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HISTORY AND PHYSICAL EXAMINATION OF THE OLDER ADULT
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.
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 nurse 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
Functions -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 or hospital visit.
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, 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 .
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 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, and disheveled appearance.
b. Rectal temperature if patient is seriously ill because of blunted immune response .
c. Orthostatic changes in blood pressure (BP) and pulse.
d. If systolic BP is greater than 160 to screen for "pseudohypertension".
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)
g.Skin--Neoplasm (especially in sun exposed areas).
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.
Neck
a. 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.. 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.
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.
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 (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 (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, 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 . 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.
Pelvic examination--Assess for pelvic prolapse, uterine 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.
Neurological
a. Mental status examination should be performed in all patients to establish a baseline in the
event of future dysfunction ( 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.
AGING
Aging, is the process of becoming older. In the broader sense, ageing can refer to single cells
within an organism which have ceased dividing. In humans, ageing represents the accumulation
of changes in a human being over time, encompassing physical, psychological, and social
change. Reaction time, for example, may slow with age, while knowledge of world events and
wisdom may expand. 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 die
from age-related causes.
Effects of ageing
A number of characteristic ageing symptoms are experienced by a majority or by a significant
proportion of humans during their lifetimes.
Commonly people older than 65 are called ‘OLD’. Gerontologists often draw finer
chronological demarcations:
• Young-old: 65-74
• Old-old: 75-84
• Oldest-old: >85
Teenagers lose the young child's ability to hear high-frequency sounds above 20 kHz.
Some cognitive decline begins in the mid-20s.Wrinkles develop mainly due to photoageing,
particularly affecting sun-exposed areas (face).
After peaking in the mid-20s, female fertility declines.
People over 35 years old are at risk for developing presbyopia, and most people benefit from
reading glasses by age 45–50.The cause is lens hardening by decreasing levels of α-crystallin, a
process which may be sped up by higher temperatures.
Hair turns grey with age. Pattern hair loss by the age of 50 affects about half of males and a
quarter of females.
Menopause typically occurs between 49 and 52 years of age.
Around a third of people between 65 and 74 have hearing loss and almost half of people older
than 75.
A loss of muscle mass and mobility, affects 25% of those over 85.
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 65–74
have dementia, 19% between 75 and 84 and nearly half of those over 85 years of age. The
spectrum includes mild cognitive impairment and the neurodegenerative diseases of Alzheimer's
disease, cerebrovascular disease and Parkinson's disease. Furthermore, many types of memory
may decline with ageing, but not semantic memory or general knowledge such as vocabulary
definitions, which typically increases or remains steady until late adulthood. Intelligence may
decline with age, though the rate may vary depending on the type and may in fact remain steady
throughout most of the lifespan, dropping suddenly only as people near the end of their lives.
Individual variations in rate of cognitive decline may therefore be explained in terms of people
having different lengths of life. There might be changes to the brain: after 20 years of age there
may be a 10% reduction each decade in the total length of the brain's myelinated axons.
Age can result in visual impairment, whereby non-verbal communication is reduced,which can
lead to isolation and possible depression. Macular degeneration causes vision loss and increases
with age, affecting nearly 12% of those above the age of 80. This degeneration is caused by
systemic changes in the circulation of waste products and by growth of abnormal vessels around
the retina.
Many people have the wrong impression of what it means to grow old. The older years of an
individual’s life can actually be a very active time for many people, with new experiences and
new connections. Many older adults may feel like they are no longer useful, productive, or
valuable in their later years of life, but “old age” can be full of meaning and purpose for those
who choose to explore the possibilities.
AGING MYTH AND REALITY
There are many misconceptions about aging those caregivers and seniors should be aware of. As
a caregiver, become sensitive to these misconceptions and be sure to reinforce the potential of
your loved one’s life, regardless of their age and limitations.
Myth and reality;1 – Brain Power Disappears with Age
While many older adults will struggle with mental conditions, like dementia, that decrease their
short-term or long-term memory, the truth is that verbal/math abilities and abstract reasoning
can actually increase with age. The key to strengthening these abilities is engaging the brain and
exercising mental faculties to combat degenerative conditions. Physical exercise and social
interaction are also important factors that can contribute to keeping the brain active and sharp.
