The Older Adult

Question 1

HEARING LOSS IN

A

GERIATRIC PATIENT

Answer 1

Hearing loss associated with aging is known as presbycusis, and becomes increasingly more evident after 50 years old.

Early hearing acuity losses involve primarily high-pitched sounds beyond the range of human speech and thus has relatively little functional significance. Gradually, this hearing acuity loss extends to sounds in the middle and lower ranges.

When a person fails to hear the higher tones of words but can still hear lower tones, words sound distorted and difficult to understand–especially in noisy environments.

Question 2

DIAPERS MNEMONIC

Answer 2

Delirium

Infection

Atrophic urethritis/vaginitis

Pharmaceuticals

Excess urine output from conditions like hyperglycemia or heart failure

Restricted mobility

Stool impaction

**This mnemonic may be helpful for identifying causes of urinary incontinence

Question 3

SYMPTOMS OF A

MYOCARDIAL INFARCTION (MI)

IN A

GERIATRIC PATIENT

Answer 3

Older patients having a myocardial infarction are less likely to report chest pain.

Symptoms of atypical or no chest pain, shortness of breath, palpitations, syncope, and confusion are more commonly reported in an elderly patient having an MI.

Question 4

HYPERTHYROIDISM

IN

GERIATRIC PATIENTS

Answer 4

**Older patients with hyperthyroidism and hypothyroidism have fewer symptoms and signs**

One-third of older adults with hyperthyroidism present with:

• fatigue
• weight loss
• tachycardia

in lieu of the classic features of heat intolerance, sweating, and hyperreflexia.

Up to 35% present with atrial fibrillation.

Hyperthyroidism increases the risk of osteoporosis, and–in affected women–the risk of hip and vertebral fractures increases threefold.

Question 5

VISUAL ASSESSMENT &

ASSOCIATED CHANGES

IN THE

GERIATRIC POPULATION

Answer 5

**The prevalence of cataracts, glaucoma, and macular degeneration all increases with aging**

• Older adults may complain of dry eyes because of fewer lacrimal secretions
• The pupils of the geriatric patient become smaller, making it 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
• Visual acuity remains fairly constant between 20-50 years old and diminishes gradually until about 70–when visual acuity loss becomes more rapid
  
  • ​Good to adequate vision is usually maintained (20/20 to 20/70) but near vision begins to blur as the lens gradually loses elasticity and progressive loss of accommodation and the ability to focus on nearby objects declines (presbyopia–i.e., the loss of near vision arising from decreased elasticity of the lens related to aging)
• Test best-corrected visual acuity in each eye
• Test pupillary constriction to light: both the direct and consensual response and during the near response. Swing the light beam back and forth between the right and left eyes. Test the six directions of gaze.
  
  • ​Except for possible impairment in upward gaze, extraocular movements should remain intact
  • If the pupil dilates as the light swings over (when cast between both eyes), then a relative afferent pupillary defect is present, which is suspicious for optic nerve disease. Refer to an opthalmalogist.
• Inspect lens and fundi carefully with opthalmascope; also checking at 1 to 2 feet for a red reflex. Assess the cup-to-disc ratio, usually 1:2 or less, for possible glaucoma. Inspect the fundi for colloid bodies causing alterations in pigmentation, called drusen.
  
  • ​A red reflex is seen with cataracts. At +10 diopeters, a cataract appears white.
  • Cataracts are the leading cause of blindness in the world.
  • 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-Americqans and Hispanics, though non-Hispanic whites, especially older women, are highest in the number affected
  • Macular degeneration causes poor central vision and blindness.
    
    • ​Types include 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.
  • Retinal microvascular disease is linked to cerebral microvascular changes and cognitive impairment.

Question 6

LUNG ASSESSMENT

& CHANGES** **IN

GERIATRIC POPULATIONS

Answer 6

• Chest wall becomes stiffer and harder to move
• Lungs lose elastic recoil
• Decline in lung mass and surface area for gas exchange
• Increase in residual volumes as the alveoli enlarge
• Increased risk for atelectasis due to closing volumes of the smaller airways, incresing the risk for pneumonia
• Diaphram strength weakens
• Cough becomes less effective
• Decrease in arterial pO2 although O2 saturation normally remains above 90%
• Skeletal changes accentuate dorsal curve of the thoracic spine and osteoporotic vertebral collapse induces kyphosis–which effectively increases the anteroposterior diameter of the chest (aka “barrel chest”)
  
