University Place Positive Aging Series Sue Heidrich, "Improving Physical and Psychological Well-Being in Old Age" 8/20/2010  UP 475   cc >> Sarah Schutt: Welcome to the last installment of the Positive Aging Lecture Series. Today's speaker is Sue Heidrich from the University of Wisconsin-Madison School of Nursing, and her topic is "Improving Physical and Psychological Well-Being in Old Age." Sue Heidrich is the Helen Denne Schulte Professor in the School of Nursing and is also an affiliate of the UW Institute on Aging. Her research focuses on understanding how older persons, particularly older women, cope successfully with stressors associated with aging and also she focuses on developing and testing an educational program to help older women cope with physical symptoms, an aging related stressor. We are very pleased today to welcome Professor Sue Heidrich. Please join me in welcoming her. (applause) >> Sue Heidrich: Thank you. Can you hear me okay? I'm all wires. When I was first asked to do this, and I forget how long ago it was, I made a pretty generic title because I really wasn't sure what I was going to talk about. And then I looked to see who all of your speakers have been in the series and it's a very impressive list of people, so I'm very honored to be among that list of people and I have heard most of them speak also, so I know a little bit about what they probably talked about when they were here. What I wanted to do then is not be redundant, because a lot of what I do has been inspired by some of your other speakers. 

And to be somewhat practical, so I want to hopefully give you some practical strategies that you can use in dealing with your own age related issues or problems, hopefully in ways that will improve your well-being. I need to acknowledge a lot of grant funding that I've had over the last ten years to do some of the research that I've done. I also want to acknowledge a lot of the nurses who've worked with me on these studies and worked with the participants in our studies, and particularly Dr. Hyun-E Yeom, who is a very recent, just in August, PhD graduate from the School of Nursing and contributed a lot to this research area. I have a couple goals I'd like to attempt to meet this morning. One is to talk about the relationship between the physical symptoms that almost everyone experiences as they age and how those are related to both physical and emotional well-being. Then I want to spend some time talking about some specific beliefs and attitudes that we think contribute to whether or not people can successfully manage dealing with symptoms or other types of physical stressors as they age, or even emotional stressors. Then give you some strategies that we've used in our research that we have found help people get better at self care in terms of taking care of their own health and interacting more positively with the health care system, which can be a challenge for all of us, I think. If I have time and I sort of doubt if I will, I also just wanted to share the recommended guidelines for preventive care and health promotion in people over the age of 65 and some of the issues related to that. I teach a large undergraduate course, it's a required senior nursing course in gerentological nursing and most of my students are about 21, and for them old age is like a different planet that they haven't visited yet. One of my goals is to help them just start thinking about the fact that we all age, hopefully, and to learn about aging, to prepare for aging, we really don't have many guidelines. 

We don't, as a society, as a culture, have a lot of experience with that. It's a relatively new phenomenon for people to live a very long time. So the best way to learn about that that we have right now is to talk to people who are there and actually experiencing it. This is not a new approach, because Socrates was said to have said this in 360 BC when he wrote "The Republic." >> Can you turn up your volume? >> Heidrich: Can I turn up my volume? Okay. Is this any better? I'll try to talk a little louder also. All of you probably have seen these statistics, the increase in the number of people age 65 and older and this big jump is just starting right now in 2010 as the Baby Boomers hit 65, the first of them, but also note the big jump that's about to occur, or has started, in the number of people aged 85 and older in the population. This is in the United States. Again, we know very little about what this experience is and what aging is like for that group of people, and that group of people is going to grow tremendously. By 2050, one in five people in the United States will be over the age of 65. If you were born today, your life expectancy, if you were a woman, would be 80, and if you were a man would be 75. 

