Geriatric The Optometric Examination of the older adults ch.pdf

lder adults are a special group within optometry’s patient population. Many of their visual characteristics and their varied needs make them different from the younger segments of the clinical population. This chapter focuses on the special considerations commonly required in the provision of...

lder adults are a special group within optometry’s patient population. Many of their visual characteristics and their varied needs make them different from the younger segments of the clinical population. This chapter focuses on the special considerations commonly required in the provision of vision care for the older patient. Inevitably, a chapter such as this is laden with generalizations because it emphasizes features that may be relatively common in older adults even though they are by no means universal within, or unique to, this group. Visual needs are often changed by retirement or by changes in lifestyle imposed by physical or sensory limitations acquired through aging. Aging brings inevitable changes to the visual system, such as loss of accommodation, reduced transmittance of ocular media, and pupillary miosis. The visual system is also affected by agerelated ocular pathological conditions, the most notable of which are maculopathy, cataracts, glaucoma, and retinopathy. Changes in the visual needs and normal and pathological changes in the visual system create a wide diversity of special clinical problems. The eye care practitioner becomes obliged to apply special emphasis and techniques, and special optical treatment or other rehabilitative attention often is essential. The diversity of vision needs and characteristics distinguishes older adults from the rest of the patient population. Therefore, when dealing with older patients, practitioners must use more imagination and flexibility in structuring the examination and treatment to suit these diverse individual needs. CASE HISTORY The goal of all case history taking is to obtain an understanding of the patient’s problems and needs. The case history shapes the sequence and emphasis of examination and assessment procedures, the design of treatment programs, and the presentation of recommendations and advice. The rapport developed in the case history interview can be a crucial factor in determining the success of any treatment. The optometrist must develop and display a genuine strong concern for the patient’s needs that are motivating the investigative procedures and treatment considerations. The patient’s demands should be given some overt attention, but the optometrist should remain conscious of the possibility of an unspoken hidden agenda that might be harbored by either the patient or the eye care practitioner. The practitioner should mentally take stock and ask three questions: (1) What does this patient want? (2) What, in my opinion, does this patient need? (3) What is the real reason for the patient’s being here today? These three questions will some- 133 times give rise to the same answer; in older adults especially, however, any differences in these answers can be important in making and presenting decisions and recommendations. The case history should begin with the patient being asked to identify the main visual problem or problems. The optometrist should encourage a full elaboration of the presenting complaint by asking questions motivated by a genuine curiosity and a desire to understand fully the patient’s problem. After the major presenting complaint has been adequately explored, the patient should be asked if other problems are present, and each of these should be pursued in turn. Some older patients, especially those who are lonely or have some doubts about their self-worth, may relish being the focus of attention, and the interview might become quite diverted. The clinician should be sensitive and tolerant toward such digressions. When the patient exhausts the self-generated list of problems, some important topics should be raised if they have not been covered already. These areas can be divided into the following four categories: 1. Distance vision. Patients should be asked about the adequacy of their distance vision for particular tasks, among which are recognizing faces, watching television or movies, and reading signs. Mobility tasks such as driving, using public transportation, and walking in familiar and unfamiliar environments can be important. Reactions to different illumination conditions may be included here. 2. Near vision. Reading is typically identified as the most important near vision task. The optometrist should establish whether the patient can satisfactorily read books and magazines, private and business correspondence, and labels and price tags. Patients should be asked about the use of computers and any optical or electronic magnifiers or special lighting conditions that are important to reading tasks. Other near vision tasks such as handicrafts, maintenance chores, self-grooming tasks, and food preparation also warrant attention. 3. Ocular and general health history. Current and previous ocular health and general health conditions or treatment should be investigated. The practitioner should determine whether the patient is currently taking any medications and, if so, consider any possible side effects. The patient’s experience with glasses or other optical aids should be investigated, and any problems or shortcomings of previous optical treatment should be identified. When some  loss of vision has occurred, the pattern of development of the loss should be established. The practitioner should ask patients about their perception of the cause, prognosis of the ocular condition, and the treatment that has been given. 