Instructor: Self-study
Revised by: Sharee A. Wiggins, NP
Edited by: Mary McDonald, MD
Specific Learning Objectives
A. Introduction
Before reviewing the learning objectives and content, please take the Pre-Test. You must do this before you can proceed with the module. The answers are given in the Post-Test that complete the module.
B. Learning Objectives - Upon completion of this web module, students should be able to:
Older adults are seen in most primary care and specialty practices. This will become increasingly true with the age wave of maturing baby boomers. There is increased heterogeneity with age; to wit, biologic uniqueness increases with age. Many older adults are active, cognitively intact, relatively well and do not require a different approach to physical diagnosis than other adults. However, aging older adults are more likely to have disease, more complex histories, more medications, and functional limitations. Knowledge of the older adult’s baseline is important to distinguish between insidious vs. acute changes. Knowledge of physiologic aging and the ability to differentiate between “normal” aging and disease is fundamental to the care of older adults.
As with younger complex patients, it is helpful to identify the patient's (or family member’s or caregiver’s) most pressing goal for the current visit. With increasing age, the Family History (FHx) becomes less relevant and is superseded by the more relevant environmental and Social History (SHx). Complete a thorough history, physical and problem list in the first couple of visits. Recognize that more than one visit may be needed if the history is complicated or the patient fatigues easily. A comprehensive physical exam may need to be done in two visits.
Screen for and manage functional impairment and quality of life issues. The most critical issue for older adults is maintaining function. Early recognition and intervention may reverse or slow decline, and positively impact quality of life. Functional loss is in itself a serious illness and frequently leads to institutionalization. Frail and disabled older adults are the most vulnerable to adverse outcomes.
Undernourished older adults are at high risk for increased morbidity (including longer and costlier hospital stays) and mortality. Maintain a high index of suspicion for nutritional risk in all older adults. ASK about appetite, current and past weights (3-6 months, one year, middle-age), dietary habit changes, lifestyle, and resource changes. Perform a nutritional assessment as indicated. Specifically inquire about types and volume of food actually consumed, as well as type of food preparation the older adult actually does. (See the Nutrition Web Module).
Impaired hearing is very common with increasing age. It is important, however, to differentiate between a hearing impairment and confusion. For the hearing impaired:
- Use low, clear, distinct voice
- Ask one question at a time
- Speak directly to patient
- An issue of dignity as well as pragmatism
- Some hearing impaired persons supplement with lip-reading
- Inquire about hearing aides; if not used, why not?
- You may learn about more than just the hearing issue
- Amplifier with small headset may be needed
- If necessary, use your stethoscope as an amplifier for the patient
In keeping with respect for the autonomy and dignity of the older adult, always inquire from the patient – to the best of his/her ability -- information about his/her symptoms or problems. When possible, avoid having family assume the primary role in providing history. History from a secondary source is often needed and helpful, but include the patient in discussions verbally and with eye contact.
- Consider a pre-visit health history packet for efficiency and enhanced accuracy by the patient/caregiver without the pressure of time to complete the information.
- Difficulty in obtaining history from the older adult may indicate a need for cognitive assessment.
- Due to well-preserved social interactions in early dementia, the dementia may be missed if mental status screening is not done.
- Be particularly alert to new or acute mental status changes since these often herald infections in older adults, especially the frail elderly.
- Always ask about caregiver stress. Unrelenting demands, poor coping skills, or lack of adequate resources increase risk of elder neglect, exploitation, or abuse.
It is very common for older adults to see multiple health care providers, use more than one pharmacy, and take multiple medications. Some older adults will consider only their prescription medications when asked about current medications. Directly ask about:
- Over-the-counter medications in general, and ask specifically about medications for pain, colds, constipation, and the use of topical agents
- Health food/herbal products and nutritional supplements
- Remember that some older adults may not recognize a product labeled as a “dietary supplement” as a medication
- Website for an overview of FDA regulation of dietary supplements http://www.cfsan.fda.gov/~dms/supplmnt.html
- Actual use, non-adherence
- Put the patient at ease to be truthful about how the medication is actually being taken – regardless of how it was prescribed
- In some cases, a statement such as: “Have you ever found yourself needing to take the medication differently?” may be appropriate and yield important information
- Follow-up if affirmative. Common reasons for variance in actual use include: side-effects, new verbal/phone instructions of prescriber, change in condition, financial constraints, misunderstanding
- Allergies or Side effects
- Obtain details about any reports of allergies vs side-effects
- An allergy may be documented in the H&P and erroneously repeated as fact by others because no one clarified
- Financial resources
- Ask patient/family to bring in all medications to appointment
- Current as well as previous medications no longer used
- Provides opportunity to obtain names of providers, pharmacies, medications/doses, indications
- May also provide opportunity for education about potential hazards of keeping older medications in the home
Functional limitations should be assessed. In more robust older adults, a simple statement noting the lack of functional impairment is all that is needed. Elderly persons with new functional limitations should be assessed thoroughly and early for intervention in the underlying problem and reversal of the limitation, or reduction in severity.
