Benefits with The Local Choice

Talking with Older Patients About Sensitive Subjects (Part 1)

Caring for an older patient requires discussing sensitive topics. Many older people have a "don't ask, don't tell" relationship with health care 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, nonthreatening 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.

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.

"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.

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.

For More Information About Driving

AAA Senior Driving
1-202-638-5944
publicaffairs@national.aaa.com
Link opens in a new windowhttps://seniordriving.aaa.com

AARP
1-888-687-2277 (toll-free)
1-877-342-2277 (español/línea gratis)
1-877-434-7598 (TTY/toll-free)
member@aarp.org
Link opens in a new windowhttps://www.aarp.org/auto/driver-safety

American Geriatrics Society
1-212-308-1414
info.amger@americangeriatrics.org
Link opens in a new windowhttps://www.americangeriatrics.org/programs/older-driver-traffic-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 health care 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 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 About Elder Abuse

National Center on Elder Abuse
1-855-500-3537 (toll-free)
ncea@med.usc.edu
Link opens in a new windowhttps://ncea.acl.gov

U.S. Department of Justice
1-202-514-2000
elder.justice@usdoj.gov
Link opens in a new windowhttps://www.justice.gov/elderjustice

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.

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, and changes in diet and nutrition, as well as medication and surgery for certain types of incontinence.

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, is 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.