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Clinical Care and Practice Advancement
Geriatrics and Nursing Facility

A Recommended Continuing Education Curriculum: Geriatric Optometry for the Primary Care Practice



Prepared by the American Optometric Association Geriatrics and Nursing Facility Committee:

  • Alfred A. Rosenbloom, Jr., O.D., M.A., Primary Author
  • N. Scott Gorman, O.D., M.S.
  • Jerry P. Davidoff, O.D.
  • Mark W. Swanson, O.D.
  • Byron E. Thomas, O.D.
  • Alfred G. Waltke, O.D.
  • Timothy A. Wingert, O.D.

© American Optometric Association June 2000

243 N. Lindbergh Blvd., St. Louis, MO 63141-7881

A Recommended Continuing Education Curriculum:

Geriatric Optometry for the Primary Care Practice

The Geriatrics and Nursing Facility Committee (GNFC) of the American Optometric Association (AOA) recognizes its ongoing commitment to excellence in optometric education and patient care. A major goal of the committee for the millennium is to encourage wider dissemination of emerging knowledge and understanding that is fundamental to the provision of comprehensive and primary vision care to older persons.

With the "graying of America," it is essential that optometry address the eye health and vision care needs of a rapidly growing and expanding older population. Anecdotal evidence suggests a relative absence of continuing education instruction in the multifaceted aspects of elder patient care at state, national, and regional conferences. Consequently, there is an urgency for the consideration and implementation of such instruction. Optometrists with their specialized expertise have provided vision care services to older adults for many years. The increased number of aging Americans and their increased socio-ethnic diversity underscore the importance of strengthening post-graduate education and training to meet the bio-psycho-social needs of the older population.

The Twentieth Century's demographics are compelling. Since the start of the century, the percentage of Americans aged 65 or older has more than tripled (4.1% in 1900; 12.7% in 1997), and the number of older Americans has increased more than 10 fold from 3.1 million to 34.1 million. By 2030, it is projected that there will be nearly 70 million people age 65 or more living in the United States, twice the number than in 1997. The older population is not only growing, it is also aging. When compared to the older population in 1900, the number of people age 85 or older is 31 times greater. This growth is further highlighted by a 16 fold increase in the 75-to-84 age group and an 8 times increase in the population aged 65-74.1 These data reinforce the need for comprehensive optometric care as an essential health care service in older persons so they can maintain a self-reliant, independent, and enhanced life style.

Today's dynamic health care environment makes it difficult to predict the future. Health care needs will increase, services will change, and the roles and relationships of health professionals will evolve into new systems of care. More and more, optometrists will become involved in interdisciplinary geriatric teams. Sometimes they will be team members, but more often they will interface with the team from the perspective of a consultant. Within this evolving professional relationship, optometrists will need to strengthen skills and acquire new understandings. There will be an increasing impetus for optometrists to demonstrate their ability to communicate effectively, to solve problems wisely, and to make decisions that will influence the actions of other professionals. Consequently, the role of continuing education in geriatric optometry acquires greater relevance and importance as we approach the challenges of this millennium.

Contemporary optometric continuing education regarding the primary care of the older adult emphasizes the diagnosis and management of ocular diseases. While this knowledge is essential, it is not considered sufficient in order to provide quality patient care in meeting the special needs of the older adult. Therefore, the AOA GNFC recommends the following learning objectives:

  1. To understand that aging is not a disease, even though there are biological, psychological, and sociological changes with time.
  2. To acquire additional knowledge not only about common ocular and systemic diseases associated with aging but also their systemic and functional implications.
  3. To differentiate expected age-related eye health and vision changes and their functional implications from pathological conditions and their effects.
  4. To comprehend the systemic and ocular effects of medications in the elderly from a pharmacological, diagnostic, and therapeutic standpoint.
  5. To obtain the most valid and reliable clinical findings by applying the appropriate modifications necessary in the examination of older patients.
  6. To prescribe the most appropriate lens design options and devices for the normally sighted and the visually impaired older person.
  7. To acquire the special clinical skills needed for the care of frail elderly in institutional and home environments.
  8. To acquire knowledge about the role of the optometrist as a member of interdisciplinary care teams.
  9. To access services within the community's aging network which help to improve the quality of life of older persons.
  10. To understand governmental regulatory provisions as they apply to the care of the older person.

