(20) Older Adult Flashcards
Geriatric Approach to Primary Care
- Learn to quickly identify frail elderly patients; they are most vulnerable
to adverse outcomes and most benefit from a holistic geriatric approach. - Look for common geriatric syndromes, including falls, delirium/cognitive
impairment, functional dependence, and urinary incontinence in every
patient. - Learn about efficient assessment tools for geriatrics and geriatric syndromes and teach clinical staff to administer them when possible.
- Be familiar with community resources, such as fall prevention programs, PACE programs, and senior centers.
- Take into account a patient’s goals, life expectancy, and functional status
before considering any test or procedure. - Review advanced directives and goals of care periodically.
- Be knowledgeable about the Beers Criteria (see p. 972) use them to identify
potentially inappropriate medications in the elderly and inform periodic
comprehensive medication review. - Adopt an evidence-based approach to health screening, especially in the
frail elderly. - Watch carefully for mood disorders in the frail elderly and consider using
geriatric-specific screening tools, such as the five-item Geriatric Depression
Scale. - Provide caregiver support when possible.
Older Adults: BP
systolic blood pressure tends to rise
with aging
- aorta and large arteries stiffen and become atherosclerotic.
- aorta becomes less distensible, a given stroke volume causes a greater rise in systolic blood pressure
systolic hypertension with a widened pulse pressure (PP) often ensues
Diastolic blood pressure (DBP) stop rising around 60s.
many older adults develop orthostatic
(postural) hypotension—a sudden drop in blood pressure when rising to a standing position.
Older Adults: Heart Rate and Rhythm
resting heart rate remains
unchanged
declines in the pacemaker cells of the sinoatrial node and the maximal heart rate, which affect the response to exercise and physiologic stress
more likely to have abnormal heart rhythms such as atrial or ventricular
ectopy
Asymptomatic rhythm changes are generally benign. However, some
rhythm changes cause syncope
Older Adults: Respiratory Rate and Temperature
remain unchanged
- changes in temperature regulation lead to susceptibility to hypothermia
Older Adults: Skin, Nails, Hair
- skin wrinkles, becomes lax, and loses
turgor - dermis is less vascular, causing lighter skin to look paler and more
opaque - Skin on the backs of the hands and forearms appears thin, fragile, loose,
and transparent - may be purple patches or macules, termed actinic purpura, that fade over time. These spots and patches come from blood that has leaked
through poorly supported capillaries and spread within the dermis
Nails lose luster with age and may yellow and thicken, especially on the
toes.
Hair undergoes a series of changes. Scalp hair loses its pigment, changing hair
color to gray. Hair loss on the scalp is genetically determined. As early as
20 years, a man’s hairline may start to recede at the temples and then at the
vertex. In women, hair loss follows a similar but less severe pattern. In both
sexes, the number of scalp hairs decreases in a generalized pattern, and the
diameter of each hair gets smaller. There is also normal hair loss elsewhere on
the body—the trunk, pubic areas, axillae, and limbs. Women over 55 years
may develop coarse facial hairs on the chin and upper lip.
Many of these changes are more common in lighter-skinned patients and may
not apply to patients with darker skin tones. For example, Native American men
have relatively little facial and body hair compared with lighter-skinned men and
should be evaluated according to their own norms.
Older Adults: Eyes and Visual Acuity
The eyes, ears, and mouth show more visible
changes of aging. The fat that surrounds and cushions the eyes within the
bony orbit may atrophy, making the eyeballs appear to recede. The skin of
the eyelids becomes wrinkled and may hang in looser folds. Fat may push
the fascia of the eyelids forward, creating soft bulges, especially in the lower
lids and the inner third of the upper lids. Because of fewer lacrimal secretions,
older patients may complain of dry eyes. The corneas lose some of
their luster.
The pupils become smaller, making it more difficult to examine the ocular fundi.
The pupils may also become slightly irregular but should continue to respond to
light and show the near reaction (see pp. 235–236).
Visual acuity remains fairly constant between ages 20 and 50 years. It diminishes
gradually until approximately 70 years and then more rapidly. Nevertheless,
most older adults retain good to adequate vision (20/20 to 20/70 as
measured by standard charts). Near vision, however, begins to blur noticeably
for virtually everyone. From childhood on, the lens gradually loses its
elasticity, with progressive loss of accommodation and the ability to focus on
nearby objects. Ensuing presbyopia usually becomes noticeable during the
fifth decade.
Aging increases the risk of developing cataracts, glaucoma, and macular
degeneration. Thickening and yellowing of the lens impairs the passage of
light to the retina, requiring more light for reading and doing fine work.
Cataracts affect 10% of patients in their 60s and over 30% in their 80s.
Because the lens continues to expand with aging, it may push the iris forward,
narrowing the angle between iris and cornea and increasing the risk
of narrow-angle glaucoma.
Older Adults: Hearing
Hearing acuity usually declines with age. Early losses, which start
in young adulthood, involve primarily the high-pitched sounds beyond the range of human speech and have relatively little functional significance. Gradually,
loss extends to sounds in the middle and lower ranges. When a person fails
to hear the higher tones of words but still hears lower tones, words sound distorted
and difficult to understand, especially in noisy environments. Hearing loss
associated with aging, known as presbycusis, becomes increasingly evident, usually
after age 50 years.
Older Adults: Mouth, Teeth, Lymph Nodes
With aging, there are decreased salivary
secretions and loss of taste; medications and various diseases can exacerbate
these changes. Decreased olfaction and increased sensitivity to bitterness
and saltiness also affect taste. Teeth may wear down, become abraded, or fall out
due to dental caries or periodontal disease. In patients without teeth, the lower
portion of the face looks small and sunken, with accentuated “purse-string”
wrinkles radiating from the mouth. Overclosure of the mouth may lead to maceration
of the skin at the corners, or angular cheilitis. The bony ridges of the jaws
that once surrounded the tooth sockets are gradually resorbed, especially in the
lower jaw.
