November 2012




Providing better treatment to elderly patients

by Vanessa Caceres EyeWorld Contributing Writer

Health Literacy Month promotes the importance of understandable health information Source: Helen Osborne, M.Ed., OTR/L

Patients aren't just "older adults"

Consider yourself a gatekeeper for the graying population. Ophthalmologists are at the forefront of treating the booming elderly patient group. One reason: The first crop of baby boomers turned 65 in 2011part of the so-called silver tsunami that will cause the elderly population to double by 2030. This is mirrored by an upswing in the "extreme elderly," patients who are 85 and older, said Hilary Beaver, M.D., associate professor of clinical ophthalmology, Weill Cornell Medical College, The Methodist Hospital System, Houston. The U.S. Census Bureau predicts that the U.S. population age 85 and over will reach 19 million by 2050, compared to only 5.7 million in 2008.

Exacerbating the elderly tsunami in eyecare is the fact that ophthalmology's most commonly treated conditions are connected with age. "All four major disorders are age-relateddiabetic retinopathy, cataract, glaucoma, and age- related macular degeneration," said Andrew Lee, M.D., chairman, Department of Ophthalmology, The Methodist Hospital, Houston. Drs. Beaver and Lee are co-authors of the book Geriatric Ophthalmology: A Competency-based Approach.

Yet another reason ophthalmologists will increasingly treat the 65+ crowd is because vision has powerful connections with other age-related health problems. For example, vision problems affect a patient's risk for falls. Cognitive problems in the elderly may actually be exacerbated by decreased vision and may initially present as a vision problem. "The aging population will affect all specialties, but ophthalmology disproportionately," said Dr. Lee.

Finally, when patients live longer, they carry their chronic health problems for longer time periods, Dr. Beaver said. An example of this is obesity and the associated conditions of diabetes and hypertension. Ophthalmologists will be seeing more diabetic-related eye problems with more type 2 diabetes, Dr. Beaver said.

This doesn't mean ophthalmic practices can merely tweak what they do with their younger or middle-aged adult patients to accommodate elderly patients. "It's like they say in pediatric ophthalmology: Pediatric patients are not just little adults, and older people are not just older adults," Dr. Lee said. "They have different needs, responses, and co-morbidities."

Below are some other common issues to consider as you treat the ever-expanding elderly patient group.

The role of caregivers

When you assess older patients, involve caregivers who bring them to appointments to get a better sense of the patient's daily visual challenges, said Barbara Resnick, Ph.D., Sonya Ziporkin Gershowitz Chair in Gerontology, University of Maryland School of Nursing, Baltimore, and chair, Board of Directors, American Geriatric Society.

"You sometimes have to ask the same question five different ways," she said. "You might ask patients if they are able to get their groceries on their own, and they say it's no problem. Yet the caregiver will tell you the patient hasn't gone alone for 6 years."

Involving caregivers will also help give a clearer picture of the patient's problem. While baby boomers are typically thought of as reaching out for help, those in the generations preceding baby boomers tend to stay mum about their health problems. "They may not understand their symptoms, or they don't want to worry their families. There is also a lot of denial," said rheumatologist Roy D. Altman, M.D., UCLA Rheumatology, Los Angeles.

Dr. Beaver finds it helpful with these patients and their caregivers to discuss the wide variety of medications now available and to emphasize the importance of accessing healthcare when necessary. It helps to contrast the options that they have compared to the health system available to their patients.

Another common challenge in the older age group is polypharmacy. "The average 80-year-old takes 5-10 drugs. This can inadvertently cause an interaction," Dr. Lee said. Caregivers can work with patients to manage medication use and maintain compliance. Caregivers can also help risk-proof the patient's living environment to prevent falls, Dr. Lee said. This might include moving electrical cords, removing throw rugs, and providing handrails near toilets.

Patient education

Vision, hearing, and cognition problems can all affect an elderly patient's ability to understand patient education, said Helen Osborne, M.Ed., OTR/L, founder and president, Health Literacy Consulting, Natick, Mass. Ms. Osborne wrote the book Health Literacy from A to Z.

Elderly patients also may experience declining literacy skills, increased pain levels, and independence issuesall factors that can impede their ability to understand and manage their visual problems, she added. "It's not just about understanding a brochure," Ms. Osborne said. "The patient has to learn, act on, and internalize information."

Education for older patients should be a team effort, Dr. Resnick said. Appoint technicians or other staff members to help fill in the extra chair time these patients may require, she recommended.

When explaining eye diseases or providing instructions on how to take medications, share that information with everyone involved with patient care. This might include family members, home health staff, physical or occupational therapists, and other health professionals.

To further reinforce what you want patients to learn, use brochures, visuals, audio and video, online resources, or even manipulatives such as a model of the eye. "There's no one-size-fits-all when it comes to patient education," Ms. Osborne said.

During an ophthalmology consultation, it's especially important that any printed material you use be easy to read. Use a larger, darker font with few visual distractions, Dr. Resnick suggested.

Depression and dementia

Although ophthalmologists do not treat depression, they may be part of the group of people that can alert other specialists to signs of depression in their patients, Dr. Beaver said. "As people get older and lose function, they are more likely to get depressed," she said.

Dr. Beaver will ask older patients if they feel sad or depressed. If she feels patients might be at risk for depression, she will ask if they have talked to their primary care physician or if they would like additional help.

Ophthalmologists can also serve as the referral source for dementia. One common scenario is a patient brought in by a spouse or family member. The patient may have a decent visual acuity of 20/25 and can see letters on the page but cannot get to the end of a sentence. In these cases, Dr. Beaver will refer to a neurologist or neuropsychologist to test for dementia.

Dementia can affect a patient's ability to remember to take medications, said Brian Yochim, Ph.D., VA Palo Alto Health Care System, and Stanford University, Palo Alto, Calif. It could also lead to patients not remembering if they took their medicationsand then inadvertently taking two doses in a short time period, he added.

Although ophthalmologists will want to refer questionable patients for formal testing, they still can do some initial screening for dementia problems. "A quick way to informally screen for cognitive deficits in patients is to ask them to say today's date and to discuss current events, such as a recent natural disaster, an election, or current military conflicts," Dr. Yochim said. Dr. Yochim is working to develop a more effective testing measure for dementia and mild cognitive impairment that can be used for patients with visual impairment.

Elder abuse

Elder abuse is "one issue doctors don't always talk about," Dr. Beaver said. The signs are not as obvious as they might be with child abuse, Dr. Lee added. A disheveled appearance or ocular trauma can be signs of elder abuse, Dr. Lee said. A patient who regularly misses appointments may be experiencing neglect, Dr. Beaver said. Although ophthalmologists would not treat abuse, they can help get social workers involved when necessary, Dr. Beaver recommended.

Editors' note: The sources have no financial interests related to this article.

Contact information

Beaver: 713-441-8843,
Lee: 713-441-8823,
Osborne: 508-653-1199,
Resnick: 410-706-5178,
Yochim: 650-493-5000,

Website resources

American Geriatrics Society

Health Literacy Consulting: Helen Osborne's website featuring
various articles and podcasts about better patient communication and education and

Number of Older Americans: Contains a number of facts and
figures on the elderly population growth in the U.S.


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