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Listen and make no assumptions when treating older patients
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Among the 7.3 billion people worldwide in 2015, an estimated 8.5%, or 617.1 million, are 65 years or older, according to a recent report from the National Institutes of Health. This population of older adults is expected to increase more than 60% in just 15 years, to 1 billion people in 2030.
“Population aging, while due primarily to lower fertility, also reflects a human success story of increased longevity,” according to a report from the U.S. Census Bureau and the NIH. “Today, living to age 70 or age 80 is no longer a rarity in many parts of the world.”
The researchers anticipate an average annual increase of 27.1 million older people from 2015 to 2050.
Image: Illinois College of Optometry
“For optometrists, this impending population jump is an opportunity to come to the aid of our older patients,” Tracy Matchinski, OD, an attending physician at the Alfred and Sarah Rosenbloom Center on Vision and Aging at the Illinois Eye Institute, Chicago, told Primary Care Optometry News in an interview. “The older population can have more demands and more visual problems that are treatable.
“Everyone practicing eye care, whether you want to or not, is going to be taking care of patients that are getting older. We need to be well versed on what are normal aging changes and what are abnormal changes and be ready to help people by taking care of the health of their eye,” she added.
“In general, older patients can take more time, more care,” Scott Schachter, OD, who practices in Pismo Beach, Calif., told PCON. “You can’t just run through the exam. Moving more slowly in the subjective part of the exam is important.”
Schachter suggested being more flexible during an exam with older patients.
“They can be fatigued with pretesting and, as a result, you may not get the refraction you are looking for,” he said. “It’s important to remember that you may not be able to conquer the whole visit in 1 day. Sometimes they need to return; you might need to spread the care out more.”
Matchinski and Schachter explained that this older group often has a story to tell, and it is important to listen to their current, individualized needs. Learning about how they spend their time, what hobbies they have and what everyday challenges they encounter is essential to providing the best care, they said.
Matchinski divulged a story about her own grandmother, in which listening was essential.
“My grandma was always so quiet, and she wouldn’t complain, and then one day – we weren’t even in my office at the time – she told me: ‘When I’m at church and I look at the pastor, I see two of them.’”
Matchinski was surprised and disappointed that she did not catch this double vision in her exam.
She treated her grandmother for divergence insufficiency, which was an easy fix by simply incorporating prism into her glasses. She was able to impact her grandmother’s life by improving her time spent in church and enabling her to enjoy her hobby of sewing.
If an older patient has a care giver, it can be helpful to listen to their observations as well, Matchinski said. If a patient is comfortable with it, she recommended encouraging care givers or family members to join the patient in the exam room, especially if there are cognitive issues at play. The care giver(s) may be helpful in identifying potential vision problems and can also be a good communication intermediary between the optometrist and the patient in cases where that may be a challenge.
“We as optometrists cannot say, ‘We don’t want to work with this population; they are hard to deal with,’” she added. “It is true that they might take more time, but by being prepared to be more careful and in making sure you’re participating in the best communication, catered to each patient, it is then that we can provide better care.”
Rosenbloom, proponent for lifelong health
The Alfred and Sarah Rosenbloom Center on Vision and Aging at the Illinois College of Optometry, which specializes in providing care to the aging population, opened in January 2015.
At the center, everything is on one floor, so mobility with older patients is not an issue or hindrance to care, according to an article in AOA Focus. The objectives are to prevent vision loss and to research geriatric eye care. In cases where vision loss cannot be prevented, patients are referred to an in-house team of 10 providers, including eye care, occupational therapy and social work.
The center also organizes community service projects, offering education about what to expect with aging vision. Another Rosenbloom center objective is training optometry students to properly and effectively care for older adults, to consider special techniques and equipping students with a greater knowledge of the demands and specifics of working with older patients compassionately and effectively, Matchinski said.
The late Alfred A. Rosenbloom Jr., OD, MA, DOS, FAAO, a former PCON Editorial Board member, is remembered fondly within the industry as a proponent for overall, comprehensive, lifelong patient health.
“In addition to the genetic factors influencing human aging,” he wrote in a PCON article from 2012, “there is now strong evidence that many aspects of the aging process are related to environmental factors such as nutrition, stress, smoking and physical activity.”
Whereas aging is typically defined chronologically, “many gerontologists believe definitions of aging that focus exclusively on calendar time are incomplete because they are independent of physiological, psychological and sociocultural factors,” he wrote.
Cynthia Owsley, MD, as quoted in Vision Research, agrees.
“While there are undoubtedly ‘general principles’ in the aging of visual function, older adults are individuals with varying lifestyle, genetic and environmental exposures during the life-course that can theoretically impact ocular and brain structure and function later in life in different ways,” she wrote. “For this reason, there is little theoretical basis for assuming that a visual processing deficit demonstrated in a handful of older adults is in fact universal.”
“The fact is that old age is not a time of loneliness and sadness for the vast majority of people,” Rosenbloom said. “For most, it is not even a time of chronic severe illness, despite the undoubted tendency to accumulate many pathological conditions with the passing years.”
