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The ART of History Taking: The Older Adult

Linda J . Keilman, DNP, GNP-BC
Gerontological Nurse Practitioner

The truth is that our finest moments are most likely to occur when we are feeling deeply
uncomfortable, unhappy or unfulfilled. For it is only in such moments, propelled by our discomforts,
that we are likely to step out of our ruts and start searching for different
ways or truer answers.

M. Scott Peck

The aging process:
Is not a disease
Does not cause symptoms
Is generally benign

The hallmark of aging is loss of physiologic organ reserves that place older adults at risk for developing
certain diseases & syndromes or change in functional status.


G Gr ro ow wi in ng g o ol ld d i is s i in ne ev vi it ta ab bl le e (if we are lucky) b bu ut t t th he e r ra at te e o of f a ag gi in ng g i is s v ve er ry y i in nd di iv vi id du ua al l! !

Older Adults Are:
Unique individuals
Walking history books
Greatly experienced
Creative & talented
Multidimensional
Complicated & complex
Increasing in #s


General Pointers:

The history may take more time because of sensory or cognitive impairment or simply because an
older individual has lived a long life full of many details & events
Several appointments may be required (referred to as incremental assessment) to obtain all
information
The older individual should be recognized as the primary source of information
o If doubts arise about accuracy, other sources should be contacted with due respect paid to the
sensitivities & confidentiality of the individual (keeping in mind HIPAA regulations)
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o When interviewing the older adult & a caregiver together, ask questions & look directly at the
older adult (patient) & then to the caregiver
Always get permission for the other individual to be in the room dont assume!
o If the individuals responses to initial questions are clearly inappropriate, turn to the mental
status exam immediately
The Mini-Cog is located at this site
http://consultgerirn.org/uploads/File/trythis/try_this_3.pdf
The older adult should be dressed & seated
The provider should be seated & facing the individual at eye level, speaking clearly with good lip
movement
o If the older adult is severely hearing impaired & an amplifier is not available, write questions
in large print (can use a white erase board)
General observations should be made regarding:
Appearance (hair, makeup, clothing, jewelry, etc)
Hygiene
Eye contact
Assistive devices (eye glasses, hearing aide, cane/walker, dentures)
Posture
Presence of tremors or fasciculations
Uncovered skin

Setting The Stage:

Address the individual
Conventional title of courtesy (Honorifics: Mr., Mrs., Miss, Ms.)
Get permission to call them by their 1
st
name, or a nickname
Shake hands this will help you to assess
Function
Strength
Tremor
Vision
Watch the individual ambulate (without them knowing you are looking)
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Get Up & Go
Tinetti Balance & Gait Test
From the exam table or chair in the room


Body Language
Facial Expression (mood)
Observe
Clothing
Grooming
Makeup
Nails
Hair
J ewelry
Listen to:
What is not said
How the story is told
Tempo of speech
Tone of voice
The words that are used
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The key to an excellent, complete older adult health history is -
Structure who plays what roles
o Be sure you introduce yourself, define your role as a graduate NP student & which preceptor you
are working with
Dynamics who does what to whom
o Tell the patient what you are going to do with them, whether your preceptor will be coming in to
chat & what your expectations are for the patient

The patient history is the single most important component in making a diagnosis. Showing interest &
allowing the patient to explain all his or her concerns are useful & economic techniques. Open-ended
questions encourage full disclosure; more narrowly focused questions test hypotheses. Positive nonverbal
provider behavior & pauses in the discussion encourage openness. Repeating & summarizing information
confirm the patient's words & reveal the providers interest & trust.

The history is the first step in treatment & often the key factor in diagnosis, with 50-60% of diagnoses
revealed by questioning of patients, as opposed to physical examination & laboratory tests, according to
one study (Rich, E.C., Crowson, T.W., & Harris, I.B. (1987). The diagnostic value of the medical history:
Perceptions of internal medicine physicians. Archives of Internal Medicine 147, 1957-1960).

The normal age changes in this handout will hopefully help you to understand why the health history
taking for an older adult is different! It truly is an art & one that I hope you can embrace in the future!


