|Everybody would like
|live a long
|nobody wants to be old.
Discussion with older patients
There were 10 million people
over 65 years in the Federal Republic of Germany in 1987, and 20% of the
population were over 60 years old. Older patients form a higher proportion
of patients in general practice and in hospitals. About 40% of patients
in general medical beds are over 70. According to calculations from the
Federal Statistical Office of Germany, the proportion of older people will
rise enormously in the near future; it is likely that by 2030, the proportion
of people over 60 will rise from 20% to 36%. Whereas there are now 35 million
employed and 12 million pensioners, in 2030 the number of employees is
expected to be very similar to the number drawing a pension.
|I am old ... it is
As the age-structure changes
in a population, so - in close relationship with advances in medicine -
there is an enormous change in the picture and spread of disease. "This
is the success of a medical generation that will never conquer death, but
will only create work for the next generation. Medicine is not able to
determine, whether one dies, but only of what one dies. Yesterday's consumptives
are the dialysis patients of today, and will be the multimorbid geriatric
cases of tomorrow" (Walter Krämer).
In Germany, the average life
expectancy has doubled in the last 110 years. It is justified to enquiry
how far this has really won years of life. "Live longer and feel worse?"
was the heading of an article against "Pessimism in an era of astronomical
success" in medicine, written by Elizabeth Whelan, director of the American
Council of Science and Health (1984). Many thoughtful people see this title
as a question of conscience for today's medicine, which allows an increasing
number of people to reach old age, nevertheless paying the price with multimorbidity.
Modern medicine uses quite a considerable number of "half-way technologies"
which "although they save life, do not make us healthy".
It is precisely the high
technical potency of modern medicine which makes it particularly difficult
to fulfill the postulate "rather give life to years than years to life".
One hears that modern gerontopsychologists
are recommending animals for lonely old peoples' homes, in order that less
depression becomes evident (Erhard Olbrich). According to this, old people
should be allowed to take their pets into the home with them, and sheep
or donkeys should be bred in the grounds. The basis for this recommendation
is disturbing. Olbrich hypothesizes that younger people react with negative
emotion when confronted with illness, pain and death of an old person.
The staff who work in the old peoples' homes and on terminal care wards
are also affected. This helplessness of the "helper" when faced with problems
of old age is encountered more and more frequently. Family members send
"signals" to the weak and the sick, which can lead to conflict in their
relationship to one another. This is not the case with dogs and other animals,
according to Olbrich. They give the impression that they understand about
growing old and know all about it, with no ifs or buts. Communication with
the animals is therefore preferred to that with people, as the "stressful
signals" are not present.
A great deal of both the
general practitioner's and the hospital doctor's time is spent in practical
geriatric. However they are not usually trained in this area, which means
that they learn from experience with all the other consequences. It is
of as little use to regard the problems of old age as if they were those
of elderly adults, as it is to regard children in pediatric practice only
as little adults.
The most successful approach
to older patients is bound up in the following questions:
are the psychological and physical peculiarities of the aged?
||What is the meaning
of sickness and approaching death to the aged?
||What does the
person expect from his doctor?
The world of the
In the same way that one cannot
refer to the child, the youth or the adult, one cannot
say that there is the old person or old patient. It is important
to recognize this fact, in order that the blanket idea of the behaviour
and way of reaction of old people in general does not get in the way of
individualized care. Recognition that the reaction to becoming and being
old, learning to face it and coping with it, can run completely different
courses in different people is a basic concept for the doctor's approach
to old people.
The doctor-patient relationship
should not be grounded on either the extreme preconception of a lonely
invalid, always frail and needing help, or the other similarly unconvincing
extreme of the "modern" old person who throws himself into very many activities,
journeys around the world, who is aware of all of his physical limitations,
who profits from the multitudinous possibilities offered by modern medicine,
and who appears a decade younger than people of his age used to, one or
two generations earlier.
Three basic phenomena must
be taken into account when dealing with old people:
of various things alters with age.
takes on a different importance.
and death itself are approaching, not only the thought of them.
With regard to sickness and
health, altered importance of things can lead to polarization of
behaviour. Illness can mean very much more but also very
much less than in youth or middle age. This is seen on one hand in
hypochondria and very nearly slavish obedience to medical advice, and on
the other hand, in cases of older folk who appear unaffected by serious
findings and diagnoses.
If illness is experienced
as an insupportable burden or as permanent threat in old age, the doctor
will be overwhelmed by symptoms which, in this diagnostic age, enable the
doctor to quickly find an apparently objective correlate and definite diagnosis,
but would probably lead to dubious therapeutic consequences. These are
the sort of older persons who only live for their sickness, who do the
rounds of all of the specialties with their ailments and complaints but
nevertheless never ever feel well. It is very important for the doctor
not to fall into one of these sometimes very well covered pitfalls of pseudomultimorbidity,
inevitably lead to an unsatisfactory doctor-patient relationship.
