Overcoming barriers
| Cognition | |
| • | Memory impairment or confusion limits 7.1% of community-dwelling individuals (age ≥ 65) |
| • | Senility and dementia limits 2.4% of older adults |
| Hearing and vision loss | |
| • | Hearing impairment affects 35%-50% of older adults |
| • | Vision impairment affects 15%-25% of older adults |
| • | Combination of hearing and vision impairment affects 7% of older adults (ages 65-79) and 17% of older adults (age ≥ 80) |
| Sources: Gerontologist 47:350-345, 2007; Am J Public Health 95:1940-1942, 2005; ASCO 2010 education session | |
In addition to disability and geriatric syndromes, Dr. Naeim added two more communications barriers with older patients (see Table 3). Communicating with older patients will require more time on the part of the healthcare provider and will require a different approach, Dr. Naeim said.
"There is something called oral literacy demand, defined as the aspects of medical communication that challenge people with low literacy, including the use of technical terms, general language complexity, and structural aspects of dialogue (how fast we talk, the density of interactivity)," he said.
Debra L. Roter and colleagues conducted a modeling study that looked at oral literacy demand. These models have been applied mainly in genetic counseling but can be transferred to oncology counseling as well, Dr. Naeim said.
Ms. Roter's group found that the more counselors used technical terms and dense, less interactive dialogue, the less satisfied the simulated clients were. Providers that monitor their vocabulary and language, as well as the structural characteristics of interaction, lower the literacy demand of routine medical dialogue, they recommended (Soc Sci Med 65:1442-1457, 2007).
Dr. Naeim offered some ways that cancer care specialists can improve their communication with older patients. First, recognize that the translation of data from population-based trials to personal risk may be puzzling for the patient. "Encourage patients to use [population-based] risk as an aid, but not as a predictor of exact future events," he said.
Consider using risk graphics such as simplified survival-only pictographs. He cited Adjuvant! Online as an example of how to present complex data. The program generates a single graphic that depicts four possible outcomes: survival, mortality from the cancer, mortality from other causes, and incremental survival with adjuvant treatment.
Finally, framing is always important, whether treatment will lead to a loss or a gain, he stressed. "You really want to frame things in many different ways to allow the patient to understand what you're trying to communicate. . . in general, it's insufficient to provide patients with objective probabilities. They need to be in some way contextualized in terms of implications for that particular patient or his life."
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
