Locus ceruleus---norepinephrine- depression, anxiety, etc…. Substantia nigra dopamine parkinsons
Assessment of the elderly
Assessment of the ElderlyMarc Evans M. Abat, M.D., FPCP, FPCGMInternal Medicine-Geriatric Medicine
Outline• Introduction• Interviewing and History Taking• Physiologic Changes with Aging• Geriatric Assessment Tools• Examples of Pitfalls That May be Encountered in Physical Assessment
Geriatric Assessment• include non-medical domains• emphasize functional ability and quality of life,• Rely on interdisciplinary teams• improve care and clinical outcomes – greater diagnostic accuracy – improved functional and mental status – reduced mortality – decreased use of nursing homes and acute care hospitals – greater satisfaction with care
Geriatric Essentials• Unless corrected, sensory deficits, especially hearing deficits, may interfere with history- taking.• Many disorders in the elderly manifest solely as functional decline.
• Health care practitioners must often interview caregivers to obtain the history of functionally dependent elderly patients.• Frail elderly patients with complex conditions (eg, multiple disorders, use of several drugs) often require assessment by an interdisciplinary team.
Approach to the interview• Asking patients to describe a typical day – establishes a rapport• Have the patient wear their eyeglasses, dentures, hearing aids, etc.
• Interview patient directly as much as possible
Medical history• Previous diseases including allergies• Previous surgeries• Past treatment regimens• Review of old medical records if available• Thorough systems review
Drug history • Patient’s drug list • If possible visually inspect all available medications • Do not overlook – Over-the-counter (OTC) medications – Vitamins and supplements – Herbal medications – Topical medications • Ability to take the medications
Tobacco, alcohol and drug use• Sensitive topic; may need to interview relatives or caregivers• Unusual preparations of above substances – “nganga” – Snuff or chewed tabacco – Unusual sources of alcohol
Nutrition History• Type, variety, quantity and frequency of feeding• Special diets or diet fads• Use of vitamins and supplements• Weight changes• Amount of money spent on food• Accessibility of kitchen and food storage• Problems with chewing, taste and smell
Mental Health• Insomnia, changes in sleep patterns, constipation, cognitive dysfunction, anorexia, weight loss, fatigue, preoccupation with bodily functions, and increased alcohol consumption• ask about delusions and hallucinations, past mental health care, use of psychoactive drugs, and recent changes in circumstances• Mood changes or cognitive changes may indicate depression
Social History• Evaluation of living arrangements• Describe typical daily activities – Hobbies, leisure activities – Socialization activities and contacts, pastoral or spiritual activities – Driving activities• Caregiver and support systems• Marital status, sexual history, educational and financial status
Physiologic Changes with AgingVital Signs• BP may be overestimated due to stiff arteries• normal respiratory rate in elderly patients may be as high as 25 breaths/min
Skin• dermis thins by 20% with age, ecchymoses may occur readily when skin is traumatized• melanocytes are progressively lost uneven tanning may be normal
• Linear nail growth decreased by 50%• Decreased number and function of eccrine and apocrine sweat glands• Decreased thermoregulation
Vision• Atrophy of periorbital tissues – May lead to ectropion or entropion• Lacrimal gland function, tear production and goblet cell production decrease• Atrophy and yellowing of the conjunctiva• Decreased corneal sensitivity by 50%• Iris becomes more rigid and sluggish
• Vitreous humor and body also shrink – Separation of the liquid and solid components”flashes of light”• Thinning of the retina• All these changes lead to presbyopia – Distance to focus near objects increases – Decline in static and dynamic visual acuity – Slower adaptation to light – Decline in contrast sensitivity
Hearing• Atrophy of the external auditory canal• Drier, more tenacious cerumen• Thicker tympanic membrane• Degenerative changes in the ossicles• Changes in the inner earloss of high- and low- frequency audition
Taste and Smell• Decrease in the lingual papillae• Olfactory detection threshold increase by 50% and recognition of smells decreases by 15%
Head and Neck• Loss of fat and connective tissue shrunken appearance• Loss of teeth• Prominence of neck vessels
Respiratory• Decreased cough reflex• Increase in diameter of the trachea and central bronchi• Calcification of tracheal cartilage• Hypertrophy of mucous glands
• ↓decreased elastic recoil (decreased lung elasticity)• chest wall expands and stiffness increases, increasing expiration work of breathing• Presence of basilar rales in normal patientsdisappears on deep inspiration• Elevated closing volumes- inability to drain certain lung areas• respiratory muscle endurance decreases
• Diaphragm may be at a mechanically suboptimal position• Mucociliary clearance slower and less effective• Forced vital capacity decreases by 0.15-0.3 liters per decade• Forced expiratory volume in 1 sec decreases by 0.2-0.3 per decade
Cardiac• Low-normal to normal heart rate but poor heart rate response with effort• Lower cardiovascular reserve• ↑vascular stiffness• ↑ventricular stiffness• Early reliance on the Starling curve to maintain cardiac output
• Recovery after exertion more prolonged• Conduction system degeneration• Valvular degeneration• ↓β-adrenergic responsiveness• ↓baroreceptor sensitivity• ↓SA node automaticity
Gastrointestinal/Hepatic• Oral mucosa thins with age• Small decrease in acinar cells of salivary glands• subtle decrease in saliva production• Less effective chewing whether or not teeth are intact• Preserved esophageal motility and sphincter tone
