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Communicating With the Geriatric Patient
Communicating With the Geriatric Patient By VIRGINIA
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~ Virginia f. Galizia, MS, is an assistant clinical professor, and Robert B. Sause, PhD, is an associate professor at St. John's University College of Pharmacy and Allied Health Professions, Grand Central and Utopia Parkways, Jamaica, NY 11439.
Arnerican Pharmacy Vol. NS22. No. 10, October 1982/547
J. GALIZIA and ROBERT B. SAUSE
Compliance with drug therapy is vitally important for elderly patients, especially when the drugs prescribed are necessary to permit the patients to take care of themselves and lead independent, normal lives. Often, however, the natural deterioration that accompanies aging increases the likelihood of noncompliance. Patients who can't read a label, can't distinguish between differently colored tablets, or have difficulty hearing the pharmacist's instructions are not going to receive proper drug therapy. It is important for pharmacists to recognize the physiologic as well as social changes that occur with aging and take steps to work around these deficits to ensure adequate drug compliance. Sensory losses tend to increase with advancing age, with hearing loss becoming evident after age 75. Hearing impairment, which is more common than visual impairment in the elderly, may be associated with disease, such as degeneration of the
inner ear which leads to the loss of the ability to perceive or discriminate sounds, especially high-frequency sound. Impaired hearing may also result from the aging process itself, ototoxicity from previous drug use, or environmental noise levels; as background noise increases, hearing loss accelerates dramatically. Elderly patients' sight may deteriorate due to opacification of the normally transparent lens, decline in retinal function, or weakening of the ciliary muscle which affects visual accommodation. Other visual problems typically encountered include glaucoma, loss of visual acuity and brightness discrimination, and reduced peripheral vision. As a result, elderly patients may require a brighter light for reading or doing handiwork, require that shades be drawn or reflective surfaces be covered to reduce glare, miss peripheral activity, overlook objects or be unable to differentiate them due to decreased color discrimination, have reduced night vi35
sion, or be unable to read magazines and newspapers because of deficits in fine visual detail. The senses of smell and taste do not change significantly with age. However, elderly patients may prefer sweet foods. Faltering oral hygiene, loss of teeth, and gum problems may reduce the choice of foods they can eat. And when they are missing teeth or have ill-fitting dentures or other oral afflictions, elderly patients may even be prevented from eating enough food to maintain their health. Some elderly also experience increased thresholds to pain and touch which make them less sensitive to both cutaneous and deep pain. This phenomenon can have deleterious effects on health because serious injuries may go unnoticed.
Overcoming the Deficits To prevent these sensory deficits from impeding drug therapy, pharmacists need · to be aware that deficits-particularly auditory and visual-exist and be able, through verbal and nonverbal techniques, to work with the patient to overcome them. Most visual changes can be alleviated by altering an eyeglass prescription or obtaining medical or surgical treatment. But serious visual impairment can impede communication by making the patient fearful because he or she can not see the medication or the label clearly. The patient may pay more attention to the visual impairment than to the message being delivered by the pharmacist. Therefore, directions for use of medications should be verbally explained to these patients when a medication is dispensed. Talking with elderly patients in a · well-lit nonglare environment also can help. It is important to help visually impaired patients differentiate between their medications . Due to the yellowing of the lens of the eye, which causes shorter wavelengths of light to be filtered, elderly patients often have difficulty distinguishing between blue, green and violet shades of color. They have less difficulty discriminating be-
36
tween reds, oranges and yellows. Thus, if given two medications, one green and one blue, patients may be unable to tell them apart. But differentiating between, say, reds and yellows or reds and blues is fairly easy. Pharmacists can ensure that the medications also can be differentiated by appearance, large printing on the label, auxiliary labeling (such as "for blood pressure" or "for cough"), or by dispensing medications in different size containers. The hearing impaired elderly, too, can run into problems, often being treated as if they were senile because mannerisms such as inattentiveness, strained facial expression, and poorly answered questions, are associated with senility. These patients have the best chance of understanding instructions if you speak to them distinctly and slowly, avoiding a monotone delivery. Background noise should be kept to a minimum. Other physiologic as well as social and psychological changes in elderly patients make modification of the pharmacist's communications methods important.