CURRICULUM OUTLINE

  1. Optometric Practice for an Aging Patient Population Base
    1. Understanding Older Patients
      1. Implications of demographic trends
      2. Aging and the life cycle continuum
      3. Ageism – myths, stereotypes, and realities about older persons
    2. Meeting the Needs of Older Patients
      1. Psychological and social aspects of aging
      2. Age-related differences in cognitive abilities
      3. Implications for staff role
      4. Implications for office design
    3. Factors that Influence the Examination and Management of the Older Patient
      1. Multiple health problems
      2. Communication problems
      3. Polypharmacy – compliance issues
      4. Interaction of psychological, social, and physical factors
      5. Clinical evaluation – methods and techniques
      6. Interdisciplinary team care
      7. Institutional and home-bound patient care
  2. Systemic Changes of Aging
    1. Homeostasis
    2. Health and Levels of Impairment: A Continuum
      1. Physiological Changes in Aging
      2. Body composition
      3. Sensory patterns
      4. Stature and posture
      5. Cardiovascular system
      6. Musculoskeletal system
      7. Endocrine system
      8. Metabolic system
      9. Immune system
      10. Neurological system
      11. Nutritional needs
      12. Rest and sleep patterns
    3. Systemic Diseases of Aging
      1. Hypertension
      2. Arthritis
      3. Diabetes
      4. The dementias
        1. Dementia of the Alzheimer type
        2. Illnesses which can be confused with dementia
        3. Physical and psychological deficits
    4. Other important systemic diseases of aging
  3. Ocular Aging
    1. Expected Age-Related Ocular Changes
      1. Changes in the adnexa
      2. Changes in extra-ocular muscles
      3. Media changes and effects
      4. Retinal aging and functional effects
      5. Central nervous system effects
    2. Visual-Perceptual Changes and Functional Ramifications
      1. Static and dynamic visual acuity
      2. Ocular motility
      3. Amplitude of accommodation
      4. Accommodative-convergence relationships
      5. Contrast sensitivity function
      6. Color vision effects
      7. Dark adaptation
      8. Changes in refractive state
      9. Other perceptual responses including changes in response to luminance levels
    3. Common Age-Related Ocular Diseases
      1. Anterior segment disease
      2. Corneal disease
      3. Cataract
      4. Vitreal disorders
      5. Retinal disease
      6. Optic nerve disorders
      7. Glaucoma
      8. Neuro-ophthalmic disease
  4. Drug Use and Abuse in the Elderly
    1. Pharmacokinetics and Dynamics
    2. Systemic and Ocular Effects of Medications
    3. Prescription Drugs and Over-the-Counter Medications
    4. Polypharmacy and Adverse Drug Interactions
    5. Patient Education and Compliance
    6. Substance Abuse
  5. Clinical Assessment and Management
    1. Goals of Geriatric Patient Care: Quality of Life
      1. Prevention
      2. Maintenance
      3. Rehabilitation
      4. Enhancement
    2. Modification of Clinical Procedures
      1. Optometric and functional case history
      2. Assessing visual acuities
      3. Refracting and prescribing
      4. Evaluating ocular health
      5. Assessing visual fields
      6. Evaluating binocularity
      7. Implications for special tests
        1. Indications for color, contrast, and glare testing
        2. Indications for laboratory and imaging testing
    3. Managing Common Vision Disorders
      1. Lens design options for refractive disorders
      2. Prescribing ophthalmic lenses for active elders
      3. Rehabilitation techniques for elders with visual impairment
      4. Drug therapy
      5. Nutrition and nutritional therapy
      6. Management and co-management considerations
      7. Monitoring performance and ensuring continuity of care
    4. General Considerations
      1. Patient understanding and compliance
      2. Evaluating cognitive status
      3. Identifying support networks
      4. Interacting with third party systems
  6. Special Considerations in Examining and Managing the Older Patient
    1. Analysis, Evaluation, and Management of Changing Visual Tasks
      1. Vision function changes in "normal" aging
      2. Characteristic signs and symptoms of visual disorders
      3. The presbyopia profile
        1. Occupational and recreational visual needs
        2. Lens design options and management considerations
        3. Impact and radiation protection
        4. Illumination and glare considerations
    2. Examination and Management of Patients with Visual Impairments or Low Vision:
      1. Functional and Rehabilitative Approaches
      2. Goals of low vision rehabilitation
      3. Essentials of primary care low vision services
      4. Important elements of comprehensive low vision care
      5. Communicating with and referral to other support professionals
      6. Follow-up appointments and ongoing assessment of visual performance – new needs
      7. Basic equipment recommendations
    3. Environmental Factors: Physical Environment, Social Environment, Illumination, Glare, Color, and Contrast
      1. Discomfort and disability glare
      2. Assessing glare disability
      3. Filters and coatings
      4. Proper illumination sources, design, and placement of luminaries
      5. Modification options in home and work environment
      6. Computers
      7. Drivers' Vision
    4. Evaluation and Care of Nursing Facility Residents and Home-Bound Persons
      1. Overview of nursing facility administrative and professional staff
      2. Obtaining nursing facility professional staff appointments
      3. Resident assessment, care plan, and the Minimum Data Set
      4. The optometric consultant's clinical role and responsibilities
      5. Co-management issues and guidelines
      6. Evaluation and management service codes
      7. Equipment recommendations for out-of-office examinations
    5. Utilization of Social/Community Services and Consultation/ Coordination with other Health Care Providers
    6. Research and Development Needs in Geriatric Patient Care
  7. Governmental Regulatory Provisions
    1. Medicare and Third Party Reimbursement
      1. Coding guidelines for the older patient
      2. Coding for low vision rehabilitation
      3. Administrative issues relating to reimbursement denial and appeals procedures

