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The graying of America means the graying of medicine. Is your practice geared up to meet seniors' needs? Your practice health will depend on it.
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The graying of America means the graying of medicine. Is your practice geared up to meet seniors' needs? Your practice health will depend on it.
"Any doctor who does family practice or internal medicine is basically a geriatrician, because young healthy people just don't go to the doctor," says William T. Sheahan, a family physician in Winter Park, FL.
Plus, America is aging, and this trend will continue. In 1900, only 4 percent of the US population was 65 or older. A century later, 12.4 percent of Americans were golden-agers. By 2030, one in five will be.
If you haven't made your medical office senior friendly yet, now's the time. Besides making certain physical changes in your office, you'll need to:
Develop strategies for treating patients with multiple problems.
Make it easier for families to participate in an elderly relative's care.
Expand your referral list to include community resources for seniors and their caregivers.
It's a tall order, but caring for seniors has its rewards. "You're dealing with survivors, many of whom have fascinating histories," says Richard G. Stefanacci, a geriatrician/internist in Philadelphia. "And unlike some younger patients, seniors generally admire their doctors and appreciate what you do for them."
We talked to doctors and consultants to find out how best to make your practice hospitable to seniors. "Medicine these days tends to be high-tech, low touch. The basis of geriatric care should be the opposite: low-tech, high touch," says William Sheahan.
Tacoma, WA, family physician Richard E. Waltman agrees. "When you see a 35-year-old, you're looking for things that are dangerous; you want to prevent things. With older people, it comes down to finding out what's bothering them and trying to improve things," he says.
And that can take time, particularly when the patient's list of ailments is three pages long. Geriatrician Kenneth Brummel-Smith of Portland, OR, encourages his patients to jot listsbut he insists that they indicate which items are most important. "That way," he explains, "if the patient brings up more and more things, I can say, 'This is pretty low on your priority list. It doesn't seem serious. Let's deal with it next visit.' "
Waltman solves the list problem by asking, " 'What can we do today that's going to make you feel better?' It might come down to treating incontinence or even cleaning out earsconcerns that normally wouldn't be a doctor's No. 1 priority.
"Nobody dies of incontinence. But in terms of quality of life, it's a huge thing," Waltman says. "Or a physician who finds a small hernia might be very interested in fixing it. Meanwhile, the patient may have had the hernia for 30 years, it doesn't bother him at all, and he's not even remotely interested in having it repaired."
Waltman isn't averse to encouraging his patients to have tests or procedures, thougheven ones they'd rather avoid. "Sometimes, we might make a deal," he says. "We'll trade off the mammogram that I want them to have for the treatment of their reflux esophagitis that they want."
Still, paying attention to functional status should be at the top of your list when seeing elderly patients, says geriatrician Patricia A. Bloom, vice chair for clinical affairs for the Brookdale Department of Geriatrics & Adult Development at Mt. Sinai School of Medicine in New York City.
"It's important for primary care doctors to assess mental status and be aware of problems such as an unstable gait and the risk of falls," she says. "Are patients depressed? Do they have problems with activities of daily living, such as dressing, shopping, cooking, housework, taking medications? Those are things that can be ameliorated by making the proper referrals."
If you use your staff appropriately, taking care of elderly patients needn't take a lot of your time, says Stefanacci. For instance, he relies on his nurse practitioner or a pharmacy consult to do medication checks. Stefanacci has elderly patients bring in all their medsincluding over-the-counter drugswhen they come to the office. The NP or pharmacy consult then checks for possible adverse interactions or whether the patient is being overmedicated.
Another time saver is asking questions during the exam: "As you're listening to someone's heart and lungs, ask open-ended questions, such as, 'What's going on in your life? How's your spouse doing? Are you caring for anyone close to you? How do you spend your day? Do you smoke? Do you exercise? What about your social activities?'" says Joan Greathouse, a health care consultant in Seattle. You can't underestimate the importance of this information since "the research on successful aging shows that the two most important factors for health and well-being are exercise and engagement in life," she observes.
Resist the temptation to dismiss complaints with comments like, "You're old. What do you expect?" Greathouse recounts the joke about a woman who wanted her doctor to do something about the pain in her right knee, which was causing her great discomfort. Upon being told, "You're 75 years old; what do you expect?" the woman retorted, "Well, my left knee is just as old, and it feels fine."
