Cognitive impairment can take many forms. For numerous reasons, many older patients process information more slowly, with a noticeable lag between question and answers, often causing poorly-concealed clinician impatience.⁷ Although cognitive impairment usually impacts the accuracy and reliability of history, what may be more significant is that there is often an associated personality change.

Most often in dementia, patients present with stubbornness, egocentricity, loss of empathy, and an indifference to social context.^8,9 These changes are common in Alzheimer's disease, but can be seen in any type of dementia. The consequence to history taking is verbosity, intrusion of irrelevant information, and oppositional behavior.

Nature of miscommunication

The following dialogue is from "Hold That Ghost," a 1941 Abbott and Costello film that illustrates one type of miscommunication: mutual misunderstanding.

Chuck: Just put it over there on that highboy.
Ferdie: What?
Chuck: Highboy.
Ferdie: Hi, Chuck!

Based on the authors' clinical experience, the specific communication pitfalls when interacting with older patients are:

• mutual misunderstanding
• not hearing
• not listening
• opinion presented as fact
• withholding of information
• verbosity, and
• oppositionality.

Although some issues are self-explanatory, others require exploration.

Mutual misunderstanding occurs when the patient misconstrues a question and the clinician misconstrues an answer. When a clinician is fatigued, rushed or preoccupied, this is more likely to occur with potentially disastrous results. The probability increases as the gap in education and socioeconomic level widens between patient and physician. For example, your patient may not understand the distinction between a stroke and a heart attack.

Patients may present opinion as fact (as may physicians) with serious consequences. Poorly educated patients often causally connect events that are temporally related, and are unwilling to explore other scenarios. Educational limitations, anxiety, and cognitive impairment may all play a part.

A patient's verbosity can be very frustrating for the busy physician. There is rarely a single cause: Anxiety, culture, cognitive impairment, and personality factors may all play a role.¹⁰

Verbosity in the physician's office can represent more than mere disorganization; it may imply more serious problems, such as hearing loss, lack of social resources, or lack of judgment and empathy.¹¹ Intact, mature persons constantly monitor the reactions of the other person, and are quickly aware of expressions of impatience, boredom, or irritation. An intact speaker is able to modify behavior in response to this monitoring.

The verbose patient not only lacks the ability to come to the point, this patient often resents being asked to do so. This phenomenon has been labeled off-target verbosity.¹² It seems to affect roughly one-third of healthy older adults, to increase in frequency with age, and to be associated with subtle neuropsychological impairment, although not with frank dementia.^13-15

Oppositionality is often seen with verbosity, and may be caused by similar factors. Patients presenting with oppositionality insist on setting the agenda and become angry at a physician's attempt to direct or structure the interview. The clinical situation can quickly turn into a power struggle.^14,15

The following vignette illustrates a physician who grows frustrated by his interaction with a demented patient and lack of success in collecting any relevant medical history.

Dr. J: What brings you here today, Mr. D?

Mr. D: I drove here in my car. My wife wanted to come but I told her I could manage.

Dr. J: What can I do for you, sir?

Mr. D: My wife always wants to get her two cents in.

Dr. J: Why are you here sir? What's bothering you?

Mr. D: Well, you're the doctor, aren't you? Where'd you go to school?

Dr. J: (smiling tightly) I would really appreciate if you would tell me more about your health complaint and not talk about other things. I don't have much time. I have to see other patients.

Mr. D: (voice raised slightly) Well, why didn't you say so in the first place? My stomach's been bothering me. I get this pain (points to sternum), this heartburn, and Tums won't help. I told my wife and she kept nagging me to go see a doctor, so here I am. That woman grabs onto things like a Bulldog and won't let go! Are you married, Doc?

Dr. J: (raising his voice) Sir, excuse me ... you are doing it again.

Mr. D: Well I've been married 42 years and we've had our ups and downs, but Grace is a good woman. She's gained a lot of weight lately.

Dr. J: (Frowning) Sir, if you continue like this, we will get nowhere. I can not help you when you are like this.

Mr. D: Where is my wife? I don't want to talk anymore. I need to go. Bye. (Patient abruptly exits the room.)

Managing miscommunication

The challenge that confronts a physician taking a history from an older patient is how to collect a complete history in a relatively brief span of time, while maintaining a good working alliance with the patient. As discussed, older patients who have a difficult time as historians generally lack insight; they see nothing wrong with their way of answering questions. For this reason, an attempt to educate the patient does not work well. Instead, we recommend alternative strategies to collect the necessary information.

Before the interview

It is strongly recommended that physicians obtain and review medical records prior to the interview. If this is not possible, the responsibility of presenting an accurate medical history lies with the patient (and caregiver in cases in which the patient is unable to give such information, eg, a demented patient). To further facilitate the information gathering process, it may be helpful to send the patient and/or caregiver a list of questions that the physician will ask in the initial interview (table). The language of the questions should be at a 6th grade level to accommodate minimal education levels. It can be helpful for the physician's office manager to contact the patient after the list of questions has been sent to answer any general questions that the patient may have before he sees the physician.

