older adults patient education issues essay and interview

Older adults patient education issues and interview

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Educator, Research Writer. Masters Degree in Nursing

Sep. 20, 2023

Sample Question

Write a 500-750-word essay on the influence patient education has in health care using the experiences of a patient. Interview a friend or family member about that person’s experiences with the health care system. You may develop your own list of questions.

Suggested interview questions:

• Did a patient education representative give you instructions on how to care for yourself after your illness or operation?
• Did a health care professional, pharmacist, nurse, doctor, or elder counselor advise you on your medication, diet, or exercise?
• Who assisted you at home after your illness or operation?
• Do you know of any assistance services, i.e., food, transportation, medication, that would help you stay in your home as you get older?

Question Explanation

Healthcare professionals, including nurses use patient education as an approach of promoting and improving health among individual patients and the community as a whole.  As a health promotion tool, patient education empowers individual clients with skills and knowledge, which enable them to take control of their health, and also enhance their wellbeing.  Experiential research studies indicate that patient education also enhances patient self-confidence   and capacity for self-care (Cramer, 2009). 

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Older Adults Patient Education Issues Essay

Patient education in nursing refers to the process of creating awareness for the sick to influence their behaviors, attitudes, knowledge, and skills. This enables them to become independent and maintain their health statuses. Some practices include administering medications in the form of injections like insulin for diabetes patients, handling equipment like oxygen tanks for home use, and dressing wounds. Further, patient education enhances preventive care by encouraging eating a healthy diet and exercising regularly. In the hospital setup, designs and chart-like models provide guidelines and checklists that remind patients of the need to practice self-care routines.

The respondent in the interview was a male whose initials were J.N and 69 years old. He had diabetes condition and I was his personal nurse and he could attend regular checkups in the hospital. After the interview, it could be identified that patient education influences the health condition management of the sick at home. Routines such as maintaining wound hygiene and watching for warning signs must be observed to reduce the risks of other infections. Additionally, maintaining a healthy diet influences the healing process by boosting immunity. After conducting patient education, it can be seen that they become more dependent and learn how to manage their conditions after leaving the hospital (Caydam & Kaya, 2019). Close monitoring enables them to give doctors feedback on their progress, and checkups can be made quickly without delay in case of severe warning signs.

Patient education promotes dietary, medication, and physical exercise guidance routines. Patients are given appropriate guidelines on the specific exercises and diet. Taking a balanced meal, including enough fruits and vegetables, reduce cases of constipation. Similarly, minimal fat, sugar, and salt intakes are additional precautions to minimize cases of additional complications. Light exercises, such as walking for 30 minutes in the evening, were recommended for physical fitness. Further, the patient was advised to avoid intake of alcohol and smoking as they could worsen his health condition.

Patient education facilitates family support at home after being released from the hospital. They could follow up to determine whether he followed instructions and took their medication on time. Further, the members joined him for a walk for safety and any emergency. During the preparation and intake of meals, they provided the required diet to boost his immunity. Therefore, the sick must receive a supportive and friendly healing environment to regain their health (Zha et al., 2022). Additional services like transportation to the hospital or checkups were done by private means for comfort and security.

Further, education increases awareness of available local support facilities to the elderly. In the surrounding society, many initiatives have been established to take care of the old, especially those living with diabetes and hypertension conditions. They are responsible for offering food and emotional encouragement support by providing guidance and counseling services. Education programs available educate the public on how to live with the elderly in society and help them in satisfying their daily activities. Through this, the parents could identify the need to allow their children to support the old in their house chores and meal preparation. They were further guided to the shopping facilities to get fresh fruits and vegetables. Engaging in intensive exercises could lead to more damage and, therefore, the need to be cautious about the activities to undertake.

Patient education facilitates cultural and religious considerations to avoid conflicts between the sick and healthcare providers. Cultural sensitivity is critical in healthcare as it makes the doctors aware of the accepted beliefs and practices. Since they interact with patients from different regions, they must be mindful of sound communication cues. In some setups, non-verbal means of interaction have different meanings and can pass on additional messages. Misinterpretations can make the sick afraid to share their diagnosis reports as they fear being judged. This lowers the government’s expenditure on medication to public hospitals creating room for other progress. The insufficient facilities in the hospitals will be utilized effectively to reduce new infection spread rate cases.

In summary, elderly patients’ education within the healthcare setting is essential in improving the condition of the sick. They learn to be more dependent and offer care services at home without depending on the nurses. This points to the need to create more awareness of this concept among the citizens as the outcome leads to more health benefits. Due to this, healthcare professionals should take the lead in patient education to ensure every need of the patients is attended to especially the old since they are vulnerable.

Caydam, O. D., & Kaya, U. P. (2019). Association between social support and diabetes burden among elderly patients with diabetes: A cross-sectional study from Turkey . Saudi Journal of Medicine and Medical Sciences , 7 (2), 86. Web.

Zha, J., Li, Y., Qu, J., Yang, X., Han, Z., & Zuo, X. (2022). Effects of enhanced education for patients with the helicobacter pylori infection: A systematic review and meta‐analysis . Helicobacter , 27 (2). Web.

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IvyPanda. (2024, February 6). Older Adults Patient Education Issues. https://ivypanda.com/essays/older-adults-patient-education-issues/

"Older Adults Patient Education Issues." IvyPanda , 6 Feb. 2024, ivypanda.com/essays/older-adults-patient-education-issues/.

IvyPanda . (2024) 'Older Adults Patient Education Issues'. 6 February.

IvyPanda . 2024. "Older Adults Patient Education Issues." February 6, 2024. https://ivypanda.com/essays/older-adults-patient-education-issues/.

1. IvyPanda . "Older Adults Patient Education Issues." February 6, 2024. https://ivypanda.com/essays/older-adults-patient-education-issues/.

Bibliography

IvyPanda . "Older Adults Patient Education Issues." February 6, 2024. https://ivypanda.com/essays/older-adults-patient-education-issues/.

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HLT 306 Older Adults Patient Education Issues Essay and Interview

by ella | Feb 9, 2024 | Health and Medical

Older Adults Patient Education Issues Essay and Interview             In the wake of new situations, human beings strive to learn new skills and acquire knowledge to cope with the challenges effectively. Fereidouni et al. (2019) note that hospitalization and illnesses increase the need for education and assistance. Through patient education, the health care provider imparts information to caregivers and patients, improving their health status and encouraging active involvement in decision-making processes regarding treatment and care. Health education enables patients to acquire essential attitudes, skills, values, and knowledge relating to adopting healthier lifestyles, adherence and correct use of medicines, and care at home (Yen & Leasure, 2019). Additionally, patient education predicts better health outcomes, increased satisfaction levels, and shared decision-making (Timmers et al., 2020). Therefore, patient education is essential for care services in various settings.             Healthcare providers must use effective communication skills and consider the individual needs of their clients to enhance the effectiveness of health education in conveying the envisioned skills and knowledge. Oliveros et al. (2019) assert that a set of good communication skills by a healthcare professional is essential in establishing a trusting relationship, reducing the likelihood of malpractice claims, increasing patient satisfaction, and ensuring adherence to the treatment regimen. This paper analyzes the influence of patient education in healthcare using the experiences of an elderly patient. The paper explores an interaction with Mr. K, a 70 years old male, particularly on his experience with healthcare education.             Mr. K lives in my neighborhood. His physical appearance indicates or demonstrates problems with his body weight and considerable impairment while walking. He had a recent medical checkup in which he was found obese and hypertensive. Moreover, the healthcare providers discovered that Mr. K had high blood sugar and lipid levels. I had an interview scheduled with the patient on a Friday afternoon. The Interview             In my first question directed to my client, I enquired whether a healthcare provider gave Mr. K instructions on how to take care of himself at home and in outpatient settings. He asserted that he was given instructions regarding medication schedules and the essence of adhering to the medication regimen. In particular, he was instructed on the correct dosages, which were also clearly written in his medication packages. In his opinion, Mr. K deemed the instructions simple, clear, and easy to follow and remember as they were given in both written and verbal forms.

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            The second question inquired whether a nurse, doctor, or healthcare professional advised the patient on diet, exercise, and medication. Mr. K was happy that the nurse who provided care exclusively educated him on changing his feeding habits to a healthier diet. Moreover, he was instructed on the need and essence of daily exercises to reduce his body weight and increase his health. The client was satisfied with the instructions given on his medication regimen. Additionally, Mr. K reported that the proposed adjustments in his diet and exercising were provided in a culturally sensitive manner. The educating nurse also motivated Mr. K to be resilient in following the instructions on diet, medication regimen and exercising. In particular, Mr. K confirmed that he was advised to avoid or reduce the intake of salt, sugar, and fats in his meals. He was also advised to take plenty of fresh vegetables and fruits daily. On exercising, he was instructed to be taking moderate walks of at least thirty-five minutes daily. He was currently implementing the instructions.             The third question interrogated the client to know who assists him at home with his current health conditions. He asserted that his wife was offering invaluable social support after his illness. The wife was motivating Mr. K to adhere to the advice and instructions given by the healthcare professional. Particularly, his wife was key in the quest for a healthier lifestyle for Mr. K by encouraging and accompanying him to exercise schedules and preparing healthy meals. Additionally, the client asserted that his wife accompanies him to scheduled clinic visits, providing him with the much-needed strength to continue facing his health challenges with great determination, courage, and confidence.             The last question was about Mr. K’s knowledge of the availability of social support and community services within their area. He responded that the community nurse had already connected him with a local support group for the elderly living with hypertension and diabetes. He was also informed about where he could acquire fresh and healthy farm products, including vegetables and fruits, from the local shops. In assertion, Mr. K reported that awareness of the available local resources has been influential in enhancing his health by providing crucial social and moral support. Conclusion             Nurses and healthcare providers have the essential role of providing patient education to all clients. Elderly patients have special learning needs to manage and promote their health in relation to chronic health conditions. Patient education for the elderly is crucial in empowering them to take a more active role in managing their health. The healthcare providers need to use effective communication skills and involve caregivers of elderly patients in imparting the intended knowledge. The healthcare professional should design the education approach to address the client’s individual needs, including the cultural and religious backgrounds. References Fereidouni, Z., Sarvestani, R. S., Hariri, G., Kuhpaye, S. A., Amirkhani, M., & Kalyani, M. N. (2019). Moving into action: The master key to patient education. Journal of Nursing Research, 27(1), e6. https://doi.org/10.1097/jnr.0000000000000280 Oliveros, E., Brailovsky, Y., & Shah, K. S. (2019). Communication Skills. JACC: Case Reports, 1(3), 446–449. https://doi.org/10.1016/j.jaccas.2019.09.003 Timmers, T., Janssen, L., Kool, R. B., & Kremer, J. A. (2020). Educating Patients by Providing Timely Information Using Smartphone and Tablet Apps: Systematic Review. Journal of Medical Internet Research, 22(4), e17342. https://doi.org/10.2196/17342 Yen, P. H., & Leasure, A. R. (2019). Use and effectiveness of the teach-back method in patient education and health outcomes. Federal Practitioner, 36(6), 284–289. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6590951/

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Older Patient Education Issues: Interview

Instructions, recommendations.

Today, much attention is paid to the worth of patient education and its impact on health care. Many researchers indicate the benefits in the fields of physiotherapy, postoperative care, and pharmaceutical services. During the late 1960s, healthcare practitioners recognized the need for patients to be fully informed about their condition and potential contributions to their positive health outcomes (Wittink & Oosterhaven, 2018).

With time, this idea became an integral point in providing and improving care. Interviews with people about their experiences with the health care system introduce one of the common methods to clarify the influence of patient education. In this paper, the results of communication with a friend will be presented to explain the urgency of clear instructions, recommendations, assistance, and services as a part of patient education in health care.