REFERENCE

  1. Administration on Aging (1999). A profile of older Americans: 1999. Washington, DC.

Recommended Readings

  • Abrams WB, Berkow R, eds. The Mercks manual of geriatrics. Rahway, NJ: Merck & Co, 1995.
  • Albert DM, Jakobiec FA. Principles and practice of ophthalmology, 2nd ed. 6 vols. Philadelphia: WB Saunders, 2000.
  • Amos JF, ed. Diagnosis and management in vision care. Boston: Butterworth-Heinemann, 1987.
  • Aston SJ, Maino JH. Clinical geriatric eyecare. Boston: Butterworth-Heinemann, 1993.
  • Berger JW, Fine SL, Maguire MG. Age-related macular degeneration. St. Louis: Mosby, 1999.
  • Bressler R. Geriatric pharmacology, 2nd ed. New York: McGraw-Hill, 1999.
  • Carabellese C, Appolionio I, Rozzini R, et al. Sensory impairment and quality of life in a community elderly population. J Am Geriatr Soc 1993;41:401-7.
  • Crews JE. The demographic, social and conceptual contexts of aging and vision. J Am Optom Assoc 1994;65:63-8.
  • Guyer DR, Yannuzzi LA, Chang S, et al. Retina-vitreous-macula. Philadelphia: WB Saunders, 1998.
  • Hamptom JK. Systems for nutrition and maintenance: nutrition and metabolism. In:
  • Hampton JK, ed. The biology of human aging. Dubuque: William Brown, 1991.
  • Hazzard W. Principles of geriatric medicine and gerontology, 4th ed. New York: McGraw-Hill, 1998.
  • Horowitz A. Vision impairment and functional disability among nursing home residents. Gerontologist 1994;34:316-23.
  • Illuminating Engineering Society of North America. Recommended practice for lighting and the visual environment for senior living. New York 1998.
  • Jahnigen D. Geriatric medicine, 2nd ed. London: Blackwell Science, 1996.
  • Marx MS, Werner P, Cohen-Mansfield J, Feldman R. The relationship between low vision and performance of activities of daily living in nursing home residents. J Am Geriatr Soc 1992;40:1018-20.
  • Melore GG, ed. Treating vision problems in the older adult. St. Louis: Mosby, 1997.
  • O'Hara-Devereaux D, et al. Eldercare: a practical guide to clinical geriatric. New York: Grune & Stratton, 1981.
  • Orr AL, ed. Vision and aging: crossroads for service delivery. New York: American Foundation for the Blind, 1992.
  • Peterson DA, Douglas E, Bolton CR, et al. Final report: a national survey of gerontology instruction in American institutions of higher education. Washington, DC, 1987.
  • Phillips S. Quick drug reference for the optometrist. Columbus: Anadem, 1998.
    Rosenbloom AA, Morgan MW, eds. Vision and aging, 2nd ed. Boston: Butterworth-Heinemann, 1993.
  • Rosenbloom AA. Vision care of the elderly: innovation and advancement in low vision services. In: Crews JE, Whittington FJ, eds. Vision loss in an aging society – a multidisciplinary perspective. New York: American Foundation for the Blind Press, 2000.
  • Rowe JW, Grossman E, Bond E. Academic geriatrics for the year 2000. New Engl J Med 1987;316:1425-8.
  • Rudberg M, Furner S, Dunn J, Cassel C. The relationship of vision and hearing impairments to disability: an analysis using the longitudinal study of aging. J
  • Gerontology: Biological Science and Medical Science 1993;48:M261-5.
  • Spalton DJ, Hitchings RA, Hunter PA. Atlas of clinical ophthalmology, 2nd ed. New York: Wolfe Publishing/Mosby-Year Book, 1994.
  • Tallis R. Brocklehurst's textbook of geriatric mining and gerontology, 5th ed. Philadelphia: Churchill, 1998.