Myth and reality;2 – Aging Robs You of Your Happiness
Though many people associate old age with depression, loneliness, and misery, getting older
does not mean your loved one will lose their joy for life. In fact, recent happiness studies
indicate that people are happiest at retirement age. Today, with the wealth of opportunities
available for older adults, this can still ring true for adults who have been retired for many years.
Getting older can mean having time to enjoy hobbies and interests that bring true happiness,
rather than having all of one's time engaged in obligations.
Myth and reality;3 – Older Adults Are Lonely
In today’s world, there is not only a multitude of social activities available for older adults, but
also a variety of senior living options. Volunteer opportunities, club memberships, senior
centers, and time with family and friends can provide human interactions and social connections
that can support an older adult through the aging process and any challenges that come along
with it. Living in an assisted living community can also provide a great sense of family and
belonging to residents.
Myth and reality;4 – Older Adults Have Multiple Health Conditions
While our bodies do wear down with age, growing old does not necessarily mean losing all of
your independence and visiting the hospital every week. While some older adults may develop
health conditions that require close monitoring and intervention, many health conditions can be
avoided by maintaining a healthy lifestyle. Taking care of your health as you age and staying
active through proper exercise will help prevent falls, improve balance and circulation, and help
increase overall independence.
Myth and reality;5 – Aging Limits the Ability to Learn New Skills
Learning new skills as an older adult is a different process than learning in your younger years,
but that doesn’t mean older adults should avoid trying new things. In fact, learning and
processing new information or taking up a new hobby can help keep the mind sharp and provide
something interesting to enjoy throughout the day. You can, and should, learn new skills as you
age.
Myth and reality; -Aging is gender blind
Age is presumed to be the great equalizer men and women, rich and poor, regardless of
background. Both males and females experience loss with age. On average, women live 7 years
longer than men.
Many people fear getting older because of these misconceptions, but the aging process should
not be considered something to be afraid of, but rather, something to explore. If you stay active
and engaged, your later years of life can be some of the best in your life!
THEORIES OF AGING
 Psychological
◦ Maslow’s Hierarchy of Needs (1943)
◦ Erikson’s Psychological Stages (1956)
◦ Selective Optimization with Compensation (SOC, 1980)
 Sociological
◦ Activity
◦ Disengagement Theory
◦ Continuity
 Biological
◦ Damage
◦ Genetic
◦ General imbalance
 PSYCHOLOGICAL
MASLOW'S HIERARCHY OF NEEDS AND ERIKSON’S
EIGHT PSYCHOSOCIALCRISIS STAGES OF
DEVELOPMENT
According to Erikson there are 8 stage of development or eight psychosocial stages of
development . Erikson's psychosocial theory essentially states that each person experiences eight
'psychosocial crises' . which help to define his or her growth and personality.
Maslow's hierarchy of needs is a theory in psychology proposed by Abraham Maslow in
1943. which focus on describing the stages of growth in humans. Maslow's hierarchy of needs is
often portrayed in the shape of a pyramid with the largest, most fundamental levels of needs at
the bottom and the need for self-actualization and self-transcendence at the top.
There are significant parallels between the growth outcomes of the Erikson psychosocial model,
and the growth aspects Maslow's Hierarchy of Needs.
