Article Date: 10/1/2012

Examining the Senior Patient
patient care

Examining the Senior Patient

Follow these seven tips to make your practice senior friendly.

Lindsey Getz, contributing editor

the senior population (persons 65 or older) constitutes approximately 13% of the nation — about one in every eight Americans, says the Administration on Aging. By 2030 — just 22 years from now — this population will comprise 19% of the U.S., reports the agency. As this population continues to grow, you'll likely see more of these patients in your practice. Given their proclivity for hearing loss, cognitive and physical impairments, in addition to ocular issues, such as age-related macular degeneration (AMD) and glaucoma, these patients' office visits can pose challenges, says geriatrician Barbara Messinger-Rapport, M.D., Ph.D., C.M.D., F.A.C.P., director of the Center for Geriatric Medicine at the Cleveland Clinic in Cleveland, Ohio.

Here, Dr. Messinger-Rapport and other senior experts provide tips on how you and your staff can meet these challenges so you can keep your practice running smoothly while providing these patients with the best care.

1 Wait up!

Make sure the tech and/or you personally approach the senior patient and walk with him/her to the exam room when it's time for his/her appointment, says Josepha A. Cheong, M.D., professor of psychiatry at the University of Florida College of Medicine and associate chief of staff education at the VA Medical Center, both in Gainesville, Fla. The reason: Senior patients' speed, in general, is likely slower than yours, and they may have sensory impairments, such as hearing loss, that prevent them from realizing it's time for their exam.

“Oftentimes, the patient's name is called, and the tech and/or doctor has already moved into an exam room, leaving the patient confused or embarrassed because they don't know where to go,” she explains.

Along these same lines, ask these patients: “‘Can I help you?’ when they approach the exam chair,” says low vision specialist Ranjoo Prasad, O.D., clinical associate in the department of Ophthalmology at the Scheme Eye Institute at Penn Medicine in Philadelphia, Pa. “If they appear physically tired or even start to nod off during the exam, say: ‘We'll do as much as we can today, and then we can finish the exam on a different day.’” “Remember that senior patients may have difficulty getting in and out of the exam chair, and can find the comprehensive eye exam incredibly fatiguing,” she explains. “So, these small considerations make my senior patients very happy.”

2 Invite the “driver” to the exam room

When the senior patient presents with a family member, friend or caregiver, invite that person into the exam room to be that extra ear when it comes to instructions, presenting any information or raising any questions or concerns the patient may not, says Dr. Messinger-Rapport.

Specifically, “ask the patient: ‘Who's here with you today?’ Once the patient answers, reply: ‘We'd love to have _______ come back to the room with us. He/she is very welcome to come,’” she explains.

This way, the patient won't assume it's not permitted, and the doctor won't assume the patient wants to be in the exam room alone, Dr. Messinger-Rapport says.

In cases in which senior patients whom you suspect have cognitive impairments present to their appointments alone, contact their emergency contact person or social worker either during or after the appointment to act as that extra ear, says Dr. Prasad.

3 Adjust the lights

Changes in lighting, an integral part of the comprehensive eye exam, can be uncomfortable for senior patients due to the aging pupil and presence of undiagnosed cataracts, among other issues.

In the parts of the exam in which specific lighting isn't required, say to the patient, “Let me know whether you'd like me to change the lighting for you,” says Dr. Prasad.

When light dimming isn't possible, like when using the slit lamp, say to the patient, “Let me know whether this becomes too uncomfortable for you or you become tired, and we can take a break,” explains Dr. Cheong.

Communicating with senior patients that you understand their needs and want to do everything you can to meet them creates goodwill and, thus, patient loyalty and referrals, say those interviewed.

Vision Loss Resources
BOOKS
Coping with Vision Loss: Maximizing What You Can See and Do. Authors: Bill Chapman and Dr. Lin Moore (Hunter House, 2001)

Coping with Vision Loss: Understanding the Psychological, Social, and Spiritual Effects. Authors: Cheri Colby Langdell and Tim Langdell (Praeger, 2010)

Macular Degeneration: How to Recognize Symptoms, Understand Treatment Options and Live Productively With Vision Loss. Authors: Betty Wason and James J. McMillan (Hunter House, 1998)

Out of the Corner of My Eye: Living With Vision Loss in Later Life (Large Print). Author: Nicolette Pernot Ringgold (Amer Foundation for the Blind, 1991)

Aging and Vision Loss: A Handbook for Families. Authors: Alberta L. Orr and Priscilla Rogers (Amer Foundation for the Blind, 2006)

Dealing With Vision Loss. Author: Fredrick A. Olver (AuthorHouse, 2007)

Making Life More Livable: Simple Adaptations for Living at Home After Vision Loss. Authors: Maureen A. Duffy and Irving R. Dickman (Amer Foundation for the Blind; 2 Tch edition, 2002)