The improvement of health outcomes in patients through education is one of the most expected outcomes, which depends on how well patients are educated by healthcare practitioners. The interview shows that a good start of education should begin with clear instructions and explanations. Teaching physician interactions with patients have to be enthusiastic and motivated to make sure a person realizes all possible benefits (Paterick, Patel, Tajik, & Chandrasekaran, 2017). As soon as a patient is interested in the necessity to be health literate, positive examples can be observed. A guide on how to search, understand, and use health information is an obligatory point in education.

Communication with a person whose experience in education was successful also helps recognize the worth of counseling and necessary pieces of advice about diet, medication, and physical exercises. Paterick et al. (2017) believe that physical activities and diet result in reducing the risks of heart diseases, hypertension, and diabetes. It is not enough to have a list of drugs that must be used to treat a disease or avoid complications. Patient education is an opportunity to gain a good understanding of what people can do to improve their health. The involvement of healthcare professionals is a strong stimulus to learn more.

Many people believe that the worst period is over when they come back home after illnesses or surgeries. They get clear instructions and medication to stabilize their condition. However, in many cases, patients are not aware of what steps to be taken next. Therefore, Wittink and Oosterhaven (2018) underline that such questions like “How are you going to do something at home?” or “Could you please repeat the just mentioned information?” cannot be ignored. This way of communication aims to clarify if a patient has enough assistance at home and understands the required care. The discussion of assistance at home is a vital part of patient education in health care.

Finally, the interview with a person who uses healthcare services indicates the need for assistance services like food, transportation, or medication. When a person gets older, it becomes difficult to follow all prescriptions and recommendations. In addition, some of them lack important health information and services (Wittink & Oosterhaven, 2018). Therefore, patient education includes the discussion of local specialized organizations that support social well-being and offer services.

In general, patient education plays a crucial role in health care and social well-being. Sometimes, adult patients do not find it necessary to ask for help or recognize their need for additional recommendations and assistance. Education initiated by healthcare providers is another step to support people and improve their health. Diets, medications, physical exercises, and regular counseling in terms of patient education are the steps to predict complications and avoid health risks.

Paterick, T. E., Patel, N., Tajik, A. J., & Chandrasekaran, K. (2017). Improving health outcomes through patient education and partnerships with patients. Proceedings: Baylor University Medical Center, 30 (1), 112-113.

Wittink, H., & Oosterhaven, J. (2018). Patient education and health literacy. Musculoskeletal Science and Practice, 38 , 120-127. Web.

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9 Interviewing Older Adults

Dr Lindsay A. Gerolimatos, West Virginia University, USA

Mr Jeffrey J. Gregg, West Virginia University, USA

Professor Barry Edelstein, University of West Virginia, USA

• Published: 02 June 2014
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Interviewing older adults requires attention to a number of issues specific to this population, including age-related changes in sensory and cognitive processes, health, and circadian rhythms. Because older adults may be less familiar with clinical interviews, establishing rapport and trust becomes especially important. Other factors that bear on the interview include the types of interview used, language and format of the interview, setting of the interview, and ethnicity. Some important content areas to address when interviewing older adults include psychological disorders, such as depression, anxiety, and personality disorders, as well as suicide, substance abuse, sleep, and elder abuse. Consideration of these factors, with an eye to various age-related issues, will enhance the effectiveness of the interview with an older adult client. This chapter discusses methods for interviewing older adults, highlights age-related issues that influence the interview process, and suggests a few content areas to address when interviewing older adults.

Introduction

The clinical interview is frequently the first, and often the only, assessment method used by health and mental health professionals when assessing older adults ( Edelstein, Martin, and Gerolimatos 2012 ). It can serve multiple functions, including screening potential clients, examining mental status, formulating the presenting problem, and establishing a diagnosis. In addition, the interview is important for establishing rapport and a working alliance. Interviews with older adults can be a challenge for any detective worth his or her salt. First, older adults can be considerably more recalcitrant than typical young adults. For example, older adults are more likely to refuse participation in surveys (e.g. DeMaio 1980 ; Herzog and Rodgers 1988 ) and respond ‘don’t know’ ( Colsher and Wallace 1989 ) to questions. The complexities of age-related cognitive and physiological changes, coupled with chronic diseases, polypharmacy, and medication adverse effects and interactions collectively militate against attempts by the clinician to assemble clues in a meaningful fashion.

This chapter will familiarize readers with age-related interviewing issues associated with various types of interviews, age-related biological, medical, and physiological factors, ethnicity and culture, interview settings, and interview content (e.g. mental disorders, suicide, sleep, substance abuse, elder abuse). Other important issues (e.g. trust, language use, interview format) will also be addressed. The discussion of the foregoing issues will be accompanied by recommendations for how one might make accommodations for these issues. Finally, suggestions for additional reading will be provided. Our goal is to enable readers to have a greater appreciation for the complexities of interviewing older adults and strategies that we and others have found useful in addressing these complexities. Interested readers are referred to specific chapters in this Handbook for more information regarding specific disorders or clinical issues such as depression and suicide.

Types of Clinical Interview

Clinical interviews with older adults range from casual, free-flowing conversations to carefully scripted diagnostic interviews that include a series of branching questions and prompts. Despite the obvious differences, each interview format (i.e. structured, semi-structured, unstructured) has strengths and weaknesses based on the primary goal. Common goals of the clinical interview include characterizing the presenting problem(s) and contextual factors, arriving at a diagnosis, and planning treatment, among others. The interviewer can opt for more or less structure, or use multiple interview approaches, based on the purpose of the interview.

Structured and semi-structured interviews

Structured and semi-structured interviews offer strong reliability and diagnostic validity. Several diagnostic interviews have been validated for use with older adults, including the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First et al. 1996 ), the Diagnostic Interview Schedule IV (DIS; Robins et al. 1999 ), the Anxiety Disorders Interview Schedule-IV (ADIS; Brown, DiNardo, and Barlow 1994 ), and the Mini International Neuropsychiatric Inventory (MINI; Lecrubier et al. 1997 ). Several of these have been translated and validated cross-culturally. For example, the SCID and the MINI are available in over fifteen languages.

These interviews range in their level of structure. For instance, the DIS is highly structured, whereas the SCID allows for more flexibility. In general, greater structure in clinical interviews leads to greater validity and reliability. Though the semi-structured nature of interviews like the SCID allows for greater flexibility, there are downsides. On each occasion where one skips questions or probes for more information, opportunities for error are produced that may influence reliability and validity. Nevertheless, studies have demonstrated that many structured and semi-structured clinical interviews demonstrate high levels of inter-rater reliability, interviewer experience notwithstanding (e.g. Ventura et al. 1998 ).

With regard to structured and semi-structured interviews with older adults, one principal concern is fatigue. Many structured and semi-structured interviews are time-consuming, especially if all sections of the interview are administered. One can reduce fatigue attributable to time by administering modules specific to the presenting complaint. In addition, some of the semi-structured interviews are briefer than others (e.g. the MINI). Overall, structured interviews have been shown to be superior to self-report instruments in assessing the presence and severity of disorders and in monitoring change in symptoms over time ( Dennis, Bodding, and Funnell 2007 ).

Unstructured interviews

The principal advantage of unstructured interviews is their flexible and permissive nature. Unstructured interviews permit the rephrasing of questions that are unclear to interviewees and allow the interviewer to pursue areas related to the presenting problem as they unfold ( Edelstein et al. 2003 ). Despite the benefits of unstructured interviews, their lack of structure results in poor psychometric properties. However, unstructured interviews can be used to build rapport with older adult clients, acquire information to use in case conceptualizations, and supplement background information for the strategic selection of additional assessment instruments ( Koerner, Hood, and Antony 2011 ).

Issues Related to Interviewing Older Adults

Numerous factors can influence the process and outcome of the interview. These include, but are not limited to, age-related sensory, cognitive, health, biological, ethnic, and cultural issues.

Age-related sensory changes

Of the sensory systems, age-related changes in the visual and auditory systems are most likely to influence the process and outcome of the interview. These two sensory systems are affected by normative changes, physical disease processes, and medications. Age-related hearing loss (presbycusis) typically occurs gradually, with approximately 33% of adults in the world over the age of 65 having disabling hearing loss ( World Health Organization (WHO) 2013 ). The prevalence of disabling hearing loss is greatest in South Asia, Asia Pacific, and sub-Saharan Africa ( WHO 2013 ). Sounds experienced by individuals with presbycusis are less clear and of lower volume. That, coupled with the age-related hearing loss for higher-pitched sounds, can lead to difficulty understanding speech, particularly high-pitched speech (e.g. women’s speech). The sounds of ‘s’ and ‘th’ are difficult to discriminate, and conversations pose hearing challenges in the presence of background noises ( National Institute on Deafness and Other Communicative Disorders (NIDCD) 2010 ). One common cause of impaired hearing is tinnitus (the perception of sounds in one or both ears in the absence of an auditory stimulus), which can cause difficulty hearing the interviewer.

Hearing loss can have psychological and psychosocial consequences that are potentially relevant to the interview process and presenting problems. Older adults with impaired hearing are less likely to hear questions and orally presented instructions. Hearing-impaired older adults are less likely to participate in leisure activities and tend to experience more depressive symptoms ( Horowitz 2003 ). Hearing impairment can also affect the outcome of cognitive assessment in the interview (e.g. attention, memory).

The following recommendations have been offered by various sources (e.g. NIDCD 2010 ; Reuben et al. 2011 ; Saxon, Etten, and Perkins 2010 ; Storandt 1994 ) to facilitate hearing and accommodate the individual with hearing loss. One should be aware that a hearing impairment can be embarrassing or stigmatizing for older adults, and they may deny or attempt to conceal the impairment. When interviewing older adults, one’s face should be well lighted, and one should face the interviewee throughout the interview. If individuals are capable of reading lips, the interviewer should be careful not to exaggerate words or cover their mouth. One should speak distinctly and at a normal rate, and pause briefly between phrases or ideas. It is advisable to speak slightly more loudly than usual but not to shout, as shouting could distort speech. Background noise, which can mask speech, should be decreased. If the individual has a hearing aid or personal amplifier, encourage its use. Finally, the principal interview questions can be provided in written form for individuals who are capable of reading.

Visual impairment is a serious health problem for older adults, with the most common causes of visual impairment being macular degeneration, cataracts, glaucoma, and diabetic retinopathy ( Prevent Blindness America 2008 ). The prevalence of visual impairment and blindness, and their causes, varies across countries. Age-related macular degeneration is the major cause of low vision and blindness among older adults in the Netherlands, followed by glaucoma, cataract, and diabetic eye disease ( World Blind Union 2011 ). In Bulgaria, Armenia, and Turkmenistan, cataracts are the major cause of low vision and blindness ( World Blind Union 2011 ). In the US, cataracts are the most common visual condition across all racial and ethnic groups, affecting 68.3% of adults aged 80 and older ( National Eye Institute 2011 ). In addition to these disorders, age-related changes in the cornea, iris, pupil, lens, vitreous humour, and retina all contribute to diminished vision.

Visual impairment is associated with a variety of physical, medical, psychosocial, and psychological problems that are relevant to the assessment interview, including falls and injuries ( Ivers et al. 2000 ), depression and social isolation ( Horowitz 2003 ; Jones et al. 2009 ), anxiety ( de Beurs et al. 2000 ), chronic health conditions ( Crews, Jones, and Kim 2006 ), impairment in daily functioning ( US Census Bureau 2010 ), and mortality ( Lee et al. 2002 ).

The implications of visual impairment for the clinical interview are considerable. Cataracts result in the dulling of colours and substantial increases in glare caused by brightly lit objects and surfaces. Cataracts, presbyopia, diminished accommodation, retinopathy, and macular degeneration can each increase the difficulty of reading text, slow or impair cognitive processing ( Glass 2007 ), and reduce speed on time-limited assessment tasks.

