Evaluation of older adults usually differs from a standard medical evaluation. For older patients, especially those who are very old or frail, history-taking and physical examination may have to be done at different times, and physical examination may require 2 sessions because patients become fatigued.
Older adults also have different, often more complicated health care problems, such as multiple disorders, which may require use of many drugs (sometimes called polypharmacy) and thus greater likelihood of a high-risk drug being prescribed (see table Potentially Inappropriate Drugs in Older Adults). Diagnosis may be complicated, resulting in delayed, missed, or erroneous diagnoses leading to inappropriate use of drugs.
Early detection of problems results in early intervention, which can prevent deterioration and improve quality of life, often through relatively minor, inexpensive interventions (eg, lifestyle changes). Thus, some older patients, particularly the frail or chronically ill, are best evaluated using a comprehensive geriatric assessment, which includes evaluation of function and quality of life, best administered by an interdisciplinary team.
Multiple disorders
On average, older patients have 6 diagnosable disorders, and the primary care physician is often unaware of some of them. A disorder in one organ system can weaken another system, exacerbating the deterioration of both and leading to disability, dependence, and, without intervention, death. Multiple disorders complicate diagnosis and treatment, and effects of the disorders are magnified by social disadvantage (eg, isolation) and poverty (as patients outlive their resources and supportive peers) and by functional and financial problems.
Clinicians should also pay particular attention to certain common geriatric symptoms (eg, delirium, dizziness, syncope, falling, mobility problems, weight or appetite loss, urinary incontinence) because they may result from disorders of multiple organ systems.
If patients have multiple disorders, treatments (eg, bed rest, surgery, drugs) must be well-integrated; treating one disorder without treating associated disorders may accelerate decline. Also, careful monitoring is needed to avoid iatrogenic consequences. For example, with complete bed rest, older patients can lose 1 to 3% of muscle mass and strength each day (causing sarcopenia and sharply reduced mobility), and effects of bed rest alone can ultimately result in death.
Missed or delayed diagnosis
Disorders that are common among older adults are frequently missed, or the diagnosis is delayed. Clinicians should use the history, physical examination, and simple laboratory tests to actively screen for disorders that occur only or more commonly in older patients (see table); when diagnosed early, these disorders can often be more easily treated. Early diagnosis frequently depends on the clinician’s familiarity with the patient’s behavior and history, including mental status. Commonly, the first signs of a physical disorder are behavioral, mental, or emotional. If clinicians are unaware of this possibility and attribute these signs to dementia, diagnosis and treatment can be delayed.
Polypharmacy
Prescription and over-the-counter drug use should be reviewed frequently, particularly for drug interactions and use of drugs considered inappropriate for older patients. When multiple drugs are used, electronic health record−based management is more efficient.
Caregiver problems
Occasionally, problems of older patients are related to neglect or abuse by their caregiver. Clinicians should consider the possibility of patient abuse and drug abuse by the caregiver if circumstances and findings suggest it. Certain injury patterns or patient behaviors are particularly suggestive, including
History
Often, more time is needed to interview and evaluate older patients, partly because they may have characteristics that interfere with the evaluation. The following should be considered:
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Sensory deficits: Dentures, eyeglasses, or hearing aids, if normally worn, should be worn to facilitate communication during the interview. Adequate lighting and elimination of visual or auditory distraction also help.
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Underreporting of symptoms: Older patients may not report symptoms that they consider part of normal aging (eg, dyspnea, hearing or vision deficits, memory problems, incontinence, gait disturbance, constipation, dizziness, falls). However, no symptom should be attributed to normal aging unless a thorough evaluation is done and other possible causes have been eliminated.
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Unusual manifestations of a disorder: In older adults, typical manifestations of a disorder may be absent. Instead, older patients may present with nonspecific symptoms (eg, fatigue, confusion, weight loss).
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Functional decline as the only manifestation: Disorders may manifest solely as functional decline. In such cases, standard questions may not apply. For example, when asked about joint symptoms, patients with severe arthritis may not report pain, swelling, or stiffness, but if asked about changes in activities, they may, for example, report that they no longer take walks or volunteer at the hospital. Questions about duration of functional decline (eg, “How long have you been unable to do your own shopping?”) can elicit useful information. Identifying people when they have just started to have difficulty doing basic activities of daily living (BADLs) or instrumental activities of daily living (IADLs) may provide more opportunities for interventions to restore function or to prevent further decline and thus maintain independence.
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Difficulty recalling: Patients may not accurately remember past illnesses, hospitalizations, operations, and drug use; clinicians may have to obtain these data elsewhere (eg, from family members, a home health aide, or medical records).
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Fear: Older adults may be reluctant to report symptoms because they fear hospitalization, which they may associate with dying.
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Age-related disorders and problems: Depression (common among older adults who are vulnerable and sick), the cumulative losses of old age, and discomfort due to a disorder may make older adults less apt to provide health-related information to clinicians. Patients with impaired cognition may have difficulty describing problems, impeding the physician’s evaluation.
Interview
A clinician’s knowledge of an older patient’s everyday concerns, social circumstances, mental function, emotional state, and sense of well-being helps orient and guide the interview. Asking patients to describe a typical day elicits information about their quality of life and mental and physical function. This approach is especially useful during the first meeting. Patients should be given time to speak about things of personal importance. Clinicians should also ask whether patients have specific concerns, such as fear of falling. The resulting rapport can help the clinician communicate better with patients and their family members.
