Geriatric otolaryngology toolbox: what you and your nurse can do to improve outcomes for older adults.

Abstract

Interest in addressing the health needs of older adults and improving their outcomes is burgeoning in otolaryngology, but the availability of practical strategies to achieve these aims is limited. In this article, we describe how otolaryngologists can capitalize on collaboration with nurses to create a toolbox of quick and effective strategies that can be incorporated into outpatient otolaryngology practice. The toolbox was compiled by a collaborative team of three: an otolaryngologist--head and neck surgeon who specializes in microvascular reconstruction, a geriatrician completing a second residency in otolaryngology, and a gerontologic clinical nurse. We selected and developed these strategies to fit within the framework of standard otolaryngology practice based on evidence we gathered from the geriatric literature and our own collective academic and clinical experience. We review our criteria for selecting each of the 10 items in our toolbox, and we discuss the potential benefits of each.

Introduction

Geriatric otolaryngology practice today is limited by a paucity of evidence in the literature and a dearth of practical and relevant tools available to optimize outcomes for older adults. There is scant research that addresses the complex intermingling ofotolaryngologic disorders and comorbidities, disease control, and functional status in older adults. Changes in the demography of our aging population will likely result in a doubling of the number of older patients who will seek otolaryngologic care in the coming decades. (1)

Fortunately, we are increasingly better able to define and address the specific otolarygologic needs of older patients with conditions such as presbyphonia, presbyphagia, presbycusis, Zenker diverticulum, and cancers of the head and neck. Yet because their otolaryngologic concerns arise in the context of comorbidities and declining functional reserve, our assessment, treatment, and follow-up of geriatric patients are often complicated. Ensuring optimal individual outcomes for older patients with complicated needs requires consideration and management of contextual concerns, which may then influence primary treatment outcomes. The selection of tools to facilitate care that supports optimal outcomes must be made carefully in order to achieve the right balance between evidence and pragmatism.

In this article, we present a compilation of clinical assessment and intervention strategies that we have found to be useful in treating older adults with otolaryngologic concerns. These assessments and interventions are presented analogously as tools in a toolbox. The use of these tools can be incorporated into otolaryngology practice by physicians and nurses. We arrived at the different components of the toolbox via a clinical review of the literature and by taking into consideration our shared clinical expertise in otolaryngology--head and neck surgery, geriatric medicine, and gerontologic nursing. After briefly reviewing significant considerations in clinical treatment and outcomes, we detail the contents of our suggested toolbox and provide the rationale for using each tool.

Background and significance

Assessments of the clinical outcomes of treatment in older adults, given the matrix of comorbidities and functional risks they have, are more nuanced than those in many younger adults. Symptom profiles and functional limitations in the aged can result in a decline in their quality of life as perceived by both the patients themselves and their family members.

Much geriatric dogma emphasizes that achieving a satisfactory functional outcome is more important than "curing" a condition and that treatment goals should vary according to individual need. However, there are scant data on how to evaluate our care for geriatric otolaryngologic patients. We believe that there are three converging issues that influence clinical outcomes in older adults, and that the nature of these issues calls for a pragmatic approach to delivering care:

* Foremost is the recognition that specialized competence in geriatric practice is necessary to deal with the unique characteristics and specific needs of older adults. We like to say that clinicians must stop merely thinking, "I take care of older patients, and I do okay with them." Instead, we believe that we must recognize our older patients' special needs and augment our knowledge and skill in geriatric practice to meet those needs. Several authors have reported that geriatric competence results in fewer errors and better quality in the care of older patients. (2-4) In geriatric care, the likelihood of complexity is high and the margin for error is narrow.

* Second, geriatric competence can be enhanced by adhering to programs intended to improve the quality of health care. Initiatives such as the National Patient Safety Goals (5) and Pay for Performance (6) provide guidelines for attaining quality care and minimizing errors.

* Finally, we believe that from both a practical and moral perspective, otolaryngologists and otolaryngology nurses should build and exercise expertise in understanding and addressing the needs of older adults. Many of these patients have diseases and disorders in which otolaryngology leads the way in terms of clinical practice and investigation.

Otolaryngologists can collaborate with nurses to stock the geriatric otolaryngology toolbox with 10 quick and effective strategies that can be incorporated into outpatient practice (see "The 10 strategies in the geriatric otolaryngology toolbox").

1. Screen all new patients and caregivers for health literacy.

Health literacy assessment may promote adherence to treatment, but it is often difficult to assess in clinical practice. Weiss et al suggested a quick and easy test: Give the patient or caregiver an ice cream container and then ask questions about the information on the label that corresponds to health literacy. (7) Other strategies such as the "teach back" or redemonstration method can support the teaching effort described in item #2 and thus increase the likelihood of improving health literacy after the initial level of literacy has been assessed.