Several steps can be taken to minimize the effects of visual impairment. When presenting visual stimuli to older adults, particularly those with cataracts, it is best to avoid the use of materials printed on glossy surfaces ( Storandt 1994 ). One should strike a balance between the glare of light and the need for sufficient illumination ( Edelstein, Martin, and Koven 2003 ). For older adults with presbyopia, printed material should be presented in a large point size, preferably 14-point ( Vanderplas and Vanderplas 1981 ). Older adults should not face a brightly lit window. Older adults who use reading glasses should be encouraged to use them, as some older adults often forget to use them or initially refuse to do so. Interviewers can keep a supply of inexpensive reading glasses and magnifiers to use as needed.

Cognitive changes

Age-related changes in cognitive functioning represent a unique challenge for the interviewer, due in part to inter-individual differences in cognitive deficits ( Salthouse 2010 ), and in part to the interviewer’s reliance upon the client’s cognitive abilities for the extraction of relevant information. Age-related cognitive deficits occur in working and episodic memory, reasoning, spatial visualization, inhibitory processes, and processing speed ( Park and Schwarz 2000 ; Salthouse 2010 ).

Deficits in memory and processing speed are likely the most apparent age-related deficits. The interviewer should encourage the interviewee to bring relevant information to the interview (e.g. a list of prescription medications, their sleep diary). When possible, an informed second party (e.g. care-giver, relative, or friend) can be encouraged to participate if the memory of the client is significantly impaired. Questions should be brief to reduce working memory and cognitive processing load, and concrete to reduce the level of reasoning required. Double-barrelled questions that touch upon more than one issue should be avoided. When long delays are encountered following queries, the interviewer can ask if the client would like the question repeated, or whether the client understood the question. Finally, providing anchors in time (e.g. mealtime, specific incident) when asking about the onset or duration of symptoms can help ( Gould, Edelstein, and Ciliberti 2010 ).

Cognitive deficits may not be apparent in the daily activities of older adults, particularly when they are performing familiar tasks in familiar situations ( Park and Schwarz 2000 ). In addition, older adults may report no cognitive deficits but experience difficulties in the activities of daily living. Thus, one could encounter discrepancies between self-reported difficulties regarding cognitive functioning and what is observed in the interview. Consequently, one should be cautious in generalizing from interview-based indices of cognitive functioning to the performance of everyday activities of the older adult.

Ethnicity and culture

Psychological symptoms may present differently for older adults across ethnic groups. Somatization, for example, is especially common among individuals from Asian and African cultures ( Kirmayer and Young 1998 ). Descriptions of symptoms may also differ, such as using ‘nerves’ or ‘nervios’ to describe anxiety instead of ‘anxious’ or ‘worried’ ( Kirmayer 2001 ). Some disorders are unique to specific cultures. For example, Japanese clients may exhibit a disorder resembling social phobia, but anxiety results from upsetting others rather than embarrassing the self ( Kirmayer 2001 ). Another potential issue when working with ethnic-minority older adults includes difference in language or dialect between the interviewer and client. Racism and acculturative stress may contribute to psychological distress ( Conner et al. 2010 ), and clinicians should assess for these stressors when interviewing ethnic-minority older adults.

Ethnic-minority older adults tend to attach stigma to mental illness. For example, older Koreans may believe that mental health problems bring shame to the family and indicate personal weakness ( Jang, Chriboga, and Okazaki 2009 ). Across numerous countries, research has shown that stigma regarding mental health remains a significant barrier to mental health treatment for ethnic minorities, regardless of age (see Saxena et al. 2007 ). Therefore clinicians must be mindful of older adults’ reluctance to discuss mental health problems. That ethnic-minority older adults may not readily discuss mental health problems could also be because they may be less knowledgeable about mental illness and may not regard their symptoms as part of a psychological syndrome ( Choi and Gonzalez 2005 ; Conner et al. 2010 ).

Professionals need to increase their knowledge about various cultures ( American Psychological Association (APA) 2003 ), and assess for culturally relevant content areas. Clinicians must be careful not to stereotype members of an ethnic group, as there is much variability within groups. The interviewer must be aware of any assumptions about the interviewee. For example, lack of eye contact may be interpreted as rude, but may be a culturally appropriate behaviour. If the client is unfamiliar with mental health practice, the interviewer should explain the interview process at the outset ( Choi and Gonzalez 2005 ). Professionals must be mindful of the limitations of assessment methods for ethnic-minority older adults. For older adults who are wary of the clinical process, clinicians could elicit the support of family members to ease the interview process ( Choi and Gonzalez 2005 ). Family members may also be elicited to help with translation. However, older adults may be less candid about their problems with a family member present. Additionally, the family member may alter or edit the interviewer’s questions or client’s responses. If one cannot refer the older client to a professional who speaks the language, paid translators, who sign confidentiality agreements, are informed on the nature of assessments, and are instructed to translate speech exactly, may be optimal.

Medical and biological considerations

Health problems and medications.

Ageing is accompanied by a progressive accumulation of risk factors for disabling chronic diseases (e.g. hypertension, heart disease, arthritis, diabetes, cancer; Nolte and McKee 2008 ). The prevalence of chronic diseases varies across countries of the world, with the highest incidence of chronic diseases in high-income countries. However, within these countries, low-income individuals carry the highest chronic disease burden ( Busse et al. 2010 ).

The prevalence of chronic diseases also varies by race and ethnicity. For example, non-Hispanic white older adults report lower levels of hypertension and diabetes than non-Hispanic black older adults ( Federal Interagency Forum on Aging Related Statistics 2010 ). Health problems complicate the assessment interview in many ways. Symptoms of physical disease (e.g. pancreatic cancer, hyperthyroidism) mimic the symptoms of psychiatric disorders (e.g. depression, anxiety). Medications taken to control diseases can have side-effects that appear as psychiatric symptoms. Finally, psychiatric disorders may be comorbid with physical disorders (e.g. anxiety disorders and chronic obstructive pulmonary disease, Parkinson’s disease and depression, diabetes and depression; Edelstein et al. 2012 ). In light of the foregoing, access to a thorough medical history is important for determining the possible causes of presenting psychological symptoms.

Approximately 25–50% of community-dwelling older adults ( Gagliese 2009 ) and 27–83% of those in institutional settings ( Malmstrom and Tait 2010 ) experience persistent pain that impairs functioning. Older adults have a higher threshold for pain than younger adults but are less tolerant of persistent pain ( Malmstrom and Tait 2010 ). Unfortunately, older adults are at considerable risk of not being adequately treated for pain ( Gagliese 2009 ). Thus, screening for pain is important when assessing older adults, particularly for older adults who cannot reliably report pain. A variety of measures are discussed by Malmstrom and Tait (2010) .

Circadian rhythms

Biological clocks or circadian rhythms regulate a wide range of processes (e.g. hormone secretions, sleep/wake cycles). There is evidence that cognitive processes are influenced by circadian rhythms through a twenty-four-hour cycle, such that peaks in cognitive performance are associated with peak periods of physiological arousal ( Schmidt et al. 2007 ). Older adults tend to experience their peak cognitive performance in the morning ( Yoon, May, and Hasher 1999 ). Thus, one will likely see differences in cognitive functioning across different times of the day. It may not always be possible to assess older adults during times of peak cognitive performance. Interviewers are encouraged to record the time of the interview so that interpretations of the interview outcome can be informed by knowledge of the client’s position on his or her performance cycle. One circadian-related issue is fatigue. Older adults may get tired more quickly than younger adults, particularly during a time of day that they are not performing at their peak level. The interviewer should consider breaking the interview into shorter intervals with opportunities for client respite. The combination of fatigue and diminished age-related inhibitory control can quickly diminish attention and motivation.

Setting of the Interview

Clinical interviews with older adults occur in various settings (e.g. primary care, outpatient mental health centres, long-term care, or inpatient institutions; Segal, June, and Marty 2010 ). Each of these settings places unique demands on the interviewer and interviewee. Older adults are most likely to seek help for mental health problems from their primary care physician ( Karlin, Duffy, and Gleaves 2008 ). Referrals to mental health professionals in primary care settings are often made by physicians, and the older adult may be reluctant to discuss mental health issues ( Segal et al. 2010 ). One can explain that one’s intention is to provide comprehensive care, which can ease the older client into discussing psychological issues. Individuals in primary healthcare settings are likely to have comorbid health problems and this information will be available in the client’s medical chart. The interviews tend to be brief ( Segal et al. 2010 ), necessitating prioritization of questions. The clinician has less opportunity for behavioural observations and may be less likely to gain collateral information.

Older adults are least likely to seek help in outpatient mental health centres ( Karlin et al. 2008 ). In an outpatient setting, more time is afforded to rapport building and comprehensive assessment. The interviewer may not have access to the older client’s medical records and may need to obtain a release from the client to request records. If the client refuses, the clinician must rely on self-report, recognizing that there may be inaccuracies.

Finally, older adults may be interviewed in residential settings, such as long-term care facilities. A primary limitation in these settings is the lack of privacy. Many residents have roommates, and there may be few other available rooms in the facility. The clinician contends with frequent interruptions from staff and other residents. Interviewers should make arrangements to conduct interviews in quiet, private locations, and attempt to schedule interviews around activities. Because privacy may not be guaranteed, interviewers should address its impact on confidentiality ( Segal et al. 2010 ; Zarit and Zarit 2007 ). Older adults in residential settings are likely to have complicated medical histories and take numerous medications ( Dwyer et al. 2010 ). Lastly, older adults in these facilities often present with cognitive problems that may interfere with the interview. Clinicians can interview collateral sources, such as facility staff and family members, to gain supplemental information. Measures such as the Cornell Scale for Depression in Dementia ( Alexopoulos et al. 1988 ) and the Rating for Anxiety in Dementia (RAID) scale ( Shankar et al. 1999 ) include interviews with proxies.

Other issues related to interviews

Rapport building.

As with all clients, rapport building requires warmth, appropriate eye contact, genuineness, attentive listening, and professionalism. Interviewers must avoid speaking in a condescending or belittling manner. Older adults tend to be less familiar with mental health evaluations than younger age groups and may be anxious about the interview. At the start of the interview, an explanation of the process, with ample opportunity for questions, can lessen uncertainty associated with the evaluation ( Mohlman et al. 2011 ).

At times, the older client may be resistant to answering questions or may conceal details. This tendency may be related to stigma associated with mental health disorders among older adults or perceived threats to independence ( Koven, Shreve-Neiger, and Edelstein 2007 ). To circumvent these problems, clinicians should communicate warmly and non-judgmentally and acknowledge difficulty discussing sensitive topics. Koven and colleagues recommend using a ‘plus minus approach’, in which the interviewer alternates between more and less threatening questions. Though these are general rules for rapport building, one must take care to tailor one’s approach to be consistent with the culture of the client and setting.

Client trust of the interviewer is often ignored in the assessment literature, yet resides at the heart of a client’s willingness to disclose important and sensitive information in the interview ( Edelstein and Semenchuk 1996 ). It is a critical element of the helping relationship ( Cormier and Cormier 1991 ). When interviewing older adults, we are asking them temporarily to suspend the reciprocity we expect in social exchanges and to engage in risk-taking behaviour. That is, by disclosing information, the older adult hopes the clinician will not respond negatively and that, in the long run, something positive will result (e.g. resolution of presenting problems). Alberts and Edelstein (1992) examined therapist trust among adult clients and revealed several behaviours that suggested whether a therapist could be trusted (e.g. behaviours suggesting positive regard or interest in the client, being directive and structuring therapy sessions). Attention to trustworthy behaviours (see Edelstein and Semenchuk for a complete list) may help the interviewer quickly gain the client’s trust in the interview or avoid a breach in trust.

Language of the interview

The interview should be conducted at a comprehension level that is suitable for the client, with a sixth-grade reading level typically being appropriate. Jargon, idioms, and slang terms should be avoided. Interviewers should offer several descriptors of psychological symptoms. For example, older adults may not ‘worry’ or feel ‘anxious’, but may be more likely to note ‘concern’ or ‘nervousness’ ( Stanley and Novy 2000 ). When administering a structured interview, rephrase questions as appropriate to ensure the client understands the items ( Mohlman et al. 2011 ).

