By Deborah Conn

According to the American Geriatrics Society, the number of Americans 65 and older is estimated to grow from 35 million in 2000 to 78 million in 2050. The number of those aged 85 and older will increase from 4 million to 31.2 million.

Those numbers are starting to have a big impact on O&P practitioners, as geriatric patients form a larger percentage of their patient base. But how are older patients different from the general population? What should practitioners know about the elderly to treat them successfully?

The first point to keep in mind is that “being elderly has nothing to do with how many years you have lived on the planet,” says Joanne G. Schwartzberg, M.D., director of the Program on Aging and Community Health of the American Medical Association. “The fact that your patient is 65 or 75 doesn’t tell you what that person’s capabilities are, whether you are determining rehabilitation goals or explaining new information.”

“Aging is not a disease,” stresses Sharon Brangman, M.D., chief of geriatrics at Upstate Medical University in Syracuse, N.Y., and a member of the American Geriatrics Society. “In our youth-oriented culture, aging is viewed as an unnatural event. It is not. I have many older patients who are relatively healthy and don’t have significant problems.

“Moreover, we tend to lump everyone 65 or older into one big category. This ignores the characteristics of each age group. A 65-year-old and a 90-year-old will have different needs. It’s the same situation as a pediatrician who has patients who are 18 months old and 18 years old—they require very different approaches. You have to individualize care based on the person in front of you, rather than an age category.”

Multiple medical conditions
That said, you may be more likely to find certain characteristics in common among older patients. For example, the elderly often have multiple medical complications. “We collect medical conditions as we get older,” explains Schwartzberg.

These “collections” often overlap. Brangman notes, “There are multi-factorial issues for every problem. For example, dizziness and falls can be caused by medications, poor vision, neuropathy, low blood pressure—or by all of these factors.”

Practitioners need to be aware of the effect of such medical conditions on O&P care, says Meredith Marks, assistant dean of the Academy for Innovation in Medical Education at the University of Ottawa. “For example,” she says, “it’s not uncommon for older patients to have congestive heart disease or renal impairment, either of which can cause swelling in the limbs. The prosthetist must understand what causes the edema and if it can be controlled with medication.”

Marks advises practitioners who see something unusual to refer the patient back to the doctor. “Sometimes the situation can’t be changed, and then the practitioner has to decide whether the device can accommodate the condition or if the patient can even use it at all.”

Assessing each patient on an individual basis is key to determining appropriate O&P care. “You have to individualize each situation and set realistic goals,” says Brangman. “One patient may just need to transfer from bed to wheelchair to toilet. Others may want the ability to walk longer distances. Some patients may have such significant cognitive impairment that they can’t even use a prosthetic limb or an orthosis. Treatment depends on the patient’s situation, interest, and ability to cooperate, such as with physical therapy or caring for a prosthesis.”

Communication and compliance
The second major issue with older patients is communication, which is key to ensuring compliance. Even if a patient has no cognitive impairment, other factors—such as failing vision or hearing—can make it difficult for a practitioner to communicate effectively.

Schwartzberg says, “The average reading level for Americans is eighth grade. Most directions are written at the 12th grade level. This can lead to mistakes and misunderstandings. When you get older, with medications and chronic illnesses, it becomes even harder to understand.”

Many patients are in pain, which can exhaust them and interfere with their comprehension. Being aware of that can help practitioners be more understanding, says Schwartzberg. She knows how important it is to be calm and supportive when dealing with patients.

Marks says the physicians in her center give instructions in many different formats—oral, written, and even in pictures. “Sometimes when we have patients with major difficulties, we’ll take snapshots of them doing the activity and make a pictorial guide. This is also helpful when we have someone in a senior’s residence, where multiple staff members come and go. Or the patient has caregivers who just aren’t familiar with a specific device. Being explicit is very important.”

Another concern is that many of these patients are simply overwhelmed. They have likely collected as many doctors as they have conditions, and each doctor has given them different instructions.

“Someone 65 and older—even without serious medical issues—interacts with an average of seven different healthcare providers,” says Schwartzberg. “They’ve gone from one place to another, seeing doctors, nurses, therapists, lab techs. Now they come to you. How can they distinguish who you are and what you expect of them? Trying to organize all this information is a great burden.”

Teach-back
Schwartzberg advises practitioners to organize in their own mind what they are going to say. “What do you want patients to know when they walk out the door? What is your take-home message?

“Once you know the two or three points you want to get across, put it in ‘living room language.’ Make sure the patient really understands. Ask, ‘When you get home, what are you going to tell your wife about what we said?’ Ask, ‘How are you going to put on this device?’ Or, ‘Why don’t you recap what I just said?’ Ask the patient to perform the activity while you watch.”

This technique is called the teach-back method, and Schwartzberg says there are lots of different ways to use it. “Everyone has his own way,” she notes. “But research shows that this is one of the most important initiatives in successful care. And it doesn’t add a lot of time to the interaction, because the professional is more organized.”

Of course, some patients do have cognitive difficulties. “Learning new processes and making decisions are often the first functions to go,” says Marks. “If a patient comes in who can’t figure out how to use the television remote control, that patient is probably going to have problems with O&P.”

Marks says an older patient’s difficulties may come as a surprise to family members who may have been compensating, intentionally or not, for a relative’s shortcomings. “Then when patients are suddenly tasked with something as significant as this, it turns out they may not be able to follow instructions or follow up with appointments or judge how long to wear a device,” she says. It can be very frustrating for everyone involved.

If a patient simply isn’t capable of following instructions, O&P practitioners should inform the referring physician and get appropriate permissions to share information about the patient’s treatment with a family member or caregiver.

Elder abuse
Detecting elder abuse is a problematic issue. “There are no good screening tools for elder abuse,” says Schwartzberg. “You have to look for medical noncompliance, problems with family relationships. You may note that someone looks malnourished or has problems with family members. It’s very tricky. For example, an older person may exhibit bruising, but there can be many reasons for that. It’s hard to distinguish what is a normal concern from a sign of abuse.”

Brangman agrees that abuse can be hard to verify. She says, “You have to try to get an opportunity to talk to the patient alone. Does the patient seem intimidated or reluctant to speak? Is the caregiver reluctant to have the patient examined on his own?” Schwartzberg advises practitioners who have suspicions to discuss the issue with the referring physician.

In the end, says Brangman, “Geriatric principles [make for] good medical care no matter what your age is. Every patient wants to be considered an individual.” Assessing patients based on their specific capabilities and goals, making sure they understand how to participate in their own care, and treating them with respect—these are the basics for any patient.

Deborah Conn is a freelance writer based in Falls Church, Va.