2. Reformat all teaching materials for older eyes.

Adapting patient education materials to older eyes is one way of improving health literacy. (8-11) The usefulness of effective teaching materials is widely acknowledged, but these materials are often little used. For ease of reading by older patients, published materials should be printed in black type on white paper with a sans serif font and a type size of at least 14 points. Writing for comprehension at the fifth-grade reading level or lower is often recommended for patients of all ages. Simple writing is especially important for today's geriatric patients because many of them grew up during the Great Depression and might not have had a chance for education beyond grade school, (11) Moreover, there will always be patients for whom English (or the primary language in your practice) is a second language. (11) Microsoft Word programs allow writers to check the Flesch Reading Ease level and other readability statistics in its spelling- and grammar-check function. Older adults also respond well to supporting materials such as illustrations. They do not learn as well when complicated language and jargon are used. (8,12)

3. Screen all patients for presbycusis and other hearing impairments.

According to Busis, presbycusis occurs in approximately 25% of 65- to 74-year-olds, 50% of 75- to 84-year-olds, 75% of 85- to 94-year-olds, and more than 95% of those older than 95 years. (13) Presbycusis can significantly diminish a patient's quality of life and impair his or her ability to perform self-care. It can promote dependency, social isolation, low self-esteem, depression, and cognitive impairment. Gates et al reported that the most effective and efficient screening technique is to simply ask the question, "Do you have a hearing problem now?" (14) Screening for and treating presbycusis supports treatment adherence and quality of life as well as patient satisfaction.

4. Screen all patients routinely for depression.

While depression does not fall directly within the scope of otolaryngologic practice, it is often a consequence of many geriatric otolaryngologic conditions. Depression is prevalent among community-dwelling older adults. The Surgeon General's 1999 report on mental health noted that 8 to 20% of community-dwelling older adults have depression, as do almost 40% of those who seek primary care. (15)

Depression has a clear influence on help-seeking and treatment adherence, and thus health outcomes. For example, prolonged postoperative hospital stays have been associated with preoperative depression. Research (16) has shown that the five-item version of the Geriatric Depression Scale (GDS) developed by Hoyl et al (17) is a quick and effective screening tool. The five-item questionnaire represents a shorter form of the original 15-item GDS. The five items were selected because they have the highest statistical correlation with a clinical diagnosis of depression. The short form, which addresses life satisfaction issues such as boredom and social behavior, takes on average less than 1 minute to complete. Identifying depression and referring affected patients for treatment may limit the risk of complications and obviate problems with treatment adherence,

5. Screen all patients for falls risk.

Falls often occur as a result of an otolaryngologic condition. But even when a patient's presenting complaint is not associated with a risk of falling, the geriatric otolaryngologist should keep this risk in mind. Unfortunately, effective instruments to measure falls risk are scarce, and falls-prevention tools are often inadequate. Yet it is still possible to assess underlying factors that predispose the elderly to falls. For example, the screening version of the Dizziness Handicap Inventory is an expedient and effective tool for assessing dizziness. (18) While falls represent a complex phenomenon, simple screening may help improve outcomes by detecting unrecognized conditions.

6. Screen all preoperative patients for delirium risk, and reduce triggers.

Delirium is another geriatric syndrome associated with poor outcomes. Delirium, like falling, is a complex phenomenon. Delirium may be difficult to detect and prevent in patients who have intensive care needs. (19) Their presentation is often unusual, and they may exhibit atypical withdrawn behavior that is often mistaken for pharmacologic sedation. At other times, patients exhibit symptoms that are more typical, such as confusion and psychomotor agitation. Unfortunately, we have no validated screening tool to identify the risk of delirium in outpatients. Most clinical research in this area has focused on delirium as a frequent inpatient concern.

In the absence of published guidelines, we believe that the best indicator of a predisposition to delirium in elder outpatients is a history of delirium or its risk factors. Use of the Beers List of potentially inappropriate medications for the elderly can help in reviewing the patient's medications. Among the known deliriogenic agents are benzodiazepines, histamine-2 antagonists (especially over-the-counter preparations), and some medications that are active in the gastrointestinal tract (e.g., metoclopramide and some sedative-hypnotics). (2) Information about prior hospitalizations and surgeries that suggests an episode of delirium--such as confusion, hallucinations, or illusions--should be elicited from the patient or family caregiver. Asking a patient or family member about strange behavior during illness or unexpected reactions to surgery may help identify a prior episode of delirium and its trigger. If possible, limit the use of any apparent triggering medication in ongoing care. Referral to a geriatric medicine or nursing specialist or to a psychiatrist may become necessary if the team detects delirium during the course of otolaryngologic care. Limiting the incidence of delirium reduces the risk of associated morbidities, including incontinence, pressure ulcers, deconditioning, and perhaps even death. (19)

7. Follow up with telephone calls.

Problems related to treatment adherence often arise after a patient has left the office and returned home. However, some patients are reluctant to contact clinicians with questions or concerns because they do not wish to be a burden. Therefore, staff should place follow-up telephone calls to older adults whenever prudence dictates. Follow-up calls may be warranted for patients who are in postprocedure recovery and for those who have risk factors for a poor outcome, such as limited family or other social support. A missed appointment should also trigger a phone call.