The completed form will lend some direction to the actual interview and will likely decrease the off-target verbosity, keeping the patient focused on the question asked. If these goals are met, the time it takes for the physician to take a complete medical history will be greatly reduced.

Interviewing strategies

During the history-taking interview, it is critical that the physician listen actively to the patient. Not only will this aid the patient's comfort level in relating potentially embarrassing medical information, it will also assure the patient that the doctor has heard the information correctly. One relevant example of active listening would be paraphrasing and/or acknowledging what the patient said, and then summarizing the information related.

Physicians should be alert not only to verbal expression, but also to the emotion behind the expression, specifically hidden fears, beliefs, and expectations. Time does not permit a truly open-ended interview in a medical setting, but a physician can learn to recognize a subjective feeling of discord. This is a subtle message that the patient and physician are not communicating. When a physician develops this impression, it is appropriate to explore these unspoken issues. Possible remedies are "Tell me your ideas about that," "You seem worried about something," or "Is there something I can answer for you?"

The following vignette is an example of a physician's finesse when a medical history from a nervous older patient provides extraneous information.

Dr. L: Good afternoon, Mrs. T. I am Dr. L. It is a pleasure to meet you. Why are you here to see me?

Mrs. T: (appears confused) I guess it is because I am having pain. My daughter could not come with me today. She is on vacation in New York with my grandchildren.

Dr. L: Well, I hope your family is enjoying their vacation. There is a lot to see and do in New York. Where are you having pain and when did the pain start?

Mrs. T: Well, my legs have been hurting for the last four years. I am used to it by now. On Sunday, I got this pain (points to sternum)...the heartburn. I took some Tums but it did not help. I told my daughter about it and she scheduled this appointment with you.

Dr. L: (expression of concern) Well, I'm sorry that you've had pain in your chest area and the Tums did not seem to help. Let's see what we can do to help ease your pain and heartburn. Can you tell me if you had this pain before Sunday?

Mrs. T: I started getting heartburn or pain...whatever you want to call it, about 6 months ago, and now it happens frequently. It used to happen when I was mowing the lawn but I stopped doing that and hired a yard man. The pain stopped for a while but now it has returned. Now I get it when I'm sitting and watching TV.

Dr. L: Do you notice any other problems when you experience this pain?

Mrs. T: Oh yeah...I feel this pressure...makes it hard to breathe. I kind of sweat when I get it. Sometimes this pain lasts 5 to 10 minutes.

Dr. L: That must be difficult for you. Do your legs and arms ever hurt when you get this pain?

Mrs. T: Oh yeah, I forgot to mention that. How'd you know about that? (Laughs)

Dr. L: I think I know what may be causing your pain, and may be able to manage it to provide you more comfort. I would like to run some tests to be sure. Is that ok with you?

Mrs. T: Yes, sure. Would you mind talking to my daughter about this when she returns from her vacation?

Dr. L: Absolutely. We will make sure to let your daughter know what is going on.

Mrs. T: Thank you so much. You are such a nice man. I appreciate your time today to help me.

Dr. L: Well, thank you. May I answer any questions before I ask my assistant to speak to you about setting up the tests?

In this example, the patient is having substernal pain, which may be due to unstable angina. Initially the patient is somewhat ambivalent and off-target, but she becomes more relaxed and focused as she becomes more comfortable. Dr. L's next question, when he asks whether Mrs. T notices any other problems when she experiences the pain, solidifies the alliance.

Although the verbal interaction between the physician and patient are important, the non-verbal dynamics of the interview are just as critical. Particular relevant components of nonverbal communication are sensitivity and congruence.¹⁶ It is important for the physician to be sensitive to the patient's non-verbal cues, as they can facilitate or interfere with the interview process. For example, a patient may not feel comfortable verbalizing his discomfort to the physician, but he will relate this feeling in his posture and facial expressions. It is also imperative that the physician maintain congruence between verbal and non-verbal behaviors in order to gain the patient's trust. Even cognitively impaired patients are surprisingly sensitive to subtle indications of disinterest or condescension in a physician and will react to them.

Conclusion

Factors such as education, socioeconomics, anxiety, and sensory/cognitive impairment, present unique challenges when conducting history taking in older patients. These factors can contribute to miscommunication between the patient and physician. Respect, patience, establishing rapport, structure, and reflecting back are all useful in collecting a good medical history. History-taking goes hand-in-hand with building a solid doctor-patient relationship, which remains essential in good medical practice.

Dr. Lesser is associate professor of psychiatry and chief of the gero-psychiatry clinic at the University of Texas (UT) Medical School in Houston.

Ms. Hughes is a psychometrician and a research assistant to Dr. Lesser at the UT Medical School in Houston.

Mr. Jemelka is research assistant at the UT Health Science Center

at Houston.

Ms. Kumar is a senior research coordinator at the UT Health Science Center at Houston.

Disclosures: The authors have no real or apparent conflicts of interest with the subject under discussion.

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