Normal Aging Vision Changes:
Lens become dense & less elastic
Decrease in visual acuity
Decreased peripheral vision & depth perception
Colors fade & disappear
Lens may develop opacity
Decreased blood flow to retina
Changes in the corneal curvature
Sclerosis & rigidity of the iris
Atrophy of photoreceptor cells
Thinning & sclerosis of retinal blood vessels
Recovery time from light to dark (& vice versa) is delayed
Decreased ability to focus on close objects

Presbyopia is the vision loss associated with the aging process

Y Yo ou ur r Accommodations or Interventions: (it is up to you to adjust your style of interviewing & not
expect the older adult to change their ways)
Sit at the patient level (in field of vision)
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Increase lighting without glare
Eye contact (unless culturally inappropriate)
No bright lights behind you
No gloss on information you want person to read
Times New Roman font 14 (minimum); bold


Normal Aging Hearing Changes:
External ear
Increased keratin
Middle ear
Less resilient tympanic membrane
Calcified ossicles
Stiffer muscle & ligaments
Inner ear
Fewer neurons
Fewer hair cells
Diminished blood supply
Degeneration of spiral ganglion

Presbycusis is the hearing loss associated with the aging process. With presbycusis elders complain of
the inability to hear high frequencies & are unable to hear consonant sounds such as f, g, s, z, t, sh, & ch.
Other age changes involve the collapse & narrowing of the auditory canal & thickening of the earwax.
This increases the difficulty in hearing.

Behavioral Cues that might make you think the individual has a hearing problem, even if they deny
having difficulty with hearing:
Inappropriate or no response to questions
Inability to follow verbal directions without cues
Short attention span
Easy distractibility
Conversational speech too loud
Mouthing of words spoken by the speaker
Turing of one ear toward the speaker
Unusual physical proximity to the speaker
Lack of response to loud environmental noises
Inarticulate speech
Abnormal voice characteristics
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Perceptions that others are talking about him/her
Frequent requests for repetition or clarification of verbal communication

Y Yo ou ur r Accommodations or Interventions:
Address person by name & then begin talking
o Get the attention of the person before speaking
Sit at eye level to the older adult, within close proximity
Talk slowly, distinctly & directly to the individual
Simple word articulation works best - do not over exaggerate words
Talk into the least impaired ear
Do not shout or raise the volume of your voice
Ask 1 question at a time & then wait for the answer
Keep sentences short
Use visual speech demonstrate what you are saying
Gestures & body language
Facial expressions
Make sure your lips can be seen
Allow the person to lip read
If you have a mustache or beard, trim away from
lips
Do not exaggerate lip movements
Avoid chewing gum or sucking on candy while
speaking
Avoid or eliminate all background noise in the room
One conversation at a time
Only one person talks at a time
Sequence topics so that you can glean as much information as possible without asking more questions
Keep all instructions simple
Give written instructions
Use large print written communication & pictures to supplement verbal communication
Ask for feedback to assess what the person heard
Avoid questions that require simple yes or no answers
Avoid glare
Provide adequate lighting
Clean eye glasses


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Normal Aging Neurological Changes:
Decreased speed of recall
Loss of short term memory
Slowed thought processes
Increased response time
Voluntary or automatic reflexes slower
Decreased ability to respond to multiple stimuli
Altered pain response
Decreased sensory input
Benign forgetfulness
Increased time needed to learn

Y Yo ou ur r Accommodations or Interventions:
Allow more time for tasks
Maintain calm, relaxing environment without multiple stimuli
Be patient!
Encourage long term memories

Incremental Assessment: in todays economic healthcare environment, you generally cannot spend all the
time you need to with an older adult in gathering a complete history & physical examination in one visit.
Therefore, it is prudent to establish a relationship & gather pertinent data on the 1
st
visit & then bring the
patient back in order to obtain more thorough information. This type of approach is billable, economic &
more elderly friendly.
Physical domain
Chief complaint
Your observation
Cognitive domain
Emotional domain or mood
Social domain
Spiritual domain

