2. History; Special Considerations in the
Elderly…
• Cognitive impairment
• Illness has atypical or nonspecific presentations; functional
impairment can result from virtually any illness.
• Severity of some illnesses may be underestimated if other conditions
coexist.
• Delayed response time & decreased vision or hearing.
EMPHASIZE ON:
Medical History
• Identify all currently taken drugs, nonprescription and supplements
Personal and Social History
-Personal Habits
• Immunization (tetanus, Pneumococcal vaccine, influenza vaccine)
• Previous illness, including allergies, prev hosp or operations, w/
discharge summaries.
3. CGA Hist…
Personal and Social History, cont’d
• Blood transfusions or anesthesia
• Responses to past illnesses and operations
• Last visit to the Dentist
• Complete OB & Gyne history
• Prostate problem
• Alcohol use, tobacco use, caffeine intake
• Sleep pattern & use of sleep medications, if any.
4. C G A, cont’d…
DIETARY ASSESSMENT
MNA (Mini-Nutritional Assessment) – targets the elders
• Basic anthropometric information
• History of weight loss
• Questions rotating to levels of independence, polypharmacy, psycho
logic stress, memory loss, skin breakdown.
• Dietary questions related to food intake
• Maximum score = 30 points;
>24---well-nourished <13---malnourished
Scores in-between, at risk.
5. C G A, cont’d…
ENVIRONMENTAL HISTORY
Living arrangement and physical layout of the home & environment
Safety concerns and functional ability
• Assessment of lighting, flooring, furniture location, heating and air
conditioning
• Kitchen, bathroom & stairway (common sites for falls & injuries)
• Outside environment (access to the neighborhood, general safety,
sense of neighbors and their ages; ease of access to the home. Basic
home protection (locks on doors and windows).
6. C G A , cont’d…
PHYSICAL EXAMINATION(should be obtained with care & precision)
1) Body temperature
Normal body temperature --- Close to 37C (98F)
Fever - > 38C (100F)
Significant fever –-38.5C (101F)
2) Pulse (60-100 bpm; some elderly, 50-60 bpm)
Osler’s sign – an artery can still be palpated distal to a point of
occlusion.
7. C G A , Phys. Exam, cont’d…
Palpable disparity between two simultaneous pulses (e .g. radial and
femoral) on each side of the body simultaneously - suggestive of
vascular compromise on the side of the diminished pulse.
Irregular pulse – compare the apical pulse rate with the peripheral
pulse rate to see if there is a pulse deficit.
Pulse pressure – difference between systolic and diastolic BP.
Example:
Bounding pulse in an octogenarian.
(Sherman sign) – suggests a wide pulse pressure (> 60 mmHg). Wide
pulse pressure is also observed in visibly pulsing (and tortuous)
arteries w/ rhythmic bobbing of head or limbs.
8. C G A , P.E., cont’d…
PHYSICAL EXAMINATION:
3. BP
• Normal /usual BP generally <140/90
• Taking and measuring BP
• Pulse pressure: 25 to 50% of BSP
• Orthostatic hypotension – a drop between supine and standing BP
0f 20 mm Hg or 10 mm Hg diastolic
- Basic causes:
1. Volume depletion
2. Autonomic or neurologic dysfunction
3. Cardiac failure
4. Pheochromocytoma
5. Postprandial orthostatic hypertension in elderly people in
4. RR
• 12-18/min in elderly people in nursing homes;16-25/min.in long-
term care patients.
9. C G A , P.E., cont’d
GENERAL APPEARANCE:
• Height and Weight
• Skin inspection, lesions suspicious for cancer, xerosis (excessive
dryness)
• EENT : Eyes – cataracts, macular degeneration
Ears – use otoscope to detect cerumen, test for hearing
acuity (rubbing 2 fingers, ticking watch)
Mouth and Throat – tongue, buccal mucosa and dentition.
Poor dental health – implications for nutritional status.
Oral cancer screening for patient with history of alcohol or
tobacco use.
10. C G A , Neurologic Exam…
• Include gait
• Tons of vibratory sense in the ankle decrease or absence of ankle
jerk
• Certain age-related changes that should not be mistaken for patho-
logy
• Longer reaction time
• Tons of upward rotations of the eye globe beyond 25 degrees above
horizontal
• Speech pattern, quality of language and ability to swallow should be
evaluated in selected patients.
11. C GExam A , P.E., cont’d…
NEUROLOGIC EXAM, cont’d…
• Cognitive testing can be done during MMSE (Mini Mental State Exam) or
the CDT (Clock Drawing Test) These tests recall written and spoken
language, contractual abilities, orientation and calculations.
Assessment of Gait, Mobility & Balance.
• Performance measurement of gait and balance; “get up & go” test, scored
1 as NORMAL, and 5 as severely abnormal.
• Measurement of gait speed over a fixed course.
• Modifications of the Romberg test that better evaluate balance.
• Patients who score fully need more careful evaluation.
12. C G A , cont’d.
•ASSESSMENT of DEPRESSION
•Questions about signs and symptoms related to emotional condition
Depression or crying spells
Use Geriatric Depression Sca
SEXUAL HISTORY
• Sexuality may be an important aspect, in that, the physician is helped In
evaluating medical, psychological and the educational needs of the patient
• Question should be asked about past and current sexual activity and any
recent changes and concerns.
• Inquiry, testing and counseling may be appropriate if at risk behaviors are
a concern.
• Common changes in sexual function.
13. C G A
EMOTIONAL HISTORY
• Previous emotional difficulty or adjustment (coping with transfers, job
changes, etc.)
• Previous episodes of depression in the patient or his family.
OCCUPATIONAL/RETIREMENT STATUS
• Exposure to tocxic materials.
• If retired, voluntary?; or forced ? Additional problems with spouse or
family? Leisure activities & traveling have added significantly to patient’s
quality of life?
FU NCTIONAL ASSESSMENT
Capacity ofr independent living
• ADL, (Dressing, Eating. Ambulating, Toileting, Hygiene)
IADL2 Shopping, Housekeeping, Accounting. Food preparation,
Transportation-Katz; (standardized functional assessment)
14. C G A
SO CIAL SUPPORTS
• List of all living relatives
FAMILY HISTORY
• Info regarding patient’ parents, siblings, spouse and children
• Age and health status of surviving siblings
• Age at death and cause of death of deceased relatives
• Dementia in family members?
REVIEW OF SYSTEMS
• Detailed system review
