Education - Consultation skills - Consultations with the elderly

Adapting your consultation style will be appreciated by elderly patients, explains Dr Mona Kular.

Elderly patients constitute a significant proportion of the patient population in most primary care settings, therefore it is necessary to understand and adapt to their needs.

As a group, elderly patients can be vulnerable. Not only do they present with complex and multiple symptoms, but also with challenges in communication and the implementation of management plans.

Ensure elderly patients can see you when you are talking to them and tailor your communication style

This group is more likely to be referred for further investigation or to have drugs prescribed for them, and so knowing how to enhance the transfer of information can make a difference to the perceived outcome of the consultation and to their concordance.

Expectations
The expectations of elderly patients may be somewhat different to those of younger patients. Generally, they place more importance on continuity of care and appreciate the opportunity to see the same doctor repeatedly and build up a rapport and relationship.

They may expect to spend more time with their doctor and perhaps cover issues more thoroughly. Over time, they are likely to prefer the emphasis on communication and interpersonal skills during a consultation rather than clinical skills.

Elderly patients may also have slightly different expectations of the respect shown to them, such as the way they are addressed or whether they are helped in and out of the room.

Surgery access
The surgery environment as well as its processes and staff can also be adapted to be friendly towards the older person.

Access to appointments may be more difficult for elderly patients who may forget to ring the surgery at the correct time or have difficulties using the phone. Clear arrangements should be made known to these patients.

The waiting room and surgery need to be comfortable for elderly patients and easy to navigate for those with walking aids, wheelchairs or visual impairment. If music is played, it should be acceptable to all age groups and any visual or auditory cues for patients should be clear and easy to interpret.1

Needs
The needs of elderly patients are subtly different to their expectations. Access, as mentioned, is important for the elderly patient group in order that they are able to see a doctor or request a home visit as necessary. They should be supported in their attempts to gain access, with appropriate help or direction from the practice staff.

Health promotion and preventive strategies form an integral part of the care delivered to elderly patients, helping to improve quality of life and anticipating potential problems and needs before they arise.

This may involve not just medication and direct intervention, but involving family or care givers and giving consideration to support frameworks needed now and in the future.

Dealing with the elderly has to be undertaken on a holistic level with a very patient-centred approach,2 although many elderly patients may not be used to this.

The patient should be involved as much as possible in the decisions made about their healthcare and management plans.

Other factors that will influence the treatment and management of complaints among the elderly include whether they are independently mobile, whether they have transport, whether they live alone, whether they care for anyone else, whether they are coping at home, and so on. Asking about these things will enable a better formulated and tailored management plan for the patient.

Another role for the GP is that of helping these patients to understand the NHS system and ensure that their vulnerability does not lead to them being unfairly discriminated against.

Help and support in making or attending appointments in secondary care, understanding what to expect or even just reinforcing information already relayed to them can be successfully delivered in the primary care setting.

Communication
Visual impairment is more common in the elderly population and this has an impact on the consultation and its outcome.

Visually impaired patients may appreciate being greeted in the waiting room and being offered an arm to guide them to the correct room. It might be helpful to ask the patient how you can help them during the consultation. If there is anyone else in the room, such as a student, it is vital to make this clear.

Verbal communication skills, encouragement and prompting will play a key part in the consultation; the patient may not be able to respond to nods or looks of encouragement.

A light touch may reinforce that they are being acknowledged and listened to. Giving the patients information about what is going on is also critical, so make sure you tell the patient if you are going to leave the room, make a phone call or look for something.

Impaired hearing is another common condition in the elderly and again calls for slight modifications in consultation skills.

Always ensure that patients can see you when you are talking to them, as a large part of their understanding will come from your lip movements and facial expressions.

Try to keep your hands away from your mouth when talking. Use concise and simple sentences and check that they have been understood before moving on. Accept that these consultations can take some time.

Non-verbal cues are important but will only have an effect if they can be seen. Using pictures, diagrams or written messages can be a useful way of reinforcing information.3

  • Dr Kular is a salaried GP in Nottingham

Learning points
Improving communication

1. Elderly patients present challenges in communication, management and concordance.

2. Interpersonal skills may be more important than clinical skills to the elderly patient.

3. A holistic and patient-centred approach is vital to ensure the optimum outcome for the consultation.

4. Specific consultation skills can be used for those with hearing or visual impairments.

References

1. Is your practice elder-friendly NZ fam physician 2001;28 www.rnzcgp.org.nz/assets/uploads/NZFP/feb2001/elderfriendly.pdf

2. Wensing M, Wetzels R, Hermsen J, Baker R. Do elderly patients feel more enabled if they had been actively involved in primary care consultations? Patient Educ Couns 2007; 68: 265-9.

3. Communicating with elderly persons. www.ec-online.net/Knowledge/Articles/communication.html

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