Who is a senior citizen? At what age do we consider ourselves old?
I am now in my fifties and I still talk about older people being significantly older than me. Generally, in this author’s opinion, people in their fifties are more engaged attending the gym and maintaining a healthy lifestyle not wanting to fall into the category where we need to be cared for as that introduces major life changes.
This article gives a general overview on what can change for our older patients and how we can adapt to those changes.
How to adapt communication for older patients?
First let us consider why we need to adapt how we talk to older patients:
- Older patients can become hard of hearing
- Older patients have an increased risk of dementia
As with all patients obtaining a detailed history and symptoms is essential, general health, ocular history, hobbies and work situation, understanding exactly what these involve along with their current visual requirements enables accurate advice and recommendations to be given.
It is through building rapport and trust, asking open questions, that make this possible, and I cannot overstate how important this is.
Discussions are always easier with people who we know and have built mutual trust. All this information helps us understand a patient’s visual requirements and helps start us thinking about how we can meet those requirements.
Remember not to pigeon hole senior citizens, many still want to live life to the full and may be able to benefit from many optical appliances that we can supply for example, sunglasses, swimming goggles, safety, occupational, work distance specific spectacles, contact lenses, and low vision aids.
Also, when booking an eye examination, it is helpful to ask senior citizens to bring a list of any medication they are taking as this could help explain any fluctuations in prescription.
Hearing
Hearing can be an issue. Age-related hearing loss can progress gradually due to changes in the inner ear and auditory nerve, so people often do not realise that they have lost some of their ability to hear.
Hearing loss is particularly noticeable in noisy environments, so if you have somewhere in the practice that is quieter like a test room, hearing clearly will be less of an issue.
Remember to always speak slowly and keep good eye contact with patients that are hard of hearing, as this will help communication.
Dementia
Dementia also progresses with time, there are three main types of dementia: vascular dementia, Alzheimer’s disease and mixed; in the longer term it will affect a person’s ability to remember and understand basic everyday facts, such as names, dates and places.
Dementia will eventually affect how a person communicates. The ability to present their ideas and to reason clearly will change.
It is crucial we consider how to start discussions, being patient, calm and encouraging is important; also remembering that a person’s ability to process information will get progressively weaker and their responses can become slower.
Check available resources like NHS Communicating with someone with dementia at nhs.uk/conditions/dementia/living-with-dementia/communication, see table 1.
Active listening should help communication with a patient with dementia, using eye contact, look at the person and encourage them to look at you when either of you ar
e talking.
Try not to interrupt them, even if you think you know what they are saying. It is so tempting to do this, as you feel that you are helping them but if we try and answer quicker for the patient it can often lead to increased frustration/misinterpretation of what they are trying to communicate to us.
Give the patient your undivided attention, stop what you are doing so you can give the person your full attention while they speak. If you do not minimise distractions they may get in the way of communication, such as colleagues asking questions.
A good tip is to repeat what you heard back to the person and ask if it is accurate, or ask them to repeat what they said. It is helpful to encourage the use of leaflets and make a summary of what you discussed in practice so the patient can take away a reminder of the discussion.
Dispensing older patients
Avoiding problems
A practical tip to use for patients with memory problems is colour coding their spectacle frames, having different coloured frames for reading and distance; this helps avoid a mix up of frames.
How facial characteristics change for older patients
As we get older our skin ages, it loses its elastic ability to snap back after stretching and is often thinner meaning it can be more easily damaged. Over time, UV light can cause damage to the elastin fibres, this makes the skin more likely to bruise and take longer to heal.
We need to take this into account when dispensing frames, if a plastic frame is dispensed try to make sure that the bridge is in contact with the nose and that the weight of the frame is evenly distributed therefore minimising sore spots.
When dispensing a metal frame, care is needed as the weight is focused through the nose pads, so replacing the pads with a saddle bridge to spread the pressure across the bridge, while ensuring the metal frame does not come into contact with the skin.