Approach Differences:
May need to interview the patient & caregiver separately
The history & PE may need to be done on different visits
A complete history may not be obtainable so more focus is on the PE
You need to spend more time with the old & frail
The older adult may present with nonspecific symptoms & thus difficult to focus the interview
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The older adult may underreport symptoms which they consider normal aging
N NO O symptom should be attributed to normal aging!
What are the symptoms?
Dyspnea
Hearing or vision loss
Problems with memory
Urinary incontinence
Gait disturbance
Constipation
Dizziness
Falls
Headache
Stiffness
Sensory deficits (hearing or vision loss) may interfere with the interview process
Clinical features of diseases may differ from those in younger patients
Diseases may manifest as functional decline
Therefore, standard questions may not apply to the situation
Unusual Presentations:
UTI
Hypothyroidism
Pneumonia
Appendicitis
MI
Heart failure
Need to ask questions pertaining to the duration of functional decline & the perceived effect on QOL
(quality of life)
Older adults may have difficulty recalling all past medical information
Illnesses (especially those in childhood), hospitalizations, surgeries, past medications, dates, etc)
You may need to obtain data from a secondary resource
Keep in mind, the older adult & their family may have different ideas about the CC
A highly structured approach is too limiting for older adults
Using the CC as the focal point of the history may not work with older adults
Have the individual describe a typical day
This approach reveals information about:
QOL
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Liveliness of thought
Physical independence
What T TH HE EY Y are thinking
Allowing an individual to talk about something they are proud of, or something of personal
importance, generally builds immediate & long-lasting rapport
A good relationship helps communication & leads to better treatment adherence
If possible, the older adult needs to be fully clothed during the interview
Patients who wear glasses, dentures or hearing aids should have them in place
A Mini-Cog or MMSE (mini mental status examination) may need to be done early in the interview to
determine historical reliability
The older adult should be interviewed alone to encourage discussion of personal matters
Exception: cognitive impairment
Ask the older adults permission before you ask a relative to be present during the interview
If the older adult presents with a symptom ask the dimension of a symptom or chronological story
questions
Ask if they have ever had the symptom before
If so ask how the symptom was treated & WHAT DO THEY THINK IT IS?
This is often extremely revealing!

Past Medical History:
Ask about diseases that were common in their lifetime
Rheumatic Fever
Poliomyelitis (iron lung)
Syphilis (treatment with mercury)
TB (institutionalization; creation of pneumothorax)
Hx of immunizations (these are the only ones that should be addressed, not childhood immunizations)
Tdap
Influenza
Pneumococcus
Shingles
These are CDC recommendations which you can learn more about at
http://www.cdc.gov/vaccines/pubs/downloads/f_imz_oldadults_pr.pdf
Adverse reactions to immunizations
Skin test results for TB (Mantoux test)
Allergies & REACTION


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Past Surgical History:
If the older adult recalls having surgery but does not remember the procedure this is something you
can talk about when you do the PE
Scars
Give memory triggers

Review of Body Regions & Organ Systems:
Head to toe
Thorough
Wait for response to each symptom cannot ask in a cluster
Every time the individual says yes, you must ask about the parameters/dimensions of a symptom or
the chronological story

Dimensions of a Symptom:
1. Body location (where)
2. Quality (what does it feel like; what gestures are being used)
3. Quantity or severity (generally use a scale; older adult quotes; intensity; functional
impairment)
4. Timing (onset, duration, frequency)
5. Setting in which symptom occurs (what were they doing)
6. Factors that aggravate (make worse) condition
7. Factors that alleviate (relieve or make better) condition
8. Associated manifestations (what other symptoms occur at same time)
9. What does the person think it is?
10. Have they ever experienced before? If so, what was it then?
11. What do you think it is?

Chronologic Story - this can be a narrative section of your documentation when the older adults chief
complaint (CC) is documented in the proper sequence of events.
1. When the symptom started
2. Whether the onset of symptoms was sudden or gradual
3. If available, specific dates when the problem was experienced
4. How often the problem occurs
5. Exact location of the distress
6. Character of the complaint (intensity of pain or quality of sputum, emesis or discharge)
7. Amount of discharge, mucus, blood, stool or urine or the size of the lesion
8. Activity in which the resident was involved when the problem occurred
9. Phenomena or symptoms associated with the CC
10. Factors that aggravate or alleviate the problem

Need to be thinking about disease process & differential diagnoses





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Medication/Drug History:
Brown Bag Test (asking the individual to bring in all medications they have in their home in a brown
paper bag)
Prescription
OTC
Herbal or botanical remedies
Home remedies
Topical
Lotions/ointments/potions
Have the patient:
Read the drug or vial label
Open the vial
Differentiate between medications
Make a list of all meds & give copy to patient
Name, dose, route, how taken, for what reason, who prescribed

It is also very important that you are aware of the medications that may be harmful to older adults
o Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Part I can be
found at http://consultgerirn.org/uploads/File/trythis/try_this_16_1.pdf
o Part II of Beers Criteria can be found at
http://consultgerirn.org/uploads/File/trythis/try_this_16_2.pdf

