It is well established that retinal disease is prevalent in the senior population. AMD, for example, is the leading cause of severe, permanent vision loss in those older than age 60. Additionally, glaucoma increases with advancing age, with nearly 6% of African Americans grappling with the silent thief of sight by age 69, according to the NEI. Something else to consider: Approximately 16% of Americans are age 65 or older, according to the Department of Health and Human Services Spring 2022 publication.

While we, as eye care providers are adept at diagnosing and managing retinal disease, we should also be aware of the senior population’s personal needs, so we can provide the best care overall. With that said, here, I provide specific action steps optometrists can take to make their practices senior friendly.

FACILITATE ACCESSIBILITY

Age-related changes in the brain can disrupt the neural circuitry of walking and cause decreased motor skill, loss of automaticity and gait inefficiency, reports a study in the Journal of Gerontology. As a result, senior patients generally move at a slower pace than other patient populations, and they may employ canes or mobility devices, such as wheelchairs or walkers, to make travel easier. Further, these patients may have conditions, such as Parkinson’s disease, that can slow movement.

In addition to educating staff about the possible movement issues that can affect the senior population, I recommend stressing to staff the importance of patience and offering help. Also, I suggest facilitating accessibility both into and throughout your practice:

• Into the practice. At my practice, senior patients often arrive in a van operated by an assisted living center. My staff meet the patient at the van and escort them into the practice.
• Throughout the practice. I suggest outfitting the entire practice with strong lighting. Lighting that enhances the direct detection of stimuli could be a practical and effective intervention to reduce the risk of falls, reports Lighting Research & Technology. Our seniors often have cataracts and other ocular pathology that reduces acuity and contrast sensitivity. We have removed nearly all the carpet from the office and installed vinyl planks. This is more sanitary and provides a more uniform surface that will, hopefully, prevent a patient from tripping and/or falling, as some senior patients may shuffle along and do not pick up their feet. We use door levers instead or doorknobs for ease of use, especially for those who have arthritis or other dexterity issues.

If rain water is brought in through the front door on a rainy day from shoes or an umbrella, I recommend mopping it up immediately and placing a bin near the front door to hold all wet umbrellas. We also place a yellow caution sign near the front door to warn of possible moisture. These signs are commonly available at Lowe’s or Home Depot. The Occupational Safety and Health Administration can look for these in an onsite audit.

In terms of the reception area itself, it should not contain items such as waste receptacles or misplaced toys where they can be a tripping hazard. Caution tape, which is readily available at Lowe’s or Home Depot, could be put where a small ledge, a step, or a wheel chair ramp may be present. Roughly 36 million older adults fall each year, resulting in over 32,000 deaths, reports the CDC.

When it comes to seating, chairs that have arms are a great way to help those who may struggle to rise after sitting.

Regarding public restrooms, I suggest they be monitored for water splashes that can be a slip hazard and to use toggle-type light switches vs. paddle switches, as they are easier for those patients who have arthritis to manipulate.

We have recently installed motion sensors to turn on the lights in the restrooms so patients don’t have to enter a dark room looking for a light switch. Restrooms where moisture is possible should be well lit.

In the pre-testing area, I recommend placing all pretesting equipment in one area, so the senior patient won’t have to move around too much, which can cause patient fatigue and could affect the accuracy of test results.

When it comes to the exam rooms, consider designating one room for wheelchairs with a slide that moves the examination chair out of the way for the wheelchair to go right in front of it.

Also, I suggest paying special attention to the positioning of the phoropter. If the senior patient is stretching to reach the lens openings, they may fatigue and drop down. If they can’t view the chart through the lenses, this could cause the refraction to go from 20/30 to nothing. The same advice goes for the slit lamp biomicroscope: Getting a good view of the eye and adnexa may be fleeting if the patient is not comfortable. I recommend holding the cover paddle when checking acuity instead of the patient because they often cannot consistently cover one eye for more than a few seconds. Further, I suggest raising the footrest to facilitate the senior patient’s ability to enter and exit the examination chair.

Senior patients can be exhausted from going through the preliminary testing, the optometric evaluation, dilation, and explanation of disease states, which puts them in a less-than-optimal state of mind to select eyewear. As a result, I recommend scheduling the senior patient’s meeting with the optical staff for another time if they are feeling fatigued, unless the patient expresses otherwise:

Many senior patients can have knee and or foot problems, which makes scooting a chair up to the dispensing table for discussion and measurements difficult. To overcome this challenge, I suggest placing sliding tabs on the bottom of the chair legs, as they have been a great help in getting the patient close to the dispensing table.

LISTEN/COMMUNICATE CAREFULLY

We should listen and communicate carefully with all our patients, regardless of their age, but this is particularly important when encountering the senior population. Specifically, age is the strongest predictor of hearing loss, with those ages 60 to 69 experiencing the greatest amount of hearing loss, according to the National Institutes on Deafness and Other Communication Disorders.

Additionally, dysarthria, or slurred speech, is common in the senior population. (Some of the symptoms of dysarthria are soft speaking, slow or fast talking, limited jaw, lip, and tongue movement.)

Further, cognitive decline is prevalent in the senior population due to aging, side effects from medication (e.g., statins), depression, and conditions, such as dementia.

The first step to listening carefully is to make staff aware of these issues. The next is to employ tactics to increase the likelihood of accurate communication. An example of a tactic: In my practice, staff are taught to face senior patients directly, speak slowly, loudly, succinctly, and enunciate their words. (With most practices now using electronic medical records, our mouths are often facing toward an electronic screen. This is not conducive to good communication, whether verbal or non-verbal.) Also, to ensure we are receiving the patients’ words correctly, we ask them to please repeat and/or clarify.

To communicate carefully, we ask patients whether they understood what was communicated. This is particularly important when it comes to explaining insurance benefits, as staff have often found themselves in three-way conversations among the patient and the plan about benefits.

As much as we try to head off problems before they start, they can still arise. Case in point: Recently, A 76-year-old patient presented desiring sunglasses as part of his regular prescription glasses. Our opticians had a lengthy discussion with him about the differences and characteristics between sunglasses and photochromic lenses. He elected to get photochromic lenses. On his way from leaving the practice with his new pair of photochromic glasses, he came back to complain the lenses weren’t dark enough, even though the opticians had explained to him that the lenses take several minutes to darken. Two days later, he demanded to know why we didn’t prescribe sunglasses. I highly recommend being understanding of our optician’s dilemma because despite doing their best to cover all the bases, sometimes, it is not enough: Memories, thoughts, and expectations are not the same at age 70 as they are at age 30.

Even if cognitive decline is not a significant factor, memory can be. We try to provide informational brochures on ocular conditions and treatments whenever possible. Specifically, we offer brochures on diseases, such as cataracts, age-related macular degeneration, glaucoma, and dry eye. We also offer pamphlets on contact lenses, premium coatings, and other products we offer in the practice. Most of the currently available information in handouts is printed in large, easy-to-read fonts with colorful pictures. These can be evaluated and redone if they are not suitable for your aging patients. We recommend printing intake forms and others, such as consent for treatment and advanced beneficiary notices, to be large print and easily readable. We often assist our patients with these forms if they are struggling due to cognition, or language or illiteracy. Some offices offer the option of electronic tablets where the font can be enlarged if needed.

QUALITY CARE

The senior population is growing rapidly and deserves our best efforts in providing them quality care in a safe and inviting environment. Having finished optometry school in 1981, I am now realizing from personal experience the challenges that aging presents. I recommend you walk around your practice and evaluate what can be done to provide this population with the best possible experience when presenting to your office. OM

DR. HENNE practices at Family Eye Care and has been in private practice since 1981. He is actively involved in the Lake Region Optometric Society, the Florida Optometric Association, and the American Optometric Association.