I enjoy the older adult population much in the way one enjoys children. Instead of smiling at life anew, I smile at the life well-lived. When it comes to practicing medicine, I consider older adults as a different physiological stage—much in the way that children are not “small adults,” but have uniquely different physiologies, burden of disease, communication challenges, pharmacologic considerations, different thresholds of acceptability for laboratory and radiographic findings, and much greater dependence upon socioeconomic graces than the population that ranges from ages 18 to 64.
It has served me well to mentally stratify my diverse patient load into pediatrics, adults and older adults in my practice.
I am not a gerontology Physician Associate (PA). I’m not a family medicine PA. I am an occupational medicine PA. I work for the workforce by performing maintenance physicals, high-risk or high-hazard exposure physicals, general pre-employment physicals and evaluation and treatment of injured workers. My youngest client is 14. My oldest client is 87. As medical professionals and good social services keep our older adult population healthier for longer, I enjoy their routine presence in my office.
My day may look something like this:
The first patient is in his late 60s and less than thrilled to continue working, but financial burdens compel him to. He is fit, with sunburned sagging skin laced with tattoos from time spent in jail, some old track marks from his younger years, and a suspicious lesion that looks a lot like melanoma. I’ll allow him to keep working because he can perform his job, but I refer him to a free clinic for that funny skin lesion. Surprised that my cheery demeanor isn’t flattened by his cloudy one, he softens and thanks me for “caring about someone like him.”
‘I need to break the hard news: he did not pass his medical physical today.’
The next older adult is here for a pre-employment physical for that post-retirement “fun job”—“something I always wanted to do and to stay busy.” It’s a fast visit and I feel refreshed.
The third older adult is a Department of Transportation (DOT) driver of 40 years. Today, he failed his vision and hearing exams. He is a patient I have never met, but I can see from previous exams that he has battled to stay within federal guidelines for his heart disease and sleep apnea, begrudgingly going through all of the hoops asked of him to maintain a minimum level of fitness to operate a commercial vehicle.
I need to break the hard news: he did not pass his medical physical today. However, this may not be the end. We have a heart-to-heart about everything that he needs to do to get back on the road. We also have a heart to heart about when it’s time to change careers.
He may be calm. His grief reaction may unfold rapidly in my exam room. These medical exams carry a degree of danger for this very reason, and I never assume that the older adult will be more docile or passive than a younger person would be. He is still a person with his own personality, traumas, struggles and goals. How I present myself—as a goalie to work around, or the tutor that can give him the answers to the test—often makes a substantial difference in the tenor of the office visit.
The fourth older adult is someone I’ve seen before—a few times. He’s 72 and looks his age, with a beautiful sense of humor and a family that motivates him. My first encounter with him was a long event: three hours to evaluate, clean, and stitch multiple lacerations over bilateral arms and face. We got to know each other well during that encounter.
I find these encounters a bold contrast to the societal stereotypes of the older adult as meek, passive, demented, slow, forgetful, weak.
The second time was when he was taking a new medication to help with dry mouth, and he started to over-salivate when he was about to eat his lunch. He began to cough violently. His coworker believed he was choking and performed the Heimlich Maneuver. Poorly. Though he was referred to me immediately following the event, my client was well and recounted the story both in disbelief and laughing. He was mostly critiquing the pathetic Heimlich Maneuver and swore that he would teach his coworkers how to do it properly next time.
Today’s visit was a head injury, something that I always watch closely in my older adult population. Because a certain degree of brain atrophy/shrinkage is normal, more bleeding needs to occur to cause the expected symptoms of a brain bleed. But does every head injury need that CT scan? This time, I thought that he did. I knew him too well, and he wasn’t laughing. Among other signs, he didn’t feel like himself. Flags were up, but I couldn’t tell if they were orange or red. A concussion or an early bleed?
I recommended the Emergency Room—at least a STAT CT scan. Just as I decided to be worried for him, he said, “Mrs. Lisa, what if I don’t go and I decide to wait it out; see what fate has in store for me? I’ve lived a good life.”
We had already spoken about the risks and he was a good listener. He was asking permission to act according to his free will instead of on clinician orders. I said, “do what is right for you, my friend.”
One week later, my friend came back to my office saying “I feel like myself again. I can keep up with my grandson running up and down the stairs, so I know I can get back to work now. I’m ready.”
I find all of these encounters a bold contrast to the societal stereotypes of the older adult: meek, passive, demented, slow, forgetful, weak. As multigenerational households become less and less common, the stereotypes persist unchallenged.
In medicine, many clinicians develop their own stereotype of the older adult: highly medically complex, slow, stubborn. Yet, from what I see, the older adult population is full of joy, energy, resilience, laughter, and—more so than any other age group—the wisdom to recognize a caring clinician.
Lisa McLean, PA-C, is an occupational medicine PA with Concentra and president of Geriatric Medicine PAs in Plymouth, Mich.
Photo credit: Shutterstock/WORACHIT YANGCHAROENKIT