The short vignette just presented illustrates the way in which many elderly patients attribute their symptoms to normal aging and may require open-ended prompting (“What do you mean by 'old age?'”) to discuss symptoms that could indicate a specific disease process as opposed to senescence. Patients may attribute nocturia or joint pains, for example, to aging, even though these symptoms may, in fact, indicate specific diseases, such as congestive heart failure or rheumatoid arthritis. Moreover, vague symptoms may have special implications in the elderly, as in the case of a 90-year-old man with pneumonia who experiences loss of appetite and feelings of malaise rather than a more typical presentation with fever and cough.
Likewise, chronic symptoms much be distinguished from acute or unstable symptoms. For example, the sudden onset of urinary incontinence requires a different approach than does a report of incontinency of many years' duration. You also will notice that the pace of the interview is often slower and that the elderly infuse their medial stories with a lifetime of experience that demands our respect. These are just some of the stylistic changes that you will note as you interview the geriatric patient.
The Content of the Interview
In addition to changes in style, the geriatric history emphasizes somewhat different content areas as well. For example, remote events, such as childhood history, are usually not relevant and may be obtained with a minimum amount of detail, with questions like “Any unusual illnesses when you were a child?” The family history is also less important because most familial diseases will have expressed themselves by the time a person reaches old age. Family history takes on a different twist because you are now looking no only at the preceding generation but at the patient's children and grandchildren as well. For example, an older woman whose daughter has breast cancer may herself be at increased risk of the disease and may not know that, in fact, it was breast cancer that took the life of her mother 40 years earlier.
Moreover, elderly persons may worry about the health of their children and grandchildren, and your interest in their families provides an opportunity to explore those concerns. Details about diet include consideration of specific nutrients such as calcium (needed to prevent osteoporosis) and fiber (which may help prevent constipation and treat diverticular disease or hemorrhoids). You should also assess sexual feelings and function, but this must be done sensitively and in context. Frail, sick, or widowed elderly patients may find questions like “Are you sexually active?” or “Are you having any sexual problems?” surprising, if not downright inappropriate. It is better to give the patient plenty of room to answer, based on his or her own situation. For example, “As people get older they sometimes find that their marriage changes. How has it been for you?” and then “Has anything changed in your sexual relationship?” Change in sexual function also may related to specific illness, rather than to age ...