When working with elderly patients, it’s a good idea to initiate your visit or phone call with a conversation rather than direct health-related questions, suggests a case manager who has extensive geriatric experience and visits patients at their homes.
“Instead of asking, ‘How many times did you have a bowel movement today,’ start with, ‘How long have you lived in this house?’” says Elisol I. McKim, BSN, RN, CCM, nurse care manager with CARE Connect of St. Joseph Heritage Healthcare in Anaheim, CA.
“The reason I ask this question is because I am a stranger coming into their home, and they don’t know what I will ask or do,” McKim says. “It’s better to have a conversational interaction.”
Once McKim puts patients at ease, she might ask some of the questions that will help her determine the patient’s ability to manage his or her medical condition, including the following:
- Do you live alone?
- Who supports you?
- How long have you had your diabetes/disease?
- How long have you been checking your blood sugar?
- How long have you had shortness of breath?
- How long have you been smoking/drinking?
- How many times have you tried to stop smoking/drinking?
- Have you tried drinking less?
“For chronic obstructive pulmonary disease [COPD] patients, I don’t lecture them about stopping smoking because they’re older, and I’m sure they’ve tried,” McKim explains. “So I ask about how many cigarettes they smoke, and if I have to give them a suggestion, I say, ‘You may want to think about decreasing your smoking from 20 cigarettes to 15.’”
McKim also tells them that the reason they’ve had health problems is because of their smoking and COPD. “Part of it is motivational interviewing,” she notes. “You want to motivate them.”
Another thing case managers should keep in mind is that their elderly patients might be experiencing depression, which also could have an effect on how well they follow their treatment plans.
“I’ve done about 200 home visits in the CARE Connect program, and I’ve seen a lot of depression in the elderly population,” McKim says. “Here you are as an 80-year-old patient who lives alone, and you get scammed by telephone marketers because no one else is calling you all day.”
McKim has seen this firsthand: “I was visiting one patient for an hour, and the person’s phone rang six times — all telemarketers.”
Patients who are in their 70s and older come from a generation that stigmatized mental healthcare. “The older generation didn’t want to see a psychiatrist because of the stigma that you’re crazy,” she says. “Some of my patients might still have that stigma, so I say, ‘Why don’t you see a therapist?’ because they just need someone to talk to.”
One way to quickly assess whether depression is an issue is to ask a patient, “When was the last time you felt joy?” McKim suggests.
“Some answer so fast, and some have to think about it. This gives you a better understanding of their depression,” she says. “So if someone says they feel joy every time they see their grandkids, you can ask, ‘How often do you see them?’”
If the patient’s answer is “every day” or “every week,” then the case manager can see that the patient’s mental health status is pretty good. But if the answer is “I don’t remember,” then there’s a hint that there’s a mental health issue that should be assessed, McKim says.
A depression screening can give healthcare professionals an idea of a patient’s risk, but even more information can be obtained from conversations, she says.
“I want to find out what is the reason they’re not feeling happy, so how can I make them talk to give me a better picture of what their situation is?” McKim says. “In my interaction with them, it’s a conversation.”
Another mental health issue is that trauma from childhood and young adult experiences, including military service during war times, can resurface in older adults.
“I have one patient who is in her 90s and in good health with only a few medications,” McKim says. “But when she saw her doctor, she revealed that she suddenly remembered that she was molested in her 20s, and 70 years later it resurfaced.”
McKim convinced the woman to see a therapist, and the woman’s physician prescribed an antidepressant.
“She saw the therapist for less than three months and then said she thought she’d be fine,” McKim recalls. “I asked her, ‘What happened in that 70 years? Did you ever have depression?’”
The woman said that she had never experienced depression as she was busy raising children, but she now realized that several of her marriages had failed probably because of her earlier traumatic experience.
A patient in her 70s had been molested as a child, and five decades later, she found herself crying every day, McKim says. “The person who had molested her was dead, and yet, it was as if it happened yesterday.”
In hospital settings, medical professionals do not see these hidden injuries, so McKim says she appreciates that she can spend time visiting with patients and helping them cope with long-buried emotional traumas.
Case managers working with older patients also need to find out what their patients’ personal goals are for their health.
When McKim asks her elderly patients what their goals are, they do not always have an answer, so she helps them think about the kinds of activities and connections they’d like to make.
“Maybe they want to see their daughter in another state or they want to be around when their great-granddaughter is born,” McKim says. “So I say, ‘Great. We need to take care of your congestive heart failure and diabetes to keep you healthy.’”
During home visits, case managers can identify problems before they occur, such as elderly couples where one person is failing rapidly and the spouse is ill-equipped to handle the physical and emotional demands.
For example, McKim had one patient, with multiple chronic illnesses, who was in his 80s and the sole caretaker for his wife, who had dementia. The man had medical problems and no children to help him with his wife. McKim first saw him at his doctor’s clinic and scheduled a time to visit his house. When she arrived, she noted that the house was clean and the couple clearly had the financial resources to obtain help with daily activities.
“One of his burdens was taking care of his wife, who would leave the house and get lost, so he’d have to call the police,” McKim explains. “She could fold the laundry and watch TV, but then she’d try to get out of the house in the middle of the night.”
It took a while, but the man finally admitted that he could no longer take care of his wife, so McKim helped him find a nearby assisted living center where she could receive continual help. And McKim helped the man find a caregiver who could clean his house.
“He said to me, ‘If I die today and she is by herself, she doesn’t know how to call 911,’” McKim recalls. “So he felt good about the assisted living because his wife was being taken care of.”