Blind and Blue: Coping with the Emotional and Psychological Trauma of Vision Loss. Author: Lynn M. White (Pro-Quest, UMI Dissertation Publishing, 2011)

Eye Envy: Perspectives into Vision Loss. Author: Michael Stone (Amazon Digital Services, Inc.)
Macular Degeneration: A Complete Guide for Patients and Their Families. Author: Michael A. Samuel (Basic Health Publications,Inc. 2008)
ORGANIZATIONS
American Council of the Blind
Phone: (800) 424-8666 Web: www.acb.org

American Diabetes Association
Phone: (800) 342-2383 Web: www.diabetes.org

American Foundation for the Blind
Phone: (800) 232-5463 Web: www.afb.org

American Macular Degeneration Foundation
Phone: (888) 622-8527 Web: www.macular.org

American Printing House for the Blind
Phone: (800) 223-1839 Web: www.aph.org

Associated Services for the Blind and Visually Impaired
Phone: (215) 627-0600 Web: www.asb.org
Council of Citizens with Low Vision International
Phone: (800) 733-2258 Web: www.cclvi.org

Foundation Fighting Blindness
Phone: (800) 683-5555 Web: www.blindness.org

Glaucoma Research Foundation
Phone: (800) 826-6693 Web: www.glaucoma.org

Independent Living Services for Older Individuals Who Are Blind
Phone: (202) 245-7454 Web: www.ed.gov/programs/rsailob/index.html

The Jewish Guild for the Blind
Phone: (800) 284-4422 Web: www.jgb.org

Lighthouse International
Phone: (800) 829-0500 Web: www.lighthouse.org

The Low Vision Gateway Web: www.lowvision.org

National Federation of the Blind
Phone: (410) 659-9314 Web: www.nfb.org

National Library Service for the Blind and Physically Handicapped
Phone: (202) 707-5100 Web: www.loc.gov/nls

Prevent Blindness America
Phone: (800) 331-2020 Web: www.Dreventblindness.org

VISIONS
Phone (888) 245-8333 Web: www.visionsvcb.org

VisionServe Alliance
Phone: (314) 961-8235 Web: www.visionservealliance.org
SUPPORT GROUPS INFORMATION
VisionAware: Resources for Independent Living with Vision Loss, American Foundation for the Blind/Reader's Digest Partners for Sight. www.visionaware.org/directory.aspx?action=results

Perkins Scout: Seniors with Vision Loss: Resources for Independence: www.perkins.org/resources/scout/seniors/

4 Maintain patient eye contact

Senior patients often have difficulty hearing higher frequencies due to aging, explains Dr. Messinger-Rapport. Translation: These patients can hear speaking but often can't differentiate many of the syllables, she says.

“If you turn away from the older adult while speaking, to write in a chart, for example, the patient won't hear what's being said,” she explains.

When you maintain eye contact with your geriatric patients, however, you're allowing them to cue in on the sounds, Dr. Messinger-Rapport says.

5 Slow your pace, but maintain grace

Speak slowly, as the senior patient may need a bit of extra time to process what you're saying, explains Dr. Prasad.

“You don't want to assume the patient is hard of hearing and shout, as that can be insulting,” she explains. “Sometimes, you just need to say to the patient: ‘Please feel free to jump in and let me know if I'm going too fast or whether you need me to repeat anything.’ And after you've finished talking, ask the patient: ‘Do you have any questions, or is there anything you'd like me to go over again?’”

Remember that tone of voice matters too, says Barbara Moscowitz, M.S.W., L.I.C.S.W., geriatric social work coordinator at Massachusetts General Hospital, in Boston.

“Don't talk down or infantilize the patient,” she says. “Your tone should align with the fact that this person is an adult who just doesn't have the same capacity to process information as younger patients,” she explains.

6 Reinforce your instructions

Provide written instructions to your senior patients in a senior-friendly font, says Ms. Moscowitz. (Visit www.nia.nih.gov/health/publication/making-your-printed-health-materials-senior-friendly.) The reason:

“A lot of times a senior patient may continuously nod their head as if they understand everything you're saying, but in actuality they're not comprehending all the information because they have a deficit in hearing, health literacy, or perhaps short-term memory, for example,” she says. “They'll get home and not be sure what they were supposed to do.”

In addition, get the patient to repeat your instructions, says Dr. Cheong.

“Say to these patients: ‘I want to make sure I've covered all the necessary bases here, so could you take me through the instructions I just gave you?’” she explains. “By phrasing the question this way, the patient perceives that you require the repetition instead of him, preventing him from being offended by the request to repeat.”

