The ‘old’ have never been so young, so healthy, wealthy and committed to making the most of life. So how do you, as an eye health professional, broach the delicate subject of their ageing eyes? In the June edition of mivision, optometrist Dr. Jim Kokkinakis wrote about the clinical management of an ageing population. Now it’s time to turn our attention to how you can help navigate the emotional journey that age takes patients on once they’ve hit their fifth decade.
When I first broached the subject of ‘baby boomers and their ageing eyes’ with Tasmanian optometrist Sue Sluce, she told me, quite abruptly, that I’d better reframe my question… or end the interview.
A baby boomer herself, Ms. Sluce who works with Optomeyes said, “the difficulty for baby boomers and those coming after us, is we don’t consider ourselves as ageing. We spend so much time and energy trying to keep fit and healthy that when someone says there’s something wrong with your eyes it can really be confronting”.
Melbourne-based optical dispenser Murray O’Brien says more than ever, his 50 plus customers are investing in a younger look. “Unlike those of my grandparents generation who hit 50+ and started to dress and behave as if they were old, people now want to dress young, and they want to look good,” he said.
My advice to young ECPs is to be very respectful, very humble and to listen to the customer because they have experience
“In terms of dispensing, what I find remarkable is how daring women in their 60s, 70s and 80s are prepared to be with their eyewear. They’re prepared to have a crack at being a bit outlandish – they’re confident and they don’t care what people think.”
Ms. Sluce said this younger mindset means any diagnosis about vision loss or eye diseases that occur with age needs to be delivered delicately and with a little empathy – but not condescension.
“When I’m providing this sort of diagnosis, I say it’s a natural change, that there’s an increase in the likelihood of some eye diseases… and the advantage of being my age is that most people believe I have empathy… because I do.”
Ms. Sluce said education is also important. “Most people are interested in their eye health. If you take some photos or get them to do another test – an OCT scan showing the nerve fibres are healthy, for instance, they appreciate the technology and that all helps them to feel in greater control.”
Ideology Consulting’s Mark Overton agrees. “This is a generation that is mostly educated. They will ask questions and they will expect to know why you’re making a particular recommendation or diagnosis. Give them the options and help them explore the possibilities. Guide and open doors but don’t dictate.”
It’s a strategy Murray O’Brien has embraced, especially now that he too, is in his 50s.
“I used to find dealing with older people very difficult – I was young and brash. I thought I knew everything and they knew nothing. Now I find them easier to deal with than younger customers.”
He said wearing glasses with progressive lenses has also helped. “I can speak from experience – that makes it so much easier than when I was dispensing at 22.”
“My advice to young ECPs is to be very respectful, very humble and to listen to the customer because they have experience. Speak with confidence and back up what you’re saying with knowledge – because they know when you’re not being truthful, and they know how long it takes to become proficient at something.”
Additionally he said “older people are comfortable in their own skin – they’re looking for someone they can trust – not just a deal. And once they trust you, they stick with you – they’re more likely to take your advice… if they don’t trust you they’ll hold you to account and then it’s going to be hard work”.
He said the ageing market is good for practice building. “Their vision is changing rapidly and they understand the importance of eye health – so once they’re over the initial hurdle of realising that their sight has changed, they’re very accepting of the need to have vision correction – the older they get the more used to the concept of regular eye checks and updated vision correction.”
A Spectrum of Reactions
Naturally the main issue encountered by patients in their 50s is presbyopia as well as looking out for cataracts, macular degeneration and glaucoma.
“Then there are those who’ve been short sighted all their life – they get to a point where they have to take their glasses off to read and that’s a hassle for them as well,” said Ms. Sluce.
“With age I’ll often detect early signs of macular degeneration, at which point the consult becomes more focused on advising on lifestyle changes. I’ll also see changes in the optic nerves, at which point you have to rule out whether or not it’s glaucoma. Some patients will develop a certain form of cataract and need to have them removed, which can be very confrontational for them.”
While glaucoma can impact anyone of any age, it is much more common as people age. Sydney ophthalmologist and glaucoma specialist Dr. Ivan Goldberg said there is a whole spectrum of reactions to expect when delivering diagnosis of an eye disease, especially when it comes to glaucoma.
“There are people who deny and refuse to accept there is anything wrong with them because they have few symptoms,” said Dr. Goldberg, adding that even with test results to show these patients, it can be difficult to persuade them of the need for treatment then get them to use the drops properly, reliably and consistently.
“Other people become desperately anxious and upset. They worry excessively.
“Then there’s everyone else in between who, with appropriate support, information and guidance, understand in a balanced way the need to tackle the disease, and have realistic expectations about treatment options.”
He said although research shows that no professional is very good at predicting which patients are using their medications reliably and consistently, it is possible to have an idea about compliance from the way in which a patient reacts to their diagnosis.
“As health professionals we tend to over-estimate the patient’s collaboration with their own care. Patients often don’t tell us what they haven’t done – either because they don’t want to disappoint us or because they can’t remember what they’ve forgotten to do.
“You can often pick those who are not taking the disease seriously or are so terrified they’re in denial – they might dismiss what you’re saying or they’ll fail to attend, or refuse to make, appointments.
“It’s so interesting because you’re dealing with human beings with different cultural backgrounds and personalities – some see disease as fearful, others see it as something to be conquered. So you have to find a way to link with that individual – and get them to lock on to the treatment program.”