Those with chronic functional impairments that have worsened should also be closely assessed and intervention initiated when possible to prevent further decline. While not part of a typical H&P, placing a Review of Function (ROF) immediately following the Review of Systems (ROS) may be entirely appropriate and useful for monitoring change over time.
Functional Screening
Office-based assessment of function can be accomplished quickly by asking the patient to demonstrate six standard maneuvers. Two video clips and case questions can be viewed on pages 6, 7, and 8 starting at this University of Iowa URL:
http://www.healthcare.uiowa.edu/igec/e-learn_lic/trainpreceptor/section02 /page06.asp
From this same site, now click on pages 26-29 for assessment practice.
There are variations of the original Katz Index of Activities of Daily Living which is designed to assess the ability of older adults to participate in 6 domains as: “independent,” “needs assistance or modification,” or “dependent.” Ambulation is usually added to the original six domains. It is important to note in the history exactly what type of assistance or modification is needed for the older adult to participate in the activity.
- Basic Activities of Daily Living (ADLs)
- Bathing
- Dressing
- Toileting
- Transfers
- Continence
- Feeding
- Ambulation
The Instrumental Activities of Daily Living assess 7 domains of more advanced functional ability. A word of caution: sometimes older adults who have been ill for some time or those with early dementia will over-estimate or over-report their abilities. Follow-up questions may be useful, such as for a patient who says she still cooks. In a non-confrontational manner, ask what she/he cooked last night and how she/he prepared the food. It may become clear that the IADL is not fully independent as claimed. For patients who state they still drive, it may be appropriate to ask how he/she arrived at today’s appointment, or when they last drove and where.
- Instrumental ADLs
- Using the telephone
- Shopping
- Food Preparation
- Housekeeping
- Travel/transportation
- Medication Responsibility
- Managing money
To download a copy of the Lawton and Brody IADL assessment tool, go to:
http://www.healthcare.uiowa.edu/igec/tools/function/lawtonBrody.pdf
During history-taking, the provider will have noticed the patient’s general level of alertness, cognition, and affect. General impression information will also come from observations of posture, motor activity during the interview, facial expression, degree of eye contact, reaction to the environment, manner and rate of speech, accents, use of language, level of distress or comfort, and sexual and cultural identity. Inferences about self-care are made from observations of condition of clothing, appropriateness of dress, hygiene, general nutritional status, and interactions with family members. You will also obtain a general impression of chronological age vs. physiological age; of whether they appear older or younger than their stated age. The photos below are examples of this.
100 years old
Photo Credit: OSCE/Rena Effendi
www.osce.org/photo_gal/2007/02/23182_web.jpg116 years old
Maria Esther de Capovilla of EcuadorPhoto Credit: http://www.supercentenarian.com/oldest/maria-capovilla.html
Weight and height are critical. Weight should be monitored over time. Potential for multifactoral contributions to weight loss must be explored. (See Nutrition Module).
Older patients often demonstrate absent or only very low-grade fever in the presence of serious illness. On the other hand, if the oral temperature is quite low (< 97 F.), recheck it being sure the probe is in the posterior sublingual pocket rather than anteriorly.
Positional blood pressures and pulse should be obtained. Standing blood pressure should be checked upon arising and again in 3 minutes. Regardless of the patient’s position, the cuff should be at heart level. Arterial stiffness is present if the artery remains palpable after the cuff is inflated to the point which Korotkoff sounds are no longer heard. This can cause pseudohypertension. An auscultatory gap may be present. Palpate the BP first. Upon releasing the cuff pressure and waiting one full minute, inflate the cuff until the manometer is 30mm Hg above the palpated BP. Check both arms to note if one has a higher BP than the other. If so, note this in the record and use that higher pressure arm. Failure to detect an auscultatory gap could result in a normotensive BP recording in a patient who actually has hypertension. Automated blood pressure machines may be quite uncomfortable, especially in persons with thin arms. Cuff pressure is higher and for a longer duration than with a manual cuff.