Length and format of the interview

Interviews with older adults often take more time than with younger adults, given older adults’ slower processing speeds and longer histories. Lengthier interviews may cause client fatigue. It may be necessary to divide the interview into several sessions and prioritize the order of questions (i.e. begin with the most important questions; Mohlman et al. 2011 ). Older adults have a propensity to tell stories ( Zarit and Zarit 2007 ). To limit the number of stories, the clinician can delineate the goals of the interview beforehand, acknowledge time constraints, and discuss the importance of remaining on-task throughout the interview. Interviewers may feel uncomfortable interrupting and redirecting the client, but doing so politely often does not hinder the interview process ( Mohlman et al. 2011 ). This goal may also be accomplished gracefully with humour. Asking direct and specific questions can also curtail digressions.

Questions can be yes/no, Likert-type, or open-ended formats. Older adults tend to have difficulty with Likert-type scales ( Mohlman et al. 2011 ). Some older adults may forget the question or the format of the response scale. Repeating the question as needed is appropriate. To ease the burden of remembering the response choices, clinicians can provide the response scales on cards ( Mohlman et al. 2011 ). The clinician should check periodically that the older adult client understands the response scale. Finally, the clinician should allow adequate time for answers. Long response latencies suggest the clinician may need to repeat the question.

Disinhibition

Older adults with dementia or executive dysfunction may display inappropriate behaviours (e.g. sexual or aggressive behaviours) or verbalizations during the interview. The behaviours may relate to frustration associated with the interview, communicative difficulties, or pain ( Talerico, Evans, and Strumpf 2002 ). Ascertaining the function of the behaviour and altering the contingencies (e.g. managing the pain) may decrease the behaviour, though some clients simply cannot control their behaviours. When inappropriate behaviours occur, the clinician can firmly and directly tell the client that the specific behaviour is inappropriate. The clinician should explain and model appropriate behaviours ( Koven et al. 2007 ). Periodically, the clinician may have to redirect the client back to the question. If the behaviours prevent the continuation of the interview, behavioural observations or interviews with family or staff can provide information.

Content Areas for Assessment

Older adults may have unique experiences or symptom presentations that are important to address in the interview. Though it is impossible to discuss all relevant content areas in this chapter, we will highlight some common clinical disorders and problem areas with an eye to age-related factors that inform the interview. These areas include psychological disorders (depression, anxiety, personality disorders), suicide, substance abuse, sleep, and elder abuse.

Psychological disorders

Though less prevalent in older adulthood than in younger adulthood, late-life depression is associated with increased social and functional impairment, decreased cognitive functioning, and increased risk of all-cause mortality ( Blazer 2003 ). Even subsyndromal symptoms of depression are linked to similar negative health outcome ( Lavretsky, Kurbanyan, and Kumar 2004 ); thus, including questions related to depression in interviews with older adults is important. Late-life depression differs from depression in other age groups in several ways. Older adults are less likely to endorse symptoms of depressed affect, guilt, and suicidal ideation, and more likely to report hopelessness, helplessness, psychomotor retardation, and somatic symptoms compared to younger age groups ( Fiske, Wetherell, and Gatz 2009 ). Somatic symptoms of depression are often difficult to disentangle from symptoms of other medical conditions associated with ageing. Evidence suggests that changes in appetite and sexual drive are not related to depression in late life, whereas other somatic symptoms, such as sleep disturbances and chronic pain, are ( Nguyen and Zonderman 2006 ).

It may be necessary to use fewer psychopathology-laden terms (e.g. ‘depressed’). Asking older clients informal questions like ‘How are your spirits today?’ can open a dialogue regarding recent life events and symptoms of depression ( Gallo and Rabins 1999 ). Interviewers should be aware of age-related medical conditions that are associated with depressive syndromes. For example, individuals with cerebrovascular disease are at increased risk of developing vascular depression. Vascular depression is characterized by increased language difficulties and more vegetative symptoms (e.g. apathy) compared to other forms of depression ( Alexopoulos 2004 ). Depressive symptoms also may be due to side-effects of prescription medications or the interaction between two or more medications. Interviewers should inquire about somatic symptoms and other non-dysphoric symptoms of depression (e.g. ‘Have you had any unusual aches or pains lately?’ or ‘Have you been keeping up with your favourite hobbies recently?’). Endorsement of these symptoms may indicate a depressive syndrome, though somatic symptoms should be interpreted with caution ( Edelstein, Drozdick, and Ciliberti 2010 ).

Anxiety disorders are the most commonly diagnosed psychiatric disorders among older adults ( Kessler et al. 2005 ). Generalized anxiety disorder and phobic disorders are the most common, with lower prevalence rates of social anxiety disorder and panic disorder ( Bryant, Jackson, and Ames 2008 ). As with late-life depression, symptoms of anxiety and worry are common among older adults and even subsyndromal levels are related to functional and social impairment, sleep difficulties, and poorer quality of life ( Gould and Edelstein 2010 ; Wetherell, Le Roux, and Gatz 2003 ). Thus, assessing for anxiety in clinical interviews is important with older adult clients.

There are several key concepts related to interviewing older adults about anxiety-related topics. Older clients tend to prefer colloquial terms for anxiety and worry such as ‘fret’ or ‘concern’ compared to psychological terms ( Stanley and Novy 2000 ). They are also more likely to emphasize physical symptoms (e.g. shortness of breath, chest pain, gastrointestinal distress) compared to cognitive or behavioural symptoms (e.g. worry, fear, avoidance; Lenze et al. 2005 ). The propensity for older adults to endorse physical symptoms of anxiety makes the detection of anxiety disorders challenging, given that these symptoms may overlap with medical conditions and anxiety-related side-effects of medications. Yet, it is critical that interviewers assess for physical symptoms of anxiety and attempt to rule out underlying medical causes.

One of the greatest differences in anxiety disorders across age groups is the content of anxiety or worry symptoms. Compared to younger age groups, older adults tend to worry less about work-related problems and more about family, health, and finances ( Hunt, Wisocki, and Yanko 2003 ). Older adults often experience anxiety in different social situations than younger adults, such as forgetting information and using technology in front of others ( Ciliberti et al. 2011 ). Physiological changes such as declines in vision, hearing, memory, and continence may affect specific anxiety or worry symptoms in social anxiety disorder or generalized anxiety disorder. Interviewers are encouraged to make adjustments to questions related to worry and anxiety content when assessing older adults.

Personality disorders

The prevalence of personality disorders declines in later life. However, roughly 10% of older adults meet criteria for at least one personality disorder ( Zweig 2008 ). Though many older adults that were diagnosed with a personality disorder in young adulthood no longer meet diagnostic criteria for a personality disorder, negative consequences associated with these disorders (e.g. interpersonal problems) appear to persist into older adulthood ( Balsis et al. 2007 ).

There are at least two possible reasons for the decline in personality disorders in late life, both of which are pertinent to clinical interviewing. First, many of the diagnostic criteria for personality disorders in the DSM-IV-TR contained age bias ( Balsis et al. 2007 ). For example, one criterion of antisocial personality disorder involves aggression, as evidenced by the presence of repeated physical altercations. This feature may not be applicable to frail older adults, who may express aggression in non-physical ways (e.g. yelling, cursing; Edelstein and Segal 2011 ). Thus, even if older adults do not meet criteria for a personality disorder, it may still be important to assess for personality disorder symptomatology (i.e. interpersonal problems, emotional lability, maladaptive behavioural traits). Second, symptoms of personality disorder may be disregarded in older adults due to negative stereotypes of ageing (e.g. that older adults are inflexible, stingy, cantankerous, depressed, or needy). Depression, anxiety, and personality disorders are not part of normal ageing, and interviewers of older adults should take care not to fall victim to these biases. Conversely, interviewers must consider and attempt to rule out the presence of physiological or neurological syndromes that may account for overlapping symptoms.

The World Health Organization reports that suicide rates worldwide have increased by 60% in the last forty-five years ( WHO 2011 ). The global mortality rate is estimated to be 16 per 100,000 deaths. Older adults, particularly older men, are disproportionally affected by suicide compared to other groups. In the US, older adults accounted for 16% of all deaths by suicide in 2008, but comprised only 12.7% of the population ( McIntosh 2011 ). Suicidal behaviour in older adults has greater lethality compared to younger adults ( Chan, Draper, and Banerjee 2007 ). Many older adults had visited their physician within one month of committing suicide, and the majority had visited a physician in the prior year ( Luoma, Martin, and Pearson 2002 ). Comprehensive screening for suicidal ideation or intent in clinical interviews is one route for preventing death by suicide.

The conceptual model of suicide risk presented by Bryan and Rudd (2006) may be useful for the clinical interview. According to their model, suicide risk is an amalgamation of baseline risk factors (i.e. demographic, historical factors) and acute risk factors (i.e. short-term, exacerbating factors). For older adults with high baseline risk, a difficult life transition (e.g. widowhood) could be enough to induce suicidal ideation or intent. Conwell (2004) identified several risk and protective factors specific to suicide in late life. Baseline risk factors in older adults include white race, male gender, older age (80+), marital status (with single, divorced, or widowed at higher risk), prior suicide attempts, a history of psychopathology, and recent suicide plans or attempts. Acute risk factors in later life include social isolation, recent bereavement, family discord, financial stressors, access to lethal means, hopelessness, perceived burdensomeness, and the presence of a suicide plan or method. Risk factors for special populations of older adults (e.g. institutionalized) may differ from those listed above. For example, nursing home residents at facilities with lower levels of patient autonomy have a higher risk of suicide than residents in facilities allowing greater patient autonomy ( Reiss and Tishler 2008 ). In addition to risk factors, protective factors (e.g. religious beliefs, concerns about family, etc.) should be considered.

Given the high degree of lethality of suicidal behaviour in older adults, it is especially beneficial for clinicians to have standardized procedures for evaluating suicide risk in older adults. The Suicidal Older Adult Protocol (SOAP), a semi-structured clinical interview, is one assessment instrument designed for this purpose ( Fremouw et al. 2009 ). Interviewers should also assess for protective factors. The Reasons for Living—Older Adults Scale (RFL-OA) is a sixty-nine-item, copyright-free measure that assesses for protective factors particular to older individuals, including family and friends, religious beliefs, and moral objections to suicide, to name a few ( Edelstein et al. 2009 ).

Substance abuse

With the ageing of the baby boomer generation, the prevalence of substance abuse disorders among older adults is increasing ( Gfroerer et al. 2003 ). Older adults are more likely to present with alcohol use disorders than illicit drug use disorders ( Lin et al. 2011 ). Misuse of prescription medications is most common among older adults ( Schonfeld et al. 2010 ) as older adults are likely to be taking several medications ( Dwyer et al. 2010 ). Substance abuse tends to begin in young adulthood and remit over the life course, though late-onset substance abuse does occur ( Sattar, Petty, and Burke 2003 ). Substance abuse is generally associated with male gender, younger age, being divorced or separated, recent major life events, and poor social support ( King et al. 1994 ; Lin et al. 2011 ). Substance abuse can be a means by which older adults cope with psychological distress, such as depression ( Rodriguez et al. 2010 ).

Assessment of substance abuse is complicated by the presence of comorbid medical problems, medication use ( King et al. 1994 ; Lin et al. 2011 ), and psychiatric disorders ( King et al. 1994 ; Sorocco and Ferrell 2006 ), which may mask or resemble symptoms of substance abuse. Cognitive impairment associated with prolonged substance abuse, especially chronic alcohol use, can hinder the clinical interview and diagnostic process. Diagnostic criteria for substance abuse may not be well suited to older adults. For example, older adults may engage in fewer activities (e.g. they may be retired, frail), which can make it difficult to determine whether substance use causes significant interference in daily life ( Sorocco and Ferrall 2006 ). Older adults may be especially unlikely to admit to problems of substance use or may not understand what constitutes substance use problems.