Based on these factors, Matchinski said an optometrist should never make assumptions on a patient or assumptions based on a patient’s age on a chart. She spoke of a 100-year-old patient in her care that is spry, in great physicality, with a good memory.
“They can be amazing to work with and can share so much wisdom with younger populations,” she said. “I tell my students not to make assumptions when you hear a patient’s age. And I ensure they are educated on aging vision and the trends.
“Never say that you don’t want to work with this population,” Matchinski continued. “You are there to provide care and you need to take care of what comes in your door. Be ready to work very hard, be patient with people and realize that you can be very effective with what you know, to help them remain independent.”
White House Conference on Aging
In September 2015, the U.S. Government made available relevant datasets on aging and older Americans at Data.gov, the repository for the government’s open data. This announcement took place at the White House Conference on Aging in July 2015, which is held every 10 years and hosted by the Executive Office of the U.S. President.
“This resource will continuously be updated with datasets on aging, much like it is for other important Administration proprieties such as climate, public safety and education,” according to a fact sheet on the conference from the White House.
In addition, private sector companies announced at the conference new actions to help technology improve support for older Americans. Walgreens, for example, has advanced digital technologies to connect individuals with its telehealth services provider, offering 24/7 access to U.S. board-certified doctors. Peapod, an Internet grocer, adopted web accessibility standards to ensure that all individuals, including those with disabilities and those unable to shop at traditional grocery stores, can use its website and mobile applications.
Furthermore, the U.S. Department of Housing and Urban Development released a guide to help older homeowners, families and care givers make changes to their homes to help older adults remain safe and independent. In the fall of 2015, the U.S. Department of Transportation launched the National Aging and Disability Transportation Center, with a $2.5 million investment, which provides technical assistance to improve the availability and accessibility of transportation options serving seniors and those with disabilities.
Other initiatives of the conference included improving efforts to understand and prevent cases of elder abuse.
Better comanagement
Cleveland Clinic’s Heather Cimino, OD, sees the increase in the older population as having ripple effects in the industry. Adults older than 65 years make up 25% to 30% of her current patient population.
She predicts a need for more cataract surgeons, better age-related macular disease management and increased monitoring of eye health along with a greater need for managing presbyopia.
“What we have now is really just multifocal contacts,” she said. “I look forward to what will be down the road with refractive surgery.
“The effects will be twofold, with a need for annual eye exams and good comanagement,” Cimino continued.
She sees postoperative cataract patients 1 day a week in her practice. She said this has helped her in identifying what their needs are.
“Much of our aging population has either been told that cataract surgery is something they should be afraid of, as their grandparents had a completely different surgery as today, or they are told by friends that the results will be immediate, that they will have perfect vision and never need glasses again,” she said.
Through this, she has learned to ask about each patient’s particular experience and perspective.
“Ask what they’ve been told in the past,” Cimino said. “There is a little bit of everyone out there; some patients will be very happy with having their cataracts gone, and some will still want that perfect vision and have the vision they had 40 years prior. If we speak to them about that preoperatively that we can prevent a lot of disappointment.”
Patients can also be frustrated and fatigued with the whole medical system, she added. A patient can be exhausted and stressed from seeing multiple doctors and may be “leery of the whole system, but we must recognize that there is still a lot we can do to help that population,” she said.
“The over-65 population comprises a wide range of people, with diverse vision abilities and challenges,” Cimino added. “You have to be prepared to deal with the patient that is in your exam room and not make assumptions based on age. Tailor your exam to that person – that is the main thing.” – by Abigail Sutton
- References:
- He W, et al. U.S. Census Bureau, International Population Reports, P95/16-1, An Aging World: 2015, U.S. Government Publishing Office, Washington, DC, 2016; https://www.census.gov/content/dam/Census/library/publications/2016/demo/p95-16-1.pdf.
- Lubell J. AOA Focus. http://www.aoa.org/news/aoa-focus/julyaugust-2015/advocates-for-aging-eyes. Accessed May 15, 2016.
- Owsley, C. Vision Research. 2011. doi:10.1016/j.visres.2010.10.020.
- Rosenbloom AA. Primary Care Optometry News. 2012;17(10). http://www.healio.com/optometry/low-vision-geriatrics/news/print/primary-care-optometry-news/%7B94d8411e-1cad-4070-b7b5-576f058645e7%7D/look-beyond-a-patients-chronological-age.
- The White House Conference on Aging. July 2015. https://www.whitehouse.gov/the-press-office/2015/07/13/fact-sheet-white-house-conference-aging. Accessed June 16, 2016.
- For more information:
- Heather Cimino, OD, can be reached at ciminoh@ccf.org.
- Tracy Matchinski, OD, can be reached at tmatchin@ico.edu.
- Scott Schachter, OD, can be reached at applescott@me.com.
Disclosures: Cimino and Matchinski reported no relevant financial disclosures. Schachter is a consultant for Allergan, Bausch + Lomb, BioTissue, Blephex, ScienceBased Health and Tearscience.