7 Assess mental health

Screen your senior patients for depression by administering the Geriatric Depression Scale (GDS), say those interviewed. This is a 30-item self-report questionnaire. (Visit http://en.wikipe dia.org/wiki/Geriatric_Depression_Scale to print it.) A 15-question version, the GDS-SF, is also available. (Visit www.psychtool kit.com/geriatric-depression-scale-short-form-gds-sf.html to print it.) Further, consider giving the patient's caregiver the Patient Health Questionnaire-9 (PHQ-9) to determine whether he or she should seek an additional assessment for the depression diagnosis. (Visit http://steppingup.wash ington.edu/keys/documents/phq-9.pdf to print it.)

“I often hear from older adults how important it is that they can still read a book or watch some television …”
Ms. Moscowitz

Also, consider employing a brief screen for cognitive impairment, says Dr. Messenger-Rapport.

“We recommend the 'minicog,’ which consists of a clock draw test and a three-item recall,” she explains. “Persons who fail should be referred back to their primary care physician for further evaluation and for consideration of a driver evaluation. (Visit http://consultgerin.org/uploads/File/try_this_3.pdf to print it.)

“Loss of vision may be a common part of aging, but to the individual it's life changing,” explains Dr. Cheong.

Indeed. Several studies reveal vision loss causes profound depression in senior individuals, in particular.1,2,3 This makes sense, as the major causes of vision loss in seniors (e.g. AMD, cataracts, diabetic retinopathy and glaucoma) can affect vision to the point at which activities of daily living, such as preparing meals, reading, driving and participating in recreational activities are no longer possible.4,5,6 Add the financial strain of treatments, vision-loss-induced social isolation and other age-induced health issues, such as vascular disease and osteoporosis, and many of these patients think their life is no longer worth living. In fact, one study reveals the emotional domain of impact of vision impairment in severely vision-impaired individuals with a median age of 80 was linked with the patient's willingness to trade part of their remaining life for vision gain.7 Also, one study shows that several caregivers of vision-impaired adults experience psychosocial distress, especially among those who have poor social problemsolving skills.8

“I often hear from older adults how important it is that they can still read a book or watch some television,” Ms. Moscowitz explains. “Many older adults have lost a lot of friends and family so they really value the ability to look through old photographs. And I hear older adults say time and time again that as long as they can see their grandchildren, they can live with their body ‘hurting.’ A lot of them define their quality of life by what they can see, so eyecare providers should remember just how precious visual abilities are to this population.”

Something else to consider: Studies on depression and AMD and diabetic retinopathy (DR) show the mental condition actually worsens these eye diseases. To start, of 51 subjects diagnosed with recent-onset bilateral AMD, 33% were depressed at baseline; had worse visual acuity and greater levels of both vision-specific and general physical disability than non-depressed subjects.9 Further, an increase in depressive symptoms through time predicted a degeneration in self-reported vision function independent of visual acuity or medical status changes. With regard to DR, patients who had comorbid depression had a significantly higher risk of developing diabetic retinopathy vs. those type 2 diabetic patients without depression.10 Specifically, the risk of incident diabetic retinopathy was estimated to increase by up to 15% for every significant increase in depressive symptoms severity on the PHQ-9.

For all these reasons, it's essential you assess these patients' and their caregiver's mental health. And, should you suspect depression, immediately refer them to the appropriate resources, say those interviewed. In addition to having the names of local psychiatrists and psychologists, have a list of mental health resources. Research shows that support groups, self-management programs and low vision aids have both prevented and decreased depression in these patients.11-17 (See “Vision Loss Resources,” page 24.)

If you feel the patient could benefit from resources, hand the resource list to him/her, and say: “Here's a list of wonderful resources. I strongly recommend that you contact one or more of them for additional help,” says Dr. Messinger-Rapport.

With regard to treatment-caused financial strains, select drugs that meet the treatment goal, while keeping in mind the patient's budget. Also, visit www.fingertipformulary.com for insurance drug coverage information, and provide patients with information from http://EyeCare America.org, which outlines various patient assistance programs.

Preparation is key

The U.S. population age 65 and older grew at 14.1% between 2000 and 2010, says the U.S. Census Bureau's Age and Sex Composition: 2010. In comparison, those ages 45-to-64 grew 31.5%, those 18-to-44 grew 0.6%, and those younger than age 18 grew 2.6%. Now is the time to get your practice senior friendly. By following the aforementioned seven tips, you have an excellent chance of achieving this. OM

Lindsey Getz is a Philadelphia-area-based freelance writer, who has written for several consumer and trade magazines. She is also a former editor of Eyecare Business magazine (a sister publication of Optometric Management). E-mail her at lindsey.getz@yahoo.com, or send comments to optometricmanage ment@gmail.com.


Optometric Management, Volume: 47 , Issue: October 2012, page(s): 22 - 29