With aging, the cervical lymph nodes become less palpable. In contrast, the
submandibular glands become easier to feel.
Older Adults: thorax and lungs
As people age, they lose lung capacity during exercise.16
The chest wall becomes stiffer and harder to move, respiratory muscles may
weaken, and the lungs lose some of their elastic recoil. Lung mass and the surface
area for gas exchange decline, and residual volume increases as the alveoli enlarge.
An increase in closing volumes of small airways predisposes to atelectasis and risk
of pneumonia. Diaphragmatic strength declines. The speed of breathing out with
maximal effort gradually diminishes, and coughing becomes less effective. There
is a decrease in arterial pO2, but the O2 saturation normally remains above 90%.
Skeletal changes can accentuate the dorsal curve of the thoracic spine. Osteoporotic
vertebral collapse produces kyphosis, which increases the anteroposterior
diameter of the chest. However, the resulting “barrel chest” has little effect on
function.
Older Adults: Neck Vessels
Lengthening and tortuosity of the aorta and its branches
occasionally result in kinking or buckling of the carotid artery low in the neck,
especially on the right. The resulting pulsatile mass, occurring chiefly in
women with hypertension, may be mistaken for a carotid aneurysm—a true
dilatation of the artery. A tortuous aorta occasionally raises the pressure in the
jugular veins on the left side of the neck by impairing their drainage within the
thorax.
In older adults, systolic bruits heard in the middle or upper portions of the
carotid arteries indicate stenosis from atherosclerotic plaque. Cervical bruits in
younger people are usually innocent
Older Adults:
Cardiac Output
Myocardial contraction is less responsive to stimulation
from β-adrenergic catecholamines. There is a modest drop in resting heart rate,
but a significant drop in the maximum heart rate during exercise. Although heart
rate drops, stroke volume increases, so cardiac output is maintained. Diastolic
dysfunction arises from decreased early diastolic filling and greater dependence
on atrial contraction. There is increased myocardial stiffness, notably in the left
ventricle, which also hypertrophies.
Risk of heart failure increases with loss of atrial contraction and onset of atrial
fibrillation due to decreased ventricular filling.
Older Adults: Extra Heart Sounds (S3/S4)
A physiologic third heart sound, commonly
heard in children and young adults, may persist as late as age 40 years,
especially in women. After age 40 years, however, an S3 strongly suggests
heart failure from volume overload of the left ventricle in conditions like
heart failure and valvular heart disease (e.g., mitral regurgitation). In contrast,
a fourth heart sound is seldom heard in young adults other than wellconditioned
athletes. An S4 can be heard in otherwise healthy older people,
but often suggests decreased ventricular compliance and impaired ventricular
filling.
Older Adults: Cardiac Murmurs
Middle-aged and older adults commonly have a
systolic aortic murmur. This murmur is detected in approximately one third of
people at age 60 years, and in more than half of those reaching 85 years. With
aging, fibrotic changes thicken the bases of the aortic cusps. Calcification
follows, resulting in audible vibrations. Turbulence produced by blood flow
into a dilated aorta may further augment this murmur. In most older adults,
the process of fibrosis and calcification, known as aortic sclerosis, does not
impede blood flow. In some, the aortic valve leaflets become calcified and
immobile, resulting in aortic stenosis and outflow obstruction. A brisk carotid
upstroke can help distinguish aortic sclerosis from aortic stenosis, which has
a delayed carotid upstroke, but clinically distinguishing these conditions
is difficult. Both carry increased risk for cardiovascular morbidity and
mortality.
Similar changes alter the mitral valve, but usually about one decade later than
the aortic valve. Calcification of the mitral valve annulus, or valve ring, impedes
normal valve closure during systole, causing the systolic murmur of mitral regurgitation.
This change in the configuration of the valve may become pathologic as
volume overload increases in the left ventricle.
Older Adults:
Peripheral Vascular System
The peripheral arteries tend to
lengthen, become tortuous, and feel harder and less resilient. There is
increased arterial stiffness and decreased endothelial function.16 The trophic
changes of the skin, nails, and hair discussed earlier occur independently,
although they may accompany arterial disease. Although arterial and venous
disorders, especially atherosclerosis, are more common in older adults, these
are not normal changes of aging. Loss of arterial pulsations is not typical and
demands careful evaluation. Abdominal or back pain in older adults raises the
important concern of possible abdominal aortic aneurysm, especially in malesmokers over age 65 years. Rarely, after age 50 years but especially after age
70 years, the temporal arteries may develop giant cell, or temporal, arteritis,
leading to loss of vision in 15% of patients and headache and jaw claudication
Older Adults: Breasts and Axillae
The normal adult female breast is soft but may be
granular, nodular, or lumpy. This uneven texture represents physiologic
nodularity, palpable throughout or only in parts of the breasts. With aging, the
female breasts tend to get smaller, more flaccid, and more pendulous as glandular
tissue atrophies and is replaced by fat. The ducts surrounding the nipple may
become more palpable as firm stringy strands. Axillary hair diminishes. Males
may develop gynecomastia or increased breast fullness due to obesity and
hormonal changes.
Older Adults: Abdomen
During the middle and later years, the abdominal muscles tend
to weaken, there is decreased activity of lipoprotein lipase, and fat may accumulate
in the lower abdomen and near the hips even when the weight is stable. These
changes often produce a softer, more protruding, abdomen which patients may
interpret as fluid or evidence of disease. The change in abdominal fat distribution
increases the risk of cardiovascular disease.
Aging can blunt the manifestations of acute abdominal disease. Pain may be
less severe, fever is often less pronounced, and signs of peritoneal inflammation,
such as guarding and rebound tenderness, may be diminished or even
absent.
