Out of Committee: Geriatric Otolaryngology | Considerations and Accommodations for the Geriatric Patient in Otolaryngologic Clinic
As of 2020, one in six people in the United States are over age 65; by 2030, it will be one in five.
Ran Annie Wang, MD, and Brian J. McKinnon, MD, MBA, MPH, members of the Geriatric Otolaryngology Committee
As of 2020, one in six people in the United States are over age 651; by 2030, it will be one in five2. Geriatric care comprises 35% of hospitalizations and 27% of outpatient visits3, with complexity of care increasing. Considering this, it is important for all physicians to evaluate, treat, and manage geriatric concerns. This review article presents observations and recommendations for the geriatric/disabled otolaryngology patient. This is not a comprehensive review but rather a starting point to discuss accommodations and effective communication for this growing population.
Sleep concerns affect up to 70% of elders4,5, and all elderly should be screened for sleep disordered breathing4. Comorbid conditions, such as reflux, can exacerbate sleep symptoms, and conservative treatment can improve subjective sleep quality and daytime function5,6. Workup for geriatric sleep concerns should include a medication review with the Beers criteria in mind: Sleep altering medications include tricyclic antidepressants, dopamine antagonists, diuretics, beta blockers, bronchodilators, and sympathomimetics6,7. There is a growing role in otolaryngologic sleep procedures with drug-induced sleep endoscopy (DISE) and hypoglossal nerve stimulator implantation. As these procedures become more widely used, studies specific to elderly patients can be conducted.
Incidence of dizziness increases with age and is often multifactorial8. Vestibular dizziness account for up to 14% of all cases8. With vestibular testing, oVEMP and cVEMP tuning shifts to higher frequencies with older age, and cVEMP response decreases9. Bilateral absent VEMPs become increasingly common with age (50% of patients over 40 do not generate oVEMP), which may lead to dizziness complaints10. Benign paroxysmal positional vertigo (BPPV) incidence is twice as high in osteoporotic patients than in non-osteoporotic matched patients11. Cervical spondylosis can increase risk of vertigo patients aged 40-64, but not those 65 and above12.
Anosmia/hyposmia affects 14%-22% of patients over 60 and significantly impacts safety and well-being13. Sudden or distinct anosmia may be an early sign of neurodegenerative disease and warrants neurological workup13,14. “Fluctuating” anosmia can be a sign of sinonasal disease13. Treatments have continued to develop, with increased interest from COVID-1915. Post-infectious anosmia shows spontaneous recovery in two-thirds of patients by three years13. Post-traumatic anosmia shows limited recovery15. Smell retraining therapy has consistently shown good results15. Medications to consider include topical theophylline, steroids, sodium citrate, vitamin A, oral steroids, pentoxifylline, caroverine, and gingko balboa13,15,16. For neurodegenerative anosmia, in vivo murine studies with topical fibroblast growth factor improved neural regeneration and smell restoration17, but there have been no human trials.
Telemedicine is a convenient and efficient means to address geriatric patient needs and decrease stress of scheduling and transportation. In assisted living facilities, 40% of complaints and 27% of emergency department visits could be appropriately assessed via telemedicine18-21. Telemedicine has been pioneered for voice therapy and shows similar efficacy to in-person sessions19. However, one problem for geriatric patients is difficulty with videoconferencing technology: 38% of elderly struggled with telemedicine or telephone calls, and 20% could not complete the telemedicine visit due to difficulty with hearing, seeing, mentation, or communicating22. This is alleviated by a companion who is comfortable with the technology being present for the appointment22. For those without companions, we can copy the popularized school nurse model of telemedicine— a trained healthcare professional familiar with current technology can perform basic history, a physical, and troubleshoot as needed21. An on-site nurse or medical assistant can perform the same roles from a community center room or mobile clinic. For patients needing face-to-face assessment, the National Aging and Disability Transportation Center has resources for patients to arrange transportation if they cannot drive themselves.
Lessons from the Mask Mandate
Hearing loss affects 14%-15% of Americans23, and COVID-19 mask mandates made clinic visits more difficult for many of our patients. For clinicians, a portable FM system amplifier set can help greatly. Patients with hearing aids can look into telecoils or other neck-loops and Bluetooth-enabled hearing aid amplification23. For cochlear implant patients, ClearVoice sound processors can be programmed to filter out background noise24. Patients with dysphonia or progressive voice fatigue can be counseled on using portable amplifiers or tablets with text-to-speech function or writing capabilities.
Examination Room Layout
The clinic room layout has significant importance for people who use mobility assistance devices. As recently as 2016, up to 20% of wheelchair users reported difficulty with non-accessible barriers in clinic25. The American Disability Act of 1990 outlines the following requirements for a clinical exam room to maximize accessibility26:
- The entry door must be at least 32 inches wide and open at least 90 degrees.
- There must be 36 inches of space between the examination table, chair, and adjacent furniture.
- There must be open floor space of at least 30 inches by 48 inches inside the room.
- There must be enough clear floor space to allow a wheelchair user to make a 180 degree turn within the room.
- The room needs an examination table or chair that lowers to 17-19 inches above the ground.
Studies on communication with deaf patients recommend the following to maximize understanding23,27:
- If an interpreter is present, they should be next to or slightly behind the provider.
- Do not stand between the patient and a bright light or window.