When assessing for substance abuse, a respectful, non-judgmental attitude should be adopted to help the older client feel more comfortable discussing substance use ( Sattar et al. 2003 ). Language used in the interview is important. Older adults seldom admit to using ‘street drugs’, but may be more likely to give an affirmative response if referred to as ‘recreational drugs’ ( Mohlman et al. 2011 ). Considerations of medical and psychological disorders are important in making a differential diagnosis. Few screeners of substance abuse have been validated with older adults, though several exist for alcohol abuse. Interested readers are referred to Barry and Blow (2010) for a discussion of screening measures.

Considering sleep in the assessment interview cannot be overemphasized. Older adults report sleeping approximately the same amount of time as young adults ( Stepnowsky and Ancoli-Israel 2008 ), but the architecture of sleep changes with age, with a reduction in non-REM sleep, a longer latency to sleep onset, and an increase in the number of awakenings. The latter results in fragmented and lighter sleep and lower sleep efficiency ( Beck and Ralls 2011 ). Some older adults experience Delayed Sleep Phase Syndrome, in which the individual falls asleep at progressively later times. In contrast, other older adults may experience Advanced Sleep Phase Syndrome, which involves earlier sleep onset and earlier wakening. These phase shifts can be influenced by factors such as decreased exposure to light, decreased physical activity, and irregular meal times ( Ancoli-Israel and Ayalon 2006 ). Insomnia complaints also increase with age, with substantially more women than men reporting difficulties falling asleep, maintaining sleep, or awakening early ( Lichstein et al. 2006 ). These age-related sleep changes can contribute to poorer quality and quantity of sleep, which can result in impaired cognitive functioning. Poor sleep is also associated with a variety of psychiatric symptoms and disorders (e.g. anxiety disorders, mood disorders). Consequently, it is important to question the older adult about his or her sleep and, if necessary, employ a brief self-report measure of sleep quality (e.g. Pittsburgh Sleep Quality Index; Buysse et al. 1991 ).

Elder abuse

Elder abuse is intentional actions that cause harm to a vulnerable older adult by a trusted person and includes physical, sexual, or emotional abuse, financial exploitation, abandonment, neglect, and self-neglect ( National Research Council 2003 ). The rate at which professionals report elder abuse to authorities is less than actual incidents ( Cooper, Selwood, and Livingston 2009 ). This trend may be explained by professionals’ lack of awareness of signs of abuse, poor methods for assessing abuse, or lack of knowledge of reporting procedures. Victims may not report abuse because of shame and embarrassment or the desire to protect the abuser, especially if the abuser is a family member. Elder abuse is associated with higher rates of psychological disorders ( Acierno et al. 2003 ), underscoring the importance of assessing for elder abuse.

Victims of elder abuse are more likely to be female ( Laumann, Leitsch, and Waite 2008 ), have less social support, and display greater cognitive and functional impairment ( Fulmer et al. 2005 ). Older adults living with non-spouse family or friends are more likely to be abused than those living in institutionalized settings or with a spouse ( Vida, Monks, and Des Rosiers 2002 ). Offenders of elder abuse are more likely to be acquaintances and male ( Krienert, Walsh, and Turner 2009 ). These characteristics are important to consider when interviewing older adults about elder abuse.

Given the sensitive nature of elder abuse, clinicians must maintain a warm, non-judgmental demeanour during the interview. It can be helpful to give definitions and descriptive examples of different types of abuse to elicit accurate answers ( Acierno et al. 2003 ). It is prudent to ask care-givers or staff members to leave the room during questioning ( Mohlman et al. 2011 ). Affirmative responses of elder abuse necessitate additional assessment. Follow-up assessment should include behavioural observations, interviews with others, as well as the use of screening instruments, such as the Hwalek-Sengstock Elder Abuse Screening Test ( Hwalek and Sengstock 1986 ) and the Indicators of Abuse Screen ( Reis and Nahmiash 1998 ).

Reporting elder abuse is mandatory in some jurisdictions, yet some professionals do not report abuse out of fear of damaging the therapeutic alliance or decreasing the client’s quality of life ( Rodriguez et al. 2006 ). However, research indicates these fears are unsupported. Consequently, when elder abuse is detected, clinicians should refer to reporting guidelines and act accordingly.

Assessment of older adults requires the interviewer to act as a detective: to consider various explanations for behaviours or symptoms, and systematically deduce the underlying cause. To do so, the clinician must address numerous factors that influence the interview process and conclusions drawn from information gathered in the interview.

Numerous interviewing tools, including structured, semi-structured, or unstructured interviews, can be used with older adults. Often, it is appropriate to modify the interview. Age-related changes in the visual and auditory systems may require changes to the testing environment, such as completing the interview in a well-lit and quiet location. Cognitive changes, including slowed processing speed and impaired memory, suggest that the interviewer change the interview format or collect collateral information. The setting of the interview (e.g. nursing home, outpatient mental health clinic) will place unique demands on the interviewer and interviewee. Finally, the interviewer should be aware that older adults have peaks and troughs in cognitive performance across the day, and note the time at which interviews are conducted.

The interviewer must gather as much information as possible, which can assist in selecting interview questions and interpreting information. When working with ethnic-minority older adults, knowledge of culture-specific presenting symptoms is important. It is essential to attain an accurate medical history and a list of current medications for the older adult client, which ought to factor into case conceptualizations.

As always, it is important to build rapport with older adult clients, as they may be less familiar with the interview process than other age groups. Establishing trust is crucial, as it will help the older adult to feel more comfortable providing answers regarding potentially sensitive information. Professionalism, warmth, and politeness will likely put the older adult client at ease.

There are a number of content areas for which the clinician can assess. Though this chapter discusses only a few psychological disorders and behaviours relevant to older adults, the overall message is that older adults often have unique symptom presentations and experiences that should be addressed in the interview. The clinician should thoroughly read relevant material before interviewing an older adult to gain an understanding of issues specific to older adults.

Interviewing older adults can be complicated. An understanding of issues related to the interview process, with appropriate modifications, can help the clinician gather accurate information. Knowledge of older adult development, ethnic and cultural issues, mental and physical health problems, and age-related behaviours will enhance the quality of the interview with an older adult client.

Key References and Sources for Further Reading

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Ageism in health care is more common than you might think, and it can harm people

Ashley Milne-Tyte

Dr. Louise Aronson, a geriatrician and author, speaks with a patient at UCSF's Osher Center for Integrative Health in San Francisco. /Julia Burns hide caption

Dr. Louise Aronson, a geriatrician and author, speaks with a patient at UCSF's Osher Center for Integrative Health in San Francisco.

A recent study found that older people spend an average of 21 days a year on medical appointments. Kathleen Hayes can believe it.

Hayes lives in Chicago and has spent a lot of time lately taking her parents, who are both in their 80s, to doctor's appointments. Her dad has Parkinson's, and her mom has had a difficult recovery from a bad bout of Covid-19. As she's sat in, Hayes has noticed some health care workers talk to her parents at top volume, to the point, she says, "that my father said to one, 'I'm not deaf, you don't have to yell.'"

In addition, while some doctors and nurses address her parents directly, others keep looking at Hayes herself.

"Their gaze is on me so long that it starts to feel like we're talking around my parents," says Hayes, who lives a few hours north of her parents. "I've had to emphasize, 'I don't want to speak for my mother. Please ask my mother that question.'"

Researchers and geriatricians say that instances like these constitute ageism – discrimination based on a person's age – and it is surprisingly common in health care settings. It can lead to both overtreatment and undertreatment of older adults, says Dr. Louise Aronson, a geriatrician and professor of geriatrics at the University of California, San Francisco.

"We all see older people differently. Ageism is a cross-cultural reality," Aronson says.

Ageism creeps in, even when the intent is benign, says Aronson, who wrote the book, Elderhood . "We all start young, and you think of yourself as young, but older people from the very beginning are other."

That tendency to see older adults as "other" doesn't just result in loud greetings, or being called "honey" while having your blood pressure taken, both of which can dent a person's morale.

Aronson says assumptions that older people are one big, frail, homogenous group can cause more serious issues. Such as when a patient doesn't receive the care they need because the doctor is seeing a number, rather than an individual.

"You look at a person's age and say, 'Ah, you're too old for this,' instead of looking at their health, and function, and priorities, which is what a geriatrician does," says Aronson.

She says the problem is most doctors receive little education on older bodies and minds.

"At my medical school we only get two weeks to teach about older people in a four-year curriculum," she says.

Aronson adds that overtreatment comes in when well-meaning physicians pile on medications and procedures. Older patients can suffer unnecessarily.

"There are things...that happen again and again and again because we don't teach [physicians] how to care about older people as fully human, and when they get old enough to appreciate it, they're already retired," says Aronson.

Kris Geerken is co-director of Changing the Narrative , an organization that wants to end ageism. She says research shows that negative beliefs about aging - our own or other people's - are detrimental to our health.

"It actually can accelerate cognitive decline, increase anxiety, it increases depression. It can shorten our lifespans by up to seven-and-a-half years," she says, adding that a 2020 study showed that discrimination against older people, negative age stereotypes, and negative perceptions around one's own age, cost the health care system $63 billion a year.

Still, beliefs can change.

"When we have positive beliefs about age and aging, those things are all flipped," Geerken says, and we tend to age better.

Geerken conducts anti-ageism trainings, often over Zoom, including trainings for health care workers. She also advises older adults on how to push back if they feel their medical concerns are being dismissed with comments like, "It's to be expected at your age."

Age-Friendly Health Systems are another initiative designed to curb ageism in the health care industry.

Leslie Pelton is vice president at the Institute for Healthcare Improvement, which launched the concept of Age-Friendly Health Systems in 2018, along with the John A. Hartford Foundation .

She describes the effort as one in which every aspect of care, including mobility, mental health and medication, is centered on the needs and desires of the older adult.

Pelton says 3,700 sites across the US - including clinics, hospitals, and nursing homes - are now designated age-friendly.

She describes the system as "a counterbalance to ageism, because it requires that a clinician begins with asking and acting on what matters to the older adult, so right away the older adult is being seen and being heard."

That sounds great to Liz Schreier. Schreier is 87 and lives in Buffalo. She walks and does yoga regularly. She also has a heart condition and emphysema and spends plenty of time at the doctor. She lives alone and says she has to be her own advocate.

"What I find is a disinterest. I'm not very interesting to them," she says. "And I'm one of many - you know, one of those old people again."

She goes from specialist to specialist, hoping for help with little things that keep cropping up.

"I had a horrible experience with a gastroenterologist who said I was old, and he didn't think he wanted to do a scope on me, which was a little insulting," she says.

She later found one of his colleagues who would.

Schreier says navigating the health care system in your 80s is tough. What she and her peers are looking for from health care workers, she says, is kindness, and advice on how to stay active and functional no matter how old they are.

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Talking With Your Older Patients

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Tips for communicating with older patients

Families and caregivers as part of the health care team, obtaining a thorough history, discussing medical conditions and treatments, confusion and cognitive problems, sensitive topics.

Effective communication can help build satisfying relationships with older patients to best manage their care. It can strengthen the patient-provider relationship, lead to improved health outcomes, help prevent medical errors, and make the most of limited interaction time.

Interpersonal communication skills are considered so important that they are a core competency identified by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties.

