Talking About Sensitive Subjects

Caring for an older patient requires discussing sensitive topics. You may be tempted to avoid these discussions, but there are helpful techniques to get you started and resources to help.

Many older people have a “don’t ask, don’t tell” relationship with health care providers about some problems, especially those related to sensitive subjects, 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 addressing some of these concerns because you don’t know how to help patients solve the problem. This chapter gives an overview of techniques for broaching sensitive subjects, as well as resources for more information or support.

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, of course always maintaining patient confidentiality to reassure the patient you are talking to that you won’t disclose personal information about him or her.

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

Advance Directives
Advance directives, including “living wills,” can help you 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 completing the form.
• Ask the patient to bring a copy of the completed form at the next visit for you to keep. If appropriate, share the plan with family members.
• Revise any advance directives based on the patient’s changing health and preferences.

Be sure to 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.

If your patient is in the early stages of an illness, it’s important for you to assess whether or not the underlying process is reversible. It’s also a good time to discuss how the illness is likely to play out. If your patient is in the early stages of a cognitive problem, it is especially important to discuss advance directives.

Driving Safety
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. Because driving is associated with independence and identity, making the decision not to drive is very hard.

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. In addition, it may be harder to move the head to look back, quickly turn the steering wheel, or safely hit the brakes. Ask the patient about any car accidents. When necessary, 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. You might ask if she or he has thought about alternative transportation methods if driving is no longer an option.

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, such as doctors and nurses, 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.

End-of-Life Care
Most older people have thought about the prospect of their own death and are willing 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. It may be helpful to do this early in your relationship with the patient when discussing medical and family history. Stay alert to cues that the patient may want to talk about this subject again. Encourage the patient to discuss end-of-life decisions early with family members and to consider a living will.

Of course, it is not always easy to determine who is close to death; even experienced clinicians find that prognostication can be difficult. Even if you have already talked with your patient about end-of-life concerns, it still can be hard to know 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 review their advance directives. Include these updates in your medical records to ensure that patients receive the care they want.

Financial Barriers
Rising health care costs make it difficult for some people to follow treatment regimens. Your patients may be too embarrassed to mention their financial concerns. Studies have shown that many clinicians also are reluctant to bring up costs. If possible, designate an administrative staff person with a good bedside manner to discuss money and payment questions. This person can also talk with your patient about changes in Medicare and the Part D prescription drug coverage plans.

The resources in this section may help when you talk with your patients about their financial concerns. In addition, your State Health Insurance Assistance Program (SHIP) may be helpful.

Long-Term Care
Long-term care includes 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 he or she might need in the future and how to plan for those needs. For instance, you might talk about what sort of assistance you think your patient will need, how soon in the future he or she will need the extra help, and where he or she might get this assistance.

Mental Health
Despite many public campaigns to educate people about mental health and illness, there is still a stigma attached to mental health problems. Some older adults may find mental health issues 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 example, “A lot of us develop sleep problems as we get older, but this can be a sign of depression, which sometimes we can treat.” 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.

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 no longer sexually active, does not care about sex, or necessarily is heterosexual. In fact, 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 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 life 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 is not in a long-term relationship with a faithful partner and has unprotected sex is at risk of sexually transmitted disease.

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 feel that their fate is in the hands of a higher power, and this 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 has helped you to deal with challenges in the past?”

Substance Abuse
Alcohol and drug abuse are major public health problems, even for older adults. Sometimes people can become dependent on alcohol or other drugs as they confront the challenges of aging, even if they did not have a problem when younger. Because baby boomers have a higher rate of lifetime substance abuse 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 the medicine’s effectiveness. From this starting point, you may find it easier to talk about alcohol or other drug use.

Urinary Incontinence
About 17 percent of men and 38 percent of women age 60 and older suffer from urinary incontinence. Several factors can contribute to incontinence. Childbirth, infection, certain medications, and some illnesses are examples. 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?” You may want to explain that 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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