life stage / relationships / issues crisis Maslow
Hierarchy of
Needs stage -
primary
correlation
infant / mother / feeding and being comforted,
teething, sleeping
1. Trust v
Mistrust
biological &
physiological
toddler / parents / bodily functions, toilet
training, muscular control, walking 2. Autonomy v
Shame & Doubt
safety
preschool / family / exploration and discovery,
adventure and play
3. Initiative v
Guilt
belongingness &
love
schoolchild / school, teachers, friends,
neighbourhood / achievement and
accomplishment
4. Industry v
Inferiority
esteem
adolescent / peers, groups, influences / resolving
identity and direction, becoming a grown-up
5. Identity v
Role Confusion
esteem
young adult / lovers, friends, work connections /
intimate relationships, work and social life
6. Intimacy v
Isolation
esteem
mid-adult / children, community / 'giving back',
helping, contributing
7. Generativity
v Stagnation
self-actualization
late adult / society, the world, life / meaning and
purpose, life achievements, acceptance
8. Integrity v
Despair
Outcome;
self-actualization
Wisdom &
Renunciation
SELECTIVE OPTIMIZATION WITH COMPENSATION
(SOC, 1980)
Most modern cultures do not provide the same richness of opportunities to older persons as are
provided to younger members of society. This is in spite of the fact that cultural opportunities
are especially needed by older adults to compensate for biologically based decreases in
functioning. Thus, in old age, individuals have to allocate more of their resources to the
maintenance of functioning and providing resilience against losses, rather than into processes of
growth.
Selective Optimization with Compensation is a strategy for improving health and wellbeing in
older adults and a model for successful ageing. According to the SOC model, successful aging
encompasses selection of functional domains on which to focus one’s resources, optimizing
developmental potential (maximization of gains) and compensating for losses—thus ensuring
the maintenance of functioning and a minimization of losses. It is recommended that seniors
select and optimize their best abilities and most intact functions while compensating for declines
and losses. For example, an elderly person with fading eyesight who loves to sing could focus
more time and attention on singing, perhaps by joining a new choir, while cutting back on time
spent reading. Overall, this model suggests that seniors take an active approach in their ageing
process and set goals that are attainable and meaningful.
 SOCIOLOGICAL
DISENGAGEMENT THEORY
The Disengagement Theory, one of the earliest and most controversial theories of aging, views
aging as a process of gradual withdrawal between society and the older adult. This mutual
withdrawal or disengagement is a natural, acceptable, and universal process that accompanies
growing old. It is applicable to elders in all cultures, although there might be variations.
According to this theory, disengagement benefits both the older population and the social system.
Gradual withdrawal from society and relationships preserves social equilibrium and promotes
self-reflection for elders who are freed from societal roles. It furnishes an orderly means for the
transfer of knowledge, capital, and power from the older generation to the young. It makes it
possible for society to continue functioning after valuable older members die.
Weakness: There is no base of evidence or research to support this theory. Additionally, many
older people desire to remain occupied and involved with society. Imposed withdrawal from
society may be harmful to elders and society alike. This theory has been largely discounted by
gerontologists.
ACTIVITY THEORY
The theory was developed by Robert J. Havighurst in 1961.This theory argues that actively
engaged older persons have greater life satisfaction. It takes the view that the ageing process is
delayed and the quality of life is enhanced when old people remain socially active. The theory
assumes that a positive relationship between activity and life satisfaction.
CONTINUITY THEORY [Atchley, 1971]
The continuity theory of normal aging states that older adults will usually maintain the same
activities, behaviors, relationships as they did in their earlier years of life. According to this
theory, older adults try to maintain this continuity of lifestyle by adapting strategies that are
connected to their past experiences. The theory considers the internal structures and external
structures of continuity to describe how people adapt to their circumstances and set their goals.
The internal structure of an individual - for instance, an individual's personality traits - remains
relatively constant throughout a person's lifetime. Other internal aspects such as beliefs can
remain relatively constant as well, though are also subject to change. This internal structure
facilitates future decision-making by providing the individual with a strong internal foundation
of the past. The external structure of an individual consists of relationships and social roles, and
it supports the maintenance of a stable self-concept and lifestyle.
 BIOLOGICAL
DAMAGE
The damage or error theory includes:
1) Wear and tear theory, where vital parts in our cells and tissues wear out resulting in
ageing.
2) Rate of living theory, that supports the theory that the greater an organism's rate of
oxygen basal, metabolism, the shorter its life span
3) Cross-linking theory, according to which an accumulation of cross-linked proteins
damages cells and tissues, slowing down bodily processes and thus result in ageing.
4) Free radicals theory, which proposes that superoxide and other free radicals cause
damage to the macromolecular components of the cell, giving rise to accumulated damage
causing cells, and eventually organs, to stop functioning.
