Physical Examination of the Older Adult

1. 1. Saedon NI, Tan MP, Frith J: The prevalence of orthostatic hypotension: A systematic review and meta-analysis. Gerontol A Biol Sci Med Sci 75 (1):117–122, 2020.

2. 2. McFadden HP, Price RC, Eastwood HD, Briggs RS: Raised respiratory rate in elderly patients: A valuable physical sign. Br Med J (Clin Res Ed) 284 (6316): 626–627, 1982. doi: 10.1136/bmj.284.6316.626

Normal age-related findings may include the following:

• Eyebrows that drop below the superior orbital rim

• Descent of the chin

• Loss of the angle between the submandibular line and neck

• Wrinkles

• Dry skin

• Thick terminal hairs on the ears, nose, upper lip, and chin

The temporal arteries should be palpated for tenderness and thickening, which may indicate giant cell arteritis, suspicion of which requires immediate evaluation and treatment.

Progressive descent of the nasal tip is a normal age-related finding. It may cause the upper and lower lateral cartilage to separate, enlarging and lengthening the nose.

Normal age-related findings include the following:

• 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.

• Pseudoptosis (decreased size of the palpebral aperture)

• Entropion (inversion of lower eyelid margins)

• Ectropion (eversion of lower eyelid margins)

• Arcus senilis (a white ring at the limbus)

• Thinning of the retina due to a decreased number of neurons

With aging, presbyopia develops; the lens becomes less elastic and less able to change shape when focusing on close objects. The lens becomes denser, making seