As patients age, physicians must adjust the way they assess and treat them. There is a great deal of variation in the cognitive and physical functioning of geriatric patients, as well as their activity level, which makes their assessment more difficult. Thus, the evaluation and treatment of every geriatric patient requires an individualized approach. The following areas should be carefully managed by physicians who treat geriatric patients to avoid enhanced liability risks.

Mental Capacity
Some geriatric patients become depressed due to life and physical changes. Others develop medical conditions which result in the patient being unable to understand the nature and consequences of his/her condition and/or treatment options. The physician must determine whether the patient seems to understand the diagnosis and the recommended treatment plan. If the patient’s capacity is so diminished that he/she cannot make appropriate decisions, or is unable to understand or retain instructions for treatment or drugs, there is an increased risk that the patient will make a medication or other error. Such patients should be encouraged to have a competent third party accompany them to all appointments. The third party can listen to the instructions and assist the patient in complying with them. This person might also assist the patient in filling pill organizers correctly, requesting prescription refills, and managing appointments with multiple providers. Alternatively, home health agencies have nurses available to fill pill organizers for a fee. This can be arranged by the physician’s staff to protect the patient.

If invasive treatment or procedures, such as surgery, are needed, obtaining a valid informed consent may be difficult when the patient’s mental capacity is a concern. If the treatment or procedure is not urgently or emergently required, a proxy agent, if one exists, may be asked to provide consent. If there is no court-appointed guardian or proxy agent for the patient, and the procedure has substantial risk, the appointment of a guardian empowered by a court to give consent might be necessary.

Many elderly patients are unable to provide an adequate medical and social history due to deficits in memory. Yet this information is often necessary to formulate a treatment plan. If the patient has brought a knowledgeable third party to the visit, this individual may be able to supply the names of other healthcare providers the patient has seen in the past (or even the names of those whom the patient is currently seeing). With the permission of the patient, proxy agent, or guardian, copies of all relevant medical records from current and prior treating practitioners should be obtained. By using pertinent medical and social information obtained from prior providers, the physician may be able to formulate a more effective and accurate treatment plan.  

Medication Management
As people age, their weight, metabolism, and mental and physical conditions change. The risk of a medication error can increase exponentially based upon a number of factors. Elderly patients often fail to inform the physician they are taking other prescription medications prescribed by multiple healthcare providers. Thus, the physician often does not know the full range of drugs or the dosages that the patient is taking. As a result, the physician may prescribe a medication for the patient which is contraindicated by another medication prescribed by a different healthcare provider. 

One solution is to ask the patient to bring in all medication bottles from all providers at each visit, including prescription, over-the-counter and herbal medications. Some over-the-counter or herbal medications may decrease the effectiveness of a prescription medication, or may even cause the patient to be injured when used in conjunction with a prescribed medication. Thus, it is important for the physician to see and evaluate the need for alternative or herbal medications, as well as prescription medications.

The physician should be aware of every medication the patient is taking and should learn the identity of all providers to make an informed determination about how to appropriately prescribe medications for the patient. Additionally, physicians may wish to utilize the “Beers Criteria”[1] to guide the choice of medications best suited for the individual geriatric patient and to help the physician review the risks of certain medications which are inherent in certain medical conditions. These risks can then either be avoided or addressed. Further, the patient’s list of medications in the office record should be updated and reconciled at every office visit. Finally, each prescription written should contain the reason for the medication. This avoids confusion when a patient is taking multiple medications. Encouraging the patient and family to use a single pharmacy also may help to decrease medication errors.

The Americans with Disabilities Act (ADA)
Geriatric patients may have mobility, hearing, and sight deficits which increase with advancing age. These patients must be reasonably accommodated to protect their safety. A physician’s office is considered a place of public accommodation under the Americans with Disabilities Act (ADA) and must be accessible to disabled patients unless the necessary changes are not readily achievable (accomplished easily, without much difficulty or expense).[2] The first priority for places of public accommodation is to provide access to the location, including provision of handicapped parking places (if the facility offers parking), doors that are easily opened and wide enough to accommodate wheelchairs and walkers; and installation of entrance ramps, if applicable.[3] If a facility is old and/or unable to be renovated to comply with the physical requirements of the ADA, the physician may either meet and examine/treat the patient at another facility or office that is accessible to handicapped individuals[4], or make reasonable arrangements for the patient to be safely transported up steps or around other physical barriers to the office by a qualified third party (e.g. ambulette service).

If the patient requests a sign language interpreter due to a hearing impairment, the ADA requires that the physician strongly consider providing one at no cost to the patient, or provide another reasonable accommodation acceptable to the patient. Written instructions are also helpful and should also be provided to patients with hearing impairments. However, these do not act as a substitute for an interpreter when one is requested. Patients who have limited sight or are blind may be accompanied by a trained service animal in the office. Such animals may not be excluded, unless they pose a safety risk to others in the waiting area or to the hygiene/sterility of an examination/treatment room. If the service animal is not allowed to enter the facility or examination room with a patient due to the above risks, the patient must instead be fully assisted into and at the facility by an alternative method, such as being accompanied by a staff member at all times and/or being pushed in a wheelchair by a staff member. This also reasonably accommodates the patient’s disability.  Finally, although not specifically an ADA issue but rather one of civil rights, as people age, they often regress in their capacity to speak the English language if it is not their primary language. If patients revert to speaking their native language and their comprehension of English is poor, we strongly recommend that patients seen at a facility be accommodated by providing a competent language interpreter in order to comply with Federal regulations.[5] Further, this is also recommended for private practitioners in their offices and to promote the communication (informed consent) and safety needs of patients with limited English Proficiency (LEP).