GENETIC THEORY
The genetic theory of aging states that lifespan is largely determined by the genes we inherit.
According to the theory, our longevity is primarily determined at the moment of conception,
and is largely reliant on our parents and their genes.
The basis behind this theory is that segments of DNA that occur at the end of chromosomes,
called telomeres, determine the maximum lifespan of a cell. Telomeres are pieces of "junk"
DNA at the end of chromosomes which become shorter every time a cell divides. These
telomeres become shorter and shorter and eventually the cells cannot divide without losing
important pieces of DNA.
GENERAL IMBALANCE
General imbalance theories of aging suggest that body systems, such as the endocrine,
nervous, and immune systems, gradually decline and ultimately fail to function. The rate of
failure varies system by system.
At the current time there is not one theory or even one category of theories which can
explain everything we observe in the aging process.
COGNITIVE ASPECTS OF AGING
Cognition is the set of all mental abilities and processes related to knowledge: attention,
memory and working memory, judgment and evaluation, reasoning, problem solving, decision
making, comprehension and production of language.
A commonly held misconception is that aging results in an inevitable loss of all cognitive
abilities and that nothing can be done to halt this decline. Research, however, does not
support these claims. While certain areas of thinking do show a normal decline as we age,
others remain stable. Moreover, interventions may actually slow some of the changes that do
occur.
 Intelligence: “Chrystalized” intelligence, i.e., knowledge or experience accumulated over
time, actually remains stable with age. On the other hand, “fluid” intelligence or abilities
not based on experience or education tend to decline.
 Memory: Remote memory or recall of past events that have been stored over many years
remains relatively preserved in old age. Recent memory or the formation of new
memories, however, is more vulnerable to aging.
 Attention: Simple or focused attention such as the ability to attend to a television program
tends to be preserved in older age. Difficulties may be encountered, however, when
divided attention is required such as trying to pay attention to the television and
simultaneously talk on the telephone.
 Language: Verbal abilities including vocabulary are preserved as we age. Common
changes have to do with word retrieval or the process of getting words out. It takes longer
and is more difficult to find the words one wants when engaged in conversation or trying to
recall names of people and objects. The information is not lost but it is more difficult to
retrieve.
 Reasoning and Problem Solving: Traditional ways of approaching solutions are maintained
in older persons. Problems that have not been encountered during your life may take extra
time to figure out.
 Speed of Processing: Aging does affect the speed with which cognitive and motor
processes are performed. This does not mean that the activities cannot be performed, but
rather that they take longer!
FACTORS AFFECTING COGNITIVE AGING
 Medications which may produce side effects such as drowsiness and mental dullness;
 Sensory changes which can interfere with the processing of information (e.g., loss of
hearing which can affect whether or not someone’s name is heard when introduced);
 Health related changes such as arthritis and pain which can affect cognitive areas such as
concentration and processing speed; and
 Changes in mood such as depression and anxiety which can alter one’s motivation to learn
new information and to apply active strategies.
COMPENSATING FOR OR SLOWING DOWN AGE RELATED
CHANGES
A previous view was that as we age, brain cells inevitably die off and are not replaced. This
concept led to the belief that nothing could be done to alter the inevitable. We now know that
certain interventions can sharpen cognitive processes. These include:
 Reducing Stress: Researchers have found that high stress levels impair learning and
memory in both animals and humans. Strategies to reduce stress such as exercise may be
beneficial.
 Maintaining Good Health: Regular visits to the doctor are critical to make sure that
medical conditions which can themselves impair thinking are under good control. In
addition, possible interactions among medications should be evaluated by letting our
physician know all of the medications you are taking, even if not prescribed by that
particular doctor. A diet rich in fruits and vegetables containing antioxidants such as
blueberries, strawberries as well as certain fats such as olive oil may be neuroprotective.
According to the research conducted by Klenk and Dallmeier in community-dwelling
older people(≥65 years, 56.4% men) they found that there is an inverse relationship
between walking duration and mortality
 Keeping Mentally Stimulated: Studies have found that engaging in challenging cognitive
tasks can protect against age-related declines in thinking and the risk of developing
Alzheimer’s disease. It is important to keep one self stimulated through activities such as
reading and attending adult education courses.

