Geriatric assessment / assessment of Elderly Patients

Assessment of Elderly Patients
4/5/2022 Mr. Bakht Munir RMI-RCN Peshawar 1

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Thank You

Objectives

GERIATRIC ASSESSMENT

Ageing Or Aging
Ageing or aging is the process of becoming older, the term refers mainly
to humans
Many other animals, and fungi, whereas for example, bacteria, plants
Chronological age is based on the calendar year, from an individual's birth date to
death date
It is usually associated with dynamic changes in the biological, psychological,
physiological, environmental, behavioral and social processes
Current ageing theories are assigned to the damage concept, whereby the
accumulation of damage (such as DNA oxidation ETC) may cause biological
systems to fail, or to the programmed ageing concept

Ageing Or Aging (Cont….)
 In the broader sense, ageing can refer to single cells within an
organism which have ceased dividing
 for example, may slow with age, while memories and general
knowledge typically increase
 Ageing increases the risk of human diseases such
as cancer, Alzheimer's disease, diabetes, cardiovascular
disease, stroke and many more
 Roughly 150,000 people who die each day across the globe, about
two-thirds die from age-related causes

Signs
Wrinkles develop mainly due to photoaging, particularly affecting sun-exposed areas
(face).
Female fertility declines
After age 30 the mass of human body is decreased until 70 years and then shows
damping oscillations
Muscles have reduced capacity of responding to exercise or injury and loss of muscle
mass and strength (sarcopenia) is common. maximum oxygen utilization and maximum
heart rate decline
Hand strength and mobility are decreased during the ageing process

Signs (Cont…)
People over 35 years of age are at increasing risk for losing strength in the ciliary
muscle of the eyes which leads to difficulty focusing on close objects
Around age 50, hair turns grey. Pattern hair loss by the age of 50 affects about
30–50% of males and a quarter of females.
Menopause typically occurs between 44 and 58 years of age.
In the 60–64 age, the incidence of osteoarthritis rises to 53%. Only 20% however
report disabling osteoarthritis at this age.
Almost half of people older than 75 have hearing loss (presbycusis) inhibiting
spoken communication. Many vertebrates such as fish, birds and amphibians do
not suffer presbycusis in old age as they are able to regenerate
their cochlear sensory cells, whereas mammals including humans have genetically
lost this ability.

Signs (Cont…)
By age 80, more than half of all Americans either have a cataract or have
had cataract surgery
Atherosclerosis is classified as an ageing disease. It leads to cardiovascular
disease (for example stroke and heart attack) which globally is the most
common cause of death
Dementia becomes more common with age. About 3% of people between
the ages of 65 and 74, 19% between 75 and 84, and nearly half of those
over 85 years of age have dementia
Ageing is among the greatest known risk factors for most
human diseases. Of the roughly 150,000 people who die each day across
the globe, about two-thirds—100,000 per day—die from age-related
causes

Aging

Syndrome
The word syndrome seems to have appeared in an English translation
of Galen
Derived from the Greek roots “syn” (meaning “together”) and
“dromos” (meaning “a running”)
 This term generally refers to “an concurrence or running together of
constant patterns of abnormal signs or symptoms”

Geriatric Syndrome

Geriatric syndromes
Geriatric syndromes are believed to develop when an individual experiences
accumulated impairments in multiple systems that compromise their compensatory
ability.
The term “Geriatric Syndrome” is used to capture those clinical conditions in older
persons that do not fit into discrete disease categories.
 Many of the most common conditions cared for by geriatricians, including Delirium,
Falls, Frailty, Dizziness, Syncope And Urinary Incontinence, Language Disorders,
Functional Dependence, Lower Extremity Problems, Oral And Dental Problems,
Malnutrition, Osteoporosis, Pain, Pressure Ulcers, Silent Angina Pectoris, Sexual
Dysfunction, Syncope And Vision Loss, are classified as geriatric syndromes.

GS (Cont ….)
Geriatric syndromes are a group of symptoms or problems that are
logically connected, associated with old age
Geriatrician, or geriatric physician, a physician who specializes in the
care of elderly people.

Cushing's Syndrome as a Traditional Medical
Syndrome Cortisol Excess
“Moon Facies”
“Buffalo Hump”
Hypertension
Proximal Muscle Weakness
Psychosis
Hyperlipidemia
Osteoporosis
Specific M

Delirium

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.

General Observation and Vital Signs
Signs of ADL deficits, poor hygiene, poor hygienic appearance.
Check temperature if patient is seriously ill
Orthostatic changes in blood pressure (BP) and pulse.
Osler's maneuver if systolic BP is greater than 160 to screen for "pseudo hypertension"-
positive if radial artery is palpable with cuff inflated above systolic BP level.
Weight (at each visit to identify losses early and to establish a pattern).
Signs of malnutrition or trauma (elder abuse and neglect or falls).