"It's important to insist that your staff treat elderly patients respectfullynot to call them 'Sweetie' or 'Honey' or other infantilizing names," says Brummel-Smith. "Most seniors like to be referred to by their last name, although they might readily grant permission for you or a staffer to use a first name once they become regular patients."
"Make sure, too, that the staff is aware that hearing problems are very common in older people," he continues. "Everyone from receptionists to nurse practitioners should be told to face hearing-impaired oldsters while speaking to them, and to enunciate clearly. Shouting is not only rudeit distorts the voice and lessens comprehension." It also threatens to compromise patient confidentiality if the conversation takes place in earshot of the waiting room. (For more tips on communicating with hearing-impaired patients, see "The hearing impaired patient".)
Have your scheduler build some padding into seniors' appointments to allow them a bit more time to get undressed and dressed. Also remember that most older people don't like to be undressed when they first meet the doctor, says Brummel-Smith. If possible, talk to them in the exam room briefly, then go to another room while the patient gets undressed and helped onto the exam table.
Another tip for staffers: Tell them to lend a hand when a senior citizen is moving on and off the exam tableand even on and off the scale. Molly Mettler, senior vice president of Healthwise, a nonprofit consumer health information company in Boise, ID, recalls her mother's physical just before she underwent hip replacement surgery. "She fell off the scale and broke her femur, wrist, and some ribs," Mettler says. "There should have been someone there to help steady her."
Barbara Mettler, who is in her mid-80s, ultimately made a full recoveryand she didn't file a lawsuit. But her daughter continues to stress the need to continuously monitor the needs of older patients. "Probably the best thing a physician and office manager can do is ask older patients directly, 'What can we do to make this office more accommodating for you?' " she says.
Geriatrician Brummel-Smith has no problem with family members being present when he's talking to patientsand he acknowledges that it can be helpful if he suspects a patient has Alzheimer's disease (see "The cognitively impaired patient"). "Although I always direct my questions to the patient, she often turns to her son or daughter for help in answering," he says. "I call that the 'positive head-turning sign.' It's an indication that the patient has cognitive problems.
"Bringing the family in also gives you a chance to see their relationships," he adds. "Since families provide 85 percent of seniors' care, we really need to know how this parent-adult child 'team' is working together."
Consultant Joan Greathouse agrees. "If someone is less mobile and his vision and hearing are failing, you might suggest that he bring another person to your office to take notes and be a second set of ears."
FP Richard Waltman, however, has a strict policy of seeing all new geriatric patients aloneno matter what their circumstances. "I want to assess the patient without having anyone else in the room. And I want to know how involved patients want their family to be," he says. "It's not unusual for a patient to say, 'My daughter doesn't need to know my business.' "
Waltman initiated his policy after he'd seen a patient with her daughter for several visits. Then, when the daughter left the room to use the phone, the patient told Waltman that her daughter had been abusing her.
Waltman relaxes his patient-only rule after the initial visit, especially when the patient clearly needs assistance. If the person is very sick, Waltman might ask the family to designate a contact person so he can keep everyone apprised without having to field phone calls from several different people.
Adult children usually want to do right by Mom or Dad, but they may need some coaching. "A daughter will come to us and say, 'I noticed some blood on Mom's underpants. Please ask her about it, but don't tell her I saw it.' I'll reply, 'You have to tell her. Just say, "Mom, I noticed there's blood on your underwear. I love you. I'm worried about you. I want you to tell Dr. Waltman." ' Most people will respond positively to that."
If there's a dispute within a family about, say, whether a parent's illness should be treated aggressively or conservatively, Waltman arranges a family meeting. The patient attends if he's able to.
Of course, there are times when you have to involve relatives without the patient's permission. "I don't feel bad going around the patient if he doesn't have the capacity to understand or make medical decisions," Brummel-Smith says.
"Ideally a patient should always designate a person they would like to make decisions for them if they're incapacitated," Mt. Sinai's Patricia Bloom says. "In our practice, we ask every new patient to designate a health care proxy. Handling the issue that way is much better than searching for a surrogate after the person is admitted to the hospital's emergency department."
It's advisable, too, to encourage patients to sign a living will. Health care proxies and living wills must be state specific. Your hospital or local medical society may have material you can give patients on how to obtain and execute both.
