While the average face time between practitioner and patient has been clocked to under 10 minutes, optometrist Marc Gannon has adopted a much more leisurely approach when it comes to taking the time to examine and talk to all his patients in his Fort Lauderdale, Fla., practice.

In fact, if you are a patient at Dr. Gannons Low Vision Institute of South Florida, expect your exam to last about an hour-and-a-half. This may seem like eons to some, but it is just good patient care for Dr. Gannon, who estimates that about 95% of his patients are senior citizens, with the average age of 85. Dr. Gannons oldest patient is 103.

Dr. Gannon knows that taking the time with senior patients is critical to their care and overall well being. This is a very underserved population that is often neglected, he says.

Whether the majority of your patients are senior citizens or not, chances are good that youll be treating more senior patients in the future. Consider that the U.S. population aged 65 and older is expected to grow to 71 million by 2030, according to the Centers for Disease Control and Prevention. In some states, fully a quarter of the population will be aged 65 and older.

The question is: Are you prepared to best serve this growing and important senior population in your practice?


Who Are Seniors?

Many might say that when you reach the age of 65, you are officially a senior citizen.

For practical purposes, senior has been defined as 65-plus years because thats when Social Security benefits start to kick in, according to optometrist Satya Verma, assistant professor at the Pennsylvania College of Optometry and recent award recipient from the National Council on Aging. Social Security was introduced in the U.S. in 1935; the age of 65 was considered a good number during a time when life expectancy was low. Since then, with the advances in health care, education, healthy lifestyles, environmental and other factors, Americans are living longer, and the age for Social Security has also been extended.

This means that 65-year-olds are no longer the old; rather, they are the youngest of the older population, says Dr. Verma. Along with the Baby Boomers, this segment of the population is the fastest-growing age group, followed by those who are now 100-plus years of age. Even among the older population, you have the young old (65 to 75 years), middle old (between 76 and 85 years) and the old old (86 and above), he adds.

But (much as many 40-something-year olds would not like to hear this), from an optometric point of view, aging begins even earlierat the onset of presbyopia.


Treat the "Whole" Patient

Of course, with aging comes additional health-related problems. For optometrists, that can mean glaucoma, cataracts, low vision and age-related macular degeneration. As a result, seniors have additional vision care needs and an increased tendency for other health-related problems.

It is important that, if we want to take care of the older patients, we must understand the whole personand not the pair of eyeballs, Dr. Verma says. We know that even with good health and medical care, older adults are the ones who consume the majority of medications. We should be familiar with age-related changes, whether they are physical, physiological, biological, anatomical, visual, environmental, social and psychological, behavioral and others.

Optometrists should also be aware that older adults are often on several systemic medications, which may impact visual health. We need to be sensitive to these changes and needs, and we must consider the whole person, as opposed to examining eyes in isolation, Dr. Verma reiterates.


What Makes an Office Senior Friendly?

Staff members who speak slowly and clearly on the phone.

An office that has plenty of easy parking close to the entranceboth handicapped and regular spots.

Handicapped-approved rest rooms, hallways and doorways.

Reception rooms chairs that are of a standard height and sturdy. Avoid cushy sofas that are hard to get out of.

A short, easy-to-complete patient history form for check-in.

Classical or easy listening music at a soft volume in the officenot rock or country, which can be annoying or hard to hear over.

Office chairs that do not scoot on casters when you sit on them.

Instrument tables that have easy access for the handicapped and do not cause

patients to bump their knees.

A wheelchair that is accessible to seniors who have difficulty walking or breathing.

An easy pace when escorting patients around the office.

A doctor who takes the time to listen while making eye contact.

A doctor who explains things in common (laymans) terms.

A staff member who explains the billing process in advance of providing services.
Neil Gailmard, O.D., M.B.A.

Communication is Key

Good communication skills are critical in successfully treating this patient base. In fact, what distinguishes one practitioner from another is not what he or she knows, but how he or she communicates with older patients, according to Dr. Verma.

When communicating with seniors, Dr. Verma offers these important suggestions:

Write instructions. Older adults have memory loss, short attention spans and may also have hearing impairments. This means they are likely to forget what you tell them, so make sure that all directions and instructions are written down for them.

Speak slowly. Some elderly patients are hearing impaired and may not correctly hear what you say to them. Their response may seem irrational as a result, which may give you an impression that this person has poor cognitive abilities. Make sure to speak to the patient at close range, while looking at them. Speak slowly and in short sentences.

Keep it simple. Optometrists should be skilled in being able to carefully explain conditions while not confusing patients by being too technical. Be ready to provide a short and simple explanation of disorders. This takes some work to learn to explain a condition adequately, not make it overly alarming and to avoid a technical discussion that leads to patient boredom, says optometrist Neil Gailmard, M.B.A., of Munster, Ind. A good technique is to stop fairly early in a discussion and ask, Would you like to hear more about this?

