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History-Taking in the Older Adult

By

Richard G. Stefanacci

, DO, MGH, MBA, Thomas Jefferson University, Jefferson College of Population Health

Last full review/revision May 2022| Content last modified May 2022
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Attention to the medical history is particularly important in older adults because the history is often more complicated than in younger patients, and information may need to be gathered from a variety of sources (see also Overview of the Evaluation of the Older Adult Overview of Evaluation of the Older Adult Evaluation of older adults usually differs from a standard medical evaluation. For older patients, especially those who are very old or frail, history-taking and physical examination may have... read more ). Often, more time is needed to interview and evaluate older patients, partly because they may have characteristics that interfere with the evaluation. The following should be considered:

  • Sensory deficits: Dentures, eyeglasses, or hearing aids, if normally worn, should be worn to facilitate communication during the interview. Adequate lighting and elimination of visual or auditory distraction also help.

  • Underreporting of symptoms: Older patients may not report symptoms that they may incorrectly consider part of normal aging (eg, dyspnea, hearing or vision deficits, memory problems, incontinence, gait disturbance, constipation, dizziness, falls). However, no symptom should be attributed to normal aging unless a thorough evaluation is done and other possible causes have been eliminated.

  • Unusual manifestations of a disorder: In older adults, typical manifestations of a disorder may be absent. Instead, older patients may present with nonspecific symptoms (eg, fatigue, confusion, weight loss).

  • Functional decline as the only manifestation: Disorders may manifest solely as functional decline. In such cases, standard questions may not apply. For example, when asked about joint symptoms, patients with severe arthritis may not report pain, swelling, or stiffness, but if asked about changes in activities, they may, for example, report that they no longer take walks or volunteer at the hospital. Questions about duration of functional decline (eg, “How long have you been unable to do your own shopping?”) can elicit useful information. Identifying people when they have just started to have difficulty doing basic activities of daily living Occupational Therapy (OT) Occupational therapy (OT) focuses on self-care activities and improvement of fine motor coordination of muscles and joints, particularly in the upper extremities. Unlike physical therapy, which... read more (ADLs) or instrumental ADLs Occupational Therapy (OT) Occupational therapy (OT) focuses on self-care activities and improvement of fine motor coordination of muscles and joints, particularly in the upper extremities. Unlike physical therapy, which... read more may provide more opportunities for interventions to restore function or to prevent further decline and thus maintain independence.

  • Difficulty recalling: Patients may not accurately remember past illnesses, hospitalizations, operations, and drug use; clinicians may have to obtain these data elsewhere (eg, from family members, a home health aide, or medical records).

  • Fear: Older adults may be reluctant to report symptoms because they fear hospitalization, which they may associate with dying.

  • Age-related disorders and problems: Depression (common among older adults who are vulnerable and sick), the cumulative losses of old age, and discomfort due to a disorder may make older adults less apt to provide health-related information to clinicians. Patients with impaired cognition may have difficulty describing problems, impeding the physician’s evaluation.

Interview

A clinician’s knowledge of an older patient’s everyday concerns, social circumstances, mental function, emotional state, and sense of well-being helps orient and guide the interview. Asking patients to describe a typical day elicits information about their quality of life and mental and physical function. This approach is especially useful during the first meeting. Patients should be given time to speak about things of personal importance. Clinicians should also ask whether patients have specific concerns, such as fear of falling. The resulting rapport can help the clinician communicate better with patients and their family members.

A mental status examination How to Assess Mental Status The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status ( see Examination... read more should be done early in the interview to determine the patient’s reliability; this examination should be conducted tactfully so that the patient does not become embarrassed, offended, or defensive. Routine screening for physical and psychologic disorders (see table ) should be done annually beginning at age 65. This screening is done as part of the initial Welcome to Medicare Exam and yearly as part of the Medicare Annual Wellness Exam (AWE).

Often, verbal and nonverbal clues (eg, the way the story is told, tempo of speech, tone of voice, eye contact) can provide information, as for the following:

  • Depression: Older patients may omit or deny symptoms of anxiety or depression but betray them by a lowered voice, subdued enthusiasm, or even tears.

  • Physical and mental health: What patients say about sleep and appetite may be revealing.

  • Weight gain or loss: Clinicians should note any change in the fit of clothing or dentures.

Unless mental status is impaired, a patient should be interviewed alone to encourage the discussion of personal matters. Clinicians may also need to speak with a relative or caregiver, who often gives a different perspective on function, mental status, and emotional state. These interviews may be done with the patient absent or present.

The clinician should ask the patient’s permission before inviting a relative or caregiver to be present and should explain that such interviews are routine. If the caregiver is interviewed alone, the patient should be kept usefully occupied (eg, filling out a standardized assessment questionnaire, being interviewed by another member of the interdisciplinary team).

