wrong, they may quote the GP diagnosis (‘Dr Brown said I had a stroke’) rather than offering their experiences. Emphasize that you work as part of a team (‘Your doctor has asked for our opinion, so we need to go over things again. I will let them know what I think.’). After a hospital admission, explain changes to prescriptions and that you will inform the GP
Acknowledge and apologize for waiting times and uncomfortable conditions (eg during an emergency admission)—it may not be your fault, but apologizing may defuse frustrations that hamper the consultation

Environment

Older patients are more likely to feel helpless and vulnerable in hospital if only partially clothed and on a couch. Interviewing a fully dressed patient sitting in a chair gives more dignity and respect
Good light, quiet, and no interruptions will minimize problems from visual and hearing impairment

Giving advice

Advice is taken more often if rapport has been good during the interview. Appearing knowledgeable and professional increases the chance of agreement to investigations and medication changes. For example, some patients refuse to take aspirin, having been told years ago by a trusted doctor ‘never to take aspirin again’ because of an ulcer. Take time to explain that risks and benefits change with evolving disease and as new therapies develop. Gain understanding and agreement (see ‘HOW TO … Discuss warfarin for AF’, p.280)
Multiple conditions require multiple investigations and medications. For example, following a TIA the patient may be well, yet tests can include bloods, ECG, chest radiograph (CXR), brain scan and carotid Doppler, and several drugs are often prescribed. Take time to explain the rationale for each, thereby increasing concordance
Write a list of planned investigations and medication changes along with their justification. Give the list to the patient. This takes time, but increases the likelihood that advice will be followed
Offer to repeat your advice to family members (who may be sitting in the waiting room) or to telephone someone who is at home. A frail spouse may not be able to attend outpatients, or a busy daughter may not have time to attend, yet both may be vital to the delivery of effective ongoing care—eg administering medications or organizing appointment diaries
It can sometimes be helpful to send a copy of your GP letter to the patient but providing a second letter with key messages in ‘lay’ language to the patient is even better

Multiple pathology and aetiology

Most diseases become more common in an older population. Some conditions such as osteoarthritis are present in the majority (radiographically 70% of over 70s). By the age of 80, it is very likely that an individual will have at least one disease. Many will have more than that (multiple pathology). As increasing numbers of medications are advocated in the practice of evidence-based medicine, so polypharmacy and adverse effects become more common too.

Chronic stable conditions

The patient may have adapted to the limitations imposed by the disease (eg not walking as far or as fast because of osteoarthritis knees; reading large print books because of failing vision) or medicated to aid symptom control (eg analgesia in arthritis). However, background multiple pathologies should be noted for two main reasons:

Cumulative chronic disease will cause decline in physiological reserve
- The older patient with multiple stable diseases has less resilience to physiological challenge than a fit young person; a smaller insult is needed to cause illness
- Non-specific presentations reflect the complexity of the pathology— background problems interacting with new (perhaps seemingly minor) insults to cause acute decline without obvious cause
Many patients adapt to impairments, particularly if the functional decline is gradual
- Assessment and intervention remains helpful, eg failing vision is often accepted as a part of ageing, yet is often amenable to treatment

Acute presentations

There are several aspects to consider:

What is the acute precipitant? This may be minor, eg medication changes, influenza, constipation
What are the underlying pathologies making the patient more susceptible to the acute precipitant?
Note that one acute pathology can lead to another in a vulnerable patient—eg a bed-bound patient with pneumonia is at high risk for thromboembolic disease

So, for any single presentation there are likely to be multiple aetiologies which need to be unravelled. This can be difficult, but applying a structured logical approach assists the process:

Use a problem list to help structure the approach (see ‘Problem lists’, p.60)
Allow time for the acute event to settle, physical and psychological adjustments to occur (much slower than in a younger person), stamina and confidence to build up, care arrangements to be put in place, etc.
Involve a multidisciplinary team to take a holistic look at the patient and evolve the problem list and action plan

Taking a history

Histories taken from older people vary as much as the patients themselves, but some common problems make the process more difficult:

Multiple pathology
Multiple aetiology
Atypical presentation of disease
Cognitive impairment, both acute and chronic
Complex social situations

Failing to recognize the importance of obtaining an accurate and comprehensive history risks misdiagnosis and mismanagement.

There is often a difficult balance to be struck between being inclusive and being focused and efficient

The patient interview

The most direct information source, but requires patience and skill.

An elderly person with multiple problems may give a history that is hard to unravel. Someone with chronic back pain will answer positively to the closed question ‘Do you have pain?’, but it may be no worse than the last 10 years and not at all a part of the new presentation. Ask ‘Is this new?’ and ‘Is it different from usual?’
Allow time to volunteer symptoms. Avoid interrupting. If a symptom is mentioned in passing, return to it later to enquire about its nature, precipitants, etc. Interrupting may cause the main issue to be lost
The patient may underplay issues that are emotive (eg failing memory, carer abuse, incontinence) or perceived as leading to institutional care. Foster an atmosphere of trust and mutual interest in problem solving

Cognitive impairment

Patients with dementia or delirium may not answer clearly or succinctly, and symptoms may need to be teased out. Quantities of seemingly irrelevant information may be interspersed with gems of important history. Don’t get frustrated and give up—continue with a combination of open questions and careful listening, punctuated by closed questions that may result in a clear ‘yes’ or ‘no’. General enquiries such as ‘Do you feel well?’ and ‘Does it hurt anywhere?’ can be rewarding. A patient who is made to feel silly will often dry up—if you are getting nowhere with specific questions, then broaden the conversation to get dialogue flowing again.