A mental status examination may be necessary early in the interview to determine the patient’s reliability; this examination should be conducted tactfully so that the patient does not become embarrassed, offended, or defensive. Routine screening for physical and psychologic disorders (see table Screening Recommendations) should be done annually, beginning at age 70.
Often, verbal and nonverbal clues (eg, the way the story is told, tempo of speech, tone of voice, eye contact) can provide information, as for the following:
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Depression: Older patients may omit or deny symptoms of anxiety or depression but betray them by a lowered voice, subdued enthusiasm, or even tears.
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Physical and mental health: What patients say about sleep and appetite may be revealing.
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Weight gain or loss: Clinicians should note any change in the fit of clothing or dentures.
Unless mental status is impaired, a patient should be interviewed alone to encourage the discussion of personal matters. Clinicians may also need to speak with a relative or caregiver, who often gives a different perspective on function, mental status, and emotional state. These interviews may be done with the patient absent or present.
The clinician should ask the patient’s permission before inviting a relative or caregiver to be present and should explain that such interviews are routine. If the caregiver is interviewed alone, the patient should be kept usefully occupied (eg, filling out a standardized assessment questionnaire, being interviewed by another member of the interdisciplinary team).
If indicated, clinicians should consider the possibility of drug abuse by the patient and patient abuse by the caregiver.
Medical history
When asking patients about their past medical history, a clinician should ask about disorders that used to be more common (eg, rheumatic fever, poliomyelitis) and about outdated treatments (eg, pneumothorax therapy for tuberculosis, mercury for syphilis). A history of immunizations (eg, tetanus, influenza, pneumococcus), adverse reactions to immunizations, and skin test results for tuberculosis is needed. If patients recall having surgery but do not remember the procedure or its purpose, surgical records should be obtained if possible.
Clinicians should ask questions designed to systematically review each body area or system (review of systems) to check for other disorders and common problems that patients may have forgotten to mention (see table).
Clues to Disorders in Older Patients
Drug history
The drug history should be recorded, and a copy should be given to patients or their caregiver. It should contain
All drugs used should be recorded, including
Patients or family members should be asked to bring in all of the above drugs and supplements at the initial visit and periodically thereafter. Clinicians can make sure patients have the prescribed drugs, but possession of these drugs does not guarantee adherence. Counting the number of tablets in each vial during the first and subsequent visits may be necessary. If someone other than a patient administers the drugs, that person is interviewed.
Patients should be asked to demonstrate their ability to read labels (often printed in small type), open containers (especially the child-resistant type), and recognize drugs. Patients should be advised not to put their drugs into one container.
Alcohol, tobacco, and recreational drug use history
Patients who smoke should be counseled to stop and, if they continue, not to smoke in bed because older adults are more likely to fall asleep while doing so.
Patients should be checked for signs of alcohol use disorders, which are underdiagnosed in older adults. Such signs include confusion, anger, hostility, alcohol odor on the breath, impaired balance and gait, tremors, peripheral neuropathy, and nutritional deficiencies. Screening questionnaires and questions about quantity and frequency of alcohol consumption can help.
The Short Michigan Alcohol Screening Test-Geriatric Version (or SMAST-G) is a 10 question test designed for people 65 and older (see Screening for Alcohol Use and Misuse in Older Adults). It is usually preferred to other screening questionnaires (eg, CAGE, AUDIT) that were not designed for older adults. Two or more “yes” responses suggest the possibility of alcohol abuse.
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When talking with others, do you ever underestimate how much you drink?
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After a few drinks, have you sometimes not eaten or been able to skip a meal because you didn’t feel hungry?
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Does having a few drinks help decrease your shakiness or tremors?
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Does alcohol sometimes make it hard for you to remember parts of the day or night?
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Do you usually take a drink to relax or calm your nerves?
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Do you drink to take your mind off your problems?
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Have you ever increased your drinking after experiencing a loss in your life?
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Has a doctor or nurse ever said they were worried or concerned about your drinking?
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Have you ever made rules to manage your drinking?
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When you feel lonely, does having a drink help?
Nutrition history
Type, quantity, and frequency of food eaten are determined. Patients who eat ≤ 2 meals a day are at risk of undernutrition. Clinicians should ask about the following:
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Any special diets (eg, low-salt, low-carbohydrate) or self-prescribed fad diets
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Intake of dietary fiber and prescribed or over-the-counter vitamins
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Weight loss and change of fit in clothing
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Amount of money patients have to spend on food
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Accessibility of food stores and suitable kitchen facilities
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Variety and freshness of foods
The ability to eat (eg, to chew and swallow) is evaluated. It may be impaired by xerostomia and/or dental problems, which are common among older adults. Decreased taste or smell may reduce the pleasure of eating, so patients may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients who are worried about urinary incontinence may reduce their fluid intake; as a result, they may eat less food.
