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

Transcription

1 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

2 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

3 Communication Sometimes called the geriatrician s procedure Physicians of all specialties must communicate clearly

4 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

5 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):

6 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

7 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

8 Common visual deficits in older adults Cataracts Blurry vision Macular degeneration Generally involves central vision loss Glaucoma Generally involves peripheral vision loss

9 Cataract

10 Macular degeneration

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12 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

13 Serif vs. san serif font

14 Electronic magnifiers

15 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.

16 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.

17 Conductive vs sensorineural hearing loss

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19 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):

20 George P, Farrell TW, Griswold MF. Hearing loss: help for the young and old. J Fam Pract 2012; 61(5):

21 Assistive devices Pocket amplifiers More affordable than hearing aids Hearing aids Analog vs. digital Cochlear implants Severe to profound hearing loss

22 Health literacy e=related

23 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

24 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.

25 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.

26 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. n/heartdisease/treatment/797.html

27 What is the grade level of the preceding passage? (A) 7 th grade (B) 9 th grade (C) 12 th grade (D) Some college (E) Graduate school

28 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.

29 What is the grade level of the modified passage? (A) 7 th grade (B) 9 th grade (C) 12 th grade (D) Some college (E) Graduate school

30 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 Syllables per word Syllables per sentence Letters per syllable Letters per word Letters per sentence

31 Health literacy level Below basic Example of task related to literacy level 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 Proficient Identify 3 substances that may interact with an OTC drug using an OTC drug label Evaluate information to determine which legal document is applicable to a given health care situation

32 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.

33 Average health literacy score and percentage of adults at each health literacy level by age (NAAL, 2003)

34 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)

35 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):

36 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): Volandes AE et al. J Palliat Med 2008; 11(5): Volandes AE et al. Med Decis Making 2010; 30(1):

37 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 > 12 th grade level *Sudore L and Schillinger D. J Clin Outcomes Manag January 1; 16(1): Farrell TW, Chandran R, Gramling R. Fam Med 2008; 40(4): Castillo LS et al. Ann Intern Med 2011; 154(2):

38 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

39 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

40 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

41 Patient-centered communication Verbal communication (continued) Avoid multiple-choice questions Avoid jargon Limit key points to <3

42 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)

43 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.

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

45 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

46 Medication compliance decreases as regimen complexity increases

47 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.

48 Questions/Comments Thank you!