Older Adults: Male Genitalia
As men age, sexual interest
appears to remain intact, although frequency of intercourse appears to decline
after age 75 years. Several physiologic changes accompany decreasing
testosterone levels.16 Erections become more dependent on tactile stimulation
and less responsive to erotic cues. The penis decreases in size, and the testicles
drop lower in the scrotum. Protracted illnesses, more than aging, lead to
decreased testicular size. Pubic hair may decrease and become gray. Erectile
dysfunction, or the inability to maintain an erection, affects approximately
50% of older men. Vascular causes are the most common, from both
atherosclerotic arterial occlusive disease and corpora cavernosa venous leak.
Chronic diseases such as diabetes, hypertension, dyslipidemia, and smoking,
as well as medication side effects, all contribute to the prevalence of erectile
dysfunction.
Older Adults: Female Genitalia
In women, ovarian function usually starts to decline during the fifth decade; on
average, menstrual periods cease between age 45 and 52 years. As estrogen
stimulation falls, many women experience hot flashes, sometimes for up to
5 years. Symptoms range from flushing, sweating, and palpitations to chills and
anxiety. Sleep disruption and mood changes are common. Women may report
vaginal dryness, urge incontinence, or dyspareunia. Several vulvovaginal
changes occur: Pubic hair becomes sparse as well as gray, and the labia and clitoris
become smaller. The vagina narrows and shortens, and the vaginal mucosa
becomes thin, pale, and dry, with loss of lubrication. The uterus and ovaries
diminish in size. Within 10 years after menopause, the ovaries are usually no longer palpable. The suspensory ligaments of the adnexa, uterus, and bladder
may also relax. Sexuality and sexual interest are often unchanged, particularly
when women are untroubled by partner issues, partner loss, or unusual work or
life stress.
Older Adults: Prostate
The prevalence of urinary incontinence increases with age, related to decreased
innervation and contractility of the detrusor muscle and loss of bladder capacity,
urinary flow rate, and the ability to inhibit voiding. In men, there is androgendependent
proliferation of prostate epithelial and stromal tissue, termed benign
prostatic hyperplasia (BPH), that begins in the third decade, continues to the
seventh decade, then appears to plateau. Only half of men will have clinically
significant enlargement, and of those, only half will report symptoms such as
urinary hesitancy, dribbling, and incomplete emptying. These symptoms can
often be traced to other causes like coexisting disease, use of medications, and
lower urinary tract abnormalities
Older Adults: Musculoskeletal System
Both men and women lose cortical and
trabecular bone mass throughout adulthood; men more slowly, and women
more rapidly after menopause, which leads to increased risk of fracture.
Calcium resorption from bone, rather than diet, increases with aging as
parathyroid hormone levels rise. Subtle losses in height begin soon after
maturity; significant shortening is obvious by old age. Most loss of height
occurs in the trunk and reflects thinning of the intervertebral discs and
shortening or even collapse of the vertebral bodies from osteoporosis, leading
to kyphosis and an increase in the anteroposterior diameter of the chest.
Added flexion at the knees and hips also contributes to shortened stature.
These changes cause the limbs of an elderly person to look long in proportion
to the trunk.
With aging, there is a 30% to 50% decline in muscle mass in relation to body
weight in both men and women, and ligaments lose some of their tensile strength.
Range of motion diminishes, in part due to osteoarthritis. Sarcopenia is the loss
of lean body mass and strength with aging.19 The causes of muscle loss are multifactorial,
including inflammatory and endocrine changes as well as sedentary
lifestyle. There is substantial evidence that strength training in older adults can
slow or reverse this process
Older Adults: Nervous System
Aging affects all aspects of the nervous system, from
mental status to motor and sensory function and reflexes. Brain volume, cortical
brain cells, and intrinsic regional connecting networks decrease, and both microanatomical
and biochemical changes have been identified.20 Nevertheless, most
older adults maintain their self-esteem and adapt well to their changing capacities
and circumstances.
Older Adults: Mental Status
Although older adults generally perform well on mental
status examinations, they may display selected impairments, especially at
advanced ages. Many older people complain about memory problems. This is
usually from “benign forgetfulness,” which can occur at any age. This term refers
to difficulty recalling the names of people or objects or details of specific events
Identifying this common phenomenon can allay fear of Alzheimer disease. Older
adults also retrieve and process data more slowly and take longer to learn new
information. Their motor responses may slow and their ability to perform complex
tasks may diminish.
Frequently, the clinician must try to distinguish these age-related changes from
manifestations of mental disorders that are prevalent in older adults like depression
and dementia. Diagnosis can be difficult because both mood disturbances
and cognitive changes can alter the patient’s ability to recognize or report
symptoms. Older patients are also more susceptible to delirium, a temporary
state of confusion that may be the first clue to infection, problems with medications,
or impending dementia. It is important to recognize these conditions
promptly to delay functional decline. Recall that sensory and motor findings
in older patients that are physiologic, such as the changes in hearing; vision;
extraocular movements; and pupillary size, shape, and reactivity, are abnormal
in younger adults.
Older Adults: Motor System
Changes in the motor system are common. Older adults
move and react with less speed and agility and skeletal muscles decrease in bulk.
The hands of an older patient often look thin and bony due to atrophy of the
interosseous muscles that leaves concavities or grooves. Muscle wasting tends to
appear first between the thumb and the hand (first and second metacarpals),
then affects the other metacarpals (see pp. 741–742). It may also flatten the thenar
and hypothenar eminences of the palms. Arm and leg muscles can show
signs of atrophy, exaggerating the apparent size of adjacent joints. Muscle
strength, though diminished, is relatively well maintained.
Occasionally, older adults develop a benign essential tremor in the head, jaw,
lips, or hands that may be confused with parkinsonism. Unlike parkinsonian
tremors, however, benign tremors are slightly faster and disappear at rest, and
there is no associated muscle rigidity.
Older Adults: Position and Vibratory Sense; Reflexes
Aging can also affect vibratory
and position sense and reflexes. Older adults frequently lose some or all vibration
sense in the feet and ankles (but not in the fingers or over the shins). Less
commonly, position sense may diminish or disappear. The gag reflex may be
decreased or absent. Abdominal reflexes may diminish or disappear. Ankle
reflexes may be symmetrically decreased or absent, even when reinforced.
