History-Taking in the Older Adult

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 ( Professional... 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:

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).

If indicated, clinicians should consider the possibility of drug abuse by the patient and patient abuse Elder Abuse Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of older adults. Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial... read more by the caregiver.

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 ).

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

All drugs and substances used should be recorded, including

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.

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 Disorder 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.

Type, quantity, and frequency of food eaten are determined. Patients who eat ≤ 2 meals a day are at risk of undernutrition Overview of Undernutrition Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.) Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss... read more . Clinicians should ask about the following:

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 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.

Whether patients can function independently, need some help with 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 , or need total assistance is determined as part of comprehensive geriatric assessment. Patients should be asked open-ended questions about their ability to do activities, or they may be asked to fill out a standardized assessment instrument with questions about specific ADLs and instrumental ADLs (eg, see tables Modified Katz ADL Scale Modified Katz Activities of Daily Living (ADL) Scale and Lawton IADL Scale Lawton Instrumental Activities of Daily Living Scale ).

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 professional'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:

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.

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.

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