Sensory impairment

Poor vision and hearing make the whole interview harder and more frightening for the patient. Use a well-lit, quiet room. Guide the patient to where you want them to sit. Ensure hearing aids are in, and turned on. Speak clearly into the good ear and do not shout. Use written questions if all else fails. Facilitate communication, however, laborious—patients will worry that they appear stupid, and may elect to withdraw completely if obstacles cannot be overcome (see also

‘HOW TO … Communicate with a deaf person’, p.549, and

‘HOW TO … Optimize vision’, p.570).

Terms that should be banned and why (Table 3.1)

Table 3.1 Terms that should be banned

‘No history available’	It is almost always possible to get a history: if not from the patient, then from family, carers, GP, community nurse, or ambulance personnel. Nursing homes are staffed 24hr a day and they all have telephones
‘Poor historian’	The historian is the person recording the history—this term is a self-criticism! If the patient is unable to give a history this is important and the reason should be documented along with evidence, eg AMTS, Glasgow Coma Scale (GCS)
‘Social admission’	A social admission is one caused solely by a change in the social situation, eg a carer who has died suddenly or a hoist that has broken. True social admissions are very rare and should in general be avoided (admit to a non-hospital setting, eg care home, or increase care at home). If the patient’s function has changed, eg new incontinence, falls, confusion, and their unchanged social situation cannot cope then the admission is NOT social. Often there is a combination of altered health and social circumstances
‘Social admission’	It is true that a younger patient might be able to stay at home with a minor change in health (eg Colles’ fracture, flu) whereas an older patient needs hospital care; but by blaming only the social care the doctor is at risk of missing the medicine, stigmatizing the patient and labelling carers as failures
‘Acopia’	Usually a more accurate description of the clerking doctor than the patient! A grammatically incorrect and unhelpful term. Ask yourself why can the patient not cope? What problem has led to this presentation and can it be treated?
‘Bed-blocker’	Pejorative term that implies that the patient is actively hindering discharge. Delayed discharge is a better term, as it removes any hint of blame from the patient

▶Patients admitted with the labels ‘social admission’ or ‘acopia’ are frail and have a high in-hospital morbidity and mortality. Statistically they are more likely to die in this hospital admission than a patient with myocardial infarction (Kee YY, Rippingale C. (2009). Age and Ageing 38: 103-105). Just because they are more challenging to diagnose and often require multidisciplinary assessment does not mean that they should be regarded as time and resource wasters for the system.

Other sources of information

Many patients, especially those with acute illness, are unable to give a full and reliable history. If so, a history must be obtained from other sources.

The family

Often a rewarding source of information, especially at the initial assessment. Older people may underplay their symptoms, fearful of being thought unable to cope, or not wishing to fuss. The family will often have concerns and it is useful to establish these as they may (or may not) be justified; weigh them up as more information is gathered.

Family members often wish to speak away from the patient—this can be useful and is acceptable if the patient gives consent.

▶Your duty is to the patient and you are their advocate. Family members may have louder voices, but take care to listen to those for whom you are responsible. Elderly people are allowed to take risks (eg live at home with a high risk of falling) providing that they are competent.

Neighbours/friends

Elderly patients with no family nearby may be very well known to their neighbours—perhaps they have been found wandering at night, or unusual behaviour has been noted. The neighbour may not feel obliged to volunteer this information and it may need to be sought. Neighbours may also act as informal carers and may contribute more care than family or formal carers. Common law partners are often heavily involved, yet may not be as prominent in hospital as other family members. Rifts may exist between established family and new partners and these need to be understood when planning care.

Professional carers

They will know the usual functional and cognitive state of the patient, and will often have alerted medical services to a change. They are rarely present at the medical assessment. Contact them and obtain all the information that you can.

General practitioner and community nurse

They may well know the patient very well, and have good insight into the dynamics of the care arrangement and family concerns. They can help clarify the medication and past medical history. If a confused patient arrives during GP practice hours, an initial clerking should always include a telephone call to the GP surgery. Patients who are housebound or who have leg ulcers, urinary catheters, or other nursing needs, are usually best known to community nurses.

Ambulance crew

The ambulance crew may be present during the initial hospital assessment of a sick older patient. Ask them what they know—this is a useful source of information that is under-utilized. If they have left, examine written ambulance team documentation—this includes timing, symptoms, and clinical signs including vital signs. Paramedics may also hold information about social situation, eg state of housing, informal carers, etc.

Nursing and residential homes

When patients are admitted from institutional care, a good history can almost always be obtained: information should be sent with the patient (many homes have a transfer of care document), but if not it can be sought by telephone immediately. Information about usual functional state, past medical history, medications, and acute illness should be kept on file at the home.

Old medical notes

Obtain them as quickly as possible, as they will provide essential medical information. A search for any MDT assessments can be fruitful but remember that this is not always filed with the medical record. If the patient is not local, arrange for information (letters, discharge summaries etc.) to be faxed or to speak to health professionals who know the patient.

Problem lists

Useful tools to help formulate plans for complex elderly patients in any setting. They act as aides-memoire for multiple pathology and prompt clinicians to consider interacting problems.

Problem lists should include:

Acute problems
- May be a symptom (eg fall) rather than a diagnosis
- List possible causes with a plan for investigation
Chronic conditions
- How stable is the disease?
- What management is already in place?
- What else can be done?

Lists can be generated at any stage in an illness—ideally at presentation— but need to be worked on and evolve as time goes on. Involve members of the MDT and make the list part of goal setting and discharge planning.

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