Physical Examination
Skin--Neoplasm (especially in sun exposed areas)
HEENT--Visual acuity, lens exam for cataracts, fundoscopy (glaucoma,
hypertension, diabetic retinopathy), visual fields, extraocular movements (stroke).
Gross auditory acuity, otoscopy to determine possible reversible causes of hearing
loss and disequilibrium (cerumen impaction, serous otitis media, ruptured
tympanic membrane)
Inspect the mouth after removal of dentures to assess conditions that may affect
nutrition (neoplasm, stomatitis, oral health, adequacy of dentures)
Palpate temporal artery for tenderness, thickening or nodularity in the patient
complaining of headaches

Physical examination (Cont…)
Neck
Dix-Hallpike positional test maneuver for benign positional vertigo
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

Examination
Cardiovascular
Atrial and ventricular arrhythmias are common.
Signs of arterial insufficiency (hair loss, bruits, decreased pulses)
 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.)

Examination
Lungs
Age-related changes in pulmonary physiology
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).

Examination
Breast exam
Tumors may be easier to palpate because of atrophy
Remember, men may have gynecomastia or malignancy

Examination
Abdomen
Patients who are unable to lie flat (kyphoscoliosis or cardiopulmonary
disease) may give the impression of distension
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.

Examination
Extremities
oArthritis
oDeformities, contractures, injuries, poor hygiene all increase the risk
of pain, infection and gait disturbances.
oDo 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.

Examination
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
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

Examination
Neurological
Mental status examination should be performed in all patients to establish a
baseline in the event of future dysfunction
Deep tendon reflexes and vibratory sense may be decreased normally.
Deficits of language, coordination and others may indicate cerebrovascular
disease
that is responsible for cognitive impairment or deficits in instrumental ADL’s.
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

10 Tips for Nurses to Effectively Communicate
with Elderly Patients
Tip 1: Start with the Right Body Language
A seated position directly opposite the patient improves communication by
reducing distractions and sending the message that the care provider has focused
on the client completely
Maintaining eye contact is also important, because this commands their
attention and helps patients

Communicate with Elderly Patients
Tip 2: Exercise Patience
Care providers must exercise patience when treating seniors
Sometimes, care providers have to repeat talking points several times before the
patient fully understands the message.
If communicating requires too much repetition, care providers should slow their
speech down and speak clearer until the client can understand.
Older patients may also take longer to react during conversations.

Tip 3: Show Proper Respect
While many have heard the phrase “respect your elders,”
The sentiment proves indispensable during treatment
Providers should remember that elder clients may have differing opinions about
contemporary topics.
It’s important to acknowledge the varied experiences offered by seniors.
This recognition can help to bridge generational gaps during communication

Tip 4: Practice Active Listening
When treating seniors, it’s important to actively listen to their words
Remember that both parties may have difficulty expressing ideas to each other
Care providers should also use body language, such as affirmative nods, to
acknowledge receipt of communications without interrupting the client
If the care provider cannot understand what a patient is trying to say, they should
ask clarifying questions

Tip 5: Build Rapport
To build patient rapport, health organizations must make sure that all personnel
create positive interactions
This starts with each employee who encounters clients properly
introducing themselves and finding out patients’ name preferences
Voicing clients’ preferred names several times creates an air of familiarity and
sets the groundwork for patients to participate in wellness planning
Strong rapport also leaves clients with a positive overall impression of the
organization.

Tip 6: Show Sincerity
During visits, care providers should ask appropriate questions about clients’ living
conditions and social circles
It’s critical that care providers understand the role that a client’s culture and
beliefs play in treatment
This understanding facilitates shared decision-making
In addition to cultural literacy, it’s important to avoid ageist assumptions when
offering recommendations

Tip 7: Recognize Sensory Challenges
Distractions, such as accompanying caregivers, cognitive impairments, or hearing
loss, can make communication difficult
Nearly one-third of seniors over 65 have hearing issues, and a quarter of seniors
over 75 report vision problems.
Ailments affect each patient differently and to varying degrees
It’s important that care providers keep these conditions in context

Tip 8: Ensure Comfort
Physical comfort is important for both patients and their family members
Alleviating physical discomfort reduces distractions during treatment
Maintaining comfort for elder patients can prove difficult, especially for those
with multiple illnesses
Care providers can ensure patient comfort with simple gestures, such as offering
a blanket or sweater to cold clients

Tip 9: Use Plain Language
As patients grow older, their physiology changes considerably
Elder clients may start to lose their hearing, sight, or short- or long-term memory,
and this changes the way they absorb and process information
Using plain language makes it easier for senior clients to understand new
concepts

Tip 10: Show Empathy
 Sincere empathy builds rapport
 Patients should feel as though care providers understand and identify with their concerns
 To communicate this sentiment, staff members can relate how they would feel given similar circumstances
when communicating undesirable information
 Such honest and open communication shows that care providers recognize client difficulties and genuinely
care about patient circumstances.
 Care providers will treat older patients more frequently as more people live well past 65
 By treating each senior as an individual, care providers can dissolve ageist stereotypes and produce positive
outcomes

References
1. Flacker, J. M. (2003). What is a geriatric syndrome anyway?. Journal of the
American Geriatrics Society, 51(4), 574-576.
https://www.healthplexus.net/files/content/2003/October/0609syndrome.pdf
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409147/
3. https://en.wikipedia.org/wiki/Ageing
4. https://ascopubs.org/doi/full/10.1200/EDBK_237641
5. http://projects.galter.northwestern.edu/geriatrics/chapters/history_physical_ex
amination.cfm
6. https://online.regiscollege.edu/blog/elderly-patient-care/

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Geriatric assessment / assessment of Elderly Patients

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