There are lid conditions associated with age entropion and ectropion see figures 3 and 4. Ectropion, is where the lower eye lid droops away from the eye and turns down and outwards, this is why we take bifocal heights from the lower limbus (bottom of the iris) rather than the eye lid.
As the lid is no longer in contact with the eye it has less protection and can lead to dryness as the tear reservoir that sits on the lower lid can overflow down the cheek. It is essential to speak to a dispensing optician or optometrist as this patient will require referral and, as a temporary measure, ocular lubricants.
Entropion is where the lower lid turns inward, which causes the lashes to rub on the eye potentially damaging the cornea. Once again it is important to speak to a dispensing optician or optometrist as this patient will require referral.
Another lid condition that occurs with age is ptosis, which is where the upper eyelid droops. This can affect vision if it obscures the pupil but spectacle frames can be adapted to incorporate support to hold the upper lid up, which are called ptosis props, an example of this are lundie loops.
Prescription changes as we get older
Patients from approximately mid-40s are likely to be presbyopic and require a prescription for close work as the eye loses its ability to focus at near, so senior citizens will be presbyopic.
There are several options that can be dispensed as separate pairs: bifocals, task specific prescriptions, progressive power lenses and occupationals.
Progressive lens designs vary and those tailored to the patients prescription and frame fitting can provide a wide field of vision, which means there will be less head movement and a more fixed posture.
Occupational lens designs provide an ideal option for computer use as lots of older/less mobile people now do their weekly shop online and get it delivered.
Bifocals these lenses offer an alternative to progressives for those that have not been able to tolerate the swim/distortion of the progressive designs or provide and ideal option for a task specific pair of spectacles incorporating an intermediate/near option where a large reading area is required.
Separate pairs should not be overlooked and may be the best option for a patient that may have health problems like vertigo, Meniere’s disease or balance problems.
For convenience having one pair is often preferred but it is important to find out each patients individual requirements and exactly what the spectacles are going to be used for, as mentioned above there are additional factors to consider like posture, those with a stooped posture, may find single vision more user-friendly.
Complications with prescriptions as we age
Anisometropia is potentially an issue for older patients. This is when a patient has a difference in refractive power between the two eyes of 1.00D or more. Good prescription analysis is important here as anisometropia can often be difficult to spot, so, if unsure, always refer to a dispensing optician.
As the eye ages cataracts can develop and while removing the crystalline lens and replacing it with an intra-ocular implant is performed routinely taking two to six weeks for full recovery it can leave the patient with an imbalance between the two eyes.
It may be that the patient is waiting for the second eye to be operated on but, if left untreated, the brain can decide to select the eye that presents the clearer image and then ignore the image from the other eye.
Patients with anisometropic prescriptions can experience diplopia (double vision) headaches and feel unbalanced, so, again, careful prescription analysis is crucial.
Visual impairment
The leading causes of sight impaired and severely sight impaired patients in the UK is primarily age-related eye diseases. Those diseases include age-related macular degeneration, cataract, diabetic retinopathy and glaucoma. Senior citizens losing their sight are much more likely to suffer from slips, trips and falls.
Senior citizens diagnosed with low vision will need more specialist help, which will be covered in a later article.
Remember, our communication skills are again important here. A patient may well have come to our practice for a new prescription because their vision feels a little blurred, to then be told, by the optometrist, we cannot change the prescription lens power to improve visual acuity as there is some pathology causing a problem.
This may be a shock for the patient to hear as many of these age-related diseases are progressive and the patient’s vision will continue to deteriorate and impact upon their quality of life and how they function in day-to-day situations. This will need handling in a professional and empathetic manner.
Here it is important to check with a dispensing optician or optometrist to confirm the patient has had a diagnosis confirmed and if they have been assessed in a low vision clinic as there are specifically trained professionals like eye care liaison officers (ECLOs) that are hospital-based who can provide support for these patients.