And life expectancy continues to increase, but if you're 65 today, how many more years you can expect to live, if you're a woman, is 20 more years, and if you're a man, is 15 more years. So your life expectancy, the longer you live, the longer your life expectancy becomes. So we have a lot of time to be old and experience that. (laughter) The leading causes of death in old age have not changed much over the last 30 or 40 or 50 years. You can see heart disease has been and remains the leading cause of death for older people, but you can see that death from heart disease has declined dramatically and continues to do that because we have much better prevention and much better treatment of heart disease. The second leading cause of death is cancers, and that has not changed in terms of mortality rates too much over the years. Within cancers, the leading cause of cancer death for both men and women is lung cancer and that is new. It used to be breast cancer for women, but it's now lung cancer. But more importantly to what I want to talk about is not causes of death, but causes of difficulty with daily life that people experience as they get older. And what this slide shows you are the types of issues that older people say interfere most with their activities of daily living, which to me means doing the things you really want to do. 

This shows you for three different ages of people what things contribute most to their problems with daily life. You can see arthritis and musculoskeletal problems are the most interfering for people. Musculoskeletal, probably a big piece of that is back pain in terms of prevalence. The second leading cause of activity limitation is heart disease. So even though mortality from heart disease has gone down, what has increased is the incidence of heart failure and heart failure specifically, we don't have good prevention for and treatment for. Heart failure contributes probably to a lot of the symptoms that interfere with people being able to do what they want to do. You just might want to note also, on this slide it shows that dementias are not a major source of activity limitation for people until after the age of 85 or so and that probably just corresponds to the incidence of dementias in older folks. The flip side of what's limiting in old age is how healthy people actually feel when they're old. If you ask older people to rate their health, just, "Tell me how healthy you are from poor to excellent," the majority of people even in the 85 and older age group say their health is good to excellent. Now, those are the same people that are having all of these activity limitations and symptoms that limit their activities. 

They still rate their health as good to excellent. And I want to make a specific point about this because we know from a lot of population-based research that the most powerful predictor we have of people's health, whether they're going to have disease or disability or die is self-rated health. It's not the number of diagnoses you have, it's not what your physician rates your health as, it's not physiological measures, objective measures of your health status. It's how you rate your health. So there's something about what people think about themselves and believe about themselves that is very powerful and I'm going to talk about that more as we go along. A lot of the research that I've done has looked at what contributes to positive well-being as people age, and what interferes with that. In many, many studies we found that what interferes the most with quality of life are two things. One is activity limitation, not being able to do what you want, and the second is symptoms. And symptoms probably work that way because they limit your activities in one way or the other. We've done lots of studies where we've asked people just to tell us how many symptoms they have and how bothered they are by those symptoms. 

Over five or six different studies, the average number of symptoms people report is 18. Now, that's a lot of symptoms. You don't usually see that many, but if you go back and look at the research, people have never given people a long list. We give them a list of 36 or 37 symptoms, not five or six. And if you give people that long of a list, they'll tell you 18 symptoms on average. Now, not all of them are bothersome or cause major problems, but that's a lot. So we have done some statistical analysis just to try to group the symptoms into things that seem to occur together or to be the most prevalent or bothersome to people. This is what some of that looks like and on your left, the column "Musculoskeletal" is the group of symptoms that are the most prevalent and the most bothersome to people. That includes things like joint pain, generalized pain, and fatigue as major problems for people. And the other group of symptoms that's a major problem for people are sleep difficulties. 

Very prevalent. Waking too often, waking too early in the morning, and having difficulty falling asleep all are things that people rate as very bothersome to them. Our interest has been in, are these things related to quality of life and then is there anything we can do to help people manage symptoms more effectively? Some of these symptoms on here are specific to women, but almost all of them are the same in men and women. We've looked at different dimensions of quality of life, and you may have heard about some of these things in previous lectures here. We look at physical quality of life, which really is how much you're able to do all of your daily activities, your leisure activities, your social activities. Mental quality of life, which is mood, but also, are you able to fulfill important roles to you in your life? Depressive symptoms. Purpose in life, which is an aspect of well-being that's having a sense that your life is meaningful, that you still have goals that you're working on. And then positive relations, which is feeling that you have warm and intimate, supportive relations with other people. With few exceptions, all of those symptom clusters are related to lower quality of life no matter how we measure it. People with more symptoms or more bothersome symptoms rate their quality of life as lower. 

