Lecture II: Approach to Older Adults

Question 1

Describe the unique ways that older adults may present with illness

Answer 1

• Non-Specific Symptoms that May Represent Illness in Older Adults:
i. Confusion + self-neglect + falling + incontinence + anorexia (losing appetite) + fatigue
ii. Typical signs and symptoms for any disease or illness can be delayed or absent.
iii. Always consider adverse drug effects, drug-drug interactions as a cause of symptoms. Stopping a medicine can often be more helpful than adding another.
• Altered presentation of illness is common
i. Depression without sadness
ii. Infection without fever (fever of 100 could be bad in older adults)
iii. “Heart attack” without chest pain
iv. Pneumonia without shortness of breath
v. Perforated bowel without abdominal pain

Question 2

Describe components of the history that are especially pertinent to older adults

Answer 2

i. Attend to sensory impairments (especially auditory and visual) – > but don’t assume that all old people can’t hear or can’t see well.
ii. Talk to the patient first, before talking to family/caregiver – > feeling of independence + ability to stand on their own. If a family member or caregiver has brought up an issue, a suggested approach is, “Your daughter has been concerned about your hearing recently. Can you tell me about it?
iii. Medication history is essential.
iv. Directly ask questions related to common “hidden illnesses” such as depression, incontinence, falling, hearing loss, dental problems, poor nutrition, and sexual dysfunction.
v. Go over support systems + availability of emergency help + needed services + transportation.

Question 3

Clock Drawing

Answer 3

i. Instruct patient to draw the face of the clock + fill in the numbers + set the hands to “10 minutes to 11” (10:50). Free-hand or w/ pre-drawn circle. (Give patient as much time as necessary.)
ii. Hour markers ok (2 points), time correct (2 points). Make sure that all numbers are there/in correct sequence + hand positions are correct – > 75% sensitivity

Question 4

Animal Fluency Test

Answer 4

i. Name as many animals as possible in 1 minute
ii. 0-4 animals=0 points; 5-9 animals=1 point; 10-14 animals=2 points; 15+ animals= 3pts;
15 animals = standard cutoff – > 85% sensitivity (watch for if they are using patterns, strategies)

Question 5

SLUMS (St. Louis University Mental Status)

Answer 5

i. Standard of care for dementia screening – > less than 10 minutes to administer
ii. The test (Ask patients the following questions or tell them to do the following things)
1. Orientation
a. What day of the week is it? What is the year? What state are we in?
b. 1 point each
2. Short term memory
a. Tell patient to remember these 5 objects: “apple + pen + tie + house + car.” Tell them that you will ask them about these later. (Make sure they register words)
3. Calculation
a. You have $100, you buy a dozen of apples for $3 + tricycle for $20
b. How much did you spend? (1 point) + How much do you have left? (2 points)
4. Animal fluency test
a. Tell patient to name as many animals as possible in 1 minute
b. 0-5 = 0 points, 5-10 = 1 point, 10-15 = 2 points, 15+ = 3 points
5. What were the 5 objects I asked you to remember? – > 1 point each
6. Number series
a. Tell patient: I am going to give you a series of numbers and I would like you to give them to me backwards. For example, if I say 42, you would say 24.
b. Give patient three numbers (Example 87= 1 points, 649=1 point, 8537=1 points) (Patient should say 78, 946, 7358 to get all of the points)
7. Visual-spatial relationships
a. Have a drawing on a sheet of paper with the shape of a square, a triangle, and a rectangle
b. “Please place an X on the triangle.” “Which of the figures is the largest?” – > 1 point each
8. Story

Question 6

Differentiate delirium from dementia

Answer 6

1. Delirium:
(Acute effect of physical illness on brain function, often a presentation of serious underlying illness)
-Abrupt, precise onset
-Clouded consciousness
-Disorientation early
-Short attention span
-Marked agitation common
-Medical emergency

2. Dementia
(Multiple cognitive deficits, sufficiently severe and persistent that they cause impairment in function)
-Gradual onset
-Consciousness not clouded
-Disorientation later in illness
Attention span not reduced
-Agitation uncommon
-Not a medical emergency

Question 7

Describe the components of the physical exam which are especially pertinent to older adults

Answer 7

o Weight – > global marker for nutrition; weight loss→ask about diet, look at teeth
o Height – > indicator of osteoporosis
o Visual acuity + auditory acuity + check for cerumen (ear wax)
o Oral exam, especially if dentures (remove them to look for ill fit)
o Range of motion of joints (ROM) – > emphasis on hips
o Muscular strength – > rising from a chair without assistance
o Gait (a manner of movement) and balance – > picking up an object from the floor