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As America ages, it's critical that you customize your care to the growing population of older patients.

The numbers confirm what you see in your practice every day: More and more patients are elderly. According to the Census Bureau, more than 33 million Americans were 65 or older in 1995, a number that is expected to explode to 69 million by the year 2030. ¹

No matter what field you work in, the effects of aging, underlying medical conditions, and the myriad of medications that older patients may be taking require your special attention. Sadly, too, you'll need to be attuned to something that is not unique to the elderly, but is all too often overlooked: abuse.

Careful assessment, as well as modifications to your normal routine, will help you properly care for this special population, and thus reduce the chances of a lawsuit down the road. The following review should help guide your care.

The aging process
Caring for the older patient requires that you be sensitive to the normal changes involved in the aging process. For one thing, all of the senses become less acute. In practical terms, that means you may need to employ certain techniques to ensure that the patient can hear you, and that she can read the printed material you've given her.

If the patient is having difficulty hearing you, for instance, you'll want to reduce background noises--if possible--to prevent distractions. It's also a good idea to face the patient directly when speaking to her. Avoid shouting or raising the pitch of your voice.

If the patient is having a problem reading some printed materials you've given her, provide her with a magnifying glass and urge her to have a thorough eye exam to rule out cataracts or glaucoma. As a general rule, you should provide your older patients with handouts that are printed in a larger typeface so that they're easier to read.

Besides being sensitive to changes in a patient's hearing and vision, you also need to keep in mind that physiologic reactions to temperature extremes--shivering, peripheral vasoconstriction or dilation, or muscle contraction--may be inadequate in an elderly patient. As a result, she may not be able to tell you when something is too hot or cold. In practical terms, that means you may need to monitor the patient's skin more frequently than you would with a younger patient if, say, you were using a hot pack. In this same example, you'd also want to make sure there were adequate towels between the hot pack and her skin to ensure that she doesn't develop a blister.

Keep in mind that range of motion, balance, and flexibility are also affected by the aging process. For one thing, soft tissues shorten as we age. As a result, an elderly patient could hurt herself with strenuous stretching.

In addition, seniors--even men--are likely to have brittle bones, so everyone from EMT’s to physical therapists must be careful when transporting a patient. PTs must be particularly careful with the exercises they recommend. Classic abdominal crunches may not be a good idea for an elderly patient because of the increased risk of damage to the thoracic spine.

Neurological changes may also come into play with these patients. They may have slowed reaction times or experience mild memory loss and confusion. If any of these factors are at work, you'll need to alter the way in which you conduct an assessment and take a history. Speak slowly and distinctly with your mouth visible to the patient. Keep questions simple and allow sufficient time for her to respond. If the question must be repeated, use the same words you used the first time; otherwise the patient will have two questions to process. When it comes to patient teaching, you'll want to keep sessions short and, when possible, have family members present.

Multiple medical conditions
Seniors are frequently affected by insomnia, diabetes, chronic pain, high blood pressure, glaucoma, arthritis, Alzheimer's disease, and cancer. Many of these conditions, including hypertension and cancer, can cause--or exacerbate--psychiatric problems such as depression. That's why you should watch for complaints of constipation, headaches, and difficulty breathing, for which there is no diagnosis. Often patients will describe these physical symptoms, rather than admit to being depressed.²

In addition, elderly patients are at particularly high risk for the "domino effect" of healthcare problems. A fractured hip, for instance, can quickly lead to problems with circulation, skin breakdown, and pulmonary function. As a result, you'll need to promptly alert the physician to signs of complications. In the case of a patient who has fractured her hip, that would include things like swelling or discoloration in the affected leg.

Medication issues
There are a number of medication issues that you'll need to be sensitive to when caring for an elderly patient. The first involves proper dosing. Bodily changes slow down the absorption, distribution, metabolism, and excretion of medicines in older people, leaving them more vulnerable to adverse effects, especially if they're just starting on the medication. That's why it's especially important to be alert to a patient who begins exhibiting signs of confusion, delirium, or psychomotor impairment, or who has an abnormally low blood pressure reading. Her physician will need to be notified so that he can review the patient's dosage.

Compliance with drug regimens can also be a problem, particularly among those who can't always afford to fill their prescriptions, and thus skip pills "when they don't need them." A healthcare provider called to treat a psychotic elderly patient, for example, needs to consider the possibility that the patient hasn't been taking her medication.

Compliance may also suffer if patients aren't adequately educated about generic forms of their medications. If, for instance, a pharmacist doesn't alert the patient to the fact that the white furosemide tablet that she took last month is now blue (because it's from a different manufacturer), the patient may become confused when looking for her "white pill." Or, she may confuse this new blue pill with another she takes.

Polypharmacy is also a concern. A patient may be seeing more than one doctor, and have her prescriptions filled at more than one pharmacy, opening up the possibility of drug interactions. Another possibility: The patient doesn't realize that the digoxin she got from one pharmacy is the same as the Lanoxin she got from another. If you suspect that the patient's health may be compromised by a polypharmacy issue, ask the patient to name all of the drugs (OTC and prescription) she is taking and ask her to list all of the pharmacies she uses.

Physical abuse
Although physical abuse is not unique to any one patient population, it is all too often overlooked in the elderly because clinicians don't even consider the possibility. Be sure to watch for pressure ulcers that are slow to heal, as well as bruises that can't be attributed to the effects of aging, poor skin integrity, or medication. (For more on what to do if you suspect your elderly patient is being abused, see our Web Flash at www.hpso.com.)

Clearly, caring for elderly patients requires careful consideration of their unique needs. However, by recognizing these needs and attending to them, you will ensure that they get the care they need and deserve. You'll also go a long way toward reducing your liability exposure.

REFERENCES

1. U.S. Bureau of the Census. (1996). Population projections of the United States by age, sex, race, and hispanic origin: 1995-2050, current population reports, P25-1130. Washington, DC: U.S. Government Printing Office.

2. Neeb, K. (1997). Fundamentals of mental health nursing. Philadelphia: F. A. Davis.