These key communication tips can help facilitate successful interactions with all of your patients, including older adults:

• Speak to the patient as a fellow adult . Having physical, sensory, or cognitive impairments does not lessen the maturity of an adult patient. Those who are older might be used to more formal terms of address. Establish respect right away by using formal language as a default (such as Mr. or Ms.) and avoiding familiar terms, such as “dear,” which could be perceived as disrespectful. You or your staff can also ask patients how they prefer to be addressed.
• Make older patients comfortable . Ask staff to ensure patients have a comfortable seat in the waiting room and, if necessary, help with filling out forms. Staff should check on them often if they have a long wait before they are seen. Patients with impaired mobility may need to be escorted to and from exam rooms, offices, restrooms, and the waiting area. They may require assistance with climbing on to the exam table or removing clothing or shoes.
• Avoid hurrying older patients . Be mindful if you are feeling impatient with an older person’s pace. Some people may have trouble following rapid-fire questioning or torrents of information. Try speaking more slowly to give them time to process what is being asked or said, and don’t interrupt. Once interrupted, a patient is less likely to reveal all of their concerns. If time is an issue, you might suggest that your patients prepare a list of their health concerns in advance of appointments.
• Speak plainly . Do not assume that patients know medical terminology. Use simple, common language and ask if clarification is needed. Check to be sure your patient understands the health issue, what they need to do, and why it is important to act.
• Address the patient face-to-face . Don’t talk to patients with your back turned or while typing. Many people with hearing impairment understand better when they can read lips as well as listen. Watching a patient’s body language can also help you know whether they understand what you’re saying.
• Write down or print out takeaway points . It can often be difficult for patients to remember everything discussed during an appointment. Older adults with more than one medical condition or health concern benefit especially from having clear and specific written notes or printed handouts. That way, they have information to review later about their health conditions, treatments, and other major points from visits.
• Recognize that people from different backgrounds may have different expectations . Be sensitive to cultural differences that can affect communication with your patients. When needed, provide professional translation services and written materials in different languages.

Compensating for hearing deficits

Age-related hearing loss is common: About one-third of older adults have hearing loss, and the chance of developing hearing loss increases with age. Here are a few tips to make it easier to communicate with a person who may have difficulty hearing:

• Make sure your patient can hear you. Ask if the patient has a working hearing aid, look at the auditory canal for excess earwax, and be aware of background noises, such as whirring computers and office equipment.
• Talk clearly and in a normal tone. Shouting or speaking in a raised voice distorts language sounds and can give the impression of anger, and a high-pitched voice can be hard to hear.
• Face the person directly, at eye level, so that they can lip read or pick up visual clues.
• Indicate to your patient when you are changing the subject, such as by pausing briefly, speaking a bit louder, gesturing toward what will be discussed, gently touching the patient, or asking a question.
• Keep a notepad handy so you can write down important points, such as diagnoses, treatments, and important terms.
• Use amplification devices if they are available in your clinic or hospital.
• If your patient has difficulty hearing the difference between certain letters and numbers, give context for them. For instance, “m as in Mary” or “five, six” instead of “56.” Be especially careful with letters that sound alike.

Compensating for visual deficits

Visual disorders become more common as people age. Here are some things you can do to help manage the difficulties in communication that can result from visual deficits:

• Make sure there is adequate lighting, including sufficient light on your face. Try to minimize glare.
• Check that your patient has brought and is wearing eyeglasses or contact lenses, if needed.
• Make sure that handwritten instructions are clear. When using printed materials, make sure the type is large enough (at least 14-point font) and the typeface is easy to read.
• If your patient has trouble reading because of low vision, consider providing alternatives, such as audio instructions, large pictures or diagrams, and large pillboxes with raised markings.

Family members and other informal caregivers play a significant role in the lives of their loved ones. They may provide transportation and accompany an older adult to medical appointments. In many cases, they act as facilitators to help the patient express concerns and can reinforce the information you give. But first, to protect and honor patient privacy, check with the patient by asking how they see the companion’s role in the appointment.

It is important to keep the patient involved in their own health care and conversation. Whenever possible, try to sit so that you can address both the patient and companion face-to-face. Be mindful not to direct your remarks only to the companion.

You might ask the companion to step out of the exam room during part of the visit so you can raise sensitive topics and provide the patient some private time if they wish to discuss personal matters. For example, if you’re conducting a test of a patient’s cognitive abilities, you might ask the companion to step out so they can’t answer questions or cover for the patient’s cognitive lapses.

Some patients may ask that you contact their long-distance caregivers to discuss conditions or treatment plans. Make sure these patients fill out any necessary paperwork giving permission for you to speak with specific family members or friends if they are not present at the appointment.

Families may want to make decisions for a loved one. Adult children especially may want to step in for a parent who has cognitive impairment . If a family member has been named the health care agent or proxy, under some circumstances they have the legal authority to make care decisions. However, without this authority, the patient is responsible for making their own choices. When necessary, set clear boundaries with family members and encourage others to respect them.

Consider caregivers as “hidden patients”

Family caregivers face many emotional, financial, and physical challenges. They often provide help with household chores, transportation, and personal care, in addition to juggling their own jobs and families. Many also give medications, injections, and other treatments and may need advice or guidance on how to provide such medical care.

Caregivers often have their own health issues to manage as well. For example, they tend to have a higher risk of physical and mental health issues, sleep problems, and chronic conditions such as high blood pressure. It makes sense to view informal caregivers as “hidden patients” and to be alert for signs of illness, stress, and burnout. The long-term demands of caregiving tax the health of the caregiver and can also lead to unintentional elder abuse . Advise caregivers to talk with their own health care providers if they need help.

Caregivers may find it hard to make time for themselves , and your support and praise can help to sustain them. Encourage them to seek respite care so they can take a break to recharge. Colleagues such as social workers and other interdisciplinary team members may be able to recommend resources for caregivers.

Obtaining a complete medical history — including current and past concerns, lifestyle, and family history — is crucial to good health care.

You may need to be especially flexible when obtaining the medical history of older patients. When possible, have the patient tell their story only once, even if other health care professionals in the office or home would typically assist in gathering the information. The process of providing their history to another staff member and then again to you can be tiring for patients.

Open-ended questions encourage a more comprehensive response, but yes-or-no or simple-choice questions may be helpful if the patient has trouble responding. Also be sure to ask if anything in a person’s health, medications, or lifestyle has changed since their last visit. You may want to get a detailed life and medical history as an ongoing part of older patients’ office visits and use each visit to add to and update information.

Here are some strategies for obtaining a thorough history:

• Gather preliminary data . If feasible, request previous medical records or ask the patient or a family member to complete forms and worksheets at home or online prior to the appointment. Try to structure questionnaires for easy reading by using large type (at least 14-point font) and providing enough space between items for thorough responses. Keep any questionnaires meant to be filled out in the waiting room as brief as possible.
• Elicit current concerns . Older patients tend to have multiple chronic conditions. You might start the session by asking your patient to talk about their main concern. For example, “What brings you in today?” or “What is bothering you the most?”
• Ask prompting questions . The main concern may not be the first one mentioned, especially if it is a sensitive topic. Asking, for example, “Is there anything else?”, which you may have to ask more than once, helps to get all of the patient’s concerns on the table at the beginning of the visit. If there are too many concerns to address in one visit, plan with the patient to address some now and others next time. Encourage the patient (and their caregivers) to bring a written list of concerns and questions to a follow-up appointment.
• Discuss medications . Older people often take many medications prescribed by several different doctors and some drug interactions can lead to major complications. Suggest that patients bring a list of all of their prescription medications, over-the-counter drugs, vitamins, and dietary supplements , including the dosage and frequency of each. Or suggest that they bring everything with them in a bag. Check to ensure the patient is using each medication as directed.
• Ask about family history . The family history not only indicates the patient’s likelihood of developing some diseases but also provides information about the health of relatives who care for the patient or who might do so in the future. Knowing the family structure will help you evaluate what support may be available from family members.
• Ask about functional status . The ability to perform basic activities of daily living (ADLs) reflects and affects a patient’s health. There are standardized ADL assessments that can be done quickly in the office. Understanding an older patient’s usual level of functioning and learning about any recent significant changes are fundamental to providing appropriate health care.
• Consider a patient’s life and social history . Ask about where they live, who else lives in the home or nearby, neighborhood safety, their driving status, and access to transportation. Determine eating habits, assess their mood, and ask about tobacco , drug, and alcohol use. Factor in typical daily activities and work, education, and financial situations. Understanding a person’s life and daily routine can help you to understand how your patient’s lifestyle might affect their health care and to devise realistic, appropriate interventions.

Approximately 85% of older adults have at least one chronic health condition, and 60% have at least two chronic conditions. Clinicians can play an important role in educating patients and families about chronic health conditions and can connect them with appropriate community resources and services.

Most older patients want to understand their medical conditions and learn how to manage them. Likewise, family members and other caregivers can benefit from having this information. Physicians typically underestimate how much patients want to know and overestimate how long they spend giving information to patients. Devoting more attention to educating patients and their caregivers can improve patients’ adherence to treatment, increase patients’ well-being, and save you time in the long run.

Clear explanations of diagnoses are critical. Uncertainty about a health problem can be upsetting, and when patients do not understand their medical conditions, they are less likely to follow their treatment plans. It is helpful to begin by finding out what the patient understands about their condition, what they think will happen, and how much more they want to know. Based on the patient’s responses, you can correct any misconceptions and provide appropriate information.

Treatment plans need to involve patients’ input and consent. Ask about their goals and preferences for care and focus on what matters most to them. Check in with your patient about feasibility and acceptability throughout the process, thinking in terms of joint problem-solving and collaborative care. This approach can increase the patient’s satisfaction while reducing demands on your time.

Treatment might involve lifestyle changes, such as a more nutritious diet and regular exercise, as well as medication. Tailor the plan to the patient’s situation and lifestyle and try to reduce disruption to their routine. Keep medication plans as simple and straightforward as possible, indicating the purpose of each medication and when it should be taken. Tell the patient what to expect from the treatment.

These tips may help discussions about medical conditions and treatment plans:

• A doctor’s advice generally receives the greatest credence, so the doctor should introduce treatment plans. Other medical team members can help build on the doctor’s original instructions.
• Let your patients know that you welcome questions. Tell them how to follow up if they think of any additional questions later.
• Some patients won’t ask questions even if they want more information. Consider making information available even if it’s not explicitly requested.
• Offer information through more than one channel. In addition to talking with the patient, you can use fact sheets, drawings, models, or videos. In many cases, referrals to websites and support groups can be helpful.
• Encourage the patient or caregiver to take notes. It’s helpful to offer a pad and pencil. Active involvement in recording information may help your patient better retain information and adhere to the treatment plan.
• Repeat key points about the health problem and treatment plan at every office visit, providing oral and written instructions, and check that the patient and their caregiver understand the information.
• Provide encouragement and continued reinforcement for treatment or necessary lifestyle changes. Call attention to the patient’s strengths and offer ideas for improvement.
• Make it clear that a referral to another doctor, if needed, does not mean you are abandoning the patient.

Referring older patients to clinical trials

Clinical trials are the primary way we learn if a promising treatment is safe and effective. Patients who participate in clinical research help others by contributing to medical research. In some cases, they can also gain access to new treatments before they are widely available. However, participants may not know whether they are receiving the experimental treatment, a placebo , or standard care. Most clinical trials test short-term interventions related to a specific illness or condition. They are designed to test research hypotheses, not to provide regular health care.

Find clinical trials information for patients .

For information about federally and privately funded clinical research, or to search for specific studies, visit ClinicalTrials.gov .

A patient may still seem confused despite your best efforts to communicate clearly. In those instances, work to:

• Support and reassure the patient, acknowledging when responses are correct or understood.
• Make it clear that the conversation is not a “test” but rather a search for information to help the patient.
• Consider having someone from your staff call the patient to follow up on instructions.

Cognitive impairment, however, is more than general confusion or normal cognitive aging . If you observe changes in an older patient’s cognition or memory, follow up with screening and diagnostic testing, as appropriate.

There are a variety of possible causes of cognitive problems, such as side effects from medications, metabolic and/or endocrine changes, delirium, or untreated depression . Some of these causes can be temporary and reversed with proper treatment. Other causes of cognitive problems, such as Alzheimer’s disease, are chronic conditions but may be treated with medications or nondrug therapies. Having an accurate diagnosis also can help families wanting to improve the person’s quality of life and better prepare for the future.

Read more about Assessing Cognitive Impairment in Older Patients and Caring for Older Patients With Cognitive Impairment .

