UNIT-VI: ASSESSMENT OF AN ELDERLY CLIENT
History and Physical Examination of the Older Adult
(Noel A. DeBacker, M.D., F.A.C.P)
The history and physical examination is the foundation of the medical treatment plan. The interplay
between the physiology of aging and pathologic conditions more common in the aged complicates
and delays diagnosis and appropriate intervention, often with disastrous consequences. This
chapter assumes that practitioners will perform the thorough history and physical examination that
is expected of an excellent general internist. It highlights the special considerations required for
the older adult.
History
General considerations
The history may take more time because of sensory or cognitive impairment or simply
because an older patient has had time to accrue numerous details. Several sessions may
be required.
The patient should be recognized as the primary source of information. If doubts arise
about accuracy, other sources should be contacted with due respect paid to the
sensitivities and confidentiality of the patient. When interviewing the patient and
caregiver together, ask questions first to the patient, then to the caregiver.
If the patient's responses to initial questions are clearly inappropriate, turn to the mental
status exam immediately.
The patient should be dressed and seated. The physician should also be seated and
facing the patient at eye level, speaking clearly with good lip movement. If the patient
is severely hearing impaired and an amplifier is not available, write questions in large
print.
Use honorifics (i.e., Mr., Mrs., Miss, or Ms.) unless the patient specifically requests you
to do otherwise.
Areas requiring special emphasis
Function- Pay attention to deficits in basic and instrumental activities of daily living (ADL).
Prepare to assess those systems in the physical examination, looking for reversible
conditions that could upgrade function, e.g., treatment of arthritis to improve dressing
capability.
Medications- Polypharmacy and excessive dosages are common causes of iatrogenic illness.
A "paper bag" test is often useful to explore this possibility, i.e., ask the patient or caregiver
to gather all medications into a paper bag and bring it to the office visit. Be sure to include
over-the-counter (OTC) preparations.
By: Farzana Khattak (Lecturer INS-KMU)
UNIT-VI: ASSESSMENT OF AN ELDERLY CLIENT
Review of systems--Cardiovascular illness is the major cause of death in older adults and
these systems should be investigated thoroughly. Of particular importance also are: weight
change and gastrointestinal (GI) symptoms, headache (temporal arthritis), dizziness and
falls, sleep pattern, sensory impairment, constipation and other changes in bowel habits
(colon cancer), urinary pattern and incontinence, sexual dysfunction, depression, cognitive
impairment, transient paralysis, paresthesias or visual changes (transient ischemic attack),
musculoskeletal stiffness or pain (osteoarthritis or polymyalgia rheumatica).
Social history-. Assessment of lifestyle, affect, cognition, function, values, health beliefs,
cultural factors and caregiver issues is also important. Consultation with a social worker in
obtaining this information and adapting the care plan is often critical but the initial identification
of need for such consultation is part of the primary care evaluation. A home visit is often very
valuable (see Interacting with Long Term Care Systems, pp. 53-56).
Nutritional history. Performing the basic nutritional assessment will identify patients at risk
of malnutrition and in need of referral for dietetic consultation.
Physical Examination
General considerations
Limit the time the patient is in the supine position as this may cause back pain for
persons with osteoarthritis or kyphoscoliosis and shortness of breath for those with
cardiopulmonary disease--having several pillows on hand for these patients will be
greatly appreciated.
Multiple sessions may be required for a complete physical exam due to patient fatigue.
While they are important, the rectal and pelvic exams may be deferred to a later
session, if not urgently required.
Areas requiring special emphasis
General Observation and Vital Signs
Check:
a. Signs of ADL deficits, poor hygiene, disheveled appearance.
b. Rectal temperature if patient is seriously ill because of blunted immune response (see
Infectious Diseases).
c. Orthostatic changes in blood pressure (BP) and pulse.
d. Osler's maneuver if systolic BP is greater than 160 to screen for
"pseudohypertension"-positive if radial artery is palpable with cuff inflated above systolic BP
level.
e. Weight (at each visit to identify losses early and to establish a pattern).
f. Signs of malnutrition or trauma (elder abuse and neglect or falls).
Skin--Neoplasm (especially in sun exposed areas), nipple retraction, peau d'orange.
HEENT--Visual acuity, lens exam for cataracts, fundoscopy (glaucoma, hypertension,
diabetic retinopathy), visual fields, extraocular movements (stroke).
a. Gross auditory acuity, otoscopy to determine possible reversible causes of hearing
loss and disequilibrium (cerumen impaction, serous otitis media, ruptured tympanic
membrane).
b. Inspect the mouth after removal of dentures to assess conditions that may affect
nutrition (neoplasm, stomatitis, oral health, adequacy of dentures).
c. Palpate temporal artery for tenderness, thickening or nodularity in the patient
complaining of headaches.
