For optometrists caring for older adults, clinical findings may represent only one component of a patient's overall care needs. Mobility limitations, cognitive impairment, hearing loss, living arrangements, caregiver dynamics, bereavement, depression, and functional independence can all influence how eye care is delivered and how treatment recommendations are implemented.

John E. Kaminski, OD, FAAO, outlined these considerations in “Understanding Your Challenging Geriatric Cases: Gerontology Insights for the Eye Care Professional” at the American Academy of Optometry meeting in Anaheim. Through a series of patient cases, Dr. Kaminski showed the importance of obtaining a detailed social history and incorporating interdisciplinary care into management of older patients.

Mrs. R

Dr. Kaminski first described Mrs. R, an 86-year-old woman with cataracts, severe hearing impairment, chronic obstructive pulmonary disease, and limited mobility who used a walker or wheelchair. She reported blurred vision while reading and moving around her home and difficulty using her glasses when locating objects in a bag attached to her mobility aid.

Her visual acuity measured 20/60 OD and 20/50 OS, and she could read 1.0M print with a +4.00 D add and supplemental lighting. Although she was a cataract surgery candidate, she was afraid to pursue surgery. The assessment also identified her existing FT-28 spectacle design as interfering with mobility and increasing her risk for falls.

Her management plan included separate distance-vision and near-vision spectacle designs, a high add, direct lighting for near activities, and improved diffuse lighting in her living area. Dr. Kaminski also recommended addressing her hearing impairment and communicating with staff at her retirement community about larger-print materials and support related to her husband's deteriorating health.

Mr. E

Next, Dr. Kaminski described a 73-year-old man who had moderate dementia and dry AMD, and lived with his daughter and her family (husband and 3 children). Although his daughter believed his glasses provided little benefit because he did not consistently wear them, examination showed BCVA of 20/30 OD and 20/25 OS with stable refraction. He could slowly read 1.0M print with his current +2.50 D add.

The clinical assessment concluded that cognitive impairment was reducing compliance with spectacle use and identified AMD as posing a high risk for visual impairment. However, observations during the examination also raised concerns about the patient's home situation. His management plan included educating his daughter about spectacle use for occasional near tasks, asking her how she was coping with caregiving responsibilities, and recommending adult day care or respite services. Mr. E continued care with his retina specialist and using his glasses. Contact was also initiated with a social worker and the patient's primary care physician.

Ms. N

Next, Dr. Kaminski presented the challenges of examining an 88-year-old nursing home resident who had advanced Alzheimer disease and glaucoma, for whom nursing staff expressed concern about crusting on her eyelids for the preceding 2 weeks. The patient had uncertain visual status and a history of lost spectacles, and her family lived out of state. Near acuity was in the 20/30 range OU using numbers on a Rosenbaum card, and retinoscopy revealed -2.25 D OD and -3.50 D OS. Attempts at Perkins tonometry were refused, although the globes were soft to palpation. The cup-to-disc ratio was 0.80 OU with grade II pallor, and blepharoconjunctivitis was identified OU. A familiar caregiver assisted during the examination because the patient exhibited delusional and reactive agitation.

Dr. Kaminski said the plan called for obtaining her records, renewing glaucoma medication after reviewing that history, and scheduling another visit to complete testing. Caregivers were also advised to incorporate spectacle wear and lid hygiene into the patient's morning routine.

Mr. L

A 67-year-old recent widower with moderate AMD sought options that would allow him to continue driving after a retina specialist told him he should stop, Dr. Kaminski described. He was a retired chemist, had lived in the same home for 40 years, had a history of extensive community involvement, and placed considerable importance on his independence, to the point that it contributed significantly to his identity.

His visual acuity measured 20/60 OD and 20/100 OS, with central visual field metamorphopsia OU. He was upset and defensive about his vision and disclosed that the year following his wife's death had been difficult, at times questioning whether life was worthwhile. His Geriatric Depression Scale findings were positive.

The assessment determined that he did not meet Michigan's driver's license standard, although he was identified as a possible bioptic driving candidate. AMD with mild vision impairment OD and moderate impairment OS, suspected uncontrolled depression with possible suicide risk, and polypharmacy were also identified. Management included referral to a low vision specialist, continued care with his retina specialist, continued hospice services, and referral to his primary care physician for evaluation and management of severe depression.

Dr. Kaminski concluded that understanding common themes of aging can improve patient interactions. “Sensitive geriatric case-management techniques can help clinicians view the aged patient as an individual with a wide range of health care needs," he said.