DEPARTMENT OF INTERNAL MEDICINE DIVISION OF GERIATRICS

Communicating with Older Adults: A Patient-Centered Approach to Sensory Deficits and

Limited Health Literacy

Timothy W. Farrell, MD, AGSF

Associate Professor of Medicine

VA SLC Geriatric Research, Education, and Clinical Center

Reynolds Next Steps Fellows’ Retreat

August 28, 2015

Objectives

• Identify and address sensory deficits in older adults

• Recognize limited health literacy as a communication

barrier

• Incorporate patient-centered communication, including

the teach-back method, within your practice

Communication

• Sometimes called “the geriatrician’s procedure”

• Physicians of all specialties must communicate clearly

Relevance to fellowship training

• Even the best treatment plans will not work if not

understood or misinterpreted by patients/caregivers

• Time invested in ensuring understanding will ultimately

save time in the long run

Adverse outcomes associated

with poor communication

• Adverse medication events

• Decreased patient satisfaction

• Increased malpractice risk

– Lower malpractice risk among physicians who communicate

well*

Lazare A. Apology in medical practice: an emerging clinical skill. JAMA 2006;

296(11): 1401-1404.

Conditions which may impede

communication with older adults

• Delirium:

– Acute change in mental status and fluctuating course

– Inattention, disorganized thinking

– Altered level of consciousness

• Depression

– Inattention

• Dementia

– Cognitive impairment

– Can be accompanied by psychosis

Physician actions that may impede

communication with older adults

• Lack of engagement with patient

– Talking past patient to speak only with family/caregivers

– Even if older adults lack medical decision making capacity, they

should be included in discussions to the extent possible

• Failing to recognize and address sensory deficits

Common visual deficits in older adults

• Cataracts – Blurry vision

• Macular degeneration – Generally involves central vision loss

• Glaucoma – Generally involves peripheral vision loss

Cataract

http://www.vincett.com/cataract-care.html

Macular degeneration

http://www.stlukeseye.com/conditions/MacularDegeneration.html

http://www.higginseyesurgeon.com/glaucoma.html

Addressing “low vision”

• Low vision clinic

• “Eccentric viewing” in macular degeneration

• Appropriate lighting

• Bold print and larger font

– Important for after-visit summary in Epic

• Electronic magnifiers

Serif vs. san serif font

Electronic magnifiers

https://www.enhancedvision.com/low-vision-

product-line/merlin-lcd-desktop-video-

magnifier.html

Hearing loss

• Prevalence:*

– Age 65-75: 10%

– Age >75: 25%

• ↓quality of life, ↑risk of functional impairment

• Associated with impaired cognition

– Caveat: Hearing loss may contribute to misdiagnosis of

cognitive impairment

Geriatrics Review Syllabus (GRS), 2008.

Types of hearing loss

• Conductive (usually cerumen impaction)

– 5 to 40 dB hearing loss

• Sensorineural (usually presbycusis)

– Associated with noise exposure

– Important to suspect among older veterans – they may qualify

for free hearing aids

Roland S et al. Clinical practice guideline: cerumen impaction. Otolaryngology – Head and Neck Surgery 2008; 139: S1-S21.

Conductive vs sensorineural hearing

loss

http://michaeldmann.net/mann8.html

http://is-learn.esc11.net/stiggs/listening/Listening_print.html

Screening for hearing loss

• Simply asking about hearing loss is as effective as the

whisper test or 10-item HHIE-S*

• Practice recommendations

– Evaluate older adults for hearing loss during their initial visit and

annually thereafter (Level A evidence)

– Speak clearly, maintain eye contact, and use nonverbal

gestures (Level C evidence)

George P, Farrell TW, Griswold MF. Hearing loss: help for the young and old. J

Fam Pract 2012: 61(5): 268-77.

George P, Farrell TW, Griswold MF. Hearing loss: help for the

young and old. J Fam Pract 2012; 61(5): 268-77.

Assistive devices

• Pocket amplifiers

– More affordable than hearing aids

• Hearing aids

– Analog vs. digital

• Cochlear implants

– Severe to profound hearing loss

Health literacy

• http://www.youtube.com/watch?v=BgTuD7l7LG8&featur

e=related

Definition of health literacy

“ The ability of US adults to use printed and health-related

information to function in society, to achieve one’s

goals, and to develop one’s knowledge and potential.”

White S. Assessing the nation’ health literacy: Key concepts and findings of the National Assessment of Adult

Literacy (NAAL): p. 11

Components of health literacy

• “Traditional” literacy skills - word recognition,

comprehension

• Numeracy

– Low numeracy has not yet shown to be associated with adverse

health outcomes*

• Familiarity with health care-related materials

– Health insurance and patient information forms

– Drug labels

– Acronyms (e.g. “COPD”)

*Berkman ND et al. Low health literacy and health outcomes: An updated systematic review.

Components of health literacy

• Self-care skills

– Inhaler use

– Insulin administration

• Information-seeking skills

– Internet use

– Navigating health care systems

Paasche-Orlow M. JAMA 2011.

Excerpt from patient handout

How is high blood pressure treated?

• High blood pressure medicines (also called

antihypertensive medicines) can help lower your blood

pressure. The goal of treatment is to reduce your blood

pressure to normal levels with medicine that is easy to

take and has few, if any, side effects. Your doctor may

also talk to you about the benefits of lifestyle changes,

such as eating a healthy diet, being physically active

and losing weight if you're overweight.

http://familydoctor.org/online/famdocen/home/commo

n/heartdisease/treatment/797.html

What is the grade level of the

preceding passage?