By: Farzana Khattak (Lecturer INS-KMU)
UNIT-VI: ASSESSMENT OF AN ELDERLY CLIENT
Neck
a. Dix-Hallpike positional test maneuver for benign positional vertigo (see Dizziness).
b. Jugular venous pulse is better observed on the right side since compression of the left
innominate vein by an elongated aortic arch may cause false distension on the left.
Cardiovascular
a. PMI may be displaced by kyphoscoliosis, so palpation is less reliable to determine
cardiomegaly. Atrial and ventricular arrhythmias are common. Systolic murmurs are
frequently present and most are due to benign aortic sclerosis. Symptoms, risk of morbidity
and special characteristics that suggest aortic stenosis or endocarditis should guide
evaluation.
Diastolic murmurs are always important, as are right and left ventricular S3 gallops.
b. Signs of arterial insufficiency (hair loss, bruits, decreased pulses) and venous disease
(stasis skin changes and edema) are common. Arterial ulcers present distally with
claudication and ischemia while venous ulcers present painlessly and are usually located near
the medial malleoli. Most peripheral edema is venous insufficiency not congestive heart
failure (CHF) although the latter is common and should be ruled out. (The effects of diuretics
on perfusion and electrolyte balance usually outweigh cosmetic benefit.)
Lungs--Age-related changes in pulmonary physiology and age-associated pulmonary
pathology often result in rales that may not indicate pneumonia or pulmonary edema. For
this reason, it is important to document a baseline exam at a time when the patient is not ill.
Localized wheezes may indicate an obstructing bronchial lesion (carcinoma).
Breast exam--Tumors may be easier to palpate because of atrophy and less
fibrocystic disease. Remember, men may have gynecomastia or malignancy.
Abdomen
a. Patients who are unable to lie flat (kyphoscoliosis or cardiopulmonary disease) may give
the impression of distension. This phenomenon and commonly occurring pulmonary
hyperaeration may cause the liver edge to be palpable below the costal margin without
hepatomegaly. This must be assessed by percussion.
b. Peritoneal signs may be blunted or absent in frail elderly patients (see Infectious
Diseases).
c. Palpation will assess urinary retention (bladder can be percussed also) or aortic aneurysm.
Ventral, inguinal and femoral hernias should be checked for reducibility. The sigmoid colon
will often be palpable and a fecal impaction may present as a left lower quadrant mass.
Extremities--Arthritis (rheumatoid, degenerative and crystalline), deformities, contractures,
injuries, podiatric care, poor hygiene all increase the risk of pain, infection and gait
disturbances. Although basic gait assessment adds little time to the examination, it yields
information that has impact on independent function and guides consultation with
rehabilitation professionals (see Falls). Invest in a good pair of nail clippers. Do not hesitate
to comment on style and fit of shoes or to refer to a podiatrist.
Rectal--Assess for diseases of the prostate, fecal impaction, integrity of sacral reflexes
in persons with impotence, spinal stenosis or posterior column findings, hemoccult.
Pelvic examination--Assess for pelvic prolapse, uterine, adnexal or vaginal neoplasm,
infections, estrogen deficit. The lithotomy position may produce discomfort in the
osteoarthritic patient. An alternative is the left lateral decubitus position with the right hip
flexed more than the left. Pap smears should be done in elderly women, but the
recommended frequency is debated.
Speculum examination may be painful and difficult due to atrophic changes and vaginal
stenosis. A pediatric speculum is often necessary and, occasionally, the examination is so
difficult that gynecologic consultation is indicated.
By: Farzana Khattak (Lecturer INS-KMU)
UNIT-VI: ASSESSMENT OF AN ELDERLY CLIENT
Neurological
a. Mental status examination should be performed in all patients to establish a baseline in the
event of future dysfunction (see Mini-Mental State Examination). This need not occur in
the first session.
b. Deep tendon reflexes and vibratory sense may be decreased normally.
c. Deficits of language, coordination and other subtle focal findings may indicate
cerebrovascular disease that is responsible for cognitive impairment or deficits in
instrumental ADL's.
d. Extrapyramidal signs (muscle rigidity, tremor) may indicate either adverse effects of
neuroleptic medication or Parkinson's disease. In most instances, intention tremor and
some resting tremors are benign conditions. Unilateral tremors may indicate stroke. A
resting tremor with a "pill-rolling" character is worrisome as is any tremor that impairs
function.
When physicians have a high index of suspicion with knowledge of the subleties of physical
assessment in the older adult, an adequate information base can guide timely intervention.
By: Farzana Khattak (Lecturer INS-KMU)