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Ageing, theories of aging,history and physical examination

  • 1. HISTORY AND PHYSICAL EXAMINATION OF THE OLDER ADULT 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. 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 nurse 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 Functions -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 or hospital visit.
  • 2. 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, 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 . 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 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, and disheveled appearance. b. Rectal temperature if patient is seriously ill because of blunted immune response . c. Orthostatic changes in blood pressure (BP) and pulse. d. If systolic BP is greater than 160 to screen for "pseudohypertension". 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)
  • 3. g.Skin--Neoplasm (especially in sun exposed areas). 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. Neck a. 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.. 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. 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. 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 (cardiopulmonary disease) may give the impression of distension. This phenomenon and commonly occurring pulmonary hyperaeration may cause
  • 4. 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 (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, 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 . 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. Pelvic examination--Assess for pelvic prolapse, uterine 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. Neurological a. Mental status examination should be performed in all patients to establish a baseline in the event of future dysfunction ( 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. AGING Aging, is the process of becoming older. In the broader sense, ageing can refer to single cells within an organism which have ceased dividing. In humans, ageing represents the accumulation
  • 5. of changes in a human being over time, encompassing physical, psychological, and social change. Reaction time, for example, may slow with age, while knowledge of world events and wisdom may expand. 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 die from age-related causes. Effects of ageing A number of characteristic ageing symptoms are experienced by a majority or by a significant proportion of humans during their lifetimes. Commonly people older than 65 are called ‘OLD’. Gerontologists often draw finer chronological demarcations: • Young-old: 65-74 • Old-old: 75-84 • Oldest-old: >85 Teenagers lose the young child's ability to hear high-frequency sounds above 20 kHz. Some cognitive decline begins in the mid-20s.Wrinkles develop mainly due to photoageing, particularly affecting sun-exposed areas (face). After peaking in the mid-20s, female fertility declines. People over 35 years old are at risk for developing presbyopia, and most people benefit from reading glasses by age 45–50.The cause is lens hardening by decreasing levels of α-crystallin, a process which may be sped up by higher temperatures. Hair turns grey with age. Pattern hair loss by the age of 50 affects about half of males and a quarter of females. Menopause typically occurs between 49 and 52 years of age. Around a third of people between 65 and 74 have hearing loss and almost half of people older than 75. A loss of muscle mass and mobility, affects 25% of those over 85.
  • 6. 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 65–74 have dementia, 19% between 75 and 84 and nearly half of those over 85 years of age. The spectrum includes mild cognitive impairment and the neurodegenerative diseases of Alzheimer's disease, cerebrovascular disease and Parkinson's disease. Furthermore, many types of memory may decline with ageing, but not semantic memory or general knowledge such as vocabulary definitions, which typically increases or remains steady until late adulthood. Intelligence may decline with age, though the rate may vary depending on the type and may in fact remain steady throughout most of the lifespan, dropping suddenly only as people near the end of their lives. Individual variations in rate of cognitive decline may therefore be explained in terms of people having different lengths of life. There might be changes to the brain: after 20 years of age there may be a 10% reduction each decade in the total length of the brain's myelinated axons. Age can result in visual impairment, whereby non-verbal communication is reduced,which can lead to isolation and possible depression. Macular degeneration causes vision loss and increases with age, affecting nearly 12% of those above the age of 80. This degeneration is caused by systemic changes in the circulation of waste products and by growth of abnormal vessels around the retina. Many people have the wrong impression of what it means to grow old. The older years of an individual’s life can actually be a very active time for many people, with new experiences and new connections. Many older adults may feel like they are no longer useful, productive, or valuable in their later years of life, but “old age” can be full of meaning and purpose for those who choose to explore the possibilities. AGING MYTH AND REALITY There are many misconceptions about aging those caregivers and seniors should be aware of. As a caregiver, become sensitive to these misconceptions and be sure to reinforce the potential of your loved one’s life, regardless of their age and limitations. Myth and reality;1 – Brain Power Disappears with Age While many older adults will struggle with mental conditions, like dementia, that decrease their short-term or long-term memory, the truth is that verbal/math abilities and abstract reasoning can actually increase with age. The key to strengthening these abilities is engaging the brain and exercising mental faculties to combat degenerative conditions. Physical exercise and social interaction are also important factors that can contribute to keeping the brain active and sharp.