And this is consistent with a lot of other research that's been done in older people across all kinds of health problems, that the common symptoms that we mostly think of as related to being old are related to worse social function, worse physical function, more psychological distress, and just overall worse quality of life. That made us look at what would influence how people manage these symptoms because they're so prevalent and common, everyone is dealing with this, are there things we can do to help people manage symptoms better? What things actually are influencing how people deal with symptoms when they're older? There's three things that we looked at. One is people's beliefs about symptoms. What do they think about symptoms themselves and what do symptoms mean to them? Health care providers' attitudes about symptoms in older people. And then the communication between the older person and health care providers. What we found that seems to be operating in all three of these areas is stereotypes about aging. I want to talk a little bit about stereotypes about aging and how they influence our own behavior and the behavior of other people, often in detrimental ways. Ben Franklin said, "All would live long, but none would be old," which I think captures many stereotypes about aging. We all look forward to living a long life and experiencing all of those things associated with a long life, but being old is something that no one ever really says they want to be. So what is this contradiction that we're dealing with? When we talk about stereotypes, we have to be careful, because there are stereotypes that can be positive as well as stereotypes that are negative. 

So we do have some stereotypes about aging that are positive. One is that older people are wise. But unfortunately in Western cultures, the negative stereotypes seem to outweigh the positive stereotypes. That's not true in other cultures, but it seems to be true in Western cultures. These negative stereotypes can lead to ageism. Ageism is a prejudice against or scapegoating of a person based solely on age. There are two ways that people experience ageism. One is that actually older people themselves often have these stereotypes, negative stereotypes about aging, we call those self-stereotypes. And then older people experience negative stereotypes that are held by other people in interactions with them. When is someone old? When do you get to this point where you start to experience these stereotypes? This is something James Thurber said. 

"I'm 65 and I guess that puts me in with the geriatric set. But, if there were 15 months in every year, I'd only be 48." (laughter) So age is a relative thing. Again, it's that attitude we have about what makes us old. Stereotypes are important because they actually have very real effects on people. There are two ways stereotypes have been studied. One is in laboratory settings. In laboratory settings, older people are brought into the laboratory. They're exposed to videos or written materials that contain negative stereotypes about aging, and another group is brought in and they're exposed to neutral materials that don't contain any negative stereotypes. Then both groups of people are tested on a number of parameters after exposure to these stereotypes, and it's been found that the people exposed to the negative stereotypes do more poorly on tests of memory, their handwriting is slower and less legible, they score worse on psychological tests that measure things like will to live, which is like purpose in life. And there are physiological differences. 

There's more cardiovascular reactivity. Their blood pressure goes up, their pulse goes up, all signs of stress, compared to people who were not exposed to those stereotypes. Positive stereotypes also have real effects on people, which is a good thing. If people are brought into the laboratory and exposed to information containing positive stereotypes about aging and then tested, what's been found is that older people exposed to the positive stereotypes walk faster or cover more distance in a walking test than those who are just exposed to neutral information. That they do better on all sorts of tests of functional ability, like tying your shoes, taking things in and out of cupboards, those kinds of things. Then another way the effect of these stereotypes has been examined is in big, national, longitudinal studies tracking people's health over their life span, and in some of these studies people have been asked to fill out questionnaires that measure their own attitudes about aging, whether they're positive or negative. It's been found that people who, when they are younger, have more positive attitudes about growing old live 7.5 years longer on average than the people who have more negative attitudes about aging. All of these things just make us think about how important our own attitudes and beliefs about our own aging could be. There are some examples of stereotypical beliefs about aging that often come out in proverbs and sayings. These are ones I often share with my students and they don't know what any of them mean. 

(laughter) I'm guessing that most of you probably know what all of these are about. "You can't teach an old dog new tricks," right? "The horse is out of the barn." My students never know what that is. For those of you who may not have heard that one, that means that once you've learned those bad habits in your youth or your personality gets set at a very young age, it's always lost, you can't ever change those things, the horse is already out of the barn, you're not going to get him back in. "The secret to successful aging is to choose your parents wisely." Well, we know that there is a genetic component to risk for disease. There's a genetic component to longevity. But more recently, with all the new research in genetics, what we're finding is that actually the role of the environment is much more powerful than we ever thought, and the role of our own behavior is much more powerful than we ever thought. "The lights may be on, but the voltage is low." (laughter) Now, that's about your sex life when you're older, isn't it? There are also myths about how people learn or don't learn as they get older. I talk about these with my students also because one of the things we teach nurses to do is to help educate people about taking care of their own health, about managing their health problems and illnesses. These are typical beliefs that younger people have about teaching older people. Older adults are resistant to change. 