Like Mr. O’Brien, Dr. Goldberg said providing solid information is critical. “Part of getting them there is to help them understand what’s going on in the eye – the structure, how the disease is attacking the vision system – then it becomes easier to explain why we’re trying to protect their vision. It’s also important to establish
goals and strategies for treatment, and then separate the strategies from the goals.
“As an example, in glaucoma management, a major goal is to lower the IOP. The strategy is in part determined by how far we need to lower it to prevent damage to the optic nerve because the magic number for any individual – the point at which the optic nerve will become damaged or more damaged – will be different. It may be different for an individual patient over time, as well.
“Glaucoma occurs more commonly as people get older – one in 200 40-year-olds have glaucoma but by the age of 80, it’s one in eight. The line is exponential, not linear – and I show patients this using a graph so they understand that with age, the nerves get more vulnerable and therefore, there’s greater risk of glaucoma starting or getting worse.
“Another message I give comes from Fred Hollows. He once said ‘glaucoma is like the ocean; you never know when the next big wave is coming through’. I explain to my patients that this is why it is so important to keep coming back for checkups. They may be using their drops to lower the pressures, but at some point, their eyes may become resistant to the drops – and as a patient they won’t have any idea; alternatively, even the pressures may remain steady on treatment, as the nerves become more vulnerable those previously satisfactory pressures may become unsafe.”
Dr. Goldberg said the amount of information that needs to be communicated – particularly in the early stages of diagnosis and disease management – can be overwhelming for patients.
“I think busy eye health professionals have to acknowledge that within the relatively short time of a consultation, they’re not able to answer or to anticipate all patient queries, to allay fears and to give a realistic impression of what the patient might expect.
“This is where Glaucoma Australia becomes so valuable – I try to get patients involved at an early stage – I encourage them to contact Glaucoma Australia to ask questions about the advice they get from the doctor – it helps people to hear the information for a second time from lay people as opposed to the doctor and it is very effective in getting people to lock in to the management strategy.
“Certainly in the early stages when patients are still building their relationship with their doctor, the assistance they get from an organisation like Glaucoma Australia is priceless.”
Dr. Goldberg said the advantage of treating people with glaucoma is that in most cases, treatment continues over many years, during which time strong professional relationships can be formed.
Having been diagnosed with glaucoma in her 40s, Rosemary Russell has visited Dr. Goldberg for over 25 years and is entirely comfortable with asking for any advice about her condition. She said it wasn’t the same for her parents.
“It’s all about the patient/ophthalmologist relationship. When my mother was diagnosed with glaucoma, I think she thought everything was too hard to understand and she didn’t want to get a second opinion. When my father had to see an ophthalmologist, he found his specialist was very dismissive,” said Ms. Russell.
“They’re all so highly trained that you can feel inadequate when they’re explaining things… but I’ve been going to my ophthalmologist for so long that I have a lot of confidence. I feel I can ask Ivan anything – even if I don’t understand all the answers!”
Ms. Russell said she has also drawn heavily on information provided by Glaucoma Australia.
“I have always been very interested in reading all about what is available in terms of treatments for glaucoma – although I’m not medically or scientifically trained. Ivan shows me little diagrams of the eye and explains things, but it is hard to take it all in at a consultation and that’s where Glaucoma Australia is so helpful.”
Even then, some of the finer details, which might seem so obvious to a specialist can pass a patient by.
“One other thing I wasn’t told when I was first prescribed drops for glaucoma was how to put the drops in properly – and it’s something a lot of people don’t know.
“When you put the drops in, they go into the tear ducts and into your body. What you have to do is stick your fingers into the inside corners of your eyes for two minutes after putting the drops in to keep them in there,” she laughed. “I’ve used all of those two minute periods over the years to teach myself new skills, like counting in French – from one – 120.”
Having discovered this tip, Mrs. Russell helped Glaucoma Australia make a DVD that demonstrates the correct technique.
As an optometrist who has worked in the same Hobart practice for 22 years, Susan Sluce has also developed long term professional relationships with patients, which she says, are often rewarding but sometimes distressing.
“A few years ago, I looked after a fellow who despite being two years younger than me had developed cataracts. He had cataract surgery and two years later I heard on the grapevine that he’d noticed a little spot in his vision. I rang and asked him to come in, which he did. I discovered a large retinal detachment that he would have ignored. There were no retinal specialists in Tasmania so he went to Melbourne for the operation. I played an integral role in saving his sight – but that’s something we all do as optometrists on a weekly or monthly basis.
Another couple she has seen since joining the Hobart practice are now in their 80s and deteriorating. “It’s become a quasi-friendship – they come in and sit down and have a chat about what’s going on before I check their eyes. One has developing dementia so they come in and out to see me quite often now – after all these years, to see the deterioration is heart-breaking,” she said.
Dr. Goldberg said the opportunity to care for people over the long term and to help them to protect their vision as they age is one of the true rewards of being an ophthalmologist.
“Older patients try to maintain quality of life and to anticipate and to enjoy their retirement. Retaining useful sight is such an important part of quality of life. That’s what makes all the effort so worthwhile,” he said.
Australia’s Ageing Population
By 2020 – just over five years away – one billion of the world’s population will be 60 years of age or older. In Australia, our population will be around 24 million and of those, almost five million – or around 20 per cent of the population – will be over 60. There will be more 65-year olds than one-year olds and as many people aged 60 to 70 as there will be people aged 10–20.1
The stats show that the opportunities are great for the eye health profession, which is uniquely positioned to help this group of the population from vision loss and the potential for reduced quality of life that follows.