Less commonly, knee reflexes are similarly affected. Partly because of musculoskeletal
changes in the feet, the plantar responses become less obvious and
more difficult to interpret. If there are associated abnormal neurologic findings,
or if atrophy and reflex changes are asymmetric, search for an explanation
other than aging.
Older adults experience the death of loved ones and friends, retirement from
valued employment, diminution in income, and often growing social isolation
in addition to physiologic changes and decreased physical capacity.
Including the impact of these significant life events in the assessment of mood and affect and addressing these issues may improve the patient’s quality of life
Approach to Older Adults (Health History) - pg. 965-968
● Adjusting the office environment (bright light, face directly, eye level, quiet room)
● Shaping the content and pace of the visit
● Eliciting symptoms
- underreport symptoms
- atypical presentation of illness
- geriatric syndromes
- cognitive impairment
● Addressing the cultural dimensions of aging
Tips for Communicating Effectively with Older Adults
● Provide a well-lit, moderately warm setting with minimal background noise,
chairs with arms, and access to the examining table.
● Face the patient and speak in low tones; make sure the patient is using
glasses, hearing devices, and dentures, if needed.
● Adjust the pace and content of the interview to the stamina of the patient;
consider two visits for initial evaluations.
● Allow time for open-ended questions and reminiscing; include family and
caregivers when indicated, especially if the patient has cognitive impairment.
● Make use of screening instruments, the clinical record, and reports from allied
disciplines.
Carefully assess symptoms, especially fatigue, loss of appetite, dizziness,
weight loss, and pain, for clues to underlying disorders and geriatric
syndromes. Make sure written instructions are in large print and easy to read.
● Always give the patient an updated medication that includes the name of the
medication, dosage instructions, and why the medication is being prescribed.
Older Adults: Common Concerns
● Activities of Daily Living ● Instrumental activities of daily living ● Medications ● Acute and persistent pain ● Smoking and alcohol ● Nutrition ● Frailty ● Advance directives and palliative care
ADLs
bathing Dressing Toileting Transferring Continence Feeding
Instrumental Activities of Daily Living (IADLs)
Using the phone Shopping Food Prep Housekeeping Laundry Transportation Taking Medicine Managing Money
Approximately 85% of adults over age 65 years have at least one of 6 chronic conditions:
(and 50% take at
least one prescription drug each day)
arthritis current asthma cancer cardiovascular disease COPD diabetes
? are the single most common modifiable risk factor associated with
falls.
Medications
start low and go slow with dosing
Hospitalized Older Adults:
Risk Factors for Adverse Drug Reactions
● More than four comorbid conditions
● Heart failure, renal failure, or liver disease
● Age ≥80 years
● Number of drugs, especially if eight or more
● Use of warfarin, insulins, oral antiplatelet agents, or oral hypoglycemic agents
● Previous adverse drug reaction
● Hyperlipidemia
● Raised white cell count
● Use of antidiabetic agents
● Length of stay ≥12 days
Older Adults and pain
-less likely to report leading to suffering and depression, social isolation, physical disability, loss of function
- usually from musculoskeletal complains (back/joint) or:
- headache
- neuralgias from DM and herpes zoster
- nighttime leg pain
- cancer pain
characteristics of acute pain
distinct onset
obvious pathology
short duration
common causes: post surgical, trauma, headache
characteristics of persistent pain
lasts > 3 months
often associated w/ psychological or functional impairment
can fluctuate in character and intensity overtime
common causes: arthritis, cancer, claudication, leg cramps, neuropathy, radiculopathy
older adults and alcohol
limits are lower after 65 d/t physiologic changes that alter alcohol metabolism, comorbid illness, and risk of drug interactions
- no more than 3 drinks/day to 7/week
Screening all older adults for harmful alcohol use is
especially important due to adverse interactions with most medications and
exacerbation of comorbid illnesses, including cirrhosis, gastrointestinal bleeding
or reflux disease, gout, hypertension, diabetes, insomnia, gait disorders,
and depression in up to 30% of older patients
Clues to Alcohol-Use Disorders in Older Adults
● Memory loss, cognitive impairment ● Depression, anxiety ● Neglect of hygiene, appearance ● Poor appetite, nutritional deficits ● Sleep disruption ● Hypertension refractory to therapy ● Blood sugar control problems ● Seizures refractory to therapy ● Impaired balance and gait, falls ● Recurrent gastritis and esophagitis ● Difficulty managing warfarin dosing ● Use of other addictive substances such as sedatives or narcotic analgesics, illicit drugs, nicotine
Frality
Frailty is a multifactorial geriatric syndrome characterized by an agerelated
lack of adaptive physiological capacity occurring even in the absence of
identifiable illness. Frailty typically signifies loss of muscle mass, decreased
energy and exercise intolerance, and decreased physiological reserve, with
increasing vulnerability to physiologic stressors. Studies generally use one of two
definitions. The narrower definition is based solely on physical conditions such
as weight loss, exhaustion, weakness, slowness, and low physical activity; the
broader definition also includes mood, cognition, and incontinence. Overall
prevalence of frailty in community-dwelling adults is ∼10%, but reports of
prevalence range from 4% to 59% depending on the definition and measurement
indexes used.70,71
Screen your patients for the presence of three components identified in the
Study for Osteoporotic Fractures and pursue related interventions: weight loss
of more than 5% over 3 years, inability to do five chair stands, and self-reported
exhaustion
Important Topics for Health Promotion
and Counseling in the Older Adult
● When to screen ● Vision and hearing ● Exercise ● Household safety and fall prevention ● Immunizations ● Cancer screening ● Depression ● Dementia, mild cognitive impairment, and cognitive decline ● Elder mistreatment and abuse
CDC Exercise Recommendations for Older Adults
Adults need at least:
● 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity
(i.e., brisk walking) every week and
● muscle-strengthening activities on two or more days a week that work all
major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
OR
● 1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e.,
jogging or running) every week and
● muscle-strengthening activities on two or more days a week that work all
major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
OR
● An equivalent mix of moderate- and vigorous-intensity aerobic activity and
● muscle-strengthening activities on two or more days a week that work all
major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
Home Safety Tips for Older Adults
● Install bright lighting and lightweight curtains or shades.