  • 7. Myth and reality;2 – Aging Robs You of Your Happiness Though many people associate old age with depression, loneliness, and misery, getting older does not mean your loved one will lose their joy for life. In fact, recent happiness studies indicate that people are happiest at retirement age. Today, with the wealth of opportunities available for older adults, this can still ring true for adults who have been retired for many years. Getting older can mean having time to enjoy hobbies and interests that bring true happiness, rather than having all of one's time engaged in obligations. Myth and reality;3 – Older Adults Are Lonely In today’s world, there is not only a multitude of social activities available for older adults, but also a variety of senior living options. Volunteer opportunities, club memberships, senior centers, and time with family and friends can provide human interactions and social connections that can support an older adult through the aging process and any challenges that come along with it. Living in an assisted living community can also provide a great sense of family and belonging to residents. Myth and reality;4 – Older Adults Have Multiple Health Conditions While our bodies do wear down with age, growing old does not necessarily mean losing all of your independence and visiting the hospital every week. While some older adults may develop health conditions that require close monitoring and intervention, many health conditions can be avoided by maintaining a healthy lifestyle. Taking care of your health as you age and staying active through proper exercise will help prevent falls, improve balance and circulation, and help increase overall independence. Myth and reality;5 – Aging Limits the Ability to Learn New Skills Learning new skills as an older adult is a different process than learning in your younger years, but that doesn’t mean older adults should avoid trying new things. In fact, learning and processing new information or taking up a new hobby can help keep the mind sharp and provide something interesting to enjoy throughout the day. You can, and should, learn new skills as you age.
  • 8. Myth and reality; -Aging is gender blind Age is presumed to be the great equalizer men and women, rich and poor, regardless of background. Both males and females experience loss with age. On average, women live 7 years longer than men. Many people fear getting older because of these misconceptions, but the aging process should not be considered something to be afraid of, but rather, something to explore. If you stay active and engaged, your later years of life can be some of the best in your life! THEORIES OF AGING  Psychological ◦ Maslow’s Hierarchy of Needs (1943) ◦ Erikson’s Psychological Stages (1956) ◦ Selective Optimization with Compensation (SOC, 1980)  Sociological ◦ Activity ◦ Disengagement Theory ◦ Continuity  Biological ◦ Damage ◦ Genetic ◦ General imbalance  PSYCHOLOGICAL MASLOW'S HIERARCHY OF NEEDS AND ERIKSON’S EIGHT PSYCHOSOCIALCRISIS STAGES OF DEVELOPMENT According to Erikson there are 8 stage of development or eight psychosocial stages of development . Erikson's psychosocial theory essentially states that each person experiences eight 'psychosocial crises' . which help to define his or her growth and personality.