Clinical Considerations
- With history or suspicion of a recent fall, inspect and palpate the head for signs of trauma
- Skin exam for common pre-malignant lesions of actinic keratosis (AK) and skin cancers: squamous cell (SCC), basal cell (BCC), and malignant melanoma (MM)
- Temple exam for temporal artery pulselessness, tenderness, hardness, or beading. Giant Cell Arteritis (CGA) occurs in adults over age 50 and can be vision threatening without urgent intervention.
- Greater than 25% of persons with GCA also have polymyalgia rheumatica (PMR).
Photo Credit: http://www.uveitis.org/medical/articles/case/gca.html
Photo Credit: Charlie Goldberg, MD; UCSD School of Medicine http://medicine.ucsd.edu/clinicalimg/head-temporal-wasting2.html
Cerumen production does not increase with age, but increased retention within the external auditory canal (EAC) can occur with increasing flaccidity of the pinna. Presbycusis is very common. Hearing aids may also promote retention in some persons. Remove a cerumen impaction before further testing. Note any screening hearing impairments and by what method; i.e. repeat whispered word or screening such as with an Audioscope ®. http://www.audiometrics.com/audioscope.htm
Clinical Considerations noted in preceding history section.
The pupils normally become smaller with age. Older adults on opioid therapy for persistent pain syndromes will demonstrate miosis (as any other person would). A history of cataract surgery is added to the list of usual differentials for irregular pupils. Cataracts are very common. Look for ectropion and entropion, and potential eye irritation or infections. Dry eyes are common due to decreased tear and goblet cell function. A “watery” eye may develop due to periorbital tissue atrophy and resulting displacement of the lacrimal punctum. Arcus senilis is common and not clinically significant. Acquired ptosis (age-related or cataract surgery) is frequently noted; assess for visual impairment with severe ptosis. Medicare has strict criteria for surgical intervention.
Clinical Considerations
- Health Maintenance: Annual eye exams. Older adults have increasing risk for development of cataracts, glaucoma macular degeneration, hypertensive retinopathy and others.
- Normal age-related changes of increased glare sensitivity and decreased contrast sensitivity result in difficulty discriminating between target and background; generally reduced visual acuity due to numerous physiologic aging changes. Potential implications include:
- Night driving difficulty
- Quality of life and functional issues
- Increased fall risk (discrimination/glare)
- Office based functional screen
- check ability to read patient education materials, consent forms, newspaper, etc
- Medication Issues
- Difficulty reading prescription bottle labels
- Color discrimination in medication box – trying to find white pill in shiny white pill box (increased risk of missed dose)
- Mistaking one medication for another
Arcus Senilis
Photo Credit: http://e-learning.studmed.unibe.ch/augenheilkunde /systematik /hornhaut/arcus.html
Entropion
Photo Credit: http://www.eyeatlas.com/box/28entropion.jpg
Involutional (age-related) Ectropion
Photo Credit: http://www.eyeatlas.com/box/28entropion.jpgMacular Degeneration (early to late) & Glaucoma
The student is encouraged to visit these images websites:
- Vision Simulation Presentation of color photographs. www.acbvi.org/albums/Vision/
- 15 second video of AMD (age related macular degeneration) from the National Eye Institute, National Institutes of Health. http://www.nei.nih.gov/photo/keyword.asp?conditions=Macular+Degeneration
The following 2 photographs are courtesy of the National Eye Institute, National Institutes of Health. First, the normal view, then peripheral vision loss with Glaucoma.
Normal View
Glaucoma (simulation photo)
The mouth should be fully inspected for dryness and lesions. While the tongue and buccal mucosa should be assessed for moisture and lesions, estimating hydration status based on oral exam is not reliable. Assessment of the teeth and gums is necessary. Dentures should be taken out to examine the gingival ridge and surrounding tissues. Lesions and poorly fitting dentures can be significant contributors to unintended weight loss. Careful attention to potential oral cancers, particularly in tobacco users (any form).