4. Lifestyle. Some major changes in the activities of daily life occur with aging. Some changes will be forced by age- related changes in health and deficits in motor, sensory, or cognitive functions. The living environment may change; interests, aspirations, and habits may be altered; the capacity of independent travel and independent home management may be curtailed; and dependence on relatives, friends, or rehabilitation personnel may develop. The practitioner should be alert to such changes because they can significantly influence the needs of the patient. Aging patients often have special fears and prejudices that require consideration. Most people have some fear of vision loss occurring in their advancing years. This fear becomes heightened when peers experience vision loss or begin to require attention or treatment for cataracts, maculopathy, or glaucoma. Older patients commonly and strongly fear impending blindness or serious vision loss, but they rarely admit this fear. The practitioner should therefore be careful to read between the lines during the history and identify such fears. In recent years the public’s awareness of health care issues has rapidly increased. The practitioner should stay abreast of the latest developments in current and emerging treatments, including nutritional supplements, particularly as they relate to disorders affecting vision. Through the Internet, patients and their families now have easy access to medical information and opinions, and consequently clinicians now have to be prepared to answer more sophisticated questions. A partial or total vision loss is inevitably an emotionally traumatic experience for the individual concerned. After the initial shock, a sequence of emotional reactions can involve depression, anxiety, disbelief, grief, denial, and anger. In time, however, the individual’s emotional state stabilizes. Practitioners dealing with patients who have a recently acquired loss of vision should be aware of the probability of changing emotional attitudes. Sometimes delaying the finalization of prescription decisions until the patient comes to reasonable terms with having visual limitations is warranted. Patients who already have some loss of vision commonly fear that total blindness or substantially worse vision is inevitable. Patients should be encouraged to discuss these fears. Often associated with the fear of blindness is a concern that some past abuse of the eyes is the cause of their vision loss and will soon produce dreaded injurious consequences. Excessive reading, excessive fine work, poor illumination, wearing glasses, failure to wear glasses, wearing the wrong glasses, sitting too close to the television, using fluorescent lamps, or watching color television are all believed to ruin vision, and such mistaken beliefs are more prevalent in older adults. Patients with these concerns should be given appropriate advice and reassurance. Patients who have already suffered some vision loss are particularly likely to be influenced by erroneous but commonly held beliefs that may lead them to expect a dismal visual future. Furthermore, low vision patients may sometimes proudly claim great virtue and restraint because they do not sit too close to the television, do not read any more than is essential, and do not use strong light, when, in fact, the avoided behaviors pose no threat to remaining vision and could provide the means for a broader and more enjoyable range of activities. Thus practitioners should take special care to counsel their older patients about their future eye care needs and the prognosis for changes in their vision and ensure that the patients really understand the status of their own vision. When an individual retires, interests and priorities often change. Especially if some agerelated disability has occurred, older people often curtail their social, vocational, and recreational activities. Withdrawal from social and other pleasurable activities can be passive and unconscious. The eye care professional should understand the patient’s range of current daily visual activities. When some vision loss has occurred, the extent to which the vision loss is restricting activities or aspirations should be determined. A useful approach is to ask patients to describe their typical daily activities. Ask what they do from the time they get out of bed in the morning until they go to bed at night. Such questioning often reveals the range of visual demands and, when restricted vision is present, often indicates the extent to which people are modifying their lives because of vision difficulties. The frustration and regret associated with a vision loss is often revealed by the question, “What things could you do when you had good vision that you cannot do now?” In bringing the introductory interview to a close, the careful optometrist will summarize the priorities for the examination process that is to follow: “So, if I understand things correctly, the most important thing for us to concentrate on is your reading, especially for bank statements. And we should thoroughly check the health of your eyes. Is this right?”  Reminding the patient that mutually agreed upon goals have been established and that these goals motivate all the examination procedures can be reassuring. Advising the patient of the purpose of various tests and relating them to the patient’s symptoms emphasizes the clinician’s concern and develops a stronger spirit of participation in the patient.