Take time. When talking with seniors, speak clearly and more slowly, but not so much that it is exaggerated. Be willing to spend a little more time in the examination process to listen to stories and to digress off the topic. Seniors may be a little lonely and they view a visit to a doctor as an opportunity where someone will pay attention to them. Satisfying this need is a great way to build loyalty with this important patient group, Dr. Gailmard says.

Dr. Gannons average 1.5 hour exam with his low vision patients are anything but rushed, he says. Half the time is spent getting the history and listening and the other half is spent explaining.

Another communications pearl: Always remember to be patient when talking with seniors and treat them the way you would want your parent or grandparent treated, adds optometrist Rosemary Cunningham of Vineland, N.J. Also, if a caregiver is in the exam room, Dr. Cunningham always addresses the patientnot just the caregiver. Even while talking with the caregiver, you should always be looking at your patient and not the caregiver, added Dr. Varma. You may include them in the examination, but do not let them overtake the patients.

Many senior patients grew up when the rules of etiquette were very different from today. Dr. Gailmard suggests that doctors and staff address seniors as Mr., Mrs. or Miss, followed by their last name, since using the first name is often perceived as too casual, unless the patient specifically indicates otherwise. Other old-school etiquette points for doctors and staff: hold the door open for patients, and let them go into the room first.

Its great to shake hands when greeting seniors of either gender, but avoid too firm of a grip, Dr. Gailmard says. Many seniors have arthritis, and a firm handshake can cause them actual pain.


Make Your Office Senior Friendly

This is a necessity if you are treating seniors. Making your office senior friendly covers everything from seating, to lighting, to doorknobs. For the latter, make sure that you have door handles with levers that can be easily pushed up or down, as opposed to doorknobs, which become hard to open when you have arthritis, says Dr. Verma.

In the waiting area, avoid deep, cushy sofas. Instead, opt for sturdy chairs with arm rests that make it easier to get up and sit as needed.
Also in the waiting area, make certain that you have adequate lighting for reading and have some magazines that address seniors, such as Modern Maturity by AARP, as well as other large-print reading material.

At the Low Vision Institute of South Florida, Dr. Gannon has staff on hand to help patients fill out forms in the reception areas. All material is in large-print format, and he provides CDs to patients to take with them that provide further information about conditions. As far as physical
layout, Dr. Gannon keeps all thresholds of his practice clear, doorways are marked with a contrasting color, and lighting is set perfectly as to be comfortable and not glaring. Everything in the practice is as also in close proximity. Long walks to the bathroom are not good, Dr. Gannon says.

Ongoing staff training is also important in keeping a practice senior friendly. Start a discussion about the typical real-life situations that many seniors live with (e.g., ailments, loneliness, financial problems, memory loss, etc.) and how the staff can be sensitive and caring, Dr. Gailmard explains.

If you are an O.D. who works in a nursing home, use a trial frame instead of a phoropter, like optometrist Victoria Weiss, of Palmyra, Va. This way, you can be closer to the patient. If you are behind the phoropter, they cant see you, she says.


Other Best Practices

Dr. Verma is a frequent visitor of senior centers and other senior facilities. What he typically finds is that a lot of older adults take medications, but they do not know what they are for and how long they need to take them. Some have even been on glaucoma medication and since stopped taking their medication. The reason? They did not know that they were to continue taking this for the rest of their lives. Dr. Verma advises that when you examine the patients and want to prescribe medication, make sure to tell them the following three points:

For what condition you are prescribing this medication.

How long they need to take this medication.

When they need to come back to see you.

You may be telling patients these three points already, but with poor memory, they may forget. Put it all in writing, and give the reminder to them.

Of course, older patients tend to have multiple health problems, which may impact compliance and follow-up. The practitioner must take into account all these factors, while making final decisions about what to prescribe or what not to prescribe, says Dr. Verma.

Before a patient leaves the office, it is also important to enforce the need for better focused light for reading. Also, keep in mind that if regular prescription glasses do not help, low vision treatment should not be ignored. If you do not practice low vision, refer the patient to a practitioner who does.

Also, dont forget that many seniors may be on fixed incomes. I have found that a majority of patients dont seek more frequent optometric care, even though they may need it. Over the years, they have understood that every time they go for an eye examination, they end up spending $200 to $300 on a pair of glasses. This means they always associate the expense of glasses with every eye exam, Dr. Verma says. Reassure patients that just because they come for an eye examination, they dont necessarily need to buy a new pair of glasses.

I always tell my patients that you dont need to change glasses either because you came for an exam or I found a change in prescription. The only time you should change glasses is when that change makes you see better or you are interested in changing the style of your glasses. Patients who dont know that find it very reassuring, and they comply better, Dr. Verma says.

Adds Dr. Gailmard: Many seniors are on a fixed income and must budget their expenses. Dont prejudge them, but be sensitive to a clue that they need to be economical, and help them achieve that. Reusing a previous frame for new lenses is quite common, and seniors dont want to be made to feel badly about it.


Seniors are a vital part of almost any optometric practice. As this key population continues to grow, make sure that you are best prepared and ready to serve their unique needs.

Vol. No: 145:10Issue: 10/15/2008