In search of age-friendly health care, finding room for improvement

A month ago, during a visit to her doctor's office in Sequim, Wash., Sue Christensen fell to her knees in the bathroom when her legs suddenly gave out.

The 74-year-old was in an accessible stall with her walker, an older model that doesn't have brakes. On her left side was a grab bar; there was nothing to hold onto on the right.

Christensen tried to pull herself up but couldn't. With difficulty, she rearranged her clothing and, inching forward on her knees, exited the stall. There, she tried calling the front desk on her cellphone but was placed on hold by the automated phone system.

Altogether, Christensen, who has a herniated disk in her back, was on the floor for almost half an hour before a nurse and her husband, who'd been parking the car, lifted her to her feet.

"I just wish there had been a button that I could have pushed indicating that someone in the restroom needs assistance," she said.

For older adults, especially those who are frail, who have impaired cognition, or who have trouble seeing, hearing and moving around, health care facilities can be difficult to navigate and, occasionally, perilous.

Grab bars may not be placed where they're needed. Doors may be too heavy to open easily. Chairs in waiting rooms may lack arms that someone can use to help them stand up.

Toilets may be too low to rise from easily. Examination tables may be too high to get onto. Lettering on signs may be too small to read. And there may not be a place to sit down while walking down a hallway if a break is needed.

"Most hospitals and clinics have been designed for 40- or 50-year-olds, not 70- or 80-year-olds," said Dr. Lee Ann Lindquist, chief of geriatrics at Northwestern University's Feinberg School of Medicine in Chicago. "Additional thought has to be given to seniors who have functional disabilities."

What changes could be made to better accommodate older adults' needs? I asked geriatric specialists and seniors to identify practical issues that should be addressed. Here are a number of suggestions that came up repeatedly.

Parking

Difficulties start in the parking lot, which may not be adjacent to the medical center.

That's the case at Long Island Jewish Medical Center, a large teaching hospital in New Hyde Park, N.Y. Every day, Dr. Maria Torroella Carney, a geriatrician at the hospital, crosses a busy road from the parking lot to the hospital's entrance.

"It's challenging. There isn't clear signage indicating where to cross safely, and if you need to stop and rest there aren't any benches nearby," said Carney, who is also chief of geriatrics at Hofstra/Northwell School of Medicine.

Dr. Michael Wasserman, a California geriatrician on the board of the American Geriatrics Society's Health in Aging Foundation, observed that accessible parking spaces are often in short supply. "Even then, not all older adults who need help have a handicap sticker," he noted.

The University of Florida's Senior Care Clinic has a solution: valet services. "When an older patient comes by themself, if they need help, the valet will call our clinic and someone will come down and take the patient up," said Dr. Bhanuprasad Sandesara, division chief of geriatrics.

Signage

All too often, easy-to-read signs indicating where patients should go can't be found, either inside or outside medical centers. For older patients, this can lead to confusion and unnecessary wandering, accompanied by pain, fatigue and annoyance.

Last year, a committee examining how Long Island Jewish Medical Center should handle patients with special needs (for instance, people with cognitive impairments or hearing or speech problems) identified better signage as a priority.

Now, signs in the parking lot and outside the medical center are bigger, with larger type. Inside the medical center, large signs have been placed at bathrooms, showing clearly if they're accessible to those with disabilities. And the staff is creating a comprehensive map of the hospital campus — a handout — to help patients find their way more easily, according to Roseanne O'Gara-Shubinsky, associate executive director for quality management at Long Island Jewish.

Appointment cards were also altered: Carney persuaded the hospital to print phone numbers in large type on cards for seven geriatricians at its senior clinic.

At Northwestern, Lindquist realized that older patients were having trouble seeing whiteboards in their hospital rooms listing scheduled procedures and the names of physicians and nurses responsible for their care. Upon Lindquist's urging, the hospital bought whiteboards that are more than double the normal size.

Getting Around

At a recent talk in the San Francisco Bay Area to promote her new book, "Elderhood," Dr. Louise Aronson was approached by an older woman who uses a portable oxygen tank to breathe and relies on a rollator walker (with a seat and basket attached).

The woman was new to the area and had been visiting various medical facilities. "Some of these places have ramps, but the angle is so steep I can't push my rollator up," she complained. "Whoever designed them wasn't thinking of someone like me."

At the University of Arkansas for Medical Sciences, Dr. Jeanne Wei, who heads the geriatrics department and the Donald W. Reynolds Institute on Aging, has seen many older adults injure themselves while pushing someone in a wheelchair up an incline. She has insisted that parking lots be on the same level as medical buildings and that sidewalks around facilities be kept in good shape to minimize older adults' risk of falling.

Also, at the University of Arkansas' Thomas and Lyon Longevity Clinic for older adults, examination tables are wider than usual and their height can be adjusted electronically. "Sometimes, it's difficult to navigate lying in a narrow strip" and many older adults are afraid of falling, Wei said.

The staff at Long Island Jewish didn't realize there weren't enough walkers and wheelchairs at the hospital's entrance until the issue came to light during deliberations by the special needs committee. Now, "we've made sure that we have plenty of these available," O'Gara-Shubinsky said.

Something as simple as having a hook to hang up a cane can be a thoughtful touch. "You see this a lot: An older patient sits down, there's nowhere to put a cane, and it falls on the floor," said Dr. Diana Anderson, a geriatric medicine fellow at the University of California-San Francisco, who's also a board-certified architect.

Doors

Diane Ashkenaz, 68, has fibromyalgia, chronic pain and a ruptured tendon. She also has undergone two knee replacements. Most of the time, she uses a walker when she visits doctors in the Washington metropolitan area.

Doors are often a problem. "Neither my primary care doctor nor my orthopedic surgeon have doors to their offices that open automatically," Ashkenaz said.

Not long ago, she said, the staff at a pain clinic's front desk handed her a pen and clipboard and asked, "Can you fill this out please?" How was Ashkenaz supposed to hold those items while finding her way to a chair? No one seemed to realize there was a problem.

At the clinic Sue Christensen visits in Washington, the front doors open wide automatically and a nursing assistant helps her into the exam room. But once her appointment is over, she's directed to an exit door that she must open herself.

"It's pretty heavy and hard to manage while trying to clunk my walker through," Christensen said. "I don't know why they don't have a door system that would be easier for people who don't have much strength or dexterity."

Seats

Ashkenaz has another pet peeve: chairs in waiting rooms with seats that are too low or without arms that she can grab to push herself up into a standing position.

At her cardiologist's office, there's a sofa with deep seats. "It looks nice, but I'd do anything not to sit there," Ashkenaz said. "I just can't get up from it."

Wei's clinic at the University of Arkansas has brought in chairs that are 4 inches taller than usual, with arms, for older patients. "These chairs are always occupied," she said.

Also, exam rooms at the clinic are large enough to accommodate chairs for multiple family members. "We'll bring everyone in to talk about Mom or Dad so they can hear what the other person is saying," Wei said.

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or suggestions for how medical facilities could become more age-friendly.