● Install handrails and lights on all staircases. Pathways and walkways should be
well-lit.
● Remove items that cause tripping like papers, books, clothes, and shoes from
stairs and walkways.
● Remove or secure small throw rugs and other rugs with double-sided tape.
● Wear shoes both inside and outside the house. Avoid bare feet and wearing
slippers.
● Store medications safely.
● Keep commonly used items in cabinets that are easy to reach without using a
step stool.
● Install grab bars and nonslip mats or safety strips in baths and showers.
● Repair faulty plugs and electrical cords.
● Install smoke alarms and have a plan for escaping fire.
● Secure all firearms.
● Have a clinical alert device/system for emergency contacts or easy access to 911.
Screening Recommendations for Older Adults:
U.S. Preventive Services Task Force
● Breast cancer (2016): Recommends mammography every 2 years for women
aged 50 to 74 years and cites insufficient evidence for screening women aged
≥75 years.
● Cervical cancer (2012): Recommends against routine screening for women
over age 65 years if they have had adequate recent screening with normal Pap
smears and are not otherwise at high risk for cervical cancer, based on fair
evidence.
● Colorectal cancer (2008): Recommends screening with colonoscopy every 10
years, sigmoidoscopy every 5 years with high-sensitivity fecal occult blood
tests (FOBTs) every 3 years, or FOBTs every year beginning age 50 years
through age 75 years. Recommends against routine screening for adults aged
76 to 85 years, due to moderate certainty that the net benefit is small.
● Prostate cancer (2012): Recommends against prostate-specific antigen-based
screening for prostate cancer in men of all ages due to evidence that expected
harms are greater than expected benefits.
● Lung cancer (2013): For adults aged 55 to 80 years with a 30-pack/yr smoking
history, and those who currently smoke or have quit within the past 15 years,
recommends annual screening with low-dose computed tomography. Screening
should be discontinued once a person has not smoked for 15 years or
develops a health problem that substantially limits life expectancy or the
ability or willingness to have curative lung surgery.
● Skin cancer (2009; updated in 2015): States that evidence is insufficient to
balance the benefits and harms of whole-body skin examination.
older adults and depression screening
Depression affects 5% to 7% of community-dwelling older
adults and approximately 10% of older men and 18% of older women, but is
often undiagnosed, untreated, or undertreated.77,104 Prevalence rises in those
with multiple comorbidities and hospitalizations. Screening for the general adult
population, with services in place for diagnosis, treatment, and follow-up, is now
recommended by the USPSTF (2015)105 and requires only one or two questions.
The single screening question, “Do you often feel sad or depressed?” has a
sensitivity of 69% and specificity of 90%. The two screening questions below are
100% sensitive and 77% specific.
■ “Over the past 2 weeks, have you felt down, depressed, or hopeless?” (screens
for depressed mood)
■ “Over the past 2 weeks, have you felt little interest or pleasure in doing
things?” (screens for anhedonia)
Positive responses should prompt further investigation with scales such as the
Geriatric Depression Scale or the 9-item Patient Health Questionnaire (PHQ-
9).104,106,107 Depressed men over age 65 years are at increased risk for suicide and
require particularly careful evaluation. Effective treatment for older adults both
reduces morbidity and extends life, and includes exercise, supportive and group
therapy, and medication.
Dementia
an acquired condition that is characterized by a decline in at least two cognitive domains (e.g., loss of memory, attention, language, or visuospatial
or executive functioning) that is severe enough to affect social or occupational functioning
The major dementia
syndromes include
Alzheimer disease (AD), vascular dementia, frontotemporal
dementia, dementia with Lewy bodies, Parkinson disease with dementia, and
dementia of mixed etiology
Dementia risk factors:
advancing age, family history, and the gene mutation apolipoprotein
Age-related Cognitive Decline
● This diagnosis is suggested by mild forgetfulness, difficulty remembering names,
mildly reduced concentration.
● Such symptoms are sporadic and do not affect daily function.
Mild Cognitive Impairment (MCI)
● Daily function is preserved, but there is evidence of modest cognitive decline in one
or more cognitive domains (complex attention, executive function, learning and
memory, language, perceptual-motor, or social cognition) based on objective
tasks, as reported by the patient, an informant, or the clinician or on clinical
testing.109,114,115
● Alertness and attention is preserved (unlike delirium).
● Other dementias are unlikely (see below).
● AD develops at a higher frequency in MCI patients, progressing to AD at a
reported rate of 6% to 15% per year.1
Alzheimer Disease
● Probable AD, based on DSM-5 criteria, consists of evidence of a causative genetic
mutation from family history or genetic testing, or the presence of cognitive decline
in two or more cognitive domains, with all three of the following features: (1) clear evidence
of a decline in memory and learning and at least one other cognitive domain
(see above); (2) steady progressive decline in cognition without extended plateaus;
and (3) no evidence of mixed etiology from other neurodegenerative, cerebrovascular,
mental, or systemic disease.114
● Possible AD is diagnosed when the patient meets all three criteria by evidence
from genetic testing or when family history is absent.
● Alertness and attention is preserved.
● Other dementias are unlikely (see below).
● Memory difficulties may take the form of repeating questions, losing objects, or confusion
when performing tasks such as shopping. Later stages include impaired judgment
and disorientation progressing to aphasia, apraxia, left–right confusion, and
ultimately, dependence of IADLs. Psychosis and agitation may also occur.
