Coaching can help older adults speak up at medical visits

By Joan Hennessy, Contributing Writer
Health Behavior News Service

Coaching sessions can help seniors become more assertive during medical visits, suggests a new review of studies on methods to increase older patients’ involvement in their own health care.

“Elderly patients should … have more of a say in not only treatment decisions but they should be supported during the whole consultation to make clear their needs and expectations about their health care,” said lead author Raymond Wetzels, a general practitioner at the Radboud University Nijmegen Medical Center in the Netherlands.

Even when coaching and handouts are provided to encourage elderly patients to play a more active role in their care, a majority may remain uninvolved in their doctor visits, one of the reviewed studies found.

In this study, more than half of the patients, 54 percent, had not identified specific issues to discuss before their visit to the doctor. Further, 80 percent did not bring a list of questions, problems or medications to the visit and asked no questions about their illness or tests or procedures. And 77 percent did nothing whatsoever to prepare for their visits.

The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The review, of three studies encompassing 433 patients, focused on two basic types of interventions: face-to-face coaching sessions, either individually or in a group, and written material such as booklets or a checklist to prioritize reasons for the visit. Two of the studies combined these types of interventions, while a third study used only coaching sessions.

More-involved patients tend to adhere to advice better, Wetzels said. This involvement is particularly important for elderly patients because they tend to have more contact with doctors. While figures vary, an estimated 80 percent of people over age 65 have at least one chronic condition, and 65 percent have multiple conditions.

For a variety of reasons, some elderly patients are reticent when dealing with doctors. In some cases, the problem is simply impaired hearing or vision. Seniors dealing with dramatic environmental changes such as the loss of a spouse or moving to new living arrangements may also have difficulty communicating with doctors.

But there are other explanations, said Ming Tai-Seale, an associate professor at Texas A&M Health Science Center. Tai-Seale, who recently wrote a separate review focusing on elderly patients and office visit time, said older patients “may be of the generation where they still see doctors as superior beings. They wouldn’t challenge their opinion. They may feel they are taking too much of the physician’s time.” Older patients “may not be as information savvy as some in the younger generation.”

But one patient left an impression on Tai-Seale: “She was a former city councilwoman. She held the floor throughout the visit. She would make sure that the physician addressed her concerns,” Tai-Seale said. “The conversation was among two equals.”

For patients unable to be assertive, face-to-face coaching sessions may help, according to one of the studies in the Cochrane review.

The 45 study patients were divided into an intervention group and a control group. Before patients in the intervention group visited the doctor, a medical student interviewed them and helped identify questions about their treatment. Of that group, 14 of 22 patients asked at least one question during their visit with the physician. In the control group, eight of 23 patients asked at least one question.

But to some degree, the intervention may have influenced study results in that “patients entering the doctor’s office with a booklet, cue card or question list may have been identified by the doctor as belonging to the intervention group, which may have influenced the doctor’s attitude,” Wetzels said.

While all participants in these studies were 65 or older, the average age was 72 in one study and 77 in another. Two studies had low patient numbers, the reviewers said, and because evidence was limited, they couldn’t recommend specific interventions in daily practice.

Asked if there is an argument for more education aimed at doctors, Wetzels said that doctors already get that training. The trend is toward patient-centered care where both “patients and doctors are responsible for patients’ health care.”

Future studies should focus on follow-up after seniors are coached. “The follow-up should be at least a year after an intervention, but ideally even longer,” according to Wetzels.

“But perhaps more important is to measure objective health outcomes,” he added. For example, an objective measure could be the walking distance of an osteoarthritis patient six months to one year after the intervention.

There should be a balance, the reviewers concluded, between respecting a patient’s autonomy and stimulating active participation in health care.