Take a more efficient senior history

Plan ahead and see elderly patients faster. Just the facts, ma'am

By Judah Issa

Taking a history from elderly patients can seem endless. But rush it and you could miss vital clues to help you clinch your diagnosis. "There's a lot of information to gather — from their ability to carry out basic activities of daily living (ADLs), like dressing and eating, to their living arrangements," notes Dr Howard Bergman, president of the Canadian Geriatrics Society.

Geriatrician Dr Howard Dombrower, of Toronto's Baycrest Centre for Geriatric Care, agrees it's a big job and says it's not uncommon to spend an hour getting a history. With Canada's senior population set to quadruple in the next decade and geriatrician numbers stagnating, that job is more and more falling to busy FPs. Here are some tips to help you speed up the history session and still get everything you need.

BEFORE THE VISIT
Request records Do some prep work before the patient's visit for a start. When scheduling the appointment, your assistant should make sure they have all the patient's records, labs and reports. Based on those, request blood-work or other tests to be done before the patient comes in.

Get it in writing Have your patients prepare a list of concerns before they come in. This will help you structure the interview. "It's also good for the patients," says Dr Dombrower. "Seniors have multiple complaints and the list will help them remember all of them."

Medication look-see Tell your patients to bring all their meds along, both docs agree. "It goes much faster when you don't have to guess what meds they're taking," says Dr Dombrower. Dr Bergman adds he likes to see their pill bottles before making any changes to their drug regimen.

LET THE HISTORY BEGIN
Body check Look for non-verbal clues to give you instant insight into the patient's ADLs. Is the patient shuffling into your office? Mobility is a problem. Are their clothes on backwards? Then dressing is also a challenge. There are quick ADL tests that can be done right in your office (see below for details).

Chew the fat A quick chat will help you check for cognitive impairment and put your patient at ease. "I sometimes ask what brings the patient to the office," says Dr Bergman. "If the answer is completely unrelated to any medical situation, you know there's a major cognitive problem."

Rein them in "The elderly sometimes go off on tangents," says Dr Dombrower. "If they come in having chest pains , they might start by saying how they dropped their Cheerios and as they bent to pick it up, the phone rang and they were talking to their daughter, then they had some chest pain — you shouldn't be afraid to end the tangents and focus your patients on the issue at hand," he adds.

Keep it simple Simpler language will spare you the need to re-phrase and repeat. "You think you're asking a question that will get you a straight answer, but you get fooled sometimes," says Dr Dombrower. "If I ask 'Are you having chest pains?' and they say 'No', then a bit later they say 'My chest feels a little tight' — in your mind it's the same thing, but to them it's not."

Ask family Family members can efficiently fill any blanks in a patient's history, especially if there are cognitive problems. "The physician can have questionnaires for the family member to fill out while in the waiting room, with questions about the functional status or living arrangements of the patient," says Dr Bergman. Keep in mind you need the patient's permission to question the family if they don't have any severe cognitive impairments.

Time is money Dr Dombrower offers one last tip: tackle fewer issues at a time. "I'd bring them back frequently for briefer, 15-minute visits," he says. "This way you don't tire your patients, and over time, you get a better idea of what's going on. Besides, this works well with the fee-for-service system."