● “The differentiation of dementia from MCI rests on the determination of whether
or not there is significant interference in the ability to function at work or in usual
daily activities
Vascular Dementia
suggested by vascular risk factors or cerebrovascular disease
causing cognitive impairment. Stepwise decline, especially in executive function,
should correlate with the onset of cerebrovascular event, but consider this
dementia even if just risk factors are present. At times, there are gait changes and
focal findings.
Lewy body disease
suggested by evidence of parkinsonism. Visual hallucinations,
delusions, and gait disorder may be early clues. At times, there are extrapyramidal
symptoms, fluctuating mental status, and sensitivity to antipsychotic medications.
Frontotemporal lobar degeneration
suggested by prominent behavioral or language
disorders, at times with personality changes including impulsivity, aggression,
and apathy. At times, there is excessive eating and drinking. There is relative
preservation of memory and visual–spatial skills. Onset may occur before age
60 years.
Caring for Patients with Altered Cognition
● Collateral information: Obtain collateral information from family members
and caretakers.
● Neuropsychological testing: Consider formal neuropsychological testing.
● Contributing factors: Investigate contributing factors such as medications;
metabolic abnormalities; depression; delirium; and other clinical and
psychiatric conditions, including vascular risk from diabetes and hypertension.
● Caregivers: Counsel families about the challenges for caregivers. The NIH
Senior Health website http://nihseniorhealth.gov/ is especially helpful about
“Alzheimer caregiving.” Review household safety measures.
● Drivers with dementia: Learn the laws about reporting drivers with dementia
in your state. Consult the American Academy of Neurology evidence-based
practice parameters for drivers with dementia, updated in 2010, and guidelines
from numerous professional organizations, including the American Medical
Association. Note, however, that underlying quantitative evidence linking
assessment to road safety is limited.125 A 2013 Cochrane review details the pitfalls
of disqualifying impaired drivers, which can lead to depression and social withdrawal
if disqualification is premature.126,127 The review concludes that for drivers
with dementia, there is no good evidence that neuropsychological or on-road
assessment will maintain mobility and improve safety. The authors call for more
research to develop assessment tools “that can reliably identify unsafe drivers
with dementia in an office setting” and determine what changes in function provide
a threshold for disqualification, as no single validated test is available.
● Advance directives: Encourage patient and family discussion of appointing
a health care proxy and arranging for power of attorney, health care power
of attorney, and advance directives while the patient can still contribute to
active decision making
10-Minute Geriatric Screener
pg 986
older adults: 2 nemonic for identifying causes of incontinence:
DIAPERS: Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals,
Excess urine output from conditions like hyperglycemia or heart failure,
Restricted mobility, and Stool impaction, and
DDRRIIPP: Delirium, Drug side effects, Retention of feces, Restricted mobility,
Infection of urine, Inflammation, Polyuria, and Psychogenic.
STEADI Falls Prevention Algorithm: Key
Features for Clinical Practice
(pg.988)
● Screen all community-dwelling older adults about risk for falls.
● Encourage all older patients to pursue gait and balance exercise.
● Do a gait, strength, and balance assessment with the Timed Get Up and Go
test in patients who screen positive.
● Stratify patients according to low, moderate, and high risk.
● Identify high-risk older adults, namely, those with a gait, strength, or balance
problem and at least one fall with an injury.
● In high-risk older adults, conduct a multifactorial risk assessment, including:
● review of the Stay Independent brochure;
● a falls history and medication review;
● physical examination including assessment of visual acuity, postural hypotension,
a cognitive screen, inspection of the feet and use of footwear, and
use of mobility aids;
● functional assessment; and
● environmental or home safety assessment.
● Implement individualized interventions, including physical therapy and follow-up
in 30 days
Undernutrition, slowed motor performance,
loss of muscle mass, or weakness
suggests
frailty
Kyphosis or abnormal gait can impair
balance and increase risk of falls
Flat or impoverished affect is seen in
depression, Parkinson disease, and
Alzheimer disease.
BP characteristics that increase risk of stroke, renal failure, and heart disease
Isolated systolic hypertension (SBP ≥ 140) after age 50 years and PP ≥ 60
Orthostatic hypotension and older adults
- occurs in 20% of older adults and in up to 50% of frail nursing home residents, especially when they first get up
- Symptoms: lightheadedness,
weakness, unsteadiness, visual blurring, syncope. - Causes: medications,
autonomic disorders, diabetes, prolonged bed rest, volume depletion, amyloidosis, postprandial state, and
cardiovascular disorders
Respiratory rate ≥25 breaths per minute in older adults points to
lower respiratory
infection, heart failure, and chronic obstructive pulmonary disease exacerbation
Hypothermia is more common in:
older patients
Low weight is a key indicator of:
Rapidly increasing daily
weights occur in:
poor nutrition, seen in depression, alcoholism,
cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pulmonary), medication use,
social isolation, poor dentition, and poverty
fluid overload
best place to listen for arrhythmias in older adults
apical
older adults: skin assessment
Note physiologic changes of aging, such as thinning, loss of elastic
tissue and turgor, and wrinkling. Skin may be dry, flaky, rough, and often itchy
(asteatosis), with a latticework of shallow fissures that creates a mosaic of small
polygons, especially on the legs.
Observe any patchy changes in
color. Check the extensor surface of
the hands and forearms for white
depigmented patches, or pseudoscars,
and for well-demarcated vividly
purple macules or patches,
actinic purpura, that may fade after
several weeks (Fig. 20-10).
Look for changes from sun exposure. Areas of skin may appear weather beaten,
thickened, yellowed, and deeply furrowed; there may be actinic lentigines, or
“liver spots,” and actinic keratoses, superficial flattened papules covered by a dry
scale.