Clinical Considerations
- Dry mouth: poor oral intake, medications, mouth breathing, salivary insufficiency such as with Sjogren’s syndrome
- Condition of teeth: type and quality of restorations can reveal values about dental care and resources (money and insurance)
- Loss of native teeth is NOT part of normal aging, but is common due to periodontal disease; up to 30% of periodontal disease occurs despite aggressive dental hygiene habits
- The tongue and mouth can suggest nutritional deficiencies such as the presence of angular cheilosis, gingivitis, or glossitis.
- Squamous cell cancer (SCC) of the lower lip is the most common oral location, with the highest incidence in older adult males
Due to ROM limitations that occur more often in the aging adult, the neck may not be “supple.” This is primarily due to c-spine arthropathy. Neck masses are of concern since, in general, neoplasms are most commonly found in older adults. Thyromegaly does not support either hyper- or hypothyroidism. The latter is the most common endocrine disorder in older adults, particularly the older woman.
Clinical Considerations
- Significant ROM limitations in the neck impact safe driving
- High index of suspicion for malignancy in neck masses until proven otherwise
- Annual TSH usually recommended
Exam can be difficult in patients who cannot understand or cooperate with deep inspirations. It is not uncommon to find minimal basilar crackles even in the absence of pathology, particularly in the frail elderly. By age 65 full lung expansion can only occur while standing. Kyphosis is not normal, but very common in the older female and can alter chest wall compliance and thus the lung exam.
Clinical Considerations
- Auscultate posteriorly and laterally from the bases up to obtain the greatest yield without exhausting your patient from hyperventilation
- Recall that most of anterior auscultation assesses upper lobes only
- However, detection of wheezing is sometimes better detected with the patient supine, with anterior auscultation, or auscultation during forced expiration
- Add to exam in older adult with reports of dyspnea but negative findings with usual exam
- Due to multiple aging physiology issues in the pulmonary system, the older adult is at greater risk for atelectatsis and pneumonia
- Risk for aspiration pneumonia increases with age due to age-related reduced cough reflex and micro-aspiration
Kyphosis
Anterior Lobes
Posterior Lobes
Lobes of Right Lateral Exam
Lobes of Left Lateral Exam
On exam, the inframammary ridge in the older woman may be perceived as more prominent due to reduction of glandular breast tissue. Assess for biopsy or mastectomy scars consistent with history and for any lymphedema. Older women are more likely to have had radical surgery. Many medications can cause gynecomastia in men, as well as some medical conditions.
The incidence of breast cancer does increase with age. However, there continues to be debate regarding recommendations for breast self exam (BSE) and mammography. The US Preventive Services Task Force (USPSTF) does recommend screening mammography – with or without BSE – every 1-2 years for women 40 and over, and that the evidence for survival benefit is strongest for women aged 50 to 69. There is insufficient evidence to recommend for or against routine clinical breast exam (CBE) alone to screen for breast cancer; and insufficient evidence to recommend for or against teaching or performing routine BSE. The USPSTF recognized imperfect evidence due to design limitations of published studies at the time these recommendations were made.
http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm
The American Cancer Society (ACS) recommends annual mammography beginning at age 40, monthly BSE beginning at age 20 and CBE every 3 years for ages 20-39, then yearly thereafter.
Mammography detection of breast cancer in older women is easier to due less dense breast tissue. Screening the older woman must be individualized based on patient preference, family history, current health, and comorbidities that could reasonably be expected to shorten life. For women over age 70 without any major health problems, screening mammography is reasonable.
Carotid bruits are common markers of atherosclerosis, but their predictive value as an asymptomatic finding remains controversial at advanced age. The absence of a bruit does not mean that atherosclerosis is lacking. Try to distinguish a carotid bruit from a radiating cardiac murmur. Murmurs are heard during the cardiac exam, diminish moving up toward the neck, and may present bilaterally. Carotid bruits are often unilateral and heard only in the neck. However, the murmur of aortic stenosis is heard during the cardiac exam and radiates into the right neck. In fact, if neck radiation is not auscultated the presence of aortic stenosis is highly questionable.
It is common to have difficulty palpating the dorsalis pedis and posterior tibial pulses. Other observations about vascular integrity of the lower extremities provide supplemental information: skin integrity; warmth; color – particularly with leg dependence (rubor) or elevation (pallor).
