We all know the population is aging, but did you know that close to half of all adults over age 65 in the U.S. have some kind of disability? The Americans with Disabilities Act (ADA) includes as a disability any “physical or mental impairment that limits one or more life activities” or a history or record of such impairment.

Thus, disabilities include: physical limitations such as mobility issues, pain, and fatigue; sensory impairments such as being hard of hearing or deaf, or having low vision or blindness; chronic health conditions (such as cancer or diabetes); cognitive or intellectual impairments (including dementia, or having had a brain injury or stroke); and psychological conditions, such as depression, PTSD, or an anxiety disorder.

Given this broad definition, I’m surprised the prevalence of older adults with disabilities isn’t much higher.

The ADA, of course, prohibits discrimination against people with disabilities. However, even without overt discrimination, I believe that much of our health care workforce is not prepared to handle older adults with disabilities. This is due primarily to lack of education and experience with this heterogeneous population, as well as simple unawareness of the issues. Unfortunately, lack of preparedness creates significant barriers to these patients accessing and receiving quality health care.

Issues include accessible physical space, but also the need for assistive devices, and accommodations or modifications to the evaluation or treatment session itself. While “compliant” office space and bathrooms are typically achieved, there are a myriad of additional considerations to be taken into account.

• Does your office have a portable amplifier and magnifier in case your patients are hard of hearing or visually impaired?
• Is the exam room sufficiently quiet?
• Is the lighting adequate?
• Could you accommodate appointments at the patient’s preferred time of day?
• Is there a need to ask or involve a family member, with the patient’s consent, in the event the patient is cognitively impaired?
• Are handouts or some kind of reminders or education needed?
• Do you need to allow the patient additional time to complete tasks or answer questions?
• Do you need to consult with or send the patient to speech therapy or OT or PT for strategies or equipment?
• In a psychotherapy appointment, should you encourage the patient to take notes, something you ordinarily may not do?
• Do transportation services or prescription deliveries need to be arranged?

These are just some examples of suggested practices required for more equitable and accessible services.

In addition to accessibility, accommodating our patients’ disabilities also avoids unnecessarily restricting their autonomy. I teach my students that, when assessing a patient’s cognition or their decision-making capacity, we first need to maximize their functioning and abilities. This could involve first ruling out reversible causes of dementia or delirium (such as a UTI). It also means providing supports such as ensuring the patient has their glasses or their hearing aids, with batteries. Or supplying enlarged written materials or a sound amplifier. Confirming the patient is not in acute and distracting pain, or hungry, or sleep deprived. Sometimes rest breaks or additional time is needed, or an assessment has to be postponed until their depression is treated, or blood sugar stabilized.

In other words, it is very important that information is presented in a clear fashion, but also that it is actually taken in and processed, and that the patient understands, before there can be any sort of examination. Thus, capacity can first be restored or optimized, and then assessed (or reassessed), to prevent a misleading result.

Years ago, my grandfather was a patient in my hospital, on the telemetry unit. He was extremely hard of hearing and usually wore hearing aids. One day I went during a break to visit him while my aunt was out buying new batteries for his hearing aids. Until she returned, we had to resort to writing notes back and forth to communicate.

In this interim, a resident came in, said hello to my grandfather, and proceeded to tell him the procedure he would be having the next day. My grandfather nodded, she left, and I wrote him a note asking, “Why did you just nod and say ‘OK’ when you couldn’t hear anything she said?” He was trying to be polite, he said. I ran after the resident to tell her that he couldn’t hear her at all. She was stunned. She promised to come back after my aunt returned to go over everything again, but I couldn’t help but think about patients who didn’t have someone there to advocate for them. What if he were being evaluated alone and found to be cognitively impaired, when he instead had severe hearing loss?

To conclude, the number of older adults with disabilities will continue to rise and clinicians, regardless of specialty, will be required to provide services that address the needs of patients with these multiple identities and related lived experiences. This is a topic not often discussed; you can find articles on older adults and aging, and some about disability, but rarely anything about the intersection and interaction of these conditions.

Therefore, there is tremendous demand for increased awareness of this topic, and for more education and training in disability issues as well as accommodations that allow for more equitable and accessible health care and the optimization of capacity.

Lynn A. Schaefer is a neuropsychologist.