By Suzanne LaKamp, OD, FAAO
Dec. 21, 2017
I work in a shared OD-MD practice where a fourth of our patients are 65 or over. We’ve thought carefully about how best to cater to these patients’ needs to ensure that we provide the care they need, and continue to grow our practice. Understanding how best to serve elderly patients allows you to become known in your community as a practice that is friendly to the needs of older people, enabling you to retain and grow your senior patient base.
Our clinic continues to see an increase in the aging population, and has seen a corresponding increase in lens procedures such as refractive lens exchange and refractive cataract surgery.
Patients have aged into the practice. Patients who started with LASIK when the practice was new, are now candidates for IOL surgery. It is important to focus on long-term vision plans for patients, and to educate the patient on possible procedures that benefit them always, not just a quick fix for immediate concerns.
For instance, patients who qualify for lens replacement will get a recommendation for a new IOL. We will not perform LASIK as a primary procedure if the lens is the problem. LASIK might be a great tool though for enhancing patients after IOL surgery. The lens procedures cost more, but can bring greater revenue to a practice. Lens procedures are about twice the cost of LASIK. When you are taking good care of a patient’s long-term visual and medical needs, you are also increasing revenue.
A wheelchair on standby in Dr. LaKamp’s practice, and the Icare Tonometer. Both the wheelchair and the Icare Tonometer enable the practice to more easily serve patients with limited mobility.
Accommodate Limited Mobility
Mobility limitations are a common concern for the elderly. Loss of mobility can create challenges for a patient for all activities of daily living, as well as leaving the home to seek health care. Health conditions such as arthritis, cancer, as well as poor balance, coordination difficulties and a decrease in muscle tone, create limited mobility.
Currently, our clinic has exam rooms on two floors, which can be problematic for an elderly patient.
Due to the difficulty for some of our patients who are mobility-limited, we are moving to a new building with the clinic designed on one level instead of two. For patients who need help getting to and from the car, there are already ramps and wheelchairs available. There is also plenty of parking close to the building.
To help with orientation, entrances are clearly marked, bathrooms are accessible and the office environment is pleasant with comfortable seating, including chairs and sofas that aren’t so deep that they are hard to get up from.
Limited Needed Moves Within Office
Limiting the amount of travel that a patient has to do throughout the office visit is important for all patients, and especially important for those with mobility issues.
There should be plenty of seating available throughout the clinic, beyond the waiting room or exam rooms. Some older patients may get faint, tired, or sick, and need to quickly find a seat.
Some patients who are in wheelchairs, have spinal cord injuries, or have challenges like tremors, cannot sit properly for a traditional biomicroscope. Portable slit-lamps are a more comfortable instrument for these patients, and an absolute must for every clinic.
We recently brought on the Icare tonometer for taking eye pressure. While other methods of measurement such as Goldmann applanation are still employed, some patients cannot fit in the biomicroscope necessary for this method. There are other hand-held tonometers on the market, but the Icare is very comfortable for the patient.
Health literacy is the big question. You have to assess the patient’s cognitive abilities and capacity to understand. It is ultimately the doctor’s responsibility to ascertain if a patient has the capacity to make competent decisions.
When a patient is suspected of cognitive impairment, it is prudent for the health care provider to perform a screening. There are screening guides available such as the Mini-Cog, which can take only a few minutes to perform. Patients may then be sent to geriatric specialists if necessary. The doctor should address the patient directly during the exam, orient the patient, and explain things clearly. The practitioner should ask the patient open-ended questions, such as “How do your eyes feel?” and “How well do you see?”
Learn to Work with Caregivers
Sometimes it can be helpful to get input from caregivers. However, caregivers may also interrupt, preventing the patient from speaking or asking questions. As the doctor, you control the flow of information. You can always tell the other person, or family member, to hold on.
It is important to note that elderly patients may have hearing difficulties whether or not the patient is wearing a hearing aid. Patients may shake their heads in agreement to avoid embarrassment of a hearing impairment.
A patient who is fully competent in his or her healthcare, may still bring along a caregiver. The doctor has to figure out the relationship between the patient and the caregiver. Some questions to ask yourself as a provider: “Is the caregiver there for mobility? Does the patient rely on the caregiver? Is it a good relationship?”
Family members may take over and dominate the medical decision making in some instances. Patient autonomy in healthcare is of vital importance. The staff or doctor should ask the patient if he or she would like the caregiver to be included for the whole exam or just part of it. The patient should always be addressed directly. Caregivers involved in medical care should be included in doctor discussion for findings and treatment plans to help improve follow through.
Ensure Treatment Follow-Through
A patient with dementia or Alzheimer’s may or may not be capable of following a medication regimen depending on the severity of cognitive decline.
The doctor should provide written instructions for treatment plans, and use teach-back methods with the patient. Have the patient repeat back instructions on medical care and what you told them. It is also important to ensure the patient has a caregiver to follow-up with the patient and treatment plans.
Train Staff to Work With Seniors
Staff encounter the patients before the OD, and can help to anticipate patient needs. For instance, the technician may observe the next patient to be in a wheelchair. The technician will then prepare that patient room in advance by creating extra space by removing some chairs or furniture. The technicians may also locate the portable slit-lamp if the patient has a neck injury and cannot sit for the biomicroscope.
Sometimes patients won’t bring the appropriate assistance device. Elderly people who don’t get out much may only take a cane, thinking it sufficient. It is important for the doctor and staff to ask if a patient needs help, and to offer a wheelchair, or arm, for a patient who appears to be struggling.