Older adults are unable to learn new material. And this last one is the one that older people complain the most to me about. Older adults defer to younger family members, so the family should be the focus of your interactions. Many older people have told me that what they really hate is, they go to their doctor's appointment, they might have their adult son or daughter along with them, and the doctor or nurse spends all the time talking to the adult son or daughter and not to them. That's a stereotype about aging. I actually cut this out of the newspaper in February of 1988 because I turned 40 that year. Either Rick, the Doonesbury character, turned 40, or Gary Trudeau turned 40 that year. He does the Doonesbury cartoon. He did a cartoon about, again, how we feel about growing old. Rick at 18, it's his birthday, it's great, everyone wants to be 18, of course. 

At 21, fantastic, now he can legally drink so this is great. 30, at 30 you're still considered not-over-30, which at least when I was younger was the age at which we considered people "old." And then he hits 40 and everything changes. So obviously aging at 40 was what Gary Trudeau was thinking about. If you ask people who are under 30 now when someone is old, any guesses of what they say? 60. 60, yeah. If you ask someone 65 when someone's old, they say 75. (laughter) And if you ask someone who's 80 when someone is old, they'll typically say 90. If you ask someone how old they feel, it's typically ten years younger than their actual age. Again, how we feel about aging is important. I talked a little bit about stereotypes of aging. 

I want to talk a little bit about how these stereotypes are related to what we believe about symptoms that are common when we're older. If you read the literature about health and aging and how people feel about it, you find some of these things. People believe that symptoms are a normal part of getting older. Actually, we don't know if that's true because it's difficult to find someone who's quite old who doesn't have some kind of health problem. Are we measuring poor health, or are we measuring normal aging? We don't know. There just aren't enough older people who have no sign of disease to know what that would look like. "Nothing can be done about age related symptoms and age related symptoms are incurable," those things go together. And "In old age, it's better just to learn to live with symptoms." One of the ways people talk about how they cope with getting older, at least with me, is, you learn to adjust and you learn to adapt. Those are all very positive things, but sometimes that can be a double-edged sword. Because what we've found is, holding these beliefs causes people to behave in different ways. 

One thing that happens when people believe these things about their health when they're older is that they're less likely to engage in health behaviors. They're less likely to eat well, they're less likely to exercise, they're less likely to do a lot of health promotion activities. And they're also less likely to seek health care for their health problem, because they're learning to live with it. Both of those things, not engaging in health promotion activities, not seeking health care when you might need some, can lead to poor symptom management and as I showed you earlier, poor symptom management can be related to lower quality of life. We actually tried to measure these attitudes in older people in a number of studies, and I'm going to show you the results from the latest study we did. This was in 200 women and their average age was 70. Their ages ranged from 65 to 92. We gave them a list of attitudes or beliefs about symptoms and symptom management and asked whether or not they agree with them. You can see that almost 100% of these women agreed that most symptoms are a normal part of getting older. But the majority of people also agreed that it's important not to complain about symptoms when you're older. 

It's important for health care providers to focus on curing illness, not wasting time managing symptoms. The "cure" for symptoms is often worse than the disease. There's probably a grain of truth in that. And health care providers might find it annoying to be told about symptoms. The majority of women also agreed that if they talk about their symptoms, their doctor will think they're a complainer. That at my age, it's better just to learn to live with symptoms. And at my age, this is the best I can expect to feel. So the majority of women agreed with all of those things. On the plus side, they disagreed with the statement, "at my age, it's not worth learning new ways to manage symptoms." There may be a little bit of bias in this study because these are all women who had just volunteered to be in a clinical trial to test a new way to manage symptoms, so they obviously are motivated to do this. So I'm guessing that generally, most people would probably not agree with that statement. 