Medical History

When asking patients about their past medical history, a clinician should ask about disorders that used to be more common (eg, rheumatic fever, poliomyelitis) and about outdated treatments (eg, pneumothorax therapy for tuberculosis, mercury for syphilis). A history of immunizations (eg, COVID-19, influenza, pneumococcus, tetanus), adverse reactions to immunizations, and skin test results for tuberculosis is needed. If patients recall having surgery but do not remember the procedure or its purpose, surgical records should be obtained if possible.

Clinicians should ask questions designed to systematically review each body area or system (review of systems) to check for other disorders and common problems that patients may have forgotten to mention (see table Clues to Disorders in Older Patients Clues to Disorders in Older Patients ).

Table

Drug History

The drug history should be recorded, and a copy should be given to patients or their caregiver. It should contain

  • Drugs used

  • Dose

  • Dosing schedule

  • Prescriber

  • Reason for prescribing the drugs

  • Precise nature of any drug allergies

All drugs and substances used should be recorded, including

  • Topical drugs (which may be absorbed systemically)

  • Over-the-counter drugs (which can have serious consequences if overused and may interact with prescription drugs)

  • Dietary supplements

  • Medicinal herb preparations (because many can interact adversely with prescription and over-the-counter drugs)

  • Alcohol

  • Caffeine

  • Other recreational drugs (eg, marijuana)

Patients or family members should be asked to bring in all of the above drugs and supplements at the initial visit and periodically thereafter. Clinicians can make sure patients have the prescribed drugs, but possession of these drugs does not guarantee adherence. Counting the number of tablets in each vial during the first and subsequent visits may be necessary. If someone other than a patient administers the drugs, that person is interviewed.

Patients should be asked to show their ability to read labels (often printed in small type), open containers (especially the child-resistant type), give themselves treatments using a device such as an inhaler, and recognize drugs. Patients should be advised not to put their drugs into one container.

Alcohol, Smoking, and Recreational Drug Use History

Patients who smoke tobacco should be counseled to stop and, if they continue, not to smoke in bed because older adults are more likely to fall asleep while doing so. Patients who use e-cigarettes and vape products Vaping Vaping refers to the inhalation of volatilized liquid (vapor) produced by battery-powered devices. The vapor is primarily water, which is the vehicle for a variety of pharmacologically active... read more should be warned about the risks of nicotine addiction and pulmonary injury.

Patients who use recreational drugs (eg, opioids, alcohol, marijuana, caffeine, hallucinogens) should be counseled about risk of addiction and possible interactions with prescription and other drugs.

Patients should be checked for signs of alcohol use disorders Alcohol Use Disorders and Rehabilitation Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism... read more , which are underdiagnosed in older adults. Such signs include confusion, anger, hostility, alcohol odor on the breath, impaired balance and gait, tremors, peripheral neuropathy, and nutritional deficiencies. Screening questionnaires and questions about quantity and frequency of alcohol consumption can help.

The Short Michigan Alcohol Screening Test-Geriatric Version (or SMAST-G) is a 10-question test designed for people 65 and older (see Screening for Alcohol Use and Misuse in Older Adults). It is usually preferred to other screening questionnaires (eg, CAGE, AUDIT) that were not designed for older adults. Two or more “yes” responses suggest the possibility of an alcohol use disorder.

  • When talking with others, do you ever underestimate how much you drink?

  • After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn’t feel hungry?

  • Does having a few drinks help decrease your shakiness or tremors?

  • Does alcohol sometimes make it hard for you to remember parts of the day or night?

  • Do you usually take a drink to relax or calm your nerves?

  • Do you drink to take your mind off your problems?

  • Have you ever increased your drinking after experiencing a loss in your life?

  • Has a doctor or nurse ever said they were worried or concerned about your drinking?

  • Have you ever made rules to manage your drinking?

  • When you feel lonely, does having a drink help?

Nutrition History

  • Any special diets (eg, low-salt, low-carbohydrate) or self-prescribed fad diets

  • Intake of dietary fiber and prescribed or over-the-counter vitamins

  • Weight loss and change of fit in clothing

  • Amount of money patients have to spend on food

  • Accessibility of food stores and suitable kitchen facilities

  • Variety and freshness of foods

The ability to eat (eg, to chew and swallow) is evaluated. It may be impaired by xerostomia and/or dental problems, which are common among older adults. Decreased taste or smell may reduce the pleasure of eating, so patients may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients who are worried about urinary incontinence may inappropriately reduce their fluid intake, increasing their risk of dehydration.