Nutrition History:
24 hour dietary recall
The Mini Nutritional Assessment is a great tool to use & can be found at this site
http://consultgerirn.org/uploads/File/trythis/try_this_9.pdf
Type, quantity, frequency of food eaten
#hot meals per week
Prepare per self?
Shopping? Cost?
Self prescribed fad diets
Special diets (DASH, low salt, etc)
ETOH intake
The Geriatric Version of the Short Michigan Alcoholism Screening Test is located here
http://consultgerirn.org/uploads/File/trythis/try_this_17.pdf
Dietary fiber intake
Ability to eat & swallow
Dental visits
Fluid intake
Kitchen safety
Smoke alarms & fire extinguishers

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The Tufts Good Guide Pyramid for Adults >50 has more information on how to interpret the
categories at http://nutrition.tufts.edu/docs/guidelines.pdf

Psychiatric History:
Not as easily detected
Common sx =insomnia, changes in sleep patterns, constipation, decreased cognition, anorexia, weight
loss, fatigue, preoccupation with bodily functions, increased ETOH consumption, somatic complaints
o The Pittsburgh Sleep Quality Index (PSQI) tool is located at
http://consultgerirn.org/uploads/File/trythis/try_this_6_1.pdf
o The Epworth Sleepiness Scale (ESS) can be found at
http://consultgerirn.org/uploads/File/trythis/try_this_6_2.pdf
Ask about delusions & hallucinations
Past psychiatric care
Psychotherapy
Institutionalization
Electroconvulsive therapy
Use of psychoactive drugs & depressants
Depression common
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o The Geriatric Depression Scale (GDS) is found at
http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf
Unrecognized
Sadness, hopelessness, powerlessness
Irritability may be primary affective symptom
May present with cognitive loss
Under treated
Grief/loss issues
o The Impact of Event Scale Revised (IES-R) is a useful tool & is located at
http://consultgerirn.org/uploads/File/trythis/try_this_19.pdf

Functional Status:
Hallmark of good geriatric care!
Review
ADLs
o Katz Index of Independence in Activities of Daily Living (ADL) tool is located here
http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf
IADLs
o The Lawton Instrumental Activities of Daily Living (IADL) Scale is located here
http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf
Independent
Requires some assistance
Dependent

Family & Social Histories:
Focus on disorders of later life known to have inherited patterns
o Alzheimers Disease
o Cancer
o Diabetes
Age of onset
Relationship & attitude toward family members & vice versa
o The Elder Assessment Instrument (EAI) is located at
http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf
Determine the ability of family members to assist the patient if necessary
Employment status
Health
Traveling time to patients house
Occupations
Exposure (noise, pollutants, chemicals, etc)
Hobbies & Interests
Helps to think about future & retirement
Social support
Volunteerism
Living arrangements
#of rooms & location
Plumbing
Presence of stairs, elevator
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Heating, air conditioning
Lighting
By self or with others
Who repairs? Lawn? Snow?
Bath tub & toilet assists
Scatter rugs, carpet
Presence of pets
Monthly cost
Type of neighborhood
Feel safe?
Access to transportation?
Know neighbors?

Sexual History:
Current sexual function
Sexual activity
#& gender of partners
Martial status
Risk of sexually transmitted diseases
How are your needs for touch met?
The PLISSIT Model can be found at http://consultgerirn.org/uploads/File/trythis/try_this_10.pdf

Advanced Care Planning:
The p pr ro oc ce es ss s of discussing end-of-life care with the patient & developing a valid expression of the
patients wishes regarding future medical care
Introducing the subject b be ef fo or re e the person becomes ill
Discussion needs to be documented in the medical record
Legal document needs to be signed & placed in the medical record
Review yearly (at least)
Ask if the patient surrogate is the same including contact information
Ask whether they would like any changes

Spiritual History:
Religious community
Participation
Sense of belonging, forgiveness
Meaning & purpose in life
How do they get through difficult times?
You can find information related to the FICA Spiritual Assessment Tool located at this site
http://www.gwumc.edu/gwish/clinical/fica.cfm


I It t i is s i im mp po or rt ta an nt t t to o a as sk k q qu ue es st ti io on ns s o of f p pa at ti ie en nt ts s b be ec ca au us se e w wi it th h t th he e h he el lp p o of f t th he es se e q qu ue es st ti io on ns s o on ne e w wi il ll l
k kn no ow w m mo or re e e ex xa ac ct tl ly y s so om me e o of f t th he e t th hi in ng gs s t th ha at t c co on nc ce er rn n d di is se ea as se e & &
o on ne e w wi il ll l t tr re ea at t t th he e d di is se ea as se e b be et tt te er r. .

Rufus of Ephesus, 1000 A.D.