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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Discussion with older patients
The situation
The world of the old person
The limitations
Loneliness and social death
Coping with illness in old age
Capability in old age
Discussion with and approach to old people
Everybody would like to
live a long time, but
nobody wants to be old.
Benjamin Franklin
I am old ... it is
incurable suffering.
Discussion with older patients
The situation
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.

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:
What are the psychological and physical peculiarities of the aged?
What is the meaning of sickness and approaching death to the aged?
What does the old person expect from his doctor?
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The world of the old person
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:
Importance of various things alters with age.
Social contact takes on a different importance.
Illness 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, which 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.
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The limitations
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 for therapy.

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.
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Loneliness and social death
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 absolutely real."
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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 younger person.

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 year."

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".
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Capability in old age
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.
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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 principles:
The recognition that there is no single type of "old person". There are however typical 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 diagnostic 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:
Not 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 social contact.
Recognition of 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.
Recognition of 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 typical incorrect behaviour in conversation and approach to old people:
Incapacitation 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.
Minimizing, 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").
Pedagogic 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.

Guide-lines for discussion with old people 
1. Major rule: recognize and respect limitations
2. Take into account barriers to communication (deafness, sight difficulties, immobility, memory disturbances)
3. Watch out for specific pitfalls 
- pseudomultimorbidity
- hidden syndromes (depression, addiction to alcohol and medication)
- illness as a mask, means or signal
4. Take the life history into account
5. Avoid deadly sins in communication 
- minimizing and trivialization
- incapacitation strategies
- injunctions
6. Involve those visiting regularly into the therapy plan
7. "Mild stress" rather than total care (encouragement for active organization of life-style)
8. Doctor is often the most important social contact
9. More discussion and less medication!
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 increased self-responsibility.

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." 

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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