Mental health history
Mental health problems may not be detected easily in older patients. Symptoms that may indicate a mental health disorder in younger patients (eg, insomnia, changes in sleep patterns, constipation, cognitive dysfunction, anorexia, weight loss, fatigue, preoccupation with bodily functions, increased alcohol consumption) may have another cause in older adults. Sadness, hopelessness, and crying episodes may indicate depression. Irritability may be the primary affective symptom of depression, or patients may present with cognitive dysfunction. Generalized anxiety is the most common mental disorder encountered in older patients and often is accompanied by depression.
Patients should be asked about delusions and hallucinations, past mental health care (including psychotherapy, institutionalization, and electroconvulsive therapy), use of psychoactive drugs, and recent changes in circumstances. Many circumstances (eg, recent loss of a loved one, hearing loss, a change in residence or living situation, loss of independence) may contribute to depression.
Patients’ spiritual and religious preferences, including their personal interpretation of aging, declining health, and death, should be clarified.
Functional status
Whether patients can function independently, need some help with basic activities of daily living (BADLs) or instrumental activities of daily living (IADLs), or need total assistance is determined as part of comprehensive geriatric assessment. Patients may be asked open-ended questions about their ability to do activities, or they may be asked to fill out a standardized assessment instrument with questions about specific ADLs and IADLs (eg, see tables Katz ADL Scale and Lawton IADL Scale).
Katz Activities of Daily Living Scale
Lawton Instrumental Activities of Daily Living Scale
Social history
Clinicians should obtain information about patients’ living arrangements, particularly where and with whom they live (eg, alone in an isolated house, in a busy apartment building), accessibility of their residence (eg, up stairs or a hill), and what modes of transportation are available to them (see also Social Issues in Older People). Such factors affect their ability to obtain food, health care, and other important resources. A home visit, although difficult to arrange, can provide critical information. For example, clinicians can gain insight about nutrition from the refrigerator’s contents and about multiple ADLs from the bathroom’s condition.
The number of rooms, number and type of phones, presence of smoke and carbon monoxide detectors, and condition of plumbing and heating system are determined, as is the availability of elevators, stairs, and air conditioning. Home safety evaluations can identify home features that can lead to falls (eg, poor lighting, slippery bathtubs, unanchored rugs), and solutions can be suggested.
Having patients describe a typical day, including activities such as reading, television viewing, work, exercise, hobbies, and interactions with other people, provides valuable information.
Clinicians should ask about the following:
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Frequency and nature of social contacts (eg, friends, senior citizens’ groups), family visits, and religious or spiritual participation
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Driving and availability of other forms of transportation
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Caregivers and support systems (eg, church, senior citizens’ groups, friends, neighbors) that are available to the patient
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The ability of family members to help the patient (eg, their employment status, their health, traveling time to the patient’s home)
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The patient’s attitude toward family members and their attitude toward the patient (including their level of interest in helping and willingness to help)
Marital status of patients is noted. Questions about sexual practices and satisfaction must be sensitive and tactful but thorough. The number and sex of sex partners are determined, and risk of sexually transmitted diseases (STDs) is evaluated. Many sexually active older people are not aware of the increasing incidence of STDs in older adults and do not follow or even know about safe sex practices.
Patients should be asked about educational level, jobs held, known exposures to radioactivity or asbestos, and current and past hobbies. Economic difficulties due to retirement, a fixed income, or death of a spouse or partner are discussed. Financial or health problems may result in loss of a home, social status, or independence. Patients should be asked about past relationships with physicians; a long-time relationship with a physician may have been lost because the physician retired or died or because the patient relocated.
Advance directives
Patient wishes regarding measures for prolonging life must be documented. Patients are asked what provisions for surrogate decision making (advance directives) have been made in case they become incapacitated, and if none have been made, patients are encouraged to make them. Getting patients and their surrogates accustomed to discussing goals of care is important; then when circumstances require medical decisions and prior documentation is unavailable or not relevant to the circumstance (which is very common), appropriate decisions can be made.
Key Points
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Unless corrected, sensory deficits, especially hearing deficits, may interfere with history-taking.
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Many disorders in older adults manifest only as functional decline.
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As part of the drug history, the patient or a family member should be asked to bring in all the patient’s drugs, including over-the-counter drugs, at the initial visit and periodically thereafter.
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Health care practitioners must often interview caregivers to obtain the history of functionally dependent older patients.
Physical Examination
Observing patients and their movements (eg, walking into the examination room, sitting in or rising from a chair, getting on and off an examination table, taking off or putting on socks and shoes) can provide valuable information about their function. Their personal hygiene (eg, state of dress, cleanliness, odor) may provide information about mental status and the ability to care for themselves.
If patients become fatigued, the physical examination may need to be stopped and continued at another visit. Older patients may require additional time to undress and transfer to the examining table; they should not be rushed. The examining table should be adjusted to a height that patients can easily access; a footstool facilitates mounting. Frail patients must not be left alone on the table. Portions of the examination may be more comfortable if patients sit in a chair.
Clinicians should describe the general appearance of patients (eg, comfortable, restless, undernourished, inattentive, pale, dyspneic, cyanotic). If they are examined at bedside, use of protective padding or a protective mattress, bedside rails (partial or full), restraints, a urinary catheter, or an adult diaper should be noted.
Vital Signs
Weight should be recorded at each visit. During measurement, patients with balance problems may need to grasp grab bars placed near or on the scale. Height is recorded annually to check for height loss due to osteoporosis.