Lower extremity edema is a frequent source of concern to older patients, but can occur in the absence of heart failure. Dependent edema (venous stasis) improves overnight in the absence of gravity and then worsens during the day with leg dependence. Persons who have had long-standing leg edema can develop chronic venous stasis changes of the skin with hyperpigmentation – hemosiderin deposits from capillary and RBC rupture secondary to capillary hypertension – and telangiectasia. In persons with chronic venous insufficiency (CVI) due to deep vein thrombosis, the changes will be on the DVT side. Long-standing CVI can lead to stasis ulcers, particularly near the medial ankle.
Chronic Venous Stasis Edema with Associated Skin Changes
Venous Stasis skin changes -- more pronounced Chronic Venous Insufficiency (CVI)Photo Credit: www.emedicine.com/derm/topic475.htm
Clinical Considerations
- Altered baroreceptor sensitivity contributes to increased risk of orthostasis
- Aggravated by medications, hydration status (which can be impacted by several age-related changes)
- Check VS for orthostatic changes, and check for postural instability
- Careful medication review
- Consider history of fall, trips, or stumbles
- Some older adults will not admit to falls, but will acknowledge trips or stumbles
- Carefully monitor for Isolated Systolic Hypertension (ISH) which accounts for 70% of adults > age 60 with HTN
- Recall your patient’s CV risk with poorly controlled ISH
- Increased risks of stroke, acute myocardial infarction (AMI), and CHF
- Assessment of JVD and hepatojugular (HJR) reflex maneuver (aka: abdominal-jugular reflex; AJR) as indicated by history and other exam data
- Consider atypical presentation of CV conditions common in older adults
- Shortness of air (SOA), fatigue symptoms can have multiple etiologies , such as:
- Congestive Heart Failure (CHF)
- Coronary Artery Disease (CAD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Pneumonia
- Anemia
- Deconditioning
- Cardiac Valvular Insufficiency (incompetent valves)
- Anxiety (may be either cause or effect of SOA)
- Recall increased importance of atrial kick due to age-related reduced diastolic filling, reduced tolerance of tachy rhythms and potential for myocardial ischemia, frequency of atrial fibrillation in older adult population
- Lower extremity edema DDx
- Bilaterally: dependent; CHF
- Unilateral: acute DVT; chronic with PPS (post-phlebitic syndrome); infection; may have unilateral valvular incompetence with varicose veins; surgical harvest of vein for use in CABG (coronary artery bypass graft)
Unexplained scars not consistent with history provide an opportunity to obtain further past medical history or clarify surgical history. The relatively thinner abdomen of many older persons with loss of muscle mass frequently allows stool in the colon to be palpable. This may be confused with a mass. Treatment of constipation, followed by re-examination, may help clarify this. Kyphosis may contribute to abdominal protuberance. Urinary retention may result in palpably enlarged bladder. The presence of inguinal and femoral hernias increase with age. As with younger adults, the digital rectal exam (DRE) should be done to assess for hemorrhoids, anal sphincter tone, presence and quality of stool in rectal vault, sessile (arising from the wall) or pedunculated (on a stalk) masses, occult blood testing, and in men: prostate size, texture, and presence of tenderness. Benign prostatic hypertrophy (BPH) increases with age, as does colon cancer and prostate cancer risk.
Clinical Considerations
- Recall atypical presentation: older adults can have acute abdomen without pain, nausea, vomiting; Murphy’s sign for suspected gallbladder disease less helpful
- Consider diverticulitis (with appropriate history) if LLQ tenderness present.
- In the frail elderly, the benefit of any invasive testing/procedures/surgeries such as colonoscopy or surgical resection of the prostate must be carefully considered
- Assess bowel sounds; percuss for distention
- Auscultate for bruits
- Palpate masses, colon and aorta
Incontinence increases with age but it is not inevitable. Etiologies to consider are included in the acronyms DIAPPERS and DRIP. (See also UI module.)
Delirium (drugs, acute illness) Delirium (drugs, acute illness) Infection/Inflammation/Immobility Retention (obstruction/hypocontractility) Atrophic Vaginitis Impacted stool/Inflammation/Infection Pharmacologic Polyuria (drugs, high output states Psychological Endocrine (Diabetes, Calcium)
Restricted Mobility/Retention Stool Impaction When present, obstructive symptoms are fairly typical. In women, however, irritative symptoms are much less common in the presence of UTI. Specifically, dysuria is quite uncommon. Frequency may or may not be present. New onset or worsened incontinence, a fall, or mental status change is more common in older women. In both sexes, genital tissues shrink and sexual dysfunction increases with age; this may or may not be problematic to the patient and/or spouse/partner. Erectile dysfunction does not necessarily mean the couple does not engage in sexual activity. To view older adults as asexual is to engage in ageism.