The second thing we've looked at is health care providers' attitudes about older people and symptom management. If you look at the research on stereotypes about aging on the part of health care professionals, what you'll find, unfortunately, is that there are a lot of negative stereotypes about aging. Among physicians, nurses, physical therapists, social workers, all sorts of people. Some of those negative stereotypes are based in some of these kinds of beliefs. Many health professionals will agree with these statements. "My older patient is too old to try a new treatment. He or she will be unwilling to try a new treatment because of their age, or that medical therapies or treatments are less effective in older people." Actually, we don't have any evidence that any of these things are true. But these are commonly held attitudes. In fact, in one study, 50% of older people said they'd experienced some of these attitudes in their interactions with health care providers. Again, we tried to measure some of these experiences. 

We asked people in our studies whether or not they've heard these kinds of things from their physicians or other health care providers. We got these items from actually interviewing older people about their interactions in the health care system. About 40% in our last study, about 40% of women said that they've heard, "You're worrying too much about your symptoms or your health problems." Now, on the face of it, these comments don't really sound so negative. They might seem supportive, but that's not how they're perceived by most older people. For most older people, they're perceived as not taking them seriously, not thinking that they're worth the time and effort to help with this problem. So these are things that the health care provider may think are positive, but they're perceived quite negatively by the older person. About 20% of women agreed or said that they'd heard things like, "Compared to other people with your health problem, your problems are minor." And what they take away from that is to quit worrying or bothering about it. "It's not necessary for you to know the details of your condition." "You should be thankful you've lived as long as you have." (laughter) And then we asked women if they've ever felt that a symptom they reported was not dealt with sufficiently or to their satisfaction. And about 16% of women said yes to that. The good side of this is, this is not the majority of people, but it's still a substantial number of people who've experienced these things. 

The last thing we looked at is communication between older people and health care providers. There's less research in this area and we've discovered some of these things just over the years, looking in this area and talking to people about difficulties they have dealing with symptoms. Some of the things they've told us is, it's really hard to know what symptoms they should actually talk about when they see their doctor. Which doctor should they talk to? Many older people have more than one health care provider. They may have their primary care physician, but many specialists involved in their care, so who would they tell what to? It's difficult to know if this is important enough to talk about. Is this something minor or is this something major? They worry about being seen as a "problem patient." And they don't want to distract the doctor. They respect the doctor's time, they know they're very busy people, they don't want to distract them from what maybe they perceive as more important than their own problem. Again, we've tried to actually measure these things and we asked people again to tell us if they have they have this difficulty in communicating with their health care providers about symptoms and symptom management. And about 40% of the women said that they don't know which doctor to talk to often. They're not sure which symptoms they should talk about. 

They're not sure if their doctors are communicating with each other when they have multiple providers, and this is, we know, a real problem in today's health care system, the communication among health care providers. Their symptoms seem minor to them and they don't want to be a complainer, but at the same time, they worry that they might be ignoring something serious. 20% to 40% of women said they have these difficulties. We have these three areas that we found were problematic for many people, even the majority of people, and we wanted to see if these specific issues, all of which we think are being influenced by stereotypes about aging, negative stereotypes about aging, are related to quality of life. And what we found just very generally is that both these negative beliefs about symptom management and difficulty communicating about symptoms are both directly related to quality of life. They're related to lower quality of life in all of those measures I talked about earlier. The negative attitudes from health care providers or perceiving those negative attitudes are not directly related to quality of life, but it's indirectly related because people who perceive those negative attitudes also had more difficulty communicating with their health care providers, and that makes sort of logical sense to me. People who had negative beliefs about symptom management also reported more difficulty communicating about symptoms. The last study that we are just finishing where we actually worked with people to try to help them learn new ways to take care of themselves with self care kinds of approaches to symptom management, and also learn new ways to deal with this communication issue. What we tried to do in these studies is to teach people to think about what they actually are believing about their symptoms and to think about that and to think about how those beliefs might be interfering with them doing anything about a symptom. 