  • 9. Maslow's hierarchy of needs is a theory in psychology proposed by Abraham Maslow in 1943. which focus on describing the stages of growth in humans. Maslow's hierarchy of needs is often portrayed in the shape of a pyramid with the largest, most fundamental levels of needs at the bottom and the need for self-actualization and self-transcendence at the top. There are significant parallels between the growth outcomes of the Erikson psychosocial model, and the growth aspects Maslow's Hierarchy of Needs. life stage / relationships / issues crisis Maslow Hierarchy of Needs stage - primary correlation infant / mother / feeding and being comforted, teething, sleeping 1. Trust v Mistrust biological & physiological toddler / parents / bodily functions, toilet training, muscular control, walking 2. Autonomy v Shame & Doubt safety preschool / family / exploration and discovery, adventure and play 3. Initiative v Guilt belongingness & love schoolchild / school, teachers, friends, neighbourhood / achievement and accomplishment 4. Industry v Inferiority esteem adolescent / peers, groups, influences / resolving identity and direction, becoming a grown-up 5. Identity v Role Confusion esteem young adult / lovers, friends, work connections / intimate relationships, work and social life 6. Intimacy v Isolation esteem mid-adult / children, community / 'giving back', helping, contributing 7. Generativity v Stagnation self-actualization late adult / society, the world, life / meaning and purpose, life achievements, acceptance 8. Integrity v Despair Outcome; self-actualization
  • 10. Wisdom & Renunciation SELECTIVE OPTIMIZATION WITH COMPENSATION (SOC, 1980) Most modern cultures do not provide the same richness of opportunities to older persons as are provided to younger members of society. This is in spite of the fact that cultural opportunities are especially needed by older adults to compensate for biologically based decreases in functioning. Thus, in old age, individuals have to allocate more of their resources to the maintenance of functioning and providing resilience against losses, rather than into processes of growth. Selective Optimization with Compensation is a strategy for improving health and wellbeing in older adults and a model for successful ageing. According to the SOC model, successful aging encompasses selection of functional domains on which to focus one’s resources, optimizing developmental potential (maximization of gains) and compensating for losses—thus ensuring the maintenance of functioning and a minimization of losses. It is recommended that seniors select and optimize their best abilities and most intact functions while compensating for declines and losses. For example, an elderly person with fading eyesight who loves to sing could focus more time and attention on singing, perhaps by joining a new choir, while cutting back on time spent reading. Overall, this model suggests that seniors take an active approach in their ageing process and set goals that are attainable and meaningful.  SOCIOLOGICAL DISENGAGEMENT THEORY The Disengagement Theory, one of the earliest and most controversial theories of aging, views aging as a process of gradual withdrawal between society and the older adult. This mutual withdrawal or disengagement is a natural, acceptable, and universal process that accompanies growing old. It is applicable to elders in all cultures, although there might be variations. According to this theory, disengagement benefits both the older population and the social system. Gradual withdrawal from society and relationships preserves social equilibrium and promotes self-reflection for elders who are freed from societal roles. It furnishes an orderly means for the
  • 11. transfer of knowledge, capital, and power from the older generation to the young. It makes it possible for society to continue functioning after valuable older members die. Weakness: There is no base of evidence or research to support this theory. Additionally, many older people desire to remain occupied and involved with society. Imposed withdrawal from society may be harmful to elders and society alike. This theory has been largely discounted by gerontologists. ACTIVITY THEORY The theory was developed by Robert J. Havighurst in 1961.This theory argues that actively engaged older persons have greater life satisfaction. It takes the view that the ageing process is delayed and the quality of life is enhanced when old people remain socially active. The theory assumes that a positive relationship between activity and life satisfaction. CONTINUITY THEORY [Atchley, 1971] The continuity theory of normal aging states that older adults will usually maintain the same activities, behaviors, relationships as they did in their earlier years of life. According to this theory, older adults try to maintain this continuity of lifestyle by adapting strategies that are connected to their past experiences. The theory considers the internal structures and external structures of continuity to describe how people adapt to their circumstances and set their goals. The internal structure of an individual - for instance, an individual's personality traits - remains relatively constant throughout a person's lifetime. Other internal aspects such as beliefs can remain relatively constant as well, though are also subject to change. This internal structure facilitates future decision-making by providing the individual with a strong internal foundation of the past. The external structure of an individual consists of relationships and social roles, and it supports the maintenance of a stable self-concept and lifestyle.  BIOLOGICAL DAMAGE The damage or error theory includes: 1) Wear and tear theory, where vital parts in our cells and tissues wear out resulting in ageing.