Temperature is recorded. Hypothermia can be missed if the thermometer cannot measure temperatures more than a few degrees lower than normal. Absence of fever does not exclude infection.
Pulses and blood pressure (BP) are checked in both arms. Pulse is taken for 30 seconds, and any irregularity is noted. Because many factors can alter BP, BP is measured several times after patients have rested > 5 minutes.
BP may be overestimated in older patients because their arteries are stiff. This rare condition, called pseudohypertension, should be suspected if dizziness develops after antihypertensives are begun or doses are increased to treat persistently elevated systolic BP.
All older patients are checked for orthostatic hypotension because it is common. BP is measured with patients in the supine position, then after they have been standing for 3 to 5 minutes. If systolic BP falls ≥ 20 mm Hg after patients stand, or any symptoms of hypotension are detected, orthostatic hypotension is diagnosed. Caution is required when testing hypovolemic patients.
A normal respiratory rate in older patients may be as high as 25 breaths/minute. A rate of > 25 breaths/minute may be the first sign of a lower respiratory tract infection, heart failure, or another disorder.
Skin and Nails
Initial observation includes color (normal rubor, pale, cyanotic). Examination includes a search for premalignant and malignant lesions, tissue ischemia, and pressure ulcers. In older patients, the following should be considered:
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Ecchymoses may occur readily when skin is traumatized, often on the forearm, because the dermis thins with aging.
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Uneven tanning may be normal because melanocytes are progressively lost with aging.
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Longitudinal ridges on the nails and absence of the crescent-shaped lunula are normal age-related findings.
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Nail plate fractures may occur because, with aging, the nail plate thins.
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Black splinter hemorrhages in the middle or distal third of the fingernail are more likely to be due to trauma than to bacteremia.
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A thickened, yellow toenail indicates onychomycosis, a fungal infection.
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Toenail borders that curve in and down indicate ingrown toenail (onychocryptosis).
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Whitish nails that scale easily, sometimes with a pitted surface, indicate psoriasis.
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Unexplained bruises may indicate abuse.
Head and Neck
Face
Normal age-related findings may include the following:
The temporal arteries should be palpated for tenderness and thickening, which may indicate giant cell arteritis, suspicion of which requires immediate evaluation and treatment.
Nose
Eyes
Normal age-related findings include the following:
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Loss of orbital fat: It may cause gradual sinking of the eye backward into the orbit (enophthalmos). Thus, enophthalmos is not necessarily a sign of dehydration in older adults. Enophthalmos is accompanied by deepening of the upper eyelid fold and slight obstruction of peripheral vision.
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Pseudoptosis (decreased size of the palpebral aperture)
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Entropion (inversion of lower eyelid margins)
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Ectropion (eversion of lower eyelid margins)
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Arcus senilis (a white ring at the limbus)
With aging, presbyopia develops; the lens becomes less elastic and less able to change shape when focusing on close objects.
The eye examination should focus on testing visual acuity (eg, using a Snellen chart). Visual fields can be tested at the bedside by confrontation—ie, patients are asked to stare at the examiner so that the examiner can determine differences between their and the examiner’s visual field. However, such testing has low sensitivity for most visual disorders. Tonometry is occasionally done in primary care; however, it is usually done by ophthalmologists or optometrists as part of routine eye examinations or by ophthalmologists when a patient is referred to them because glaucoma is clinically suspected.
Ophthalmoscopy is done to check for cataracts, optic nerve or macular degeneration, and evidence of glaucoma, hypertension, or diabetes. Findings may be unremarkable unless a disorder is present because the retina’s appearance usually does not change much with aging. In older patients, mild to moderate elevated intracranial pressure may not result in papilledema because cortical atrophy occurs with aging; papilledema is more likely when pressure is markedly increased. Areas of black pigment or hemorrhages in and around the macula indicate macular degeneration.
For all older patients, an eye examination by an ophthalmologist or optometrist is recommended every 1 to 2 years because such an examination may be much more sensitive for certain common eye disorders (eg, glaucoma, cataracts, retinal disorders).
Ears
The external auditory canal is examined for cerumen, especially if a hearing problem is noted during the interview. If a patient wears an external hearing aid, it is removed and examined. The ear mold and plastic tubing can become plugged with wax, or the battery may be dead, indicated by absence of a whistle (feedback) when the volume of the hearing aid is turned up.
To evaluate hearing, examiners, with their face out of the patient’s view, whisper 3 to 6 random words or letters into each of the patient’s ears. If a patient correctly repeats at least half of these words for each ear, hearing is considered functional for one-on-one conversations. Patients with presbycusis (age-related, gradual, bilateral, symmetric, and predominantly high-frequency hearing deficits) are more likely to report difficulty in understanding speech than in hearing sounds. Evaluation with a portable audioscope, if available, is also recommended because the testing sounds are standardized; thus, this evaluation can be useful when multiple providers are caring for a patient.
Patients are asked whether hearing loss interferes with social, work, or family functioning, or they may be given the Hearing Handicap Inventory for the Elderly (HHIE), a self-assessment tool designed to determine the effects of hearing loss on the emotional and social adjustment of older adults. If hearing loss interferes with functioning or if the HHIE score is positive, they are referred for formal audiologic testing.