As an OA it is useful to be able to offer some low vision aids and advice on adaptions that others in the same situation have found useful.
Familiarity with the practice’s stock of magnifiers – hand held, stand magnifiers – and knowledge of accessibility options available on smartphones, can all help patients with reduced vision. For example:
- Products that use colour or contrast to make them easier to see and use
- Products that are larger than standard, for example a larger wall clock
- Large-print products.
- Many other items such as reading stands, anti-reflection spectacles and task lights.
It is important that low vision patients are clearly identified and are properly assessed, as discussed earlier as some of the above examples may be of no benefit, also finding the right low vision aid for a patient can take time.
Slips trips and falls
Around one in three adults over 65, and half of people over 80, will have at least one fall a year. Most falls do not result in serious injury. But there is always a risk that a fall could lead to broken bones, and cause the person to lose confidence, become withdrawn and feel as if they have lost their independence.
As OAs we work in a medical environment and as such owe our patients a duty of care. This could be described as promoting wellbeing and making sure people are kept safe form harm, abuse and injury.
Research shows that patients with impaired functional vision, depth perception and contrast are significant visual risk factors for falls above that of visual acuity.
Safeguarding
What can we do as OAs? Be alert to signs of neglect or abuse for example, consider a patient coming into practice for an eye examination and/or new spectacles aged 80 years+ and has several bruises on their hands and face.
It is important to make the optometrist and dispensing optician aware as well as the practice safeguarding lead as a referral (with the patient’s consent) to social services to enable the patient to get whatever additional support may be required.
Sometimes our older patients just want to talk to someone as life can be quite lonely for them if they do not have any family or they do not live locally. It can be helpful to keep a list of all the local support groups in your area that older patients living alone may benefit from attending.
Optical appliances
In terms of the optical appliances, which are the most suitable? The first point to consider is a trip or fall caused by the positioning of a bifocal segment? The segment top position in relation to the patient’s posture - is the patient looking through the reading portion when it is not required? - for example walking around. It may be that bifocals are never going to work. Would single vision spectacles be a better solution?
Some senior citizens may be unaware that there is specific help and advice available to help manage slips, trips and falls. All councils will have some online advice and links to local help, Age UK is nationwide and offers support groups, advice on aids and how the home environment can be adapted to reduce the likelihood of slips trips and falls.
Summary
When considering our older patients, we need to think carefully about what we are dispensing and if it is in the patient’s best interests as well as whether it meets their individual needs? This could be colour coding frames (the red spectacles are your reading glasses), making sure segment heights for example are not generating a problem but also acknowledging injuries. Try to find out the details and help signpost the patient to suitable help.
Always aim to keep an upbeat and pleasant atmosphere, senior citizens are the best for having a chat in my experience.
Student perspectives
‘This lesson has given me lots of new, interesting information, I did not know that we can get glasses that support a patient’s drooping eyelid.’
‘There was lots of great stuff in this lesson about dispensing senior citizens, I learnt some new things, in particular about what to do if you suspect a patient has been having slips, trips and falls.’
Employer perspectives
‘Communication skills are so important especially with older patients. My learner has highlighted areas where we can improve following Tony’s lecture.’
- Tony Douglass currently works part-time at UCLan as a lecturer in ophthalmic dispensing and part-time as a tutor on Training 2000 level 3 Optical Assistant apprenticeship.
- Douglass designed, developed, and managed the level 3 Optical Assistant Apprenticeship course at Training 2000, and was involved in the development and delivery of the benchmark Btec level 4 certificate in optical dispensing, which started hundreds of students’ careers in optics with around 70% of students going onto further study as a dispensing optician. Douglass is also an experienced author and presenter of CPD lectures and discussion workshops with audiences of up to 500. He also previously worked as a part-time lecturer in ophthalmic dispensing at Anglia Ruskin University.