  • ​Despite this change, this normally has little effect on function

**Increased AP diameter. purse-lipped breathing, and dyspnea with talking or minimal exertion suggest COPD. However, there is considerable overlap of asthma and COPD in older adults, accompanied with nonspecific symptoms like dyspnea, cough, wheezing, and nocturnal onset. IN THIS CASE, PROCEED TO OBJECTIVE TESTING WITH SPIROMETRY TO DISCERN, as this is tolerated well.**

Question 7

OLDER ADULT

​IMMUNIZATIONS

2015

Answer 7

INFLUENZA VACCINE

• annual vaccine that protects against two strains of influenza A and influenza B
• available in trivalent and quadrivalent formulations
• recommended for annually for the following groups:
  
  • all adults >/= 50
  • adults with chronic pulmonary and cardiovascular disorders including asthma (but excluding hypertension), and renal, hepatic, neurologic, hematologic, or metabolic disorders including diabete
  • adults who are immunosuppressed from medication or HIV
  • residents of nursing homes and other long-term care facilities; adults with morbid obesity (BMI >/= 40)

PNEUMOCOCCAL VACCINE

• PCV13 protects against 13 of the 90 types of pneumococcal bacteria–these types cause infection in about half of all affected adults
• PPSV23 protects against 23 types of pneumococcal bacteria
• Adults aged >/= 65 years
  
  • ​Older adults who have not received PCV13 should receive that first, followed 6 to 12 months later by PPSV23
  • Older adults who have already received one or more doses of PPSV23 should receive PSV13 at least 1 year after the most recent dose of PPSV23
• Adults aged 19 to 64 years
  
  • ​This age group should also be vaccinated as above if they have the following conditions:
    
    • ​HIV infection
    • long-term immunosuppresive therapy
    • chronic renal failure
    • nephrotic syndrome
    • functional or anatomic asplenia
    • cochlear implants
    • sickle cell disease or other hemoglobinopathies
    • congenital or acquired immunodeficiencies
    • generalized malignancy
    • Hodgkin disease
    • leukemia
    • multiple myeloma
    • solid organ transplant
    • CSF leaks

ZOSTER VACCINE

• live attenuated vaccine
• has an efficacy of 97% across all age groups, but significant local site injection reactions and myalgias have been reported
• All adults aged >/= 60 years recommended to receive vaccination, regardless of whether they had chicken pox or shingles
• Contraindications:
  
  • ​The vaccine should NOT be given to adults with a history of primary or acquired immunodeficiency state, including leukemia, lymphoma, or other malignant neoplasm affecting the bone marrow or lymphatic system, or with HIV/AIDS or to those receiving immunosuppressive therapy, incuding high-dose corticosteroids

TETANUS/DIPHTHERIA (Td) AND TETANUS/DIPHTHERIA/PERTUSSIS (Tdap)

• All adults aged >/= 19 years, including those aged >/= 65 years:
  
  • ​All adults >/= 19 years old who have not been vaccinated with Tdap should receive a single dose regardless of the time interval since last receiving Td. After receiving Tdap, they should receive Td boosters at 10-year intervals. For adults aged >/= 65 years, this will reduce the likelihood of transmission to infants aged < 12 months.

Question 8

ASSESSMENT AND CHANGES

TO THE SKIN/INTEGUMENT

OF THE ELDERLY PATIENT

Answer 8

Physiologic changes of the aging to the skin include thinning, loss of elastic tissue and turgor, and wrinkling. Skin may be dry, flaky, rough, and often itchy (asteatosis). Shallow fissures may be present.

• Pseudoscars*: white, depigmented patches often on the extensor surface of the hands and forearms
• Actinic purpura*: well-demarcated, vividly purple macules or patches which may fade after a few weeks
• these spots and patches come from blood that has leaked through poorly supported capillaries and spread within the dermis
• Actinic lentigines:* aka “liver spots”
• Actinic keratoses*: superficial flattened papules covered by a dry scale
• Comedones*: i.e., blackheads
• Cherry angiomas*
• Seborrheic keratoses*: raised, yellowish lesions that feel greasy and velvety or warty

**Distinguish such lesions from a basal cell carcinoma, a translucent nodule that spreads and leaves a depressed center with a firm elevated border, and squamous cell carcinoma, a firm reddish-appearing lesion often emerging in a sun-exposed area. A dark raised asymmetric lesion with irregular borders may be a melanoma.

**Watch for any painful vesicular lesions in a dermatomal distribution, which 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.

Question 9

REFLEXES IN

THE

ELDERLY PATIENT

Answer 9

• gag reflex may be diminished or absent
• ankle reflexes may be symmetrically decreased or absent, even when reinforced–less commonly, knee reflexes can be similarly affected
• abdominal reflexes may diminish or disappear
• plantar responses become less obvious and more difficult to interpret largely due to musculoskeletal changes