Inspect for the benign lesions of aging, namely comedones, or blackheads, on the
cheeks or around the eyes; cherry angiomas, which often appear early in adulthood;
and seborrheic keratoses, raised yellowish lesions that feel greasy and velvety
or warty
basal cell carcinoma
a translucent nodule
that spreads and leaves a depressed
center with a firm elevated border,
A dark
raised asymmetric lesion with irregular
borders may be
a melanoma
Vesicular lesions occurring in a dermatomal distribution are suspicious for
herpes zoster from reactivation of latent varicella-zoster virus in the dorsal root ganglia. Risk increases with age and impaired cell-mediated immunity
Pressure ulcers arise from
obliteration of arteriolar and capillary blood flow to the skin or from shear forces during movement across sheets or when lifted upright incorrectly
If the pupil dilates as the light swings
over,
a relative afferent pupillary
defect is present, which is suspicious
for optic nerve disease. Refer to an
ophthalmologist.
eye changes that increase with age
The prevalence of cataracts, glaucoma,
and macular degeneration all
increases with aging.
A red reflex is seen with
cataracts
At +10 diopters,
a cataract appears white
? are the world’s leading cause of blindness.
Risk factors?
Cataracts
include cigarette
smoking, exposure to UV-B light,
high alcohol intake, diabetes, medications
(including steroids), and trauma.
Retinal microvascular disease is linked
to
cerebral microvascular changes and
cognitive impairment
An increased cup-to-disc ratio suggests
primary open angle glaucoma (POAG), caused by irreversible optic neuropathy and leading to loss of peripheral and central vision and blindness. Prevalence of POAG is four to five times higher in African Americans and Hispanics, though non-Hispanic whites, especially older women, are highest in the number affected
Macular degeneration causes ?
Types include:
poor central
vision and blindness
dry atrophic (more common but less severe) and wet exudative, or neovascular. Drusen may be hard and sharply defined, or soft and confluent with altered pigmentation
Drusen
colloid bodies causing alterations in pigmentation
older adults and oral exam
Malodor points to poor oral hygiene, periodontitis, and caries. Gingivitis accompanies periodontal disease. Dental plaque and cavitation may cause caries. For increased tooth mobility from abscesses or advanced caries, consider removal to prevent aspiration. Decreased salivation results from medication effects, radiation, Sjögren syndrome, or dehydration. Oral tumors can cause lesions, usually on the lateral margins of the tongue and floor of the mouth
In older adults, common causes of hyperthyroidism:
Causes of hypothyroidism:
Graves disease
and toxic multinodular goiter.
autoimmune
thyroiditis, followed by drugs,
neck radiotherapy, thyroidectomy, or
radioiodine ablation
Increased anteroposterior diameter,
purse-lipped breathing, and dyspnea
with talking or minimal exertion suggest
chronic obstructive pulmonary disease. There is considerable overlap of asthma and COPD in older adults, heralded by nonspecific symptoms like dyspnea, cough, wheezing, and nocturnal onset. Proceed to objective testing with spirometry, which most tolerate well
Isolated systolic hypertension and a
widened PP are cardiac risk factors,
prompting a search for
left ventricular
hypertrophy (LVH).
A tortuous atherosclerotic aorta can
raise pressure in the left jugular veins by impairing emptying into the right atrium. A tortuous aorta can also cause kinking of the carotid artery low in the neck on the right, chiefly in women with hypertension, which can be mistaken for a carotid aneurysm
Carotid bruits can occur in
aortic stenosis.
The presence of bruits from
carotid stenosis increases risk of
ipsilateral stroke
A sustained PMI is present in
a diffuse PMI and an S3 signal left ventricular dilatation from
An S4 often accompanies
LVH
heart failure or cardiomyopathy
hypertension
A systolic crescendo–decrescendo
murmur in the second right interspace suggests
aortic sclerosis or aortic stenosis,
Both are associated with
an increased risk of cardiovascular
disease and death
A harsh holosystolic murmur at the
apex radiating to the axilla suggests
mitral regurgitation, the most common
murmur in older adults
Any lumps or masses in older women,
and, more rarely, in older men, mandate
further investigation for possible
breast cancer
a
Paget disease with eczematoid scaling
of the nipple is uncommon, but peaks
between the ages of 50 and 60 years
a
Abdominal bruits are suspicious for
atherosclerotic vascular disease
A widened aorta of ≥3 cm and pulsatile
mass occur in ?
especially in older male smokers
abdominal aortic aneurysm,
Benign masses include condylomata,
fibromas, leiomyomas, and sebaceous
cysts.
a
Erythema with satellite lesions results
from
erythema with ulceration or a necrotic center is suspicious for
Multifocal reddened lesions with white
scaling plaques occur in
Candida infection
vulvar carcinoma
extramammary Paget disease, a form of intraepithelial adenocarcinoma.
Clitoral enlargement may accompany
androgen-producing tumors and use
of androgen creams
a
The thin patchy atrophic white
plaques of lichen sclerosus are more
common in postmenopausal women
and may be precancerous
a
Estrogen-stimulated cervical mucus with
ferning is seen in
use of hormone
replacement therapy, endometrial hyperplasia,
and estrogen-producing tumors
Discharge may accompany vaginitis
or cervicitis
a
Current USPSTF recommendations are
to discontinue screening in low-risk
women >age 65 years if adequate
prior screening has been negative
a
Mobility of the cervix is restricted with inflammation, malignancy, or surgical adhesion. Enlarging uterine fibroids, or leiomyomas, can be normal or malignant leiomyosarcoma; ovarian masses or enlargement are seen in ovarian cancer
a
A uterus that is enlarged, fixed, or
irregular may have adhesions or contain
a malignancy. Rectal masses are
found in colorectal cancer
a
A loss of rectal tone can result in fecal
incontinence. Rectal masses suggest
colorectal cancer. Rule out prostate
cancer if nodules or masses are present.
a
Look for degenerative joint changes in
or
joint inflammation from
osteoarthritis
rheumatoid or gouty arthritis
Timed Get Up and Go Test
Performed with patient wearing regular footwear, using usual walking aid if
needed, and sitting back in a chair with armrest.