Mental Health History

Mental health problems may not be detected easily in older patients. Symptoms that may indicate a mental health disorder in younger patients (eg, insomnia, changes in sleep patterns, constipation, cognitive dysfunction, anorexia, weight loss, fatigue, preoccupation with bodily functions, increased alcohol consumption) may have another cause in older adults. Sadness, hopelessness, and crying episodes may indicate depression. Irritability may be the primary affective symptom of depression, or patients may present with cognitive dysfunction. Generalized anxiety is the most common mental disorder encountered in older patients and often is accompanied by depression.

Patients should be asked about delusions and hallucinations, past mental health care (including psychotherapy, institutionalization, and electroconvulsive therapy), use of psychoactive drugs, and recent changes in circumstances. Many circumstances (eg, recent loss of a loved one, hearing loss, a change in residence or living situation, loss of independence) may contribute to depression.

Patients’ spiritual and religious preferences, including their personal interpretation of aging, declining health, and death, should be clarified because these preferences and viewpoints impact their goals of care and quality of life.

Functional Status

Table
Table

Social History

Clinicians should obtain information about patients’ living arrangements, particularly where and with whom they live (eg, alone in an isolated house, in a busy apartment building), accessibility of their residence (eg, up stairs or a hill), and what modes of transportation are available to them (see also Social Issues in Older People Introduction to Social Issues in Older Adults Social issues influence an older person’s risk and experience of illness as well as a health care practitioner’s ability to deliver timely and appropriate care. A social history helps members... read more ). Ownership of a smart phone and ability to use it to access ride-sharing, food delivery, and other supportive services should also be assessed. Such factors affect their ability to obtain food, health care, and other important resources. A home visit, although difficult to arrange, can provide critical information. For example, clinicians can gain insight about nutrition from the refrigerator’s contents and about multiple ADLs from the bathroom’s condition.

The number of rooms, number and type of phones, presence of smoke and carbon monoxide detectors, and condition of plumbing and heating system are determined, as is the availability of elevators, stairs, and air conditioning. Home safety evaluations can identify home features that can lead to falls (eg, poor lighting, slippery bathtubs, unanchored rugs), and solutions can be suggested.

Having patients describe a typical day, including activities such as reading, television viewing, work, exercise, hobbies, and interactions with other people, provides valuable information.

Clinicians should ask about the following:

  • Frequency and nature of social contacts both in person, via telephone, and online (eg, friends, senior citizens’ groups), family visits, and religious or spiritual participation

  • Driving and availability of other forms of transportation, including ride-sharing services

  • Caregivers and support systems (eg, places of worship, senior citizens’ groups, friends, neighbors) that are available to the patient

  • The ability of family members to help the patient (eg, their employment status, their health, traveling time to the patient’s home)

  • The patient’s attitude toward family members and their attitude toward the patient (including their level of interest in helping and willingness to help)

Marital status of patients is noted. Questions about sexual practices and satisfaction must be sensitive and tactful but thorough. The number and sex of sex partners are determined, and risk of sexually transmitted infections (STIs) is evaluated. Many sexually active older people are not aware of the increasing incidence of STIs in older adults and do not follow or even know about safe sex practices.

Patients should be asked about educational level, jobs held, known exposures to toxins, and current and past hobbies. Economic difficulties due to retirement, a fixed income, or death of a spouse or partner are discussed. Financial or health problems may result in loss of a home, social status, or independence.

Advance Directives

Patient wishes regarding measures for prolonging life must be documented. Patients are asked what provisions for surrogate decision making ( advance directives Advance Directives Advance directives are legal documents that extend a person's control over health care decisions in the event that the person becomes incapacitated. They are called advance directives because... read more ) have been made in case they become incapacitated, and if none have been made, patients are encouraged to make them. Getting patients and their surrogates accustomed to discussing goals of care is important because when circumstances require medical decisions and prior documentation is unavailable or not relevant to the circumstance, which is very common, appropriate decisions can be made.

Key Points

  • Unless corrected, sensory deficits, especially hearing deficits, may interfere with history-taking.

  • Many disorders in older adults manifest only as functional decline.

  • As part of the drug history, the patient or a family member should be asked to bring in all the patient’s drugs, including over-the-counter drugs, at the initial visit and periodically thereafter.

  • Health care practitioners must often interview caregivers to obtain the history of functionally dependent older patients.

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

  • Medicare: Annual Wellness Examination (AWE): A US resource that includes the main components of a comprehensive geriatric assessment and provides a detailed health risk assessment and personalized prevention plan

  • Centers for Disease Control and Prevention (CDC): Promoting Health for Older Adults: A web site providing resources for older adults, older adults with dementia, and caregivers and information about preventive screening services and other health interventions

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