The best protection is that
of active listening, of consciously being aware of this potential source
of misinterpretation. The second step must lie in the exposure of the causes
which are at the bottom of this behaviour. The third is to attempt (with
care) to make the patient aware of the roots of discontent, or at least
to mention them. This can help to overcome age-specific anxieties when
faced with chronic sickness, helplessness, surrender and dying.
However it is important that
the doctor respects the behaviour of the older person who does not appear
to take his findings, frailness and sickness seriously. Renoir, who became
paralyzed on one side at the age of 60, simply said "one does not need
a hand to paint". It must not be presumed that resignation is hidden behind
such an approach, as it can also be a process of repression which ideally
leads to a new activity. It is known that Renoir painted up to his death
at 78. Colours were pressed onto the palette, brush tied to the wrist,
and he finally worked in an obsession that he did not have before his illness.
An important basic rule in dealing
with old people is that of recognizing and respecting the boundaries.
Every doctor should know that it is not necessary to treat every symptom.
This is particularly relevant for the treatment of old people. There should
be as little disturbance of old-established habits as possible, even where
they appear to be medically inadvisable. This is by no means a resigned
way of thinking, but far more a consequence of common sense and a result
of weighing the efficacy against the damage resulting from a recommendation
Many enjoyments take on another
importance for the old. This applies for example especially to eating,
which becomes a very important part of life for many. The saying that "eating
is the sexuality of old age" ironically recognizes the core of this phenomenon.
Dietary restrictions can lead to strong opposition from old people, and
excessive pressure for compliance can stress the doctor-patient relationship.
The multimorbidity of the
old person is particularly likely to lead to overdiagnosis and excessive
therapy. This is still carried out, driven by a quasi monocular view of
the complaints and results of investigations, without taking the social
circumstances or the life history of the person into account.
The youth or the person in
middle-age rarely have a closed "life history" or "story". The old person
however usually looks back on a fairly finalized life history. This is
often the major content of a discussion with old people. It is very important
that the doctor is aware of this life story, as it is the most effective
key to understanding the thoughts and behaviour of his patient.
Loneliness and social
Loneliness and the feeling of
neglecting characterize the lives of many old people. An Italian study
from Milan found that 10% of men and 13% of women questioned felt "very
lonely", 20% of men and 22% of woman occasionally felt lonely. In a Californian
study of old people, 57% of those who lived without a partner, and even
16% of those with a partner felt "very alone".
Sickness can take on a completely
different function. It creates "... welcome contact with doctors, nursing
staff and other sufferers. This is taken to offer substitution for missed
opportunities or lost meaning of life, or a life partner, but imposes the
nursing staff with often insupportable responsibilities" (Meerwein) .
Nowadays "old" is taken less
in the sense of its biological meaning but rather in the sociological sense
of the word. The person is old who is out of the circuit of production
and consumption in the modern industrial society. Retirement is experienced
as "social death" and can, as can every life crisis, lead to illness of
body or mind. Moving into retirement is an especially difficult time of
life for the working man. Hemingway wrote, "The worst death for a person
is the loss of that which formed the center of his life, and made him what
really is. Retirement is the most repugnant word in language. Whether one
decides on it out of freewill, or whether one is forced into it, to enter
into retirement and give up one's way of life, this occupation which made
us what we are, means exactly the same as stepping into the grave".
Simone de Beauvoir's book
about old age quotes a young house officer who is responsible for a home
in which old people from the lower social classes are looked after. "At
first, I asked them what they had done in the past: they had clipped Metro
tickets, or done odd jobs, they answered, and tears came into their eyes:
'At that time we worked, were men ...'. I understood. I no longer ask."
The gap left when no longer
working leads to a self-awareness, and an introspection with continual
self-judgement and the consequent over-reaction to and misunderstanding
of physical and other symptoms. As Simone de Beauvoir says: "Often retired
people give all of the attention that they would previously have concentrated
on their job, to their body. They complain of pains in order to conceal
the pain of loss of prestige. Many use the excuse of illness as an excuse
for the lower social status that is now their lot. Illness can also be
a justification for egocentricity - the body now needs total dedication.
Nevertheless the anxiety, which lies at the bottom of this behaviour, is
Coping with illness
in old age
There are few reliable studies
which describe how sickness and health are actually experienced in old
age. The results contradict each other, and this is not surprising. Individual
life stories, attitudes towards growing old and old age, as well as social
opportunities, vary to a very large extent.