Caring for an older patient requires discussing sensitive topics related to safety, independence, and health. Older patients may be hesitant to bring up certain problems and other concerns such as:

• Advance care planning
• Elder abuse
• End of life
• Health care costs
• Long-term care
• Mental health issues, such as depression
• Sexuality and sexual health
• Social isolation and loneliness
• Substance use/misuse, including alcohol
• Urinary incontinence

There are techniques for broaching sensitive subjects that can help you successfully start the conversation. Try to take a universal, nonthreatening approach that frames the subject as a common concern of many older patients (such as, “Many people experience …” or “Some people taking this medication have trouble with...”). You can also share anecdotes about patients in similar circumstances, though always clearly maintaining patient confidentiality, to ease your patient into the discussion.

Some patients will still avoid issues that they think are inappropriate to discuss with clinicians. One way to overcome this hesitation is to keep informative brochures and materials readily available in the exam room and waiting areas.

You may also be interested in

• Exploring healthy aging and dementia resources for health care professionals
• Finding Alzheimer's and related dementias resources for professionals
• Learning about providing care to a diverse older adult population

For more information about talking with your older patients

Eldercare Locator 800-677-1116 [email protected] https://eldercare.acl.gov

American Academy of Family Physicians 800-274-2237 [email protected] www.familydoctor.org

American Geriatrics Society 800-247-4779  [email protected] www.americangeriatrics.org

Gerontological Society of America 202-842-1275 www.geron.org

This content is provided by the NIH National Institute on Aging (NIA). NIA scientists and other experts review this content to ensure it is accurate and up to date.

Content reviewed: January 25, 2023

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HC System Older Adults Patient Education Issues Essay and Interview Paper

User Generated

Description

Write a 500‐750‐word essay on the influence patient education has in health care using the experiences of a patient. Interview a friend or family member about that person's experiences with the health care system. You may develop your own list of questions. Complete interview and rubric/instructions are included in the attachment.

• What was the reason for your most recent hospitalization?
• Did a patient education representative give you instructions on how to care for yourself after your illness or operation?
• What were these instructions?
• Did a health care professional, pharmacist, nurse, doctor, or elder counselor advise you on your medication, diet, or exercise?
• What did they advise?
• Who assisted you at home after your illness or operation?
• Do you know of any assistance services, i.e., food, transportation, medication, that would help you stay in your home as you get older?

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Hi, please see the attached paper. Have a look at it and in case of any edit, please let me know. Otherwise, it is my pleasure to have you as my buddy now and future. Until the next invite, Bye! Running Head: OLDER ADULT PATIENT EDUCATION Older Adult Patient Education Student’s Name Course Institutional Affiliation 1 OLDER ADULT PATIENT EDUCATION 2 Older Adult Patient Education Having a sound education in the healthcare system promote not only excellent health care services and facilities but also improve the quality of health for a diverse group of patients. For example, older adults are vulnerable to diseases and need proper knowledge of how they can sustain their condition. The aspect of education should be of significant value while providing patient care to the elderly population to enable them to have a healthy life (Peter et al., 2015). My interview was with Mr. John, a 98-year-old retired construction worker relaxing at his home after being diagnosed and on treatment for Tuberculosis. Patient education provides an understanding of how individuals address several health care issues a...

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Middle East Crisis Blinken Says Challenges Remain as U.S. Pushes for Gaza Cease-Fire Deal

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• A destroyed house in Rafah in southern Gaza. Mohammed Abed/Agence France-Presse — Getty Images
• A mass prayer for the release of hostages held in Gaza at the Western Wall in Jerusalem. Ronen Zvulun/Reuters
• Israeli military bulldozers maneuvering near the border with Gaza. Ammar Awad/Reuters
• Carrying the body of a person killed after an Israeli raid near the West Bank city of Tulkarem. Alaa Badarneh/EPA, via Shutterstock
• Palestinians in central Gaza after leaving the compound around Al-Shifa Hospital in Gaza City. Agence France-Presse — Getty Images
• Smoke near the site of an Israeli airstrike on the Lebanese village of Adaysseh. Rabih Daher/Agence France-Presse — Getty Images
• Aid packages airdropped on the Gaza Strip. Agence France-Presse — Getty Images

‘We’ve closed the gaps, but there are still gaps,’ Blinken says of cease-fire talks.

Secretary of State Antony J. Blinken said on Thursday that “challenges” and “gaps” remain in talks for a possible deal between Israel and Hamas that would pause the war in Gaza and allow for the release of Israeli hostages.

“There’s still real challenges. We’ve closed the gaps, but there are still gaps,” Mr. Blinken said, speaking alongside his Egyptian counterpart at a news conference in Cairo.

“It’s still difficult work to get there,” he later added.

While Mr. Blinken also repeated an assessment he made in a Wednesday television interview that the “gaps are narrowing” between Israel and Hamas, and that an agreement is possible, his words indicated caution. A U.S. official confirmed that William Burns, the director of the Central Intelligence Agency, would travel to Qatar on Friday for negotiations. Mr. Blinken declined to confirm Mr. Burns’s travel.

People briefed on the talks said an agreement between Israel and Hamas was unlikely to be reached imminently.

Mr. Blinken spoke on Thursday after meetings with President Abdel Fattah el-Sisi and Egypt’s foreign minister, Sameh Shoukry, continuing his sixth swing through the Middle East since the war began. Mr. Blinken plans to travel on to Israel .

Among his goals is brokering a temporary Gaza cease-fire, which the United States is also seeking through a United Nations resolution . It will bring the resolution to a vote Friday morning, Nate Evans, a spokesman for the U.S. mission, said in a statement.

Mr. Blinken also joined several Arab foreign ministers to discuss how Gaza could be governed and kept secure once Israel finishes its military campaign there. Among them were ministers from Saudi Arabia, Qatar, the United Arab Emirates, Jordan and the Palestinian Authority. The group also discussed providing Gaza’s desperate population with more humanitarian aid.

Before his trip to Egypt, Mr. Blinken visited Jeddah, Saudi Arabia, where he held a late-night meeting with Crown Prince Mohammed bin Salman. Mr. Blinken emphasized the Biden administration’s long-term goal of “the establishment of a future Palestinian state with security guarantees for Israel,” the State Department spokesman, Matthew Miller, said in a statement on Thursday.

Mr. Blinken and the crown prince also “continued discussions on achieving lasting regional peace and security, including through greater integration among countries in the region and enhanced bilateral cooperation between the United States and Saudi Arabia,” Mr. Miller said.

That was a reference to discussions between the Biden administration and Saudi Arabia about a possible deal in which the country would establish normal diplomatic relations with Israel for the first time. In return the Saudis have asked the U.S. for security guarantees, arms sales and backing for a civil nuclear program. Such a deal would also likely require Israeli support for a path to Palestinian statehood.

“We are getting close to a point where we will have agreements,” Mr. Blinken said when asked about the negotiations.

A senior U.S. official said that most of the progress had been made on bilateral issues between the United States and Saudi Arabia.

Such a U.S.-Saudi agreement would require approval from the U.S. Senate, which is not assured. And Israel’s prime minister, Benjamin Netanyahu, has said that he would not support a Palestinian state.

Mr. Blinken acknowledged the obstacles, but called the effort critical.

Mr. Netanyahu’s office said Thursday that a delegation of mediators from Israel, Egypt, Qatar and the United States would meet in Doha, Qatar’s capital, on Friday to “advance the release of hostages” still being held in Gaza.

Along with Mr. Burns, of the C.I.A., that will include David Barnea, the director of Mossad; Prime Minister Mohammed bin Abdulrahman Al Thani of Qatar; and Abbas Kamel, the Egyptian intelligence minister, according to Mr. Netanyahu’s office.

In Israel, Mr. Blinken will discuss the potential Saudi normalization agreement as well as Israel’s war plans and ways to protect and deliver more aid to civilians there.

Julian E. Barnes contributed reporting.

— Michael Crowley traveling with Secretary of State Antony J. Blinken

U.S. resolution at the U.N. calls for a sustained cease-fire in Gaza.

The United States is circulating a resolution at the United Nations calling for “an immediate and sustained cease-fire” in the Gaza Strip, as experts warn of imminent famine in the enclave and pressure grows for stronger international action.

The Security Council resolution drafted by the United States contains the strongest language that Washington has supported so far, and was an apparent reversal for Israel’s closest ally. In February, the United States vetoed a Council resolution demanding an immediate humanitarian cease-fire.

The new resolution also condemns the Hamas-led attacks on Israel of Oct. 7 that set off the war and the hostage-taking that day, and expresses support for the negotiations to free those still being held in Gaza.

The Security Council will bring the resolution to a vote on Friday, Nate Evans, a spokesman for the U.S. mission to the United Nations, said in a statement.

When the United States vetoed the earlier resolution, which had been put forward by Algeria, American officials said they had done so because they were concerned that it could disrupt hostage negotiations. But Biden administration officials have grown more forceful in recent weeks in their push for a cease-fire, as conditions have further deteriorated in Gaza and the death toll has exceeded 30,000 .

The resolution being circulated by U.S. diplomats and obtained by The New York Times on Thursday says that the Council “ determines the imperative of an immediate and sustained cease-fire to protect civilians on all sides, allow for the delivery of essential humanitarian assistance, and alleviate humanitarian suffering, and towards that end unequivocally supports ongoing international diplomatic efforts to secure such a cease-fire in connection with the release of all remaining hostages.”

The resolution also notes the “deep concern about the threat of conflict-induced famine and epidemics.”

The call for an “immediate” cease-fire was markedly stronger language than a draft Security Council resolution that the United States circulated in February, which called for a temporary cease-fire “as soon as practicable.”

The Biden administration also used the resolution to reiterate its opposition to Israel’s planned invasion of Rafah, a city in southern Gaza, which is packed with war refugees. It expresses “concern that a ground offensive into Rafah would result in further harm to civilians and their further displacement including potentially into neighboring countries.”

— Michael Crowley and Thomas Fuller Michael Crowley reported from Cairo and the Middle East and Thomas Fuller from San Francisco.

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Back from Gaza, these doctors want Washington to know the horrors they witnessed.

Volunteer doctor details dire conditions at a gaza hospital, nick maynard, part of a delegation of doctors who volunteered in gaza, described “appalling atrocities” and the need for an immediate cease-fire at a news conference at the united nations on tuesday..

I spent two weeks at Al Aqsa Hospital, and I think it’s fair to say I wasn’t remotely prepared for what I was going – what I saw. I saw the most appalling atrocities. One child that I’ll never forget had burned so bad you could see her facial bones. We knew there was no chance of her surviving that, but there was no morphine to give her. So, not only was she inevitably going to die, but she would die in agony. Some days we didn’t have any surgical gloves, so we had to wash previous ones. Sometimes we had no surgical drapes. Many days we had no morphine. Knowing that actually a lot of those resources were probably in depots somewhere or maybe in lorries queuing up outside at Rafah but could not be distributed. And this is what is so urgent about the need for a cease-fire is, the only way that aid that’s being delivered to Gaza - and we welcome every bit of aid - the only way that aid is going to get to where it’s needed is if there is a cease-fire.

The memories are unforgettable. A flood of screaming families carrying their bloodied loved ones through the doors of an already inundated hospital. A small boy trying to resuscitate a child who looked not much older than himself. A 12-year-old with shrapnel wounds to his head and abdomen being intubated on the ground.

That January day at the Nasser Hospital in Khan Younis in southern Gaza — the aftermath of a missile strike on an aid distribution site — has haunted Dr. Zaher Sahloul, an American critical care specialist with years of experience treating patients in war zones, including in Syria and Ukraine.

He and other volunteer doctors who have returned from besieged hospitals in Gaza took their firsthand accounts of the carnage to Washington this week, hoping to convey to the Biden administration and senior government officials that an immediate cease-fire was needed to provide lifesaving medical care.

Among the evidence Dr. Sahloul took to show the American officials — including members of Congress and officials from the White House, State Department, Defense Department and the United States Agency for International Development — was a photo of the 12-year-old boy and his death certificate. The child never woke up from surgery after being intubated, the doctor said, and the hospital could not reach his family amid a near-total communications blackout.