• (A) 7th grade

• (B) 9th grade

• (C) 12th grade

• (D) Some college

• (E) Graduate school

My attempt to lower the grade level

How is high blood pressure treated?

• High blood pressure medicines lower blood pressure.

The pills are easy to take. They have few side effects.

Your doctor will ask you about exercise, food and

weight. These changes can help you live longer.

What is the grade level of the modified

passage?

• (A) 7th grade

• (B) 9th grade

• (C) 12th grade

• (D) Some college

• (E) Graduate school

How did I do?

FamilyDoctor.org Tim

Reading level Some college Some high school

Equivalent text New York Times Reader’s Digest

Words per sentence 26.67 9.2

Syllables per word 1.62 1.5

Syllables per sentence 43.3 13.8

Letters per syllable 3.0 3.12

Letters per word 4.88 4.67

Letters per sentence 130.0 43.0

Health literacy

level

Example of task related to literacy level

Below basic Circle the date of an appointment on a calendar

Basic Use a pamphlet to explain why persons with no symptoms

of a disease should be tested for it

Intermediate Identify 3 substances that may interact with an OTC drug

using an OTC drug label

Proficient Evaluate information to determine which legal document is

applicable to a given health care situation

National Assessment of Adult

Literacy (NAAL) • 2003 sample of 19,000 US adults

– 22% “Basic”

– 14% “Below Basic

– 2% “Nonliterate in English” (unable to complete the

survey due to language barrier)*

*These “nonliterate in English” adults may be literate in their primary language.

Average health literacy score and percentage of

adults at each health literacy level by age

(NAAL, 2003)

Limited health literacy (LHL)

• LHL = basic + below basic + nonliterate

• Functional definition: “A limited capacity to obtain,

process, and understand basic health information and

services needed to make appropriate health decisions.”

IOM: Health literacy: a prescription to end confusion (2004)

Why should we care about LHL?

• Adverse outcomes

– ↑ mortality (including older adults)

– ↑ hospitalization rates

– ↑ ED utilization

– ↑ all-cause mortality among outpatients with heart failure*

– ↓ influenza vaccination and mammography rates

*Peterson N et al. Health literacy and outcomes among patients with heart failure.

JAMA 2011; 305(16): 1695-1701.

Why should we care about LHL?

• Racial disparities*

– Preventive care

– Prostate cancer

– Adherence to HIV medications

– Glycemic control

• End-of-life preferences

– Health literacy level is predictive of EOL preference†

– LHL patients are more uncertain about EOL preferences than

patients with adequate HL§

*Paasche-Orlow M. JAMA 2011; 306 (10): 1122-1120.

†Volandes AE et al. J Palliat Med 2008; 11(5): 754-762.

§Volandes AE et al. Med Decis Making 2010; 30(1): 29-34.

Why should we care about LHL?

• Economic burden

– $50-$73 billion per year*

• Patients’ emotional experience

– Shame/humiliation†

– Power differential

• Capacity and consent

• Increased burden on health care professionals to explain

complex ethical principles in an understandable way

• Advance directive laws in all states written at > 12th grade level

*Sudore L and Schillinger D. J Clin Outcomes Manag. 2009 January 1; 16(1): 20-29.

†Farrell TW, Chandran R, Gramling R. Fam Med 2008; 40(4): 235-6.

§Castillo LS et al. Ann Intern Med 2011; 154(2): 121-8.

Drawbacks to screening for LHL

• No evidence that screening improves outcomes

• Why screen if most patients will understand

materials designed for the LHL population?

– Caveat: Risk of “dumbing down” for those with

intermediate to proficient health literacy

Patient-centered communication

• Avoid assumptions:

– Ask “What do you already know/believe about X?”

• Assess patient’s perceived barriers to carrying out a

recommendation

– Allow him or her to participate in formulating the plan of care

Patient-centered communication

• Not all patients prefer verbal communication

– Provide a written after-visit summary

• When communicating verbally:

– Speak slowly and clearly

• Special considerations for hearing-impaired patients

– Face the patient to allow for lip reading

– Use a stethoscope or Pocket Talker for amplification

Patient-centered communication

• Verbal communication (continued)

– Avoid multiple-choice questions

– Avoid jargon

– Limit key points to <3

Patient-centered communication

• Confirm understanding

– Ask “What questions do you have?”

• Avoid asking “Do you have any questions?” or “Do you

understand?”

– Teach-back method

• State “I’ve just said a lot of things. To make sure I did a good

job and explained things clearly, can you describe to me…?”

• Ask patient to use his or her own words (not yours)

Patient-centered communication

• Communicating risks:

– Provide absolute risk, not relative risk

– State risk as a frequency, not as a percentage

• E.g. “5 out of 100” instead of 5%

– Present risks objectively to avoid “framing” effect

• Avoid stating “5 in 100 are expected to get the outcome.”

• Instead, state “5 in 100 are expected to get the outcome,

meaning that 95 in 100 will not get the outcome.”

Fraenkel L, Street RL, Fried T. BMC Medical Informatics and Decision Making, 2011.

Patient-centered communication

• Simplify medication regimens

– Dose at the same time of day if possible

• Clinical pharmacists can be extremely helpful

– Evidence supports ↑ adherence and ↓ADEs

• Medication reconciliation (including “Brown Bag” review)

• Devices

– (Automated) pill boxes

– Calendars with pills taped to each date

Medication compliance decreases as

regimen complexity increases

http://www.medicine.ox.ac.uk/bandolier/band127/b127-5.html

Summary

• Sensory deficits in older adults include vision and

hearing loss.

• Limited health literacy (LHL) contributes to adverse

health outcomes.

• Patient-centered communication can help identify and

address sensory deficits and LHL.

Questions/Comments

• Thank you!