The pelvic examination may be uncomfortable for the older woman due to pain from the speculum exam (atrophic vaginal changes, vaginal stenosis, history of dyspareunia) or the traditional lithotomy position. Vaginal wall tissues thin, rugae flatten, pH changes, and vaginitis symptoms may increase. The frequency of papanicolau smears in older women varies with the recommending agency. The U.S. Preventative Services Task Force recommends against routine screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap tests and they are not otherwise at high risk for cervical cancer.
Clinical Considerations
- Avoid assumptions about sexual activity in older adults
- Ask about ED, dyspareunia, interest in sexual help
- PAP smears are not recommended in women 65-70 who have normal recent screening (past 3 years suggested) and are not high risk
Assessment of ROM and joint exam are very important in older adults. Prevalence of arthritis in older adults is at least 60% or more. Osteoarthritis is the most common source of somatic pain in older adults. However, the appearance of joint deformity on clinical exam may not correspond well to the degree of pain or limitation. This is also true for appearance on x-ray. Functional limitations and the patient’s report of intensity and quality of pain -- not the appearance -- should drive intervention decisions. Compression fractures or fall-related fractures are common with osteoporosis. Several conditions can result in a kyphotic spine but a high index of suspicion for osteoporosis should be maintained. Compression fractures range from asymptomatic to exquisitely painful.
Clinical Considerations
- Ask about the presence of pain in all older adults
- Detailed pain assessment should be done as indicated
- Adhesive capsulitis (frozen shoulder) can occur with acute or chronic shoulder injury
- Aggressive treatment with medication for pain, inflammation, and PT often needs to be instituted to prevent the condition from being permanent
- Observe for ability to rise from a chair without arms/hands to push up
- Rocking motion to assist the body up suggests quadriceps weakness – common in functional decline
- BMD (bone mineral density) testing is covered by Medicare for these individuals age 65 and older:
- Estrogen deficient women at clinical risk for osteoporosis
- Individuals with vertebral abnormalities
- Individuals receiving, or planning to receive, long-term glucocorticoid (steroid) therapy
- Individuals with primary hyperparathyroidism
- Individuals being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy
Feet
Excessive pressure can cause calluses, corns, and bunions (hallux valgus). Fungal infections of nails (onychomycosis) and very dry, flaky skin (xerosis) are quite common. Mobility limitations can make it difficult for patients to reach their feet to care for them. Properly fitting shoes are a necessity, and improper fit is often at the root of many problems. Feet problems can contribute to gait difficulties and functional limitations. Referral to good podiatrist can be very helpful, particularly with diabetics or those with arterial disease. A nice hallux valgus photo can be seen online at:
www.wheelessonline.com/image9/hv1.jpg. Hammertoe photos and other problems can be seen in this online article: www.podiatrytoday.com/article/4516.
Observations about movement, speech, and cognition are made throughout history-taking and exam, functional assessment, and during mental status screening. A systematic and thorough neurologic examination should be made including assessment for tremor (and type), cogwheel rigidity (often brought out by use of RAM – rapid alternating movements such as with the opposite hand/arm), motor strength, tone, gait, function, and mental status. There are several neurologic changes with age. These findings do not have the same meaning as they might in younger persons provided they are isolated, asymptomatic findings that are not part of an overall larger worrisome pattern.