• Decreased acid production• Adaptive relaxation is impaired• Moderate atrophy of small intestine villi• Some lost of myenteric plexi throughout the GI tract• Decreased absorption of iron, calcium, vitamin D• Decreased lactase levels
• Slowed transit and altered contraction of the colon• Increased colonic opioid receptors• Decreased liver mass• Decreased hepatic blood flow by 10% per decade• Higher lithogenic index of bile
Renal• Decreased renal mass by 25-30%• Renal fibrosis and fatty infiltration• Nephron loss, preferably those with the longest loops• Diffuse sclerosis of glomeruli
• Loss of capillary loops• Thickening of the basement membrane• Decrease in creatinine clearance by 7.5-10.0 ml per decade• No significant change in serum creatinine due to loss of muscle mass• Reduction in urine acidification• Impairment of urine dilution• Impaired ability to retain amino acids and glucose• Vitamin D hydroxylation is impaired.
Musculoskeletal• ↓skeletal muscle mass in relation to body weight by 30-40% – Non-linear – Accelerates with age – Decrease in fiber number and size – Accompanied by altered innervation
• Loss of muscle strength – Up to 60% loss of grip strength – Slower time to peak tension and slower relaxation – Important role of activity• Decrease in muscle glycolytic enzymes with age
• Decreased bone density• Degenerative joint changes• Joint cartilage changes – Decrease in tensile strength – Bound water content decreases – Decrease in proteoglycan units and fragmentation of polymers• Variable resistance to manipulation
Hematopoietic System• Decreased bone marrow mass, increased marrow fat• Response to phlebotomy or hypoxia is slower• WBC generation of free radicals and enzymes is reduced• Tissue macrophage is decreased
Endocrine• Increased postprandial glucose levels• Decreased insulin secretion• Decreased insulin sensitivity• Decreased thyroid volume with fibrosis• Decreased conversion of T4 to T3• Increased ADH response to osmotic stimuli
• GH levels decline with age• Delayed negative feedback with ACTH and cortisol levels• Decrease in DHEA by 10% per decade
Reproductive System• Decrease in ovarian size• Decreased estrogen and progesterone production; testosterone and androstenedione production also decreased• Atrophy of uterus and vagina• Reduced vaginal secretions• Involution of breast glandular and ductal tissue• Ligamentous support of breasts relaxes
• Gradual decline but no total loss of male reproductive ability• Decreased sperm production and quality• Decreased in total, free and available testosterone• Benign prostatic hyperplasia
Nervous System• Decreased brain weight, age- related neuronal loss – Not uniform – Tends to occur in the largest neurons • Cerebellum: more for the Purkinje cells • Subcortical regions: locus ceruleus, substantia nigra• Decreased blood flow by 20%• Alteration in cerebral autoregulation
• In general, decreased dendritic density of the remaining neurons – May have a compensatory increase in some areas• Decrease in myelin in the white matter• Significant loss in the anterior horn cells• Finger thermal threshold increases with age
• Decreased muscle strength• Increased reaction time• Decrease in size of peripheral nerves decreased sensation• with aging, information processing and memory retrieval slow but are essentially unimpaired – With extra time and encouragement, patients perform such tasks satisfactorily
Timed Get Up and Go Test• Prepare the following: – Armless chair – A marker 10 feet away from the chair• Procedure: 10 ft. Rise downchair Sit from again Walk to the marker chair floor Return to the on the Turn
Fever • Amplitude of normal circadian temperature fluctuations is lower • Reduced mean baseline temperature in the elderly (mean oral temperature 36.7°C) • in those who initially present with a blunted or absent febrile response, fever may occur over time. – onset of pyrexia was delayed several hours in a significant number of patients; delayed >12 hours in 12% of patientsClinical Infectious Diseases 2000;31:148–51
• fever in the elderly can be defined: – Persistent oral or TM temperature >37.27C or; – Persistent rectal temperature>37.57C – Moreover, an increase over baseline temperature >1.3°C, independent of site measured or device usedClinical Infectious Diseases 2000;31:148–51
• sensitivity for detecting an infection increased to 83% when 37.2°C became the threshold, but the specificity dropped to 89% • specificity was 99.7% when 38.5°C was the threshold and 98.3% when 37.8°C was usedClinical Infectious Diseases 2000;31:148–51
• a blunted fever response to a serious bacterial, viral, or fungal infection suggests a poorer prognosis than does a robust fever response – 20%–30% of elderly persons – lower baseline temperatures observed in the elderly may lower the maximum temperature of a fever response to an infectionClinical Infectious Diseases 2000;31:148–51
• Possible mechanism(s) for the blunted temperature responses to infection – Diminished thermoregulatory responses, such as sudomotor and vasomotor responses – quantitative and qualitative abnormalities in both the production of and response to endogenous pyrogens, such as IL-1, IL-6, and TNF – limit the ability of the hypothalamic circumventricular organs to allow endogenous pyrogens to cross from the blood stream to exert their effect on the CNSClinical Infectious Diseases 2000;31:148–51
PEARLS:In a patient with an acute change in sensorium or functionality, always rule out an infection even if without a fever at the onsetFever is not just defined as temperature across a certain threshold but also a significant change from baselineFever will almost always appear in the course of the disease
Crackles Age-Related Pulmonary Crackles (Rales) in Asymptomatic Cardiovascular Patients • 274 participants, in whom the heart was structurally (based on Doppler echocardiography) and functionally (B-type natriuretic peptide <80 pg/mL) normal and the lung (X-ray evaluation) was normal, were eligible for the analysis.Ann Fam Med. 2008. 6(3): 239-245.