Mouth
The mouth is examined for bleeding or swollen gums, loose or broken teeth, fungal infections, and signs of cancer (eg, leukoplakia, erythroplakia, ulceration, mass). Findings may include
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Darkened teeth: Due to extrinsic stains and less translucent enamel, which occur with aging
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Fissures in the mouth and tongue and a tongue that sticks to the buccal mucosa: Due to xerostomia
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Erythematous, edematous gingiva that bleeds easily: Usually indicating a gingival or periodontal disorder
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Bad breath: Possibly indicating caries, periodontitis, another oral disorder, or sometimes a pulmonary disorder
The dorsal and ventral surfaces of the tongue are examined. Common age-related changes include varicose veins on the ventral surface, benign migratory glossitis (geographic tongue), and atrophied papillae on the sides of the tongue. In edentulous patients, the tongue may enlarge to facilitate chewing; however, enlargement may also indicate amyloidosis or hypothyroidism. A smooth, painful tongue may indicate vitamin B12 deficiency.
Dentures should be removed before the mouth is examined. Dentures increase risk of oral candidiasis and resorption of the alveolar ridges. Inflammation of the palatal mucosa and ulcers of the alveolar ridges may result from poorly fitting dentures.
The interior of the mouth is palpated. A swollen, firm, and tender parotid gland may indicate parotitis, particularly in dehydrated patients; pus may be expressed from Stensen duct when bacterial parotitis is present. The infecting organisms are often staphylococci.
Painful, inflamed, fissured lesions at the lip commissures (angular cheilitis) may be noted in edentulous patients who do not wear dentures; these lesions are usually accompanied by a fungal infection.
Temporomandibular joint
This joint should be evaluated for degeneration (osteoarthrosis), a common age-related change. The joint can degenerate as teeth are lost and compressive forces in the joint become excessive. Degeneration may be indicated by joint crepitus felt at the head of the condyle as patients lower and raise their jaw, by painful jaw movements, or by both.
Neck
The thyroid gland, which is located low in the neck of older adults, often beneath the sternum, is examined for enlargement and nodules.
Carotid bruits due to transmitted heart murmurs can be differentiated from those due to carotid artery stenosis by moving the stethoscope up the neck: A transmitted heart murmur becomes softer; the bruit of carotid artery stenosis becomes louder. Bruits due to carotid artery stenosis suggest systemic atherosclerosis. Whether asymptomatic patients with carotid bruits require evaluation or treatment for cerebrovascular disease is unclear.
The neck is checked for flexibility. Resistance to passive flexion, extension, and lateral rotation may indicate a cervical spine disorder. Resistance to flexion and extension can also occur in patients with meningitis, but unless meningitis is accompanied by a cervical spine disorder, the neck can be rotated passively from side to side without resistance.
Chest and Back
All areas of the lungs are examined by percussion and auscultation. Basilar rales may be heard in the lungs of healthy patients but should disappear after patients take a few deep breaths. The extent of respiratory excursions (movement of the diaphragm and ability to expand the chest) should be noted.
The back is examined for scoliosis and tenderness. Severe low back, hip, and leg pain with marked sacral tenderness may indicate spontaneous osteoporotic fractures of the sacrum, which can occur in older adults.
Breasts
In men and women, the breasts should be examined annually for irregularities and nodules. For women ≤ age 74, screening mammography is also recommended, especially for women who have a family history of breast cancer. If nipples are retracted, pressure should be applied around the nipples; pressure everts the nipples when retraction is due to aging but not when it is due to an underlying lesion.
Heart
Heart size can usually be assessed by palpating the apex. However, displacement caused by kyphoscoliosis may make assessment difficult.
Auscultation should be done systematically (rate, regularity, murmurs, clicks, and rubs). Unexplained and asymptomatic sinus bradycardia in apparently healthy older adults may not be clinically important. An irregularly irregular rhythm suggests atrial fibrillation.
In older adults, a systolic murmur heard at the base (between the apex and the sternum) most commonly indicates
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Aortic valve sclerosis: Typically, this murmur is not hemodynamically significant, although risk of stroke may be increased. It peaks early during systole and is rarely heard in the carotid arteries. Rarely, sclerosis of the aortic valve progresses to hemodynamic significance and calcification; although infrequent, aortic valve sclerosis is now the most common lesion leading to symptomatic aortic stenosis and need for treatment.
However, systolic murmurs may be due to other disorders, which should be identified:
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Aortic valve stenosis: This murmur, in contrast to that of usual aortic valve sclerosis, typically peaks later during systole, is transmitted to the carotid arteries, and is loud (greater than grade 2); the 2nd heart sound is dampened, pulse pressure is narrow, and the carotid upstroke is slowed. However, in older patients, the murmur of aortic valve stenosis may be difficult to identify because it may be softer, a 2nd heart sound is rarely audible, and narrow pulse pressures are uncommon. Also, in many older patients with aortic valve stenosis, the carotid upstroke does not slow because vascular compliance is diminished.
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Mitral regurgitation: This murmur is usually loudest at the apex and radiates to the axilla.
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Hypertrophic obstructive cardiomyopathy: This murmur intensifies when patients do a Valsalva maneuver.