Neurologic changes:
Clinical Considerations
- Olfaction declines gradually with age – by about 15% at age 80
- Pupillary changes noted in HEENT section; decrease in upward gaze common
- Voice quality changes such as subtly increased harshness related to thickened laryngeal epithelium; sometimes a “breathy” quality
- Measured muscle strength declines gradually and symmetrically on research testing, but clinically strength should be normal (5/5) in healthy aging
- Varying degrees of weakness may represent old musculoskeletal injury if consistent with history
- Motor reaction time commonly increases, and reflects integration of many systems: sensory, motor, and central processing
- Vibratory sense may be decreased in the distal foot
- Greatly diminished or absent ankle jerk (Achilles) DTR is quite common among normal older people, but the same is not true for other deep tendon reflexes
- Knee jerk response in any adult should be interpreted in light of quadriceps mass
- Reduced mass/strength will result in a diminished DTR
- Quadricep strength decrease is common (but not normal) in many older adults
- Minor changes in recent memory
- Misplaced keys, names of persons recently met, a particular word
- There are no impairments in short-term or long-term memory
- The memory does not worsen over time
- Mental status information is needed to establish a baseline standard to compare with potential future mental status changes
- Not every older adult needs a Mini Mental State Exam for screening
- Mental Status information can be gleaned from:
- Appearance & Behavior, Speech & Language, Mood & Affect, Thought Process & Content, Basic & Higher Cognitive Functions (orientation, attention, memory, new learning, abstract thinking)
- Monitor gait for evidence of pathology and pattern related to particular pathology
- Common gait pathologies of older adults include cerebrovascular insult, Parkinsonian, cerebellar, and sensory ataxias
- Not all gait ataxias are of neurological origin
- Musculoskeletal pain and deformities are also common etiologies
- Maintain high index of suspicion for NPH (Normal Pressure Hydrocephalus) in any older adult with the triad of gait disturbance, features of dementia, and new urinary incontinence. UI is a late sign. The dementia is predominantly a problem of memory rather than the global impairment of Alzheimer’s disease (AD). The classic NPH gait is slow, broad-based, and feet “magnetized” to the floor in a sort of shuffle.
- Patients are sometimes misdiagnosed with AD or PD (Parkinson's disease).
- Subtle focal findings along with speech or functional deficits certainly suggest potential cerebrovascular disease may be responsible for, or contributing to, dementia (VaD – vascular dementia)
- EPS (extrapyramidal signs) of rigidity and tremor (not essential type) suggest potential Parkinson’s disease or drug-induced response from atypical antipsychotic agents (such as risperidone, olanzepine, and others)
- Intention-type tremors, essential/familial, or physiologic tremors are benign though sometimes disabling.
- Good article on assessment of geriatric gait and balance can be viewed at: http://www.medscape.com/viewarticle/514567
Numerous age-related changes occur in the skin and supporting structure. Dermal thinning by 20% occurs with normal aging. Subcutaneous fat atrophy and capillary fragility develop. Ecchymoses and skin tears are common on areas of minor trauma such as the dorsum of the hands and forearms. Turgor is lost due to decreased collagen and elastin, as well as reduced non-collagen extracellular matrix such as proteoglycans, matrix proteins, and water. Volume status cannot be accurately gauged by skin turgor in older adults. Older adults with functional limitations are at increased risk of pressure ulcer. If erythema is seen in areas that have just had pressure from the patient's position, see if the erythema blanches. If not, recheck after a period of no pressure. Non-blanching erythema over intact skin indicates a Stage I pressure ulcer. (Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.)
Clinical Considerations
- Pre-malignant or malignant changes
- Pressure problems and intervention
- Need for skin tear prevention/risk reduction strategies
- Skin tears can be a source of bacterial entry for cellulitis
- Secondary lesion evidence of pruritus – local vs. systemic disease
- Evidence of falls or other trauma such as physical abuse
Xanthomas are skin lesions that contain cholesterol and fat. They are common in older adults. They can occur anywhere but have a predilection for hands, feet, and joints. Xanthelasma palpebrae is a specific form of xanthoma that occurs on the eyelids and most are unrelated to hyperlipidemia.
Bilateral Xanthelasma
Solar elastosis is excessive wrinkling from cumulative sun exposure. The condition causes one to “appear older than stated age.”
Solar Elastosis of the FaceSolar lentigines (aka: lentigo, senile lentigines, actinic lentigines, “sun spots”) are well-demarcated brown macules on sun-exposed areas (hand, arms, face). They are present in > 90% of fair skinned older adults. The lesions do not fade.
Solar LentiginesSeborrheic keratoses are benign, "stuck-on" appearing lesions quite common on the face and trunk.
Seborrheic KeratosesActinic keratosis (aka: solar keratosis, senile keratosis) is a precancerous lesion (conversion to SCC) which appears as rough, red or brown scaly patches, and/or waxy thickened skin. It is usually associated with photodamage and thus, usually appears on sun-exposed areas but can be found elsewhere.
Actinic Keratoses
©
The University of Kansas Medical Center