• prevalence of crackles among patients – low age(45-64 years; n = 97; 11%; 95% CI, 5%-18%), – Medium age (65-79 years; n = 121; 34%; 95% CI, 27%-40%) – high age (80-95 years; n = 56; 70%; 95% CI, 58%-82%) – p <.001Ann Fam Med. 2008. 6(3): 239-245.
• crackles in such patients – fine – almost always restricted to an area localized to the lower quadrant of the lung field. – diffuse basal crackles involving the bilateral hemithorax were exceptional – not considered clinically significant over the medium- term follow-upAnn Fam Med. 2008. 6(3): 239-245.
• risk ratio of pulmonary crackles increases approximately threefold every 10 years after 45 years of age in patients with cardiovascular disease and apparently normal heart function • Minimal interstitial changes in some patients with crackles were found with high-resolution CTAnn Fam Med. 2008. 6(3): 239-245.
Diagnosing Pneumonia in the Elderly • the utility of the physical examination alone in predicting pulmonary disease or in distinguishing among pulmonary conditions • 52 male patients, who were generally elderly – 24 had pneumonia confirmed by chest radiographsArch Intern Med May 24, 1999;159:1082-7
• 2 most frequent abnormal findings in all patients were rales in the sitting position (22 to 65%) and bronchial breath sounds (8 to 43%) • sensitivity and specificity of physical findings varied considerably among physicians, as well as for a given physician in eliciting findings between the right and left lungsArch Intern Med May 24, 1999;159:1082-7
PEARLS:Recognition of age-related crackles is important because such clinically unimportant crackles are so common among elderly patients-consider other signs and symptoms, functionality.Their existence might interfere with the physician’s management of patients with suspected heart failure or presumable pulmonary disease.
Hydration Status Axillary sweating in clinical assessment of dehydration in ill elderly patients • Dehydration is difficult to assess clinically in older patients – collagen changes reduce skin turgor – tongue may be dry from mouth breathing – eyes may be sunken due to reduced periorbital fatBMJ 1994;308:1271 (14 May)
• Value of axillary moisture to assess hydration• 38 men and 62 women (age 70-98 (mean 80.2) years)• preweighed tissue paper to the patients right axilla for 15 minutes, then weight measured again• Sensitivity 50%, specificity 84%
PEARLS:Need to use multiple modalities, both clinical and laboratory parameters, to assess hydration status.Some PE findings like hypotension, decreasing urine output and tachycardia may be late findings.If in doubt and the benefit outweigh possible risks, carefully rehydrate and evaluate frequently.
Acute Abdominal Pain • Abdominal musculature is often thin in elderly patients, leading to less guarding and rigidity even in the presence of frank peritonitis • detailed search for hernias • rectal examination • General physical examination also importantEmerg Med Clin N Am. 24 (2006) 371–388
Acute abdominal pain among elderly patients • 557 patients aged 65-79 years and 274 patients aged > or = 80 years • older patients were more often misdiagnosed than control patients (52 vs. 45%; p = 0.002) • Rebound tenderness (p < 0.0001), local rigidity (p = 0.003) and rectal tenderness (p = 0.004) were less common in the older than in the control patients with peritonitisGerontology. 2006;52(6):339-44. Epub 2006 Aug 11.
PEARLSNeed to have a very high index of suspicion for causes of acute abdominal pain.Extensive use of physical examination, both general and abdominal to determine the cause.Lower threshold for use of other modalities for diagnosis.