Two other doctors in the delegation — Amber Alayyan, a Paris-based deputy program manager for Doctors Without Borders, and Nick Maynard, a British surgeon — said that robust medical advancements achieved by local doctors in Gaza had been wiped out by Israel’s war against Hamas.

Dr. Maynard, who earlier this year met with the British foreign secretary, David Cameron, said he was hopeful that if the U.S. changed its tune on backing what Israeli forces were doing in Gaza, then Britain would follow.

“This is the deliberate destruction of the whole health care system,” he said in an interview.

Dr. Maynard described operating on chest injuries from explosions with few anesthetics or antibiotics at the Al-Aqsa Hospital in Deir al Balah in central Gaza in December and January. “The lack of pain relief was particularly disturbing because we saw lots of children with awful burns,” he said.

The availability of sterile gloves and surgical drapes was also limited, and the hospital’s record-keeping abilities had collapsed, rendering follow-up care nearly impossible, he said. Dr. Maynard said he walked through hallways overcrowded with displaced people to check on patients he had operated on and sometimes failed to find them.

Also in the delegation was Thaer Ahmad, a Palestinian American emergency medicine physician who was with Dr. Sahloul in January as Israeli forces encircled Khan Younis and began closing in on Nasser Hospital, the largest one still functioning in the enclave at the time.

He said in an interview that he had a toddler and a 2-month-old baby at home in Chicago when he traveled to Gaza. He contrasted his wife’s experience of being able to deliver in a safe, well-resourced hospital with an obstetrician she knows well with the plight of pregnant women in Gaza , who have been starving and giving birth in shelters. “I had to go,” he said. “They’re my people.”

Not long after the doctors’ departure from Gaza, Nasser Hospital was raided by Israeli forces and forced to cease operations .

“I will regret, for the rest of my life, leaving when I did,” Dr. Ahmad said.

As the death toll in Gaza has soared to nearly 32,000 in five months, according to the Gaza Health Ministry, Palestinian Americans have been “yelling at the top of our lungs, and no one is listening,” he added.

“The numbers clearly aren’t making a difference,” Dr. Ahmad said. “I’m afraid the toll could reach 40,000, or 50,000, and we’ll be in the same position. What else am I going to do?”

— Anushka Patil

Israel’s raid on Al-Shifa Hospital grows into one of the longest of the war.

One of Israel’s longest hospital raids of the Gaza war stretched into a fourth day on Thursday, as the military said that it had killed dozens of people it described as terrorists in the previous 24 hours in its operation at Al-Shifa Hospital.

Israel has staged a series of raids on Al-Shifa in northern Gaza, the largest medical facility in the territory, arguing that Hamas used it as a command center and concealed weapons and fighters in underground tunnels there. Since the latest attack began on Monday, the Israeli military has reported killing more than 140 people it said were terrorists in and around the hospital, far more than in past raids.

On Thursday, the military said it had also detained 600 people at the hospital. The Israeli accounts could not be independently verified.

The Al Jazeera news network and Wafa, the Palestinian Authority’s news agency, reported on Thursday that Israeli forces had blown up a building used for surgery that is one of the largest at the complex. The Israeli military said it had no comment on the reports.

Iyad Elejel, who lives about 500 yards from Al-Shifa, said the situation was “very terrifying,” adding in a phone call on Thursday: “We are hearing the constant sounds of clashes, gunshots, shelling, bombing, quadcopters and planes all day and all night.” Smoke had infiltrated the apartment where he is staying with 30 relatives, making it hard to breathe, he said.

Mr. Elejel said the children in the apartment were becoming used to the cacophony. “We try to convince them that the sounds they are hearing are from fireworks, but they don’t believe it,” he said.

Nobody has been able to leave the apartment since the raid began, Mr. Elejel said, and the family feared that they could run out of food soon. He said that when he looked out of his window Thursday morning, he saw “many dead bodies lying on the main street” out front. Israeli soldiers have been forcing people in the area to leave their apartments and head south, so the neighborhood was emptying out, Mr. Elejel said.

The military said in an earlier statement that it was continuing to “conduct precise operational activity in the Shifa hospital, eliminating dozens of terrorists over the past day during exchanges of fire.” It also said it was preventing harm to civilians and had located storage sites for weapons.

Mohammed Abu Kmail, a 35-year-old marketing consultant, said in an interview that he was with his wife and two daughters in their apartment, near the hospital, when they woke up before dawn Tuesday to the sound of gunfire close to their building.

He said that around 8 a.m., Israeli soldiers entered nearby buildings, and stripped and handcuffed about 25 men, including himself. He said that, after being scanned by a camera, he and some of the others were released. The account resembled those of other men detained in Gaza since the war began.

The Israeli military said in a statement that detained people “are treated in accordance with international law” and that “it is often necessary” to have detainees remove clothing so it “can be searched and to ensure that they are not concealing explosive vests or other weaponry.”

Israeli forces have carried out a series of raids on medical facilities in Gaza, arguing that Hamas has used them for military purposes. The armed group has denied doing so.

Israel made northern Gaza the initial target of its ground invasion of the enclave, which started on Oct. 27, and it first raided the hospital in November. It later provided evidence that Hamas had constructed a lengthy tunnel under the hospital. A later analysis by The New York Times found that Hamas had used the complex for military purposes. The Israeli military, however, has struggled to prove that Hamas maintained a command-and-control center under it.

Even before the current raid began, international aid workers said that the hospital barely functioned and was incapable of serving the acute health care needs of northern Gaza as it had before the conflict.

The World Health Organization had hoped to conduct a mission to the hospital on Thursday to provide fuel and food for staff and patients, as well as to assess the situation there, but permission had been denied because of security issues, according to Dr. Rik Peeperkorn, who represents the organization in Gaza and the West Bank.

The W.H.O. is “terribly worried” about the situation, he said, adding that it had not been possible to contact staff members there.

Israeli officials said earlier this week that Hamas personnel had returned to the hospital, prompting its operation. Military analysts said Israel’s decision to withdraw most of its forces from the north, in part to concentrate on defeating Hamas in other parts of Gaza, had in effect left a security vacuum .

The initial raid on Al-Shifa became a lightning rod for criticism of Israel over military action around hospitals and the danger it poses to patients and medical staff. The raid also became a symbol of a broader debate about the human cost of Israel’s military campaign to destroy Hamas in Gaza, in which tens of thousands of civilians have been killed or wounded.

Lauren Leatherby contributed reporting.

— Matthew Mpoke Bigg and Hiba Yazbek

The House speaker says he will invite Netanyahu to address Congress.

House Speaker Mike Johnson said Thursday that he planned to invite Prime Minister Benjamin Netanyahu of Israel to address a joint session of Congress, moving to welcome a leader who has become a flashpoint for partisan disagreement in American politics over the war in Gaza.

Mr. Johnson, Republican of Louisiana, brought up the invitation one day after Mr. Netanyahu assailed Senator Chuck Schumer, the majority leader, in a private meeting with Senate Republicans for a speech in which the New York Democrat singled him out as an impediment to peace and called for eventual elections to replace him.

“I would love to have him come and address a joint session of Congress; we’ll certainly extend that invitation,” Mr. Johnson said of Mr. Netanyahu in an interview on CNBC. Mr. Johnson said he had also been invited to speak in front of the Israeli Knesset.

Mr. Schumer on Wednesday declined a request from Mr. Netanyahu to speak virtually to Senate Democrats at their own closed-door party lunch, saying it was not helpful to Israel for discussions with the prime minister to happen in a partisan forum.

But on Thursday, he said he would support an address by the Israeli prime minister in front of the entire Congress if Mr. Johnson moved forward with the invitation.

“Israel has no stronger ally than the United States and our relationship transcends any one president or any one prime minister,” Mr. Schumer said in a statement. “I will always welcome the opportunity for the prime minister of Israel to speak to Congress in a bipartisan way.”

The statement came a week after Mr. Schumer delivered an explosive speech on the Senate floor in which he harshly criticized Mr. Netanyahu, naming him and his right-wing coalition alongside Hamas and Mahmoud Abbas, the Palestinian Authority leader, as the main obstacles to peace.

The remarks and the Republican backlash that has followed have underscored a growing partisan divide in the United States over Mr. Netanyahu’s leadership as Israel’s war against Hamas rages on, and a struggle between members of both parties to define themselves as the true allies of the Jewish state.

A spokesman said that Mr. Johnson had not yet discussed any plans with Mr. Schumer, who would have to sign off on any invitation for an address before a joint session of Congress.

Mr. Netanyahu enraged Democrats in 2015 by accepting an invitation from Republicans who then controlled the House and Senate to deliver an address to Congress condemning the Iran nuclear deal as the Obama administration was negotiating it.

— Annie Karni Reporting from the Capitol

Israel’s Supreme Court asks authorities to hold off on the deportation of Gazan cancer patients.

Gazans who had been receiving medical treatment in Israel were to be deported back to the Palestinian territory on Thursday but have received a temporary reprieve from Israel’s Supreme Court.

The Supreme Court decision came in response to a last-minute petition filed by rights organizations and 13 cancer patients on Wednesday evening asking for the deportation to be blocked. The court asked the Israeli government to hold off on any action until it had time to review the petition.

Tamir Blank, the lead attorney for the patients, said on Thursday that seven names had been added to the petition since the decision.

“We’re making the argument that Israel created such conditions in Gaza that it cannot sustain people who have cancer and nobody with cancer can survive there for a reasonable amount of time,” he said.

The Israeli government said in a court filing on Thursday that it agreed to the court’s request not to deport any of the patients while the petition was under review. It also asked for 30 days to prepare its own response to the petition.

COGAT, the Israeli agency that oversees policy for the Palestinian territories and that was named along with the government in the petition, did not respond to questions about the petition or the patients involved. It said in a statement that “at present, Gazan residents and their escorts, who have received medical treatment in Israeli hospitals and who are not in need of further medical care, are returned to the Gaza Strip.”

“We emphasize that as of this moment, the coordination of the return of the Gazan patients has stopped and the issue is being discussed in court,” the statement added.

Months of bombardment and dire shortages of supplies since the war began in October have brought Gaza’s already struggling health care system to what aid organizations have said is the brink of collapse. Israel has raided several of Gaza’s main medical complexes , saying it is rooting out Hamas activity, a charge health officials deny.

The health care system was ill equipped to provide advanced cancer treatment even before the war. To get treatment in Israel, Gazans had to navigate several obstacles, including getting the Palestinian Authority’s Health Ministry to agree to absorb the cost of treatment and the Israeli authorities to issue a permit to cross the border.

Since the war began, Israel has sent some Palestinian workers back to Gaza, and rights groups say some Gazans receiving medical treatment have chosen to go back.

The 20 people named on the petition, most of whom are cancer patients and the majority of whom are adults, according to Mr. Black, do not want to return to Gaza. All of them were in Israel before the war began, mostly at hospitals in occupied East Jerusalem.

They were scheduled for deportation because they were no longer receiving “active treatment,” according to the attorney, rights groups and a hospital.

Dr. Fadi Atrash, the head of the Augusta Victoria Hospital in East Jerusalem, said that the Israeli authorities had contacted his hospital last week for an updated list with the names and statuses of Gazan patients. The hospital was told that 11 cancer patients who were no longer receiving active treatment would be sent back to Gaza this week, he said.

Completing chemotherapy or radiation is not the end of treatment for cancer patients, the doctor and rights groups argued. Patients might need hormone therapies, and require follow-ups and regular checkups, none of which are feasible in Gaza.

“Sending them back to Gaza — it’s like putting them in a higher risk to be killed because it’s a war zone,” Dr. Atrash said.

Aseel Aburass, the director of the department for occupied Palestinian territories at Physicians for Human Rights-Israel, which took the lead on the petition, said that it was “crazy” to send the patients back to a war zone when they need follow-up care.

“They’re still weak and their immune system is weak,” she said, adding: “This is a death sentence.”

Myra Noveck and Johnatan Reiss contributed reporting.

— Cassandra Vinograd