Chapter 5: Talking About Sensitive Subjects

Many older people have a “don’t ask/don’t tell” relationship with doctors about health care problems, especially about sensitive subjects, such as urinary incontinence or sexuality. Hidden health problems, ranging from foot disorders to mental illness, are a challenge. Addressing problems related to safety and independence, such as giving up one’s driver’s license or moving to assisted living, can be difficult. This chapter gives an overview of techniques for broaching sensitive subjects.

Try to take a universal, non-threatening approach. Start by saying, “Many people your age 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.

Some patients avoid issues that they think are inappropriate for a doctor. One way to overcome this is to keep informative brochures and materials readily available in the waiting room. Following each topic listed below is a sampling of resources. Although the lists are not exhaustive, they are a starting point for locating useful information and referrals.

Advance Care Directives
Advance care directives, popularly known as ‘living wills,’ honor individual end-of-life preferences and desires. You may feel uncomfortable raising the issue, fearing that patients will assume the end is near. But, in fact, this is a conversation that is best begun well before end-of-life care is appropriate. Let your patients know that advance care planning is a part of good health care. You can say that increasingly people realize the importance of making plans while they are still healthy. You can let them know that these plans can be revised and updated over time or as their health changes.

An advance care planning discussion can take about 5 minutes with a healthy patient:

• Talk about the steps your patient would want you to take in the event of certain conditions or eventualities.
• Discuss the meaning of a health care proxy and how to select one.
• Give the patient the materials to review, complete, and return at the next visit. In some cases, the patient may want help in completing the form.
• Put a copy of the completed form in the medical record. Too often, forms are completed, but when needed, they cannot be found. Many organizations now photocopy the forms on neon-colored paper which is easy to spot in the medical record.
• Provide your patient with a copy of the completed form to keep. If appropriate, share the plan with family members.
• Revise any advance directives based on the patient’s changing health and preferences.

If your patient is in the early stages of an illness, it’s especially important for you to assess whether the underlying process is reversible. It’s also a good time to discuss how the illness is likely to play out.

Driving Safety
Recommending that a patient limit driving—or that a patient surrender his or her driver’s license—is one of the most difficult topics a doctor has to address. Because driving is associated with independence and identity, giving up the right to drive is a very difficult decision.

As with other difficult subjects, try to frame it as a common concern of older patients. Mention, for instance, that aging can lead to slowed reaction times and impaired vision. 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. When necessary, warn patients about medications that may make them sleepy or impair judgment.

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 helping 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 caregivers deal with lots of stress and may sometimes lose their temper. If this is the case for your patient or his or her family, you can assist by recommending a support group or alternative arrangements (such as respite care). Give the patient opportunities to bring up this concern and if necessary, raise the issue yourself.

End-of-Life Care
Caring for patients at the end of life goes hand-in-hand with caring for older patients. For all patients, regardless of age or health, the real goal is to live well despite illness. Most older people have thought about the prospect of their own death and want to discuss their wishes regarding end-of-life care. You can help ease some of the discomfort simply by being willing to talk about dying and by being open to discussions about these important issues and concerns.

Of course, it is not always easy to determine who is close to death; even experienced clinicians find that prognostication can be difficult. Although you may have already talked with your patient about advance directives and other end-of-life concerns, still, it can be hard to know when is the right time to re-introduce this issue. Some clinicians find it helpful to ask themselves, “Would I be surprised if Mr. Flowers were to die this year?” If the answer is ‘no,’ then it makes sense to start working with the patient and family to address end-of-life concerns, pain and symptom management, home health, and hospice care. You can offer to help patients to review their advance directives. Include these updates in your medical records to ensure that patients receive the type of care they want.

Financial Barriers
Rising health care costs, especially for prescription drugs, make it difficult for some people to follow treatment regimens. Your patients may be too embarrassed to mention their financial constraints. It may be that simply putting the topic on the table is all the encouragement a patient needs. Doctors may feel awkward addressing this concern because they don’t know how to help their patients solve the problem.

Your State Health Insurance Assistance Program (SHIP) may be helpful. If you have online access, check with the Medicare Rights Center which has a database of state and national medication assistance (Medicaid) programs.

Long-Term Care
As you may know, long-term care is more than nursing home care. It includes many sources of care: informal caregiving, assisted living, home health services, adult day care, nursing homes, and community-based programs.

Early in your relationship with an older patient you can begin to talk about the possibility that he or she may eventually require long-term care of some kind. By raising this topic, you are helping your patient think about what they might need in the future and how to plan for those needs.

Mental Health
Despite many public campaigns to educate people about mental health and illness, there is still a stigma about mental illness. Older adults, who grew up with different ideas about mental health, may feel this stigma even more keenly and find mental health difficult to discuss.

Such conversations, however, can be lifesavers. Primary care doctors have a key opportunity to recognize when a patient is depressed and/or suicidal: In fact, 70 percent of older patients who commit suicide have seen a primary care physician within the previous month. This makes it especially important for you to be alert to the signs and symptoms of depression.

As with other subjects, try a general approach to bringing up mental health concerns. For instance, mention that many patients taking medications experience depression as a side effect and that the depression can be treated. Because older adults may have atypical symptoms, it is important to listen closely to what your patient has to say about trouble sleeping, lack of energy, and general aches and pains. It is easy to dismiss these as “just aging,” and leave depression undiagnosed and therefore untreated.

Another issue to consider is substance abuse, a major public health problem, even for older adults. Because “Baby Boomers” have a higher rate of lifetime alcohol and drug use than did their parents, the number of people in this age group needing treatment is likely to grow. One approach you might try is to mention that some medical conditions can become more complicated as a result of alcohol and other drug use. Another point to make is that alcohol and other drugs can increase the side effects of medication, or even reduce their effectiveness. From this starting point, you may find it easier to talk about alcohol or other drug use.

Sexuality
An understanding, accepting attitude and a sensitivity to verbal and other cues help promote a more comfortable discussion of sexuality. 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 more obliquely with allusions to changes that sometimes occur in marriage. If appropriate, you can follow up on patient cues. You might note that patients sometimes have concerns about their sex life and then wait for a response. Also effective are sharing anecdotes about a person in a similar situation or raising 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 assume that an older patient is no longer sexually active, does not care about sex, or necessarily is heterosexual. And, don’t forget to talk to your patient about the importance of safe sex.

Spirituality
For some older people, spirituality takes on new meaning as they age or face serious illness. By asking patients about their religious and spiritual practices, you can learn something about their health care choices and preferences. How a patient views the afterlife can sometimes help in framing the conversation.

For example, some patients with deeply held religious beliefs may believe in miracles, and this expectation may prevent them from making treatment decisions. For patients who report suffering and distress about illness or end-of-life, a referral to a hospital or nursing home chaplain may be helpful.

Clinicians have found that very direct and simple questions are the best way to broach this subject. You might start, for instance, by asking, “What experiences are most important for you to be able to live well at this time in your life?” Follow-up questions might include, “What are your fears or worries about your illness?” and “You’ve lived a long life. How have you dealt with challenges in the past?”

Urinary Incontinence
Up to 15 percent of older men and 30 percent of older women suffer from urinary incontinence. Several factors can contribute to incontinence: childbirth, infection, certain medications, or some illnesses. Incontinence may go untreated because patients are embarrassed to mention it. Be sure to ask specifically about the problem. Try the “some people” approach: “When some people cough or sneeze, they leak urine. Have you had this problem?” Incontinence can often be significantly improved through bladder training; medication and surgery can also be effective treatments for certain types of incontinence.

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