In an age and society such
as our own, where even in medicine everything is thought to be possible,
in which (although not immediately available) soon there will be treatment
for every disease and therapy for every disorder, in which nearly every
organ can be transplanted or replaced by an artificial organ, an attitude
of demanding is encouraged that makes it difficult for old people to accept
that, in spite of all the successes of medicine, the older person to a
large extent cannot see, hear and breathe as well nor move as fast as the
As Galen said, old age is
"somewhere halfway between sickness and health". It is a "normal abnormal
condition". The experience of illness in old age therefore varies between
the most extreme poles. Léautaud writes: "Perhaps the hardest thing
to bear in old age is the feeling that one can no longer turn back; that
something definite is going to happen. At least the thought that illness
can be healed or coped with leaves the door open. The physical evolutions
of old age are irreparable and we know that they increase from year to
Every change of the condition
of health can take on the character of "judgement" with increasing age,
as the old person suspects that every minimal symptom could be the first
sign of the "final illness". Edmond de Goncourt wrote in his diary in 1892:
"Years full of anxiety, days full of restrictions, as every small ache
or pain immediately leads to the thought of death".
Hemingway also in his book
"The old man and the sea" wrote that "a man can be crushed but not beaten"
but contradicted this in his own life. When he discovered that he could
no longer maintain his self-image of vital, exuberant and inexhaustible
masculinity, he killed himself with his own hunting rifle.
This pessimistic picture
should be contrasted with the optimistic strength of a Paul Claudel who
wrote in his diary: "80 years old! No longer any sight, no longer any hearing,
no longer any teeth, no longer any legs, no longer any breath! It is amazing
that one can survive without all that." This is taken further in another
passage "It is true that I am somewhat deaf, somewhat blind, somewhat impotent,
and all of that is crowned by three or four miserable ailments. However
nothing prevents me from hoping".
Capability in old
In an industrialized society,
in which the gross national product has become a golden calf, old people
are often referred to as unproductive. This is not found to be true when
looked at more closely. For example, the Nuffield Foundation investigated
15.000 elderly workers who had continued to work after 65. They examined
which abilities and characteristics were accentuated positively in older
people, and which changed for the worse. The study showed that the following
abilities and characteristics improved with age; regularity, methodicalness,
punctuality, concentration and alertness, good will, discipline, attention
to detail, patience and precision. The abilities which decreased where
those of sight and hearing, strength and manual dexterity, resistance to
stress, working speed, memory, imagination, creativity and adjustment to
new situations, dynamism and sociability.
There are also incorrect
presumptions about the decline in intellect in old age. Hoyer estimates
that only 7% of the 10 million Germans over the age of 65 have serious
dementia with moderate dementia in 10%. Considered as a whole, only 20%
of old people have cerebral insufficiency which is of practical importance.
It should also be taken into account that limitation of intellectual abilities
is occasionally mistaken for other illness (such as depressive mood disorders).
It can often be the result of understimulation. Studies in older inpatients
have shown that even after a few weeks of medical treatment in hospital
(during which social contacts, stimulation and opportunities to remain
busy dropped off) led to a measurable fall in IQ.
A very much underestimated
cause of cerebral insufficiency in the elderly is the misuse of alcohol
and medication, especially that of sleeping tablets and tranquilizers.
Although those over 70 are only 10% of the population in West Germany,
they receive 75% of all of the psychopharmaceuticals. 25% of old people
who live in a family, 50% of those in old people's homes and 75% requiring
hospital care receive these regularly.
Discussion with and
approach to old people
If the doctor is to have successful
conversation with old people, he must know and recognize some basic
recognition that there is no single type of "old person". There are however
patterns of behaviour and reaction in old age. The spectrum passes
from the passive-resigned behaviour of the old person who no longer expects
anything, to that in which illness is considered the be-all and end-all
of daily living.
||The life history
of the old person is an important key to understanding his perception and
experience of the illness.
||There are particular
and therapeutic limits in old age.
||The doctor is
often the only and the last social contact for the old person.
Barriers typical for old
age often get in the way of the older person fulfilling his increasing
need for social contacts: hearing problems, sight difficulties, immobility,
loss of skin sensitivity, as well as memory disturbances, which make it
difficult to remember names of doctors and nurses and to orientated himself.
Patiently taking these difficulties into account is an important precondition
for the creation of a functioning contact. Regular care by a certain
person, especially in the daily hospital life, are of particular importance
for old people. It is particularly advisable that he has the repeated possibility
of getting to know the names of those looking after him.