- Confirm with the patient their preferred method of communication first (verbal, writing, lip reading, etc.).
- Speak in simple, short phrases.
If a computer is in the clinic room, it should be placed so that the clinician can face the patient and type, but the computer (or laptop) is not between them. Another possibility is installing a floating desk on a wall that repositions as needed.
For those using typed instructions, multiple typography studies show font choice can influence legibility and ease of reading28-30. Serif fonts increase legibility for low-vision patients28,29, but sans-serif fonts read faster30. Verdana is the most easily readable font for adults30. Fonts should be at least 10 points in size29,30. Avoid excessive bold and highlighting as it decreases legibility28. There are unique fonts being developed for adults with eye diseases31, and typed electronic documents may be easily converted for these patients.
Elder Abuse: Nuances in Otolaryngology
Elder abuse affects at least 10% of adults over 6532, and all practitioners should be vigilant in screening. In otolaryngologic clinics, suspicious behavior may be harder to distinguish. Caregivers of hard of hearing/deaf/dysphonic patients may speak over the patient automatically or express frustration frequently due to their familiarity with the patient. Some elderly may also be suffering from delusions of persecution, which complicates screening33. Abusers are more often “friends” of the patient, have issues with alcoholism and/or psychiatric illness, have financial/social difficulty, and steadfastly refuse outside help33. Risk factors for abuse include recent female widowhood, functional dependence, and history of urinary incontinence33. The abused may seem unduly agitated or appear disheveled in clinic. While engaging in small talk, the elder or caretaker may disclose that the elder is suddenly deciding to change their will or sell their home33.
When elder abuse is suspected, keep in mind the Pillemer and Modified Conflict Tactics scale for proposed criteria for elder abuse34. Clinical questionnaires for documenting elder abuse include Indicators of Abuse, Elder Abuse and Neglect Assessment, and Elder Abuse Screening Test35. Cases should be reported to Adult Protective Services or its equivalent. In the U.S., the National Center on Elder Abuse has listings for reporting elder abuse36. The Eldercare Locator through the Department of Health and Human Services can also assist in finding appropriate resources37.
1. 2020 Census. U.S. Census Bureau. Published Dec 2020.
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16. Goldstein MF et al. “Intra-Nasal Theophylline for the Treatment of Chronic Anosmia and Hyposmia.” J of All and Clin Immunol. 139(2)supplement: AB252. Feb 2017.
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18. Batsis et al. “Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review.” J of the Am Geri Soc: 67 (8): 1737-1749. May 2019.
19. Lin et al. “Voice Therapy for Benign Voice Disorders in the Elderly: A Randomized Controlled Trial Comparing Telepractice and Conventional Face-to-Face Therapy.” J of Speech, Lang, and Hearing Res. 63(7): 2132-2140. Jul 2020.
20. Merrell RC. “Geriatric Telemedicine: Background and Evidence for Telemedicine as a Way to Address the Challenges of Geriatrics.” Health Info Res. 21(4): 223-229. 2015 Oct.
21. Shah et al. “Potential of telemedicine to provide acute medical care for adults in senior living communities.” Acad Em Med: 20(2): 162-168. 13 Feb 2013.
22. Lam et al. “Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic.” JAMA Int Med. 180(10):1389-1391. 3 Aug 2020.
23. Trotter et al. “Communication strategies and accommodations utilized by health care providers with hearing loss: a pilot study.” Am J of Audio. 23(1): 7-19. Mar 2014.
24. Advanced Bionics. “Clear Voice (™)” https://advancedbionics.com/us/en/home/solutions/sound-processing/clearvoice.html. Accessed 4 Apr 2021.
25. Stillman et al. “Healthcare utilization and associated barriers experienced by wheelchair users: A pilot study.” Disab and Health J 10(4): 2017. 502-508.
26. Department of Justice, Office for Civil Rights, Disability Right Section. “Americans with Disabilities Act: Access to Medical Care for Individuals with Mobility Disabilities.” First published 22 Jul 2010. Last updated Feb 28 2020. https://www.ada.gov/medcare_mobility_ta/medcare_ta.htm
27. Harris MJ et al. “Assessing deaf patients in the neurology clinic.” Prac Neurol. 20(2): 132-138. 2020.
28. Uysa et al. “Writing and reading training effects on font type and size preferences by students with low vision.” Perceptual and Motor Skills. 2012 Jun; 114(3): 837-46.
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30. Sheedy et al. “Text legibility and the Letter Superiority Effect.” The J of the Hum Fac and Ergonom Society. 47(4): 797-815. Dec 2005.
31. Xiong et al. “Fonts designed for macular degeneration: impact on reading.” Invest ophthal & vis sci. Aug 2018: 59(10), 4182-4189.
32. Lachs, M., & Pillemer, K. “Elder abuse.” New Eng J of Med, 373, 1947–56. 2015.
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34. Cooper C and Livingstone G. “Elder Abuse: A UK perspective.” Pathy's Principles and Practice of Geriatric Medicine. Eds. Sinclair et al. John Wiley & Sons Incorporated. 2012.
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36. National Center of Elder Abuse. State Resources. https://ncea.acl.gov/Resources/State.aspx. Accessed 3/25/21.
37. The Eldercare Locator. Department of Health and Human Services. https://eldercare.acl.gov/Public/Index.aspx. Accessed 3/25/21.