  • 12. 2) Rate of living theory, that supports the theory that the greater an organism's rate of oxygen basal, metabolism, the shorter its life span 3) Cross-linking theory, according to which an accumulation of cross-linked proteins damages cells and tissues, slowing down bodily processes and thus result in ageing. 4) Free radicals theory, which proposes that superoxide and other free radicals cause damage to the macromolecular components of the cell, giving rise to accumulated damage causing cells, and eventually organs, to stop functioning. GENETIC THEORY The genetic theory of aging states that lifespan is largely determined by the genes we inherit. According to the theory, our longevity is primarily determined at the moment of conception, and is largely reliant on our parents and their genes. The basis behind this theory is that segments of DNA that occur at the end of chromosomes, called telomeres, determine the maximum lifespan of a cell. Telomeres are pieces of "junk" DNA at the end of chromosomes which become shorter every time a cell divides. These telomeres become shorter and shorter and eventually the cells cannot divide without losing important pieces of DNA. GENERAL IMBALANCE General imbalance theories of aging suggest that body systems, such as the endocrine, nervous, and immune systems, gradually decline and ultimately fail to function. The rate of failure varies system by system. At the current time there is not one theory or even one category of theories which can explain everything we observe in the aging process. COGNITIVE ASPECTS OF AGING Cognition is the set of all mental abilities and processes related to knowledge: attention, memory and working memory, judgment and evaluation, reasoning, problem solving, decision making, comprehension and production of language. A commonly held misconception is that aging results in an inevitable loss of all cognitive abilities and that nothing can be done to halt this decline. Research, however, does not support these claims. While certain areas of thinking do show a normal decline as we age, others remain stable. Moreover, interventions may actually slow some of the changes that do occur.
  • 13.  Intelligence: “Chrystalized” intelligence, i.e., knowledge or experience accumulated over time, actually remains stable with age. On the other hand, “fluid” intelligence or abilities not based on experience or education tend to decline.  Memory: Remote memory or recall of past events that have been stored over many years remains relatively preserved in old age. Recent memory or the formation of new memories, however, is more vulnerable to aging.  Attention: Simple or focused attention such as the ability to attend to a television program tends to be preserved in older age. Difficulties may be encountered, however, when divided attention is required such as trying to pay attention to the television and simultaneously talk on the telephone.  Language: Verbal abilities including vocabulary are preserved as we age. Common changes have to do with word retrieval or the process of getting words out. It takes longer and is more difficult to find the words one wants when engaged in conversation or trying to recall names of people and objects. The information is not lost but it is more difficult to retrieve.  Reasoning and Problem Solving: Traditional ways of approaching solutions are maintained in older persons. Problems that have not been encountered during your life may take extra time to figure out.  Speed of Processing: Aging does affect the speed with which cognitive and motor processes are performed. This does not mean that the activities cannot be performed, but rather that they take longer! FACTORS AFFECTING COGNITIVE AGING  Medications which may produce side effects such as drowsiness and mental dullness;  Sensory changes which can interfere with the processing of information (e.g., loss of hearing which can affect whether or not someone’s name is heard when introduced);  Health related changes such as arthritis and pain which can affect cognitive areas such as concentration and processing speed; and  Changes in mood such as depression and anxiety which can alter one’s motivation to learn new information and to apply active strategies. COMPENSATING FOR OR SLOWING DOWN AGE RELATED CHANGES
  • 14. A previous view was that as we age, brain cells inevitably die off and are not replaced. This concept led to the belief that nothing could be done to alter the inevitable. We now know that certain interventions can sharpen cognitive processes. These include:  Reducing Stress: Researchers have found that high stress levels impair learning and memory in both animals and humans. Strategies to reduce stress such as exercise may be beneficial.  Maintaining Good Health: Regular visits to the doctor are critical to make sure that medical conditions which can themselves impair thinking are under good control. In addition, possible interactions among medications should be evaluated by letting our physician know all of the medications you are taking, even if not prescribed by that particular doctor. A diet rich in fruits and vegetables containing antioxidants such as blueberries, strawberries as well as certain fats such as olive oil may be neuroprotective. According to the research conducted by Klenk and Dallmeier in community-dwelling older people(≥65 years, 56.4% men) they found that there is an inverse relationship between walking duration and mortality  Keeping Mentally Stimulated: Studies have found that engaging in challenging cognitive tasks can protect against age-related declines in thinking and the risk of developing Alzheimer’s disease. It is important to keep one self stimulated through activities such as reading and attending adult education courses.