"I firmly believe that if we're going to have a better health care system, we've got to create a better patient," says consumer advocate Molly Mettler, co-author of Healthwise for Life: Medical Self-Care for People Age 50 and Better. The book contains information on prevention, self-management of chronic diseases, and when to call a health professional.
Brummel-Smith likes the fact that such books help him "establish a working relationship with the patient as a partner rather than as a passive recipient of care. Resources like these focus on things patients can handle themselves. That can cut down on telephone interruptions."
Mettler urges doctors to provide "information therapy" as a means of helping older patients help themselves. "Say an older adult has been diagnosed with diabetes," she says. Now, you can give him minimal information, thus creating a dependency, or you can give him appropriate handouts, access to nurse advice lines, and other means of taking control of his illness. It puts some of the decision-making in the patient's hands."
Find out what resources for seniors are available in your area, and refer patients accordingly. In Brummel-Smith's view, "contacting Aging Services and finding out about community resources should be a basic part of setting up a practice."
Look for "7 questions to ask senior patients" in our October 25 issue.
"Making your practice safe and welcoming for elderly patients starts with the parking lot," says Richard G. Stefanacci, a geriatrician/internist in Philadelphia. "It should be well lit, with wide, obstruction-free pathways to accommodate wheelchairs and walkers."
Geriatrician Kenneth Brummel-Smith of Providence Health System in Portland, OR, stresses the need for easily negotiable waiting rooms with practical furniture, such as sturdy chairs with armrests. "Couches aren't good for old people," he notes.
Other indications of a senior-friendly office include:
Ramps with handrails to allow patients to bypass steps.
Signage with limited graphics and good contrast, such as black on white, rather than blue on green.
Rooms with extra chairs for family members or attendants.
Use of 14-point type in printed information, such as medical history forms and handouts.
Minimal background noise.
Grab bars in the bathrooms.
An exam table that raises and lowers, so seniors can get on it without climbing.
A chair scale.
You don't have to be an audiologist to know that hearing usually declines with age. If an elderly patient is having trouble hearing you, speak more slowly and distinctly than usualbut don't overdo either. Lowering the pitch of your voice also helps, because most hearing-impaired people pick up bass sounds better than treble sounds. Other tips:
Face the person directly, and make sure he can see your lips, eyes, and gestures. All provide clues about what you're saying.
Keep background noiseincluding radios and air conditionersto a minimum.
Make sure you have the person's attention before you speak.
If you haven't been understood, rephrase the statement.
If a hearing-impaired patient doesn't wear a hearing aid, an assistive listening device called a Pocketalker Pro can be helpful. It's a Walkman-like amplifier that consists of earphones, a microphone, and a volume-control knob. Many hearing aid suppliers sell Pocketalkers, and they can be purchased over the Internet for about $150.
SHHH (Self Help for Hard of Hearing People), an advocacy group for the hearing impaired, publishes a brochure, "The Patient with Hearing Loss: Information for Health Care Professionals." Single copies are free, and you can order them by calling 301-657-2248.
"If a patient is showing signs of early dementia, the spouse usually sees it before I do. So I've learned to listen to the spouse because they're right about dementia almost 100 percent of the time," says FP Richard E. Waltman of Tacoma, WA.
"Some cognitive function tests are very good at picking up early dementia," Waltman continues. "If I sense some impairmentor if a relative alerts meI might do the Folstein test, then I'll tell the patient to come back in four months and redo the test. I think people need to know that they might have Alzheimer's because legal and financial issues have to be addressed."
Kathleen O'Brien, vice president of program services for the Alzheimer's Association in Chicago, encourages full disclosure. "Present the diagnosis as you would for any serious chronic illness: 'This is the situation, these are the treatment options, here are some of the potential problems we'll keep an eye on in the future.' "
Alzheimer's is first and foremost a family disease, so physicians must pay attention to the caregiver. Some 80 percent of Alzheimer's caregivers report high levels of stress, and nearly half say they suffer from depression, says O'Brien.
Any treatment plan should include referral to a local Alzheimer's Association, which can link the patient and caregiver to community services. For information, go to www.alz.org , e-mail firstname.lastname@example.org, or call 800-272-3900.
Gail Weiss. Practical approaches for senior patients. Medical Economics 2002;18:42.