Relatives can raise
particular problems for the doctor caring for an old person. On the one
hand are the "overprotective daughter" or the "overcaring son" who are
excessively critical, suspicious and demanding of doctors, nursing staff
and the hospital, and on the other are the relatives who insist in "an
emergency admission" just before the holiday period. Many of the problems
which arise from these situations can be understood and solved satisfactorily,
when both the life story of the old person, as well as the family situation
are known. Certain behaviour can be seen in a different light when the
suffering of a family is taken into account. The doctor should also avoid
as much as possible being drawn into the role of judge on behalf of the
family. Apparently justified criticism of the relatives often leads to
the doctor being drawn into the role of "good son or daughter". This psychological
position only leads to a temporary relief, and indirectly increases the
tension between the patient and his relatives, and creates difficult conditions
for further care after discharge from hospital.
There are typical pitfalls
in discussions with older patients:
to recognize pseudomultimorbidity as an expression of an underlying
fear of death.
||To diagnose and
treat in cases where the patient probably is not seeking either, but rather
the fact that in old age, illness is often a mask, means or signal
covering loneliness, excessive reaction to loss of prestige, pressure for
care, or contact-seeking.
what can really be hidden behind the term "organic" such as depressive
mood disorders, addiction to alcohol and/or medications.
There is a (long) list of
incorrect behaviour in conversation and approach to old people:
strategies, which are manifest in condescension, childish forms of
speech and use of the "royal plural" ("Did we go to the toilet today?").
This approach increases the feeling of helplessness and dependence, and
encourages the regressive tendencies, which appear relatively often in
old patients. The use of the terms "granny" or "grandpa" is typical of
this form of speech.
trivializing and dismissing phrases such as "that is not half as bad",
"it will soon come back", "that doesn't mean anything", "almost every old
person has that" are the opposite of an empathetic approach, and always
prevent a credible doctor-patient relationship.
||Forms of speech
which bring thought and memory problems to the attention of the
old person ("you have told me that a couple of times before", "you are
always complaining about the same thing", "you must be able to remember
whether or not you took these tablets yesterday").
injunctions ("old people don't cry").
The weight the older
person attaches to medical findings has to be estimated from conversation.
The old person who experiences his illness as a constant threat and warning
of death, mostly tends to notice unimportant and minimal findings with
meticulous care, to register them and weigh them. The smallest swings in
blood pressure, blood sugar, ocular pressure or pulse rate take on excessive
proportions. The doctor must use intuition and special wisdom in describing
the findings, and choose his words with particular care.
To ask too little of the
old person is probably a widely unappreciated cause at the root of illness
and abnormal findings in old age. Old people in our day and age are particularly
likely to suffer from the feeling of uselessness. This is a result of the
paradox that although old people enjoy a better health than those of previous
generations, and stay "younger" longer, they retire earlier. All gerontologists
agree that it is impossible, both from a psychological and sociological
view-point, to maintain somebody in good shape without useful activity.
This is because "naked survival" is worse than death.
Modem gerontopsychology teaches
that the basic feeling of "inevitable unchangeability" determines depressive
mood disorders and the decline in competence. Competence is defined as
the ability to overcome stress that is in adequate relationship to the
available resources. The most commonly used approach of considerate and
friendly caring and the unburdening of responsibilities increases this
sensation of unchangeability, and reduces ability and competence in a vicious
circle. A mixture of challenges and assistance on the part of the
doctor and nursing staff who look after old people is probably the most
effective way of dealing with this unfavourable development. Mild stress
is most likely to be the appropriate method of maintaining cognitive and
physical competence in old age.
A certain extent of self-responsibility
in daily tasks does not only maintain pleasure in life; it also maintains
life of the old person. This has been shown dramatically in an American
study. One group of inhabitants of an old peoples' home were encouraged
to organize their own lives, their meals and outings, as well as arranging
their rooms as they liked. A similar group was looked after in a friendly
and caring fashion, and the nursing staff took care of all of the details
of daily life. The findings of the study were astounding. Even after 1
½ years the death rate amongst the totally cared-for group was twice
as high as that in which the old people were independent. Consequently,
the aim of the doctor's care should be that of countering the "inevitable
unchangeability" of the old person with its fatal consequences by an
|Guide-lines for discussion
with old people
rule: recognize and respect limitations
||Take into account
to communication (deafness, sight difficulties, immobility, memory
||Watch out for
|- hidden syndromes (depression,
addiction to alcohol and medication)
|- illness as a mask, means
||Take the life
history into account
sins in communication
|- minimizing and
|- incapacitation strategies
visiting regularly into the therapy plan
rather than total care (encouragement for active organization of life-style)
often the most important social contact
and less medication!
The old person does not (only)
need all the blessings of a highly technological medicine. Other qualities
are also required. As Horst Berewski, a Berlin psychiatrist, says "It is
particularly old people who need encouragement, strengthening, constant
caring and programming of success. Often modest measures are enough to
lead to stabilization or disappearance of symptoms. These measures include
regular, short but intensive use of discussion, solving of certain psychosocial
problems, arranging help from those around, and training in daily tasks."
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
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