Diastolic murmurs are abnormal in people of any age.
Fourth heart sounds are common among older patients without evidence of a cardiovascular disorder and are commonly absent among older patients with evidence of a cardiovascular disorder.
If new neurologic or cardiovascular symptoms develop in patients with a pacemaker, evaluation for variable heart sounds, murmurs, and pulses and for hypotension and heart failure is required. These symptoms and signs may be due to loss of atrioventricular synchrony.
Gastrointestinal System
The abdomen is palpated to check for weak abdominal muscles, which are common among older patients and which may predispose to hernias. Most abdominal aortic aneurysms are palpable as a pulsatile mass; however, only their lateral width can be assessed during physical examination. In some patients (particularly thin ones), a normal aorta is palpable, but the vessel and pulsations do not extend laterally. Screening ultrasonography of the aorta is recommended for all older men who have ever smoked. The liver and spleen are palpated for enlargement. Frequency and quality of bowel sounds are checked, and the suprapubic area is percussed for tenderness, discomfort, and evidence of urinary retention.
The anorectal area is examined externally for fissures, hemorrhoids, and other lesions. Sensation and the anal wink reflex are tested. A digital rectal examination (DRE) to detect a mass, stricture, tenderness, or fecal impaction is done in men and women. Fecal occult blood testing is also done.
Male Reproductive System
The prostate gland is palpated for nodules, tenderness, and consistency. Estimating prostate size by DRE is inaccurate, and size does not correlate with urethral obstruction; however, DRE provides a qualitative evaluation.
Female Reproductive System
Some experts recommend that patients ≥ 21 years have pelvic examinations annually. However, no evidence supports or refutes pelvic examinations for asymptomatic, low-risk patients. Thus, for such patients, the decision about how often these examinations should be done should be made after the health care practitioner and patient discuss the issues.
For bimanual pelvic examination, patients who lack hip mobility may lie on their left side. Postmenopausal reduction of estrogen leads to atrophy of the vaginal and urethral mucosa; the vaginal mucosa appears dry and lacks rugal folds. The ovaries should not be palpable 10 years after menopause; palpable ovaries suggest cancer. Patients should be examined for evidence of prolapse of the urethra, vagina, cervix, and uterus. They are asked to cough to check for urine leakage and intermittent prolapse.
A Papanicolaou (Pap) test is not recommended for women ≥ age 65 who have had normal test results in the preceding 10 years.
Musculoskeletal System
Joints are examined for tenderness, swelling, subluxation, crepitus, warmth, redness, and other abnormalities, which may suggest a disorder:
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Heberden nodes (bony overgrowths at the distal interphalangeal joints) or Bouchard nodes (bony overgrowths at the proximal interphalangeal joints): Osteoarthritis
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Subluxation of the metacarpophalangeal joints with ulnar deviation of the fingers: Chronic rheumatoid arthritis
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Swan-neck deformity (hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint) and boutonnière deformity (hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint): Rheumatoid arthritis
These deformities may interfere with functioning or usual activities.
Active and passive range of joint motion should be determined. The presence of contractures should be noted. Variable resistance to passive manipulation of the extremities (gegenhalten) sometimes occurs with aging.
Feet
Diagnosis and treatment of foot problems, which become common with aging, help older people maintain their independence. Common age-related findings include hallux valgus, medial prominence of the 1st metatarsal head with lateral deviation and rotation of the big toe, and lateral deviation of the 5th metatarsal head. Hammer toe (hyperflexion of the proximal interphalangeal joint) and claw toe (hyperflexion of the proximal and distal interphalangeal toe joints) may interfere with functioning and daily activities. Toe deformities may result from years of wearing poorly fitting shoes or from rheumatoid arthritis, diabetes, or neurologic disorders (eg, Charcot-Marie-Tooth disease). Occasionally, foot problems indicate other systemic disorders (see table Foot Manifestations of Systemic Disorders).
Patients with foot problems should be referred to a podiatrist for regular evaluation and treatment.
Neurologic System
Neurologic examination for older patients is similar to that for any adult. However, nonneurologic disorders that are common among older people may complicate this examination. For example, visual and hearing deficits may impede evaluation of cranial nerves, and periarthritis (inflammation of tissues around a joint) in certain joints, especially shoulders and hips, may interfere with evaluation of motor function.
Signs detected during the examination must be considered in light of the patient’s age, history, and other findings. Symmetric findings unaccompanied by functional loss and other neurologic symptoms and signs may be noted in older patients. Clinicians must decide whether these findings justify a detailed evaluation to check for a neurologic lesion. Patients should be reevaluated periodically for functional changes, asymmetry, and new symptoms.
Cranial nerves
Evaluation may be complex.
Older people often have small pupils; their pupillary light reflex may be sluggish, and their pupillary mitotic response to near vision may be diminished. Upward gaze and, to a lesser extent, downward gaze can be slightly limited. Eye movements, when tracking an examiner’s finger during evaluation of visual fields, may appear jerky and irregular. Bell phenomenon (reflex upward movement of the eyes during closure) is sometimes absent. These changes occur normally with aging.