Changing Habits Since older people may need closer medical supervision and changes in their drugs and medication schedules, the pharmacist may need to remind the patient to see a physician frequently. Changes in daily patterns seen with aging may mandate modifications in medication regimens. Many elderly people rise early because of poor sleep patterns, nap during the day and go to bed early. They may not eat three meals a day. Dosage schedules that presume a normal daily pattern of eating and sleeping may be impractical for them, making individualization and flexibility of dosage schedules especially important. Elderly patients who live alone often have few opportunities for human contact. These patients appreciate and are more likely to listen to a pharmacist who is willing to spend time with them. They should be encouraged to call the pharmacist when they have questions or prob-
lems, or just to report on their progress. Physical contact, by touching a hand, arm or shoulder, can bring comfort and understanding to the pharmacist-patient interaction and can help maintain the attention of the elderly patient. However, the pharmacist's respect for elderly patients should be emphasized by addressing them formally by their last names unless told otherwise. Elderly patients' need for privacy during counseling should be respected as well since they may become more embarrassed about sharing personal information than younger patients do . They may need to be encouraged to talk about themselves through the use of open-ended questions. Also local or regional slang should be avoided when speaking to aged patients. With large numbers of retirees relocating, particularly to Sun Belt areas, some period of time may go by before they adapt to geographic patterns of speech. More than for any other group of patients, pharmacists should pay particular attention to the details of communicating with the elderly. Their need for proper therapy and drug use is more evident than for any other age group except infants. And their growing numbers make it increasingly important to understand and respond to their needs. An observant, attentive pharmacist can make a big difference in their lives. D
Heart disease and stroke will cause half of all deaths this year.
A American Hearf y Association WE'RE FIGHTING FOR YOUR LIFE American Pharmacy Vol. NS22, No. 10, October
19821~
©®IQ1ffi1~1ID®ffi@
ITrn @L@@IT
~ Virginia f. Galizia, MS, is an assistant clinical professor, and Robert B. Sause, PhD, is an associate professor at St. John's University College of Pharmacy and Allied Health Professions, Grand Central and Utopia Parkways, Jamaica, NY 11439.
Arnerican Pharmacy Vol. NS22. No. 10, October 1982/547
J. GALIZIA and ROBERT B. SAUSE
Compliance with drug therapy is vitally important for elderly patients, especially when the drugs prescribed are necessary to permit the patients to take care of themselves and lead independent, normal lives. Often, however, the natural deterioration that accompanies aging increases the likelihood of noncompliance. Patients who can't read a label, can't distinguish between differently colored tablets, or have difficulty hearing the pharmacist's instructions are not going to receive proper drug therapy. It is important for pharmacists to recognize the physiologic as well as social changes that occur with aging and take steps to work around these deficits to ensure adequate drug compliance. Sensory losses tend to increase with advancing age, with hearing loss becoming evident after age 75. Hearing impairment, which is more common than visual impairment in the elderly, may be associated with disease, such as degeneration of the
inner ear which leads to the loss of the ability to perceive or discriminate sounds, especially high-frequency sound. Impaired hearing may also result from the aging process itself, ototoxicity from previous drug use, or environmental noise levels; as background noise increases, hearing loss accelerates dramatically. Elderly patients' sight may deteriorate due to opacification of the normally transparent lens, decline in retinal function, or weakening of the ciliary muscle which affects visual accommodation. Other visual problems typically encountered include glaucoma, loss of visual acuity and brightness discrimination, and reduced peripheral vision. As a result, elderly patients may require a brighter light for reading or doing handiwork, require that shades be drawn or reflective surfaces be covered to reduce glare, miss peripheral activity, overlook objects or be unable to differentiate them due to decreased color discrimination, have reduced night vi35
sion, or be unable to read magazines and newspapers because of deficits in fine visual detail. The senses of smell and taste do not change significantly with age. However, elderly patients may prefer sweet foods. Faltering oral hygiene, loss of teeth, and gum problems may reduce the choice of foods they can eat. And when they are missing teeth or have ill-fitting dentures or other oral afflictions, elderly patients may even be prevented from eating enough food to maintain their health. Some elderly also experience increased thresholds to pain and touch which make them less sensitive to both cutaneous and deep pain. This phenomenon can have deleterious effects on health because serious injuries may go unnoticed.