Then giving them some specific strategies to help them get those symptoms taken care of in ways that reduce the bother that they're having from the symptoms. What I'd like to spend the last time talking about are some very specific, concrete, and practical things that we did with women in our study that actually improved their symptom management. I want to talk about six strategies that were pretty generic that we did with everyone. This was across all of those different symptoms that I showed you earlier, so regardless of the symptom, these were strategies that pretty much we could tell everyone about and that they could use. One is self monitoring. The second is using language that gets someone to listen to you. Utilizing the nurse. Talking about all your symptoms. Prioritizing. And what to do if you have a long-term chronic problem. 

I want to just talk a few minutes about each of these. Self monitoring. What we taught people how to do is actually keep track of things and collect data. We think this works because most physicians and other health care providers are trained as scientists and they really like data, and if you come in with data, they're going to pay attention to it. So keep a log or a diary or calendar or journal, and in that you should note when this problem started, how often does it occur and how severe does it get? Track whether it's getting better or worse over time, and you can track if there are things that make it better that you do, or things that you do that make it worse. Once you start tracking things, you might see patterns, and you can take this information with you when you see your physician or other health care providers and say, "Look at this, this is what I'm experiencing, this is what I'm dealing with." The second strategy is using language that gets someone to listen to you. The women in our study, almost 90% of them, had already told their physician or other people about their symptoms and they were still having a lot of problems with symptom management, so it's not like they hadn't tried to take care of it. There's a way to talk about these things that gets people's attention. There are a couple things we've told people to do. When you want to report a symptom, like "I'm having pain in my back," say how that's affecting you. 

"I have this new pain in my back and it's really an issue for me because I can't pick up my grandchild anymore. That's really important to me so I really want to get something done about this because this is an important thing in my life." Or, we had one woman who was having shortness of breath. Her main issue with that is that she couldn't go to movies anymore because she couldn't walk up the stairs to get to her seat. She had never talked about it that way with her doctor. Any way in which a symptom is keeping you from doing something important to you, talk about it in that language. "The way that it's affecting me is serious in my life." The second thing is to state what your major concern or worry is. It's one thing to say you're having a symptom. It's another thing to say, "I'm having this new symptom and one thing that's bothering me is, I'm really scared because I don't know what it means." It might mean nothing. "I'm having new pain in my knee. It might mean I have arthritis, I could cope with that. 

But it might mean that I was treated for cancer five years ago. A new pain is always scary." So say what you're concerned about. I'm here not just because I'm having this pain, but because I'm really worried about it. Maybe you can at least get rid of my worry. Then the third thing is to state what your goal is. So it may be that you want to totally get rid of the symptom. "I never want to have this knee pain because I want to keep running marathons for the next 20 years." That could be a logical goal or not, it might not be reasonable, but at least knowing what you're thinking about is important. Or it may be that I'm having this new knee pain and I realize it may be going to limit me in some way, but I still want to be able to walk three miles a day if I can, as long as I can, and that's my goal. If you say what your goal is, that can help motivate your health care provider to be as aggressive or not aggressive as you want in taking care of this problem. If you just say you have knee pain, so who doesn't, right? What do you want to happen about that is important for your health care provider to know. 

The third strategy we used is to tell people to utilize the nurse. The nurse is not the person that answers the phone when you call the clinic. That person is the gatekeeper. That person may not have the skills or knowledge necessary to help you navigate the system and get in to see someone if you need to or want to. We often tell people, if you're not sure what to do about this symptom, not sure if you really want to go in and see the doctor, call the clinic and ask to talk to the nurse in the clinic, and there's almost always a nurse in the clinic. Tell the nurse all the things you would tell the doctor if you were going in for a regular appointment. That nurse could help you figure out if there's things that you can do on your own about it right now, if this is something urgent that you really need to get in to see someone about, and then can help get you in faster because she can directly have access to your doctor or your nurse practitioner if you see a nurse practitioner. They can help navigate and sort that out and address some of your concerns perhaps. We've used this really successfully in lots of cases where people just really, really, they were really worried about a symptom, but they really didn't want to go see the doctor. This was a way to help without making that commitment to going in to see the doctor. 