On the word, “Go,” the patient is asked to do the following:
1. Stand up from the arm chair
2. Walk 3 m (in a line)
3. Turn
4. Walk back to chair
5. Sit down
Time the second effort.
Observe patient for postural stability, steppage, stride length, and sway.
Scoring:
● Normal: completes task in <10 s
● Abnormal: completes task in >20 s
Low scores correlate with good functional independence; high scores correlate
with poor functional independence and higher risk of falls.
Abnormalities of gait and balance, especially widening of base, slowing and lengthening of stride, and difficulty turning, are correlated with risk for falls
a
examples of age related neuro abnormalities
unequal pupil
size, decreased arm swing and spontaneous movements, increased leg rigidity
and abnormal gait, presence of the snout and grasp reflexes, and decreased toe
vibratory sense
most common features of Parkinson’s disease
Tremor, Rigidity, Akinesia, and Postural instability, or
TRAP
Also look for bradykinesia, the most characteristic clinical sign, and micrographia,
shuffling “freezing” gait, and difficulty rising from a chair.
most common features of Parkinson’s disease
Tremor, Rigidity, Akinesia, and Postural instability, or
TRAP
Also look for bradykinesia, the most characteristic clinical sign, and micrographia,
shuffling “freezing” gait, and difficulty rising from a chair.
These findings are seen in Parkinson disease, found in ∼60,000 new cases a year and affecting about 1 million people in the United States.177 Tremor is slow frequency, occurs at rest, has a “pill-rolling” quality, and is aggravated by stress and inhibited during sleep or movement. Prodromal nonmotor symptoms including depression, rapid eye movement behavior disorder, and daytime sleepiness are now being identified
Essential tremor
bilateral and
symmetric, with a positive family
history and commonly diminished
by alcohol
Cultural Identity of the
Individual
Where are you and your family from?
What is your ancestry?
Are there cultural differences between you and your parents or you and your significant
other?
Do you feel a strong connection to any groups of people? If so, whom?
What foods do you eat?
What holidays do you celebrate?
What languages do you speak?
With whom do you speak these languages?
What languages would you like to speak with me?
What types of activities do you enjoy?
What are your sources for news and entertainment?
Has this changed over time?
Cultural Explanations of the
Individual’s Illness
Do you or anyone else have a name for the problem you’re having now?
Why do you think it’s happening to you?
What will make it better or worse?
When did it start and when do you think you’ll get better?
Has anyone else you know had this problem?
What activities has this problem stopped you from doing that you, your family, or your
friends expect?
Who else have you seen for help with this problem?
Should I talk to anyone else you trust to help you with this problem?
Cultural Factors Related to
Psychological Environment
and Levels of Functioning
Who lives at home with you? Can they help with this problem? Who else can help you? Is anything going on to make this problem better or worse? How has this problem affected your life? Is it preventing you from working? Moving, grooming, feeding, or sleeping? Do people close to you understand how you feel?
Cultural Elements of the
Clinician–Patient
Relationship
Do you think your friends or family would be upset if you spoke to me about the
problem?
What can I do to make you feel more comfortable?
How often can you see me?
Do you have any wishes for or concerns about treatment?
What are your thoughts about medications?
Can I share your answers with anyone else you trust?
Delirium v. Dementia:
onset
Delirium: acute
Dementia: insidious
Delirium v. Dementia:
course
Delirium: Fluctuating, with lucid intervals; worse at
night
Dementia: slowly progressive
Delirium v. Dementia:
duration
Delirium: hours to weeks
Dementia: months to years
Delirium v. Dementia:
sleep/wake cycle
Delirium: always disrupted
Dementia: sleep fragmented
Delirium v. Dementia:
general clinical illness or drug toxicity
Delirium: either or both present
Dementia: Often absent, especially in Alzheimer
disease
Delirium v. Dementia:
LOC
Delirium: Disturbed. Person less alert to clearly aware
of the environment and less able to focus,
sustain, or shift attention
Dementia: Usually normal until late in the course of
the illness
Delirium v. Dementia:
behavior
Delirium: Activity often abnormally decreased
(somnolence) or increased (agitation,
hypervigilance)
Dementia: Normal to slow; may become inappropriate
Delirium v. Dementia:
speech
Delirium: May be hesitant, slow or rapid, incoherent
Dementia: Difficulty in finding words, aphasia
Delirium v. Dementia:
mood
Delirium: Fluctuating, labile, from fearful or irritable
to normal or depressed
Dementia: Often flat, depressed
Delirium v. Dementia:
thought process
Delirium: Disorganized, may be incoherent
Dementia: Impoverished. Speech gives little
information
Delirium v. Dementia:
thought content
Delirium: Delusions common, often transient
Dementia: Delusions may occur
Delirium v. Dementia:
perceptions
Delirium: Illusions, hallucinations, most often visual
Dementia: Hallucinations may occur
Delirium v. Dementia:
judgment
Delirium: Impaired, often to a varying degree
Dementia: Increasingly impaired over the course of
the illness
Delirium v. Dementia:
orientation
Delirium: Usually disoriented, especially for time. A
known place may seem unfamiliar
Dementia: Fairly well maintained, but becomes
Delirium v. Dementia:
attention
Delirium: Fluctuates, with inattention. Person easily
distracted, unable to concentrate on
selected tasks
Dementia: Usually unaffected until late in the illness
Delirium v. Dementia:
memory
Delirium: Immediate and recent memory impaired
Dementia: Recent memory and new learning
especially impaired
Delirium v. Dementia:
examples of cause
Delirium: Delirium tremens (due to withdrawal from alcohol) Uremia Acute hepatic failure Acute cerebral vasculitis Atropine poisoning
Dementia: Reversible: Vitamin B12 deficiency, thyroid
disorders
Irreversible: Alzheimer disease, vascular
dementia (from multiple infarcts),
dementia due to head trauma
(screening for dementia)
Table 20-3 Mini-Cog
Table 20-4 Montreal Cognitive Assessment
pg. 1002
pg. 1003