The results of studies of patients of all ages suggest that the value of telephone contacts is comparable to that of face-to-face consultations in facilitating health-promoting interventions, in performing triage, and in promoting access to and the delivery of routine health care to patients with chronic disorders. (20,21) Telephone calls should certainly be helpful for patients who do not qualify for home care (see item #8), and they can also be an effective adjunct for patients who do receive home care. Routine telephone follow-ups can prevent treatment disruption and unplanned office visits and hospitalizations. No specific protocols have been established, however, so procedures must be developed within each practice. (20,22)

8. Develop a list of geriatric referral resources.

Psychosocial impairments limit an older patient's ability to seek help, set goals, and adhere to treatment. Their care is enhanced when psychosocial care services are in place before they are needed. (23,24) In our experience, scrambling for psychosocial resources when a crisis occurs is often a predictor of a poor outcome. We suggest having the telephone number of your local Area Agency on Aging (AAA), a service center and clearinghouse that is available in almost every county in the United States, and sharing that number with the patient's family. Most local AAAs also have Web sites (the URL for the National Association of Area Agencies on Aging is www.n4a.org).

As part of the telephone follow-up program, staff can determine what a patient requires in the way of social services and home care. A substantial body of evidence supports the use of home care for high-risk older adults to reduce complications, improve outcomes, and thereby limit cost. (23-26) Addressing home-care needs often means the difference between a successful treatment plan and serial nonmedical problems that can disrupt the course of care and limit achievable outcomes. An established protocol within a practice that guides geriatric psychological and social care as well as home care will help clinicians avoid last-minute scrambles for services and save much time and effort.

9. Support in-hospital and health system geriatric resources.

Best-practices programs for geriatric care are widely available. (3,27-34) They commonly focus on education for nurses because it is they who spend the most time with patients. Best-practices programs address a variety of outcomes concerns, including the management of high-risk events such as delirium and the promotion of patient and family satisfaction. However, these programs require interdisciplinary support and institutional commitment, and physician endorsement is a valuable aid to achieving these objectives. While evaluations of the effectiveness of these programs compared with standard care are somewhat limited, there is some evidence that geriatric resource programs do improve outcomes in hospitalized patients. (3,28,33) The use of in-hospital and health system geriatric resources will likely provide a positive return on investment and improve the odds of reducing postdischarge complications, functional decline, and dissatisfaction With care.

10. Make teamwork the hallmark of your geriatric care.

The importance of teamwork should not be underrated. Interdisciplinary communication, collaboration, and coordination are essential to the delivery of effective health care to patients of any age. (35) Older adults have disproportionately greater medical, general health, and impinging social needs, and these needs make care more complex and pose a higher risk of error, complication, and adverse outcomes. Therefore, communication, collaboration, and coordination that result in therapeutic relationships with patients and family members are essential. (36,37) Surgeons should be adept at teamwork in view of their appreciation of the cooperation that is necessary in the operating room and their awareness of the consequences of errors. (38) We suggest that in addition to the nurses, speech language pathologists, and audiologists who help make up the interdisciplinary otolaryngology effort, the geriatric team be expanded to include the consultative services of a geriatric physician or nurse practitioner, a social worker, and a physical therapist among others who can support the goal of meeting older patients' needs.

Conclusion

Our proposed toolbox for geriatric otolaryngology practice highlights available strategies to improve care and optimize outcomes for older adults who seek otolaryngologic treatment. Optimal use of the tools in our toolbox requires an assessment of individual practice needs and a commitment to follow-through.

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P.A.C. van Vuuren, MD; Sarah H. Kagan, PhD, RN; Ara A. Chalian, MD, FACS

The 10 strategies in the geriatric otolaryngology toolbox

1. Screen all new patients and caregivers for health literacy.

2. Reformat all teaching materials for older eyes.

3. Screen all patients for presbycusis and other hearing impairments.

4. Screen all patients routinely for depression.

5. Screen all patients for falls risk.

6. Screen all preoperative patients for delirium risk, and reduce triggers.

7. Follow up with telephone calls.

8. Develop a list of geriatric referral resources.

9. Support in-hospital and health system geriatric resources.

10. Make teamwork the hallmark of your geriatric care.

The items in our toolbox are grouped into three general areas of focus. The first three items address changes in those senses with which otolaryngologists are generally expert. Items 4, 5, and 6 concern early detection of geriatric syndromes that limit patient outcomes. The final four items concern the creation of a geriatric-friendly system of care in which necessary resources are routinely available and an interdisciplinary team ensures optimal care.

From the Academic Medical Centre, Amsterdam, The Netherlands (Dr. van Vuuren); the University of Pennsylvania School of Nursing, Philadelphia (Dr. Kagan); and the Department of Otorhinolaryngology--Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia (Dr. Chalian).

Previous presentation: The information in this article was originally presented at the 2nd annual meeting of the American Society of Geriatric Otolaryngology; April 30, 2008; Orlando, Fla.

Corresponding author: Sarah H. Kagan, PhD, RN, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104. E-mail: [e-mail]