In many older people, sense of smell is diminished because they have fewer olfactory neurons, have had numerous upper respiratory infections, or have chronic rhinitis. However, asymmetric loss (loss of smell in one nostril) is abnormal. Taste may be altered because the sense of smell is diminished or because patients take drugs that decrease salivation.
Visual and hearing deficits may result from abnormalities in the eyes and ears rather than in nerve pathways.
Motor function
Patients can be evaluated for tremor during handshaking and other simple activities. If tremor is detected, amplitude, rhythm, distribution, frequency, and time of occurrence (at rest, with action, or with intention) are noted.
Muscle strength
Older people, particularly those who do not do resistance training regularly, may appear weak during routine testing. For example, during the physical examination, the clinician may easily straighten a patient’s elbow despite the patient’s effort to sustain a contraction. If weakness is symmetric, does not bother the patient, and has not changed the patient’s function or activity level, it is likely to be due to disuse rather than neurologic disease. Such weakness is treatable with resistance training; for the legs especially, it can improve mobility and reduce fall risk. Strengthening the upper extremities is also beneficial for overall function. Increased muscle tone, measured by flexing and extending the elbow or knee, is a normal finding in older people; however, jerky movements during examination and cogwheel rigidity are abnormal.
Sarcopenia (a decrease in muscle mass) is a common age-related finding. It is insignificant unless accompanied by a decline or change in function (eg, patients can no longer rise from a chair without using chair arms). Sarcopenia affects the hand muscles (eg, interosseous and thenar muscles) in particular. Weak extensor muscles of the wrist, fingers, and thumb are common among patients who use wheelchairs because compression of the upper arm against the armrest injures the radial nerve. Arm function can be tested by having patients pick up an eating utensil or touch the back of their head with both hands.
Coordination
Gait and posture
All components of gait should be assessed; they include initiation of walking; step length, height, symmetry, continuity, and cadence (rhythm); velocity (speed of walking); stride width; and walking posture. Sensation, musculoskeletal and motor control, and attention, which are necessary for independent, coordinated walking, must also be considered.
Normal age-related findings may include the following:
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Shorter steps, possibly because calf muscles are weak or because balance is poor
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Reduced gait velocity in patients > 70 because steps are shorter
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Increased time in double stance (when both feet are on the ground), which may be due to impaired balance or fear of falling
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Reduced motion in some joints (eg, ankle plantar flexion just before the back foot lifts off, pelvic motion in the frontal and transverse planes)
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Slight changes in walking posture (eg, greater downward pelvic rotation, possibly due to a combination of increased abdominal fat, abdominal muscle weakness, and tight hip flexor muscles; a slightly greater turn-out of the toes, possibly due to loss of hip internal rotation or to an attempt to increase lateral stability)
In people with a gait velocity of < 1 meter/second, mortality risk is significantly increased.
Aging has little effect on walking cadence or posture; typically, older people walk upright unless a disorder is present (see table).
Some Causes of Gait Dysfunction
Overall postural control is evaluated using the Romberg test (patients stand with feet together and eyes closed). Safety is paramount, and a clinician doing the Romberg test must be in position to prevent the patient from falling. With aging, postural control is often impaired, and postural sway (movement in the anteroposterior plane when patients remain stationary and upright) may increase.
Reflexes
The deep tendon reflexes are checked. Aging usually has little effect on them. However, eliciting the Achilles tendon reflex may require special techniques (eg, testing while patients kneel with their feet over the edge of a bed and with their hands clasped). A diminished or absent reflex, present in nearly half of older patients, may not indicate pathology, especially if symmetric. It occurs because tendon elasticity decreases and nerve conduction in the tendon’s long reflex arc slows. Asymmetric Achilles tendon reflexes usually indicate a disorder (eg, sciatica).
Cortical release reflexes (known as pathologic reflexes), which include snout, sucking, and palmomental reflexes, commonly occur in older patients without a detectable brain disorder (eg, dementia). A Babinski reflex (extensor plantar response) in older patients is abnormal; it indicates an upper motor neuron lesion, often cervical spondylosis with partial cord compression.
Sensation
Evaluation of sensation includes touch (using a skin prick test), cortical sensory function (eg, graphesthesia, stereognosis), temperature sense, proprioception (joint position sense), and vibration sense testing. Aging has limited effects on sensation. Many older patients report numbness, especially in the feet. It may result from a decrease in size of fibers in the peripheral nerves, particularly the large fibers. Nonetheless, patients with numbness should be checked for peripheral neuropathies. In many patients, no cause of numbness can be identified.
Many older people lose vibratory sensation below the knees. It is lost because small vessels in the posterior column of the spinal cord sclerose. However, proprioception, which is thought to use a similar pathway, is unaffected.
Mental status
A mental status examination is important for people ≥ 70 years. Patients who are disturbed by such a test should be reassured that it is routine. The examiner must make sure that patients can hear; hearing deficits that prevent patients from hearing and understanding questions may be mistaken for cognitive dysfunction. Evaluating the mental status of patients who have a speech or language disorder (eg, mutism, dysarthria, speech apraxia, aphasia) can be difficult.
Orientation may be normal in many patients with dementia or other cognitive disorders. Thus, evaluation may require questions that identify abnormalities in consciousness, judgment, calculations, speech, language, praxis, executive function, or memory, as well as orientation. Abnormalities in these areas cannot be attributed solely to age, and if abnormalities are noted, further evaluation, including a formal test of mental status, is needed.