Overcoming the Deficits To prevent these sensory deficits from impeding drug therapy, pharmacists need · to be aware that deficits-particularly auditory and visual-exist and be able, through verbal and nonverbal techniques, to work with the patient to overcome them. Most visual changes can be alleviated by altering an eyeglass prescription or obtaining medical or surgical treatment. But serious visual impairment can impede communication by making the patient fearful because he or she can not see the medication or the label clearly. The patient may pay more attention to the visual impairment than to the message being delivered by the pharmacist. Therefore, directions for use of medications should be verbally explained to these patients when a medication is dispensed. Talking with elderly patients in a · well-lit nonglare environment also can help. It is important to help visually impaired patients differentiate between their medications . Due to the yellowing of the lens of the eye, which causes shorter wavelengths of light to be filtered, elderly patients often have difficulty distinguishing between blue, green and violet shades of color. They have less difficulty discriminating be-
36
tween reds, oranges and yellows. Thus, if given two medications, one green and one blue, patients may be unable to tell them apart. But differentiating between, say, reds and yellows or reds and blues is fairly easy. Pharmacists can ensure that the medications also can be differentiated by appearance, large printing on the label, auxiliary labeling (such as "for blood pressure" or "for cough"), or by dispensing medications in different size containers. The hearing impaired elderly, too, can run into problems, often being treated as if they were senile because mannerisms such as inattentiveness, strained facial expression, and poorly answered questions, are associated with senility. These patients have the best chance of understanding instructions if you speak to them distinctly and slowly, avoiding a monotone delivery. Background noise should be kept to a minimum. Other physiologic as well as social and psychological changes in elderly patients make modification of the pharmacist's communications methods important.
Changing Habits Since older people may need closer medical supervision and changes in their drugs and medication schedules, the pharmacist may need to remind the patient to see a physician frequently. Changes in daily patterns seen with aging may mandate modifications in medication regimens. Many elderly people rise early because of poor sleep patterns, nap during the day and go to bed early. They may not eat three meals a day. Dosage schedules that presume a normal daily pattern of eating and sleeping may be impractical for them, making individualization and flexibility of dosage schedules especially important. Elderly patients who live alone often have few opportunities for human contact. These patients appreciate and are more likely to listen to a pharmacist who is willing to spend time with them. They should be encouraged to call the pharmacist when they have questions or prob-
lems, or just to report on their progress. Physical contact, by touching a hand, arm or shoulder, can bring comfort and understanding to the pharmacist-patient interaction and can help maintain the attention of the elderly patient. However, the pharmacist's respect for elderly patients should be emphasized by addressing them formally by their last names unless told otherwise. Elderly patients' need for privacy during counseling should be respected as well since they may become more embarrassed about sharing personal information than younger patients do . They may need to be encouraged to talk about themselves through the use of open-ended questions. Also local or regional slang should be avoided when speaking to aged patients. With large numbers of retirees relocating, particularly to Sun Belt areas, some period of time may go by before they adapt to geographic patterns of speech. More than for any other group of patients, pharmacists should pay particular attention to the details of communicating with the elderly. Their need for proper therapy and drug use is more evident than for any other age group except infants. And their growing numbers make it increasingly important to understand and respond to their needs. An observant, attentive pharmacist can make a big difference in their lives. D
Heart disease and stroke will cause half of all deaths this year.
A American Hearf y Association WE'RE FIGHTING FOR YOUR LIFE American Pharmacy Vol. NS22, No. 10, October
19821~