"What brings you here today?" 
Mr. Symonds has advanced lung disease and usually manages well with home oxygen. But recently he has been admitted to the emergency room three times in as many weeks, unable to breathe. His doctors are puzzled because Mr. Symonds is taking his medications on schedule and, he says, using the oxygen. Finally, a home care nurse is sent to his house. She discovers that because of this winter’s bitter cold, Mr. Symonds has been running a kerosene heater in his kitchen. He does not run the oxygen and heaters at the same time for fear of fire.
Understanding a person’s life and daily routine can help you to understand how your patient’s lifestyle might affect his or her health care. To this end, the following guidelines can help you to obtain a thorough history of current and past concerns, health experience and family history, medications, and socioeconomic situation.
These suggestions are less time consuming than they first appear. Some involve a one-shot investment of time. Other health care professionals in the office or home setting may assist you in gathering the information. You may want to get detailed life and medical history as an ongoing part of older patients’ office visits and use each visit to add to and update information.
General Suggestions
You may need to be especially flexible when conducting the medical history with older patients. Here are some strategies to make efficient use of your time and of theirs:
- If feasible, try to gather preliminary data before the session. Request previous medical records, or, if there is time, mail forms that the patient or a family member can complete at home. Try to structure questionnaires for easy reading by using large type and providing enough space between items. Questionnaires to fill out in the waiting room should be brief.
- Try to have the patient tell his or her story only once, not to a nurse and then to you. For older patients who are ill, this process can be very tiring.
- Be willing to depart from the usual interview structure. You might understand the patient’s condition more quickly if you elicit his or her past medical history immediately after the chief complaint, before making a complete evaluation of the present illness.
- If the patient has trouble with open-ended questions, make greater use of yes-or-no or simple choice questions.
- Remember that the interview itself can be beneficial. Although you see many patients a day, the patient may only see you, and your attention is important. The patient’s chance to express concerns to an interested person can be therapeutic.
Current Concerns
Older patients tend to have multiple chronic conditions. They often have vague complaints or atypical presentations. Thinking in terms of current concerns rather than a chief complaint may be helpful. You might start the session by asking your patient to talk about whatever is bothering him or her the most.
Resist the tendency to interrupt and give the patient time to answer your questions. Giving someone uninterrupted time to express concerns enables him or her to be more open and complete.
Encourage the patient and his or her caregivers to bring a written list of their concerns and questions. Sometimes an older patient will see a physician because of concerns of family members or caregivers. Find out what concern led to the visit.
Medications
Side effects, interactions, and misuse of medications can lead to major complications in older people. It is crucial to find out which medications older patients are using and how often. Older people often take many medications prescribed by several different doctors, e.g., internists, cardiologists, urologists, or rheumatologists. Sometimes they take prescriptions intended for other household members.
Remember to ask about any alternative treatments, such as dietary supplements, homeopathic remedies, or teas that the patient might be using.
Ask patients to bring all medications, both prescription and over-the-counter, to your office. A good approach is to have the patient put everything he or she takes in a brown bag and bring it to each visit. Check to see if the patient has (or needs) a medical alert ID bracelet.
Find out about the patient’s habits of taking each medication and check to be sure that he or she is using it as directed.
Family History
The family history is valuable, in part because it gives you an opportunity to explore the patient’s experiences, perceptions, and attitudes regarding illness and death. For example, a patient may say, “I never want to be in a nursing home like my mother.” Be alert for openings to discuss issues such as advance directives.
The family history indicates the patient’s likelihood of developing some diseases and provides information on the health of relatives who care for the patient or who might do so in the future.
Obtain sufficient information not only on previous generations and siblings but also on children and grandchildren. If a patient needs long-term care, you will know what support may be available from family members.
Life History
If you plan to continue caring for an older patient, consider taking time to learn about his or her life. A life history is an excellent investment. It helps to understand the patient. It also strengthens the clinician-patient relationship by showing your interest in the patient as a person.
Be alert for information about the patient’s relationships with others, thoughts about families or coworkers, typical responses to stress, and attitudes toward aging, illness, work, and death. This information may help you interpret the patient’s concerns and can help you make appropriate recommendations.
Functional Status
Knowing an older patient’s usual level of functioning and learning about any recent significant changes are fundamental to providing appropriate health care. They also influence which treatment regimens are suitable. The ability to perform basic activities of daily living (ADLs) reflects and affects a patient’s health. Depending on the patient’s status, ask about ADLs such as eating, bathing, and dressing and more complex instrumental activities of daily living (IADLs) such as cooking, shopping, and managing finances. There are standardized ADL assessments that can be done quickly and in the office.
Sudden changes in ADLs or IADLs are valuable diagnostic clues. If your older patient stops eating, becomes confused or incontinent, or stops getting out of bed, look for underlying medical problems. Keep in mind the possibility that the problem may be acute.
Social History
The social history also is crucial. If you are aware of your patient’s living arrangements or his/her access to transportation, you are much more likely to devise realistic, appropriate interventions. Ask about type of dwelling, neighborhood safety, eating habits, tobacco and alcohol use, typical daily activities, work, education, and financial situation. It also helps to find out who lives with or near the patient.
Determine if the patient is an informal caregiver for others. Many older people care for spouses, elderly parents, or grandchildren. A patient’s willingness to report symptoms sometimes depends on whether they think they can “afford to get sick.”
Although “house calls” are an excellent way to find out about your patient’s home life, most doctors no longer have the time to call on their patients at home. If you cannot schedule a home visit, consider sending another staff member to visit your patient. If that’s not possible, try to learn some details about the patient’s home life: Does he or she use oil or gas heat? Have steep stairs to navigate? Own a pet? Can he get to the grocery store or pharmacy independently? Is she friendly with anyone in the neighborhood? Learning about your patient’s home life will help you understand aspects of his or her illness and may improve adherence to treatment.
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