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Caring for Our Elderly Patients

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With the typical ophthalmology practice having 65 percent or more Medicare age patients, it is important not to draw conclusions about patients based on their age alone or their medical condition. However, elderly patients seen in the ophthalmology office have special age-related health problems and emotional needs, which ophthalmic medical assistants should consider.

Elderly patients are often anxious and fearful of losing their independence and financial security. They may be facing limitations of mobility that may cause them not to relate well or be difficult to examine. An elderly person may also be particularly worried about declining health and may notice or complain about subtle changes in vision. Examiners should not overlook or downplay these observations. Make note of the symptoms so that the doctor can follow up.

In elderly patients as well as in others, worry may manifest itself in the form of crossness, unreasonable blaming of others or anxiety. The ophthalmic medical assistant needs to treat elderly patients with special consideration, keeping in mind the following:

  • Healing may be slower.
  • Understanding may be slower.
  • Apprehension about their condition may be greater than with younger patients. Some elderly patient fear impending blindness, even with relatively minor eye problems. Loss of eyesight is another obstacle to independence.
  • Visual acuity is only one aspect of functional vision that may be affected by eye diseases. Color perception and contract sensitivity are often affected as well.
  • Many elderly people live alone, so a small change in objective acuity may cause a big change in functional ability; for example, changing from 20/30 to 20/40 may seem trivial, but it may make the difference between being able to read the newspaper or the label on a medication container easily and with confident.
  • Having to give up shopping alone, driving or other independent activities because of declining abilities and eyesight can be a very difficult adjustment and one that requires sensitivity and compassion on the part of health care providers.

Age-Related Vision Changes
Many changes in vision in elderly patients occur as a result of age-related alteration of the ocular tissues. With age, the lens gradually yellows, resulting in some difficulty with color discrimination. It also becomes increasingly rigid, resulting in a significant loss of accommodative ability. Therefore, the patient has difficulty shifting focus from distance to near. Over time the lens becomes opaque (cataractous), creating difficulty in reading clearly at near, intermediate areas and for long distances with or without corrective lenses.

When ophthalmic medical assistants appreciate and understand the problems that elderly patients face daily, they can become more sensitive and responsive to their needs. This sensitivity and care will help you achieve more accurate and complete results. 

Common complaints and ophthalmic entities of the elderly include:

  • Floaters
  • Watery, dry or itchy eyes
  • Difficulty seeing when going down stairs
  • Decreased vision at night
  • Decreased contract sensitivity
  • Difficulty with glare
  • Extra time needed to adjust when entering a darkened room
  • More light needed to read, yet have problems with glare
  • Diminished color discrimination, especially blues and greens
  • Changes in visual ability related to cataract (present to some degree in 95 percent of people over age 65), glaucoma or diabetes

The special needs of elderly patients can be multifaceted. Some elderly patients may have one or more chronic illness or limitations on their ability to maneuver easily through their daily activities. The current visual loss may be just the latest event to occur among other medical concerns.

Some elderly patients also have loss of hearing, which can compound their sense of isolation. Speak slowly and distinctly to patients who have difficulty in hearing, but do not assume that an elderly patient will have difficulty hearing based on his or her age alone. If you determine that the patient is having trouble hearing you, face your patient squarely and allow the patient to see your lips so he or she can obtain extra clues to what you are saying. It is rarely necessary to raise your voice excessively and never necessary to shout.

Many elderly people who are “partially sighted” do not get around as well as a younger and possibly more severely visually impaired individual who may be in better general health, have a broader support system and be more optimistic. However, no one can predict a patient’s reaction based on age. A sudden loss of vision for one patient may be far more devastating than a slowly progressive one for another.

Some older persons mistakenly believe they should “preserve” their eyes by not “using them up.” Tell them it is not possible to use up their eyesight, even if a visual abnormality exists. Encourage them not to sit in the dark, not to give up hobbies and to continue reading or doing other near work. By participating in living as fully as possible, they will have a better quality of life.

Visual Acuity Testing
As with most adult patients, visual acuity in elderly persons is tested using a standard Sneller chart and procedure. When distance acuity is less that 20/200, you usually would have the patient walk toward the chart. As an example, if a patient reads the 200 line at 10 feet, record the vision as 10/200. With elderly patients, however, consider their ability to get in and out of the examining chair; instead, move the chart toward the patient if possible.

Check the near acuity of elderly patients even if distance acuity is poor. The importance of near vision in this age group cannot be overestimated. Reading, needlework or arts and crafts may be the person’s major, if not only, independent activity and source of enjoyment. It is particularly important to adjust the near-vision test appropriately to avoid glare, which can be a problem for patients in the initial states of cataract formation. Glare presents a paradox for the elderly person, who may benefit from additional lightly for reading but at the same time may be bothered by the glare it creates. Maintain the standard distance required for a particular test but allow the patient to adjust the tilt of the near card. The ideal situation is to have the highest contact with the least amount of glare. Good contrast can often be an easier and better solution to comfortable reading than high magnification.

When checking both distance and near visual acuity, remember that the elderly patient may require extra time to search for and locate the letters, especially the patient with macular degeneration. Give these patients coaching and extra prompting as needed. Elderly patients may have a slower reaction time than younger patients, so it is important also to give them some additional time to respond. 

If an elderly patient is unable to read a distance or near acuity chart at all, proceed with low-vision testing. Elderly patients may also require additional tests of visual abilities, such as contrast-sensitivity and glare testing.

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About the author: Reprinted with permission in the January/February 2007 issue of Techniques, from Ophthalmic Medical Assisting: An Independent Study Course, 4th Edition Text and Exam, edited by Emanual Newmark, MD (Product Number: 0211204).