Next I want to, even if there's one symptom that you really are worried about or want to take care of, it's important to talk about all your symptoms when you see somebody. That doesn't mean that if you have 18 like women and other people in our studies have, that you're going to address all of those symptoms, but it does mean that your health care provider is going to get more critical information to help you sort this out. You may have a symptom that's the priority, but if you can be monitoring those other things going on with you and bring those up at the same time, that can be really useful to your health care provider. It's one thing to go in and say something like, "I'm short of breath and that's new, it hasn't happened before." That's a different story than hearing, "I have this shortness of breath and it's new, but also, at night my ankles are swollen and also I just get fatigued really easily." It gives a really different picture to your health care provider. A good health care provider is going to ask you all those questions, but if you haven't been keeping track of those things, you might not have the information readily in your head to be able to share it with them. Talking about all of those things can be helpful. The fifth one is prioritizing. We always hear about prioritizing, but I mean prioritizing a little differently, perhaps. You probably have always heard, "Write down all your questions you have before you go to your clinic. Take them with you, make sure you get all your questions answered." What's been found in a lot of research on patient-provider communication is that, we all do this, people save their most worrisome question until the end, right? (audience murmurs in agreement) Right when it's time to walk out the door, that's when you blurt out what's really bothering you and what's really on your mind. 

Of course, chances are it's not going to get addressed to your satisfaction. If you write down all of your questions and look through them, and then mark the one that really is bothering you the most, it may not be the most important question from your physician's point of view, but it is your most important question, so ask that question first and that might really just clear your mind to talk about other issues and at least you'll get that addressed. If you can't get all of your questions answered, it's okay to ask for a follow-up appointment. People don't usually like to do that, but it's okay to do that. It's also okay to ask if you can email the rest of your questions. Many, many more physicians and nurse practitioners now are willing and happy to have you do that. It doesn't hurt to ask and it might be really helpful to do that. If your symptom is a very long-term problem or chronic problem, and this is very typical, this is not unusual, and maybe this is something that you've had for years, you got treated for it originally, and you've just been going along. It's not really much better, it's a little better, maybe it's getting worse. It's okay to go back and say, let's look at this again. 

There's a lot of reasons to do that. Treatments and therapies change a lot. There may be some new approach to your problem that would really be helpful. It just may be that your health care provider will think about it differently when you come back again. Your health status might have changed and is influencing what's going on. So even if it's something that you think, well, I did talk to my doctor about this a couple years ago and it got a little better, and that's the way it is. You don't have to just accept that. Go back and say, let's take another look at this. Let's see if we can make it any better than it is now. It's also okay to ask for consultations and ask for referrals. 

You don't have to wait for someone to offer that to you. A lot of health insurances will cover a lot of these things now. That's going to continue to change, so it's always worth it to ask. If you want to try physical therapy, ask for that. If you want to go to health education classes for your diabetes or your asthma, ask for that. If you want to see a nutritionist for any kind of weight problem or even special diets that you're on, ask for that. If you need to see someone, just a psychologist or a social worker, to talk about family issues or health issues you're dealing with, ask about that. Again, people might be assuming that because you're older, you're not going to be willing  to do any of those things, or you're not going to want to do any of those things, and it's not necessarily true. If you do change something that you're doing, again, go back to number one, that self monitoring. Keep track of whether that change has made a difference. 

If it doesn't make a difference, go back in and say, well, that doesn't seem to be working, what else can we try? My final message, I guess, is to say that you and your health care provider should be a team. You both have jobs. Your job is to communicate as much information as you can, as clearly as you can. That's why writing things down is helpful. To be clear about what your concerns and worries are. Don't worry about them sounding minor or insignificant. They're your concerns, they're your worries, they're important. They do affect you. Be clear about what your goals are and then you have to be ready to work hard at trying new treatments and therapies, because it is a lot of work. There are very few magic bullets out there for the chronic kinds of symptoms people who are older experience. 

Your health care provider has a job also. One job is to listen to you. To answer your questions. To do an examination and assessment of your symptoms. To communicate all the options to you that are out there. And then help you consider those options and make decisions about those options. I'll just leave you with... (laughter) I hope you learned some new tricks and some old tricks, and I hope that I could be helpful to you as you experience the next 25 years. Thank you very much. (applause)