With aging, information processing and memory retrieval slow but are essentially unimpaired. With extra time and encouragement, patients do such tasks satisfactorily (unless a neurologic abnormality is present).
Nutritional Status
Aging changes the interpretation of many measurements that reflect nutritional status in younger people. For example, aging can alter height. Weight changes can reflect alterations in nutrition, fluid balance, or both. The proportion of lean body mass and body fat content changes. Despite these age-related changes, body mass index (BMI) is still useful in older patients, although it underestimates obesity. Waist circumference and waist-to-hip ratio have been used instead. Risks due to obesity are increased if the waist circumference is > 102 cm (> 40 inches) in men and > 88 cm (> 35 inches) in women or if the waist-to-hip ratio is > 0.9 in men and > 0.85 in women.
If abnormalities in the nutrition history (eg, weight loss, suspected deficiencies in essential nutrients) or BMI are identified, thorough nutritional evaluation, including laboratory measurements, is indicated.
Key Points
Comprehensive geriatric assessment
The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors, as well as physical and mental health. Ideally, a regular examination of older patients incorporates many aspects of the comprehensive geriatric assessment, making the 2 approaches very similar. Assessment results are coupled with sustained individually tailored interventions (eg, rehabilitation, education, counseling, supportive services).
The cost of geriatric assessment limits its use. Thus, this assessment may be used best mainly in high-risk older patients, such as the frail or chronically ill (eg, identified via mailed health questionnaires or interviews in the home or meeting places). Family members may also request a referral for geriatric assessment.
Assessment can have the following benefits:
If older patients are relatively healthy, a standard medical evaluation may be appropriate.
Comprehensive geriatric assessment is most successful when done by a geriatric interdisciplinary team (typically, a geriatrician, nurse, social worker, and pharmacist). Usually, assessments are done in an outpatient setting. However, patients with physical or mental impairments and chronically ill patients may require inpatient assessment.
A Geriatric Assessment Instrument
Domain |
Item |
|
Degree of difficulty eating, dressing, bathing, transferring between bed and chair, using the toilet, and controlling bladder and bowel Degree of difficulty preparing meals, doing housework, taking drugs, going on errands (eg, shopping), managing finances, and using the telephone |
|
|
Assistive devices |
Use of personal devices (eg, cane, walker, wheelchair, oxygen) Use of environmental devices (eg, grab bars, shower bench, hospital bed) |
|
Caregivers |
Use of paid caregivers (eg, nurses, aides) Use of unpaid caregivers (eg, family members, friends, volunteers) |
|
Drugs |
Name of prescription drugs used Name of nonprescription drugs used |
|
Nutrition |
Height, weight Stability of weight (eg, Has the patient lost 4.54 kg [10 lb] in the past 6 months without trying?) |
|
Preventive measures |
Regularity of BP measurements, guaiac test for occult blood in stool, sigmoidoscopy or colonoscopy, immunizations (influenza, pneumococcal, tetanus), thyroid-stimulating hormone assessment, and dental care Intake of calcium and vitamin D Regularity of exercise Use of smoke detectors |
|
Cognition |
Ability to remember 3 objects after 1 minute and draw a clock face (Mini-Cog©) |
|
Affect |
Feelings of sadness, depression, or hopelessness Lack of interest or pleasure in doing things |
|
Advance directives |
Possession of a living will Establishment of durable power of attorney for health care |
|
Substance abuse/misuse |
Use of alcohol Use of cigarettes Overuse of prescribed or unprescribed drugs |
|
Gait and balance |
Number of falls in the past 6 months Time required to rise from a chair, walk 3.05 meters (10 feet), turn around, return, and sit down Extent of maximal forward reach while standing |
|
Sensory ability |
Ability to report 3 numbers whispered 0.61 meters (2 feet) behind the head Ability to read Snellen chart at 20/40 or better (with corrective lenses, if needed) |
|
Upper extremities |
Ability to clasp hands behind the head and back |
Assessment Domains
The principal domains assessed are
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Functional ability: Ability to do activities of daily living (ADLs) and instrumental ADLs (IADLs) are assessed. ADLs include eating, dressing, bathing, transferring between the bed and a chair, using the toilet, and controlling bladder and bowel. IADLs enable people to live independently and include preparing meals, doing housework, taking drugs, going on errands, managing finances, and using a telephone.
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Physical health: History and physical examination should include problems common among older people (eg, problems with vision, hearing, continence, gait, and balance).
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Cognition and mental health: Several validated screening tests for cognitive dysfunction (eg, mental status examination) and for depression (eg, Geriatric Depression Scale, Hamilton Depression Scale) can be used.
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Socioenvironmental situation: The patient’s social interaction network, available social support resources, special needs, and the safety and convenience of the patient’s environment are determined, often by a nurse or social worker. Such factors influence the treatment approach used. A checklist can be used to assess home safety.
Geriatric Depression Scale (Short Form)
Standardized instruments make evaluation of these domains more reliable and efficient (see table A Geriatric Assessment Instrument). They also facilitate communication of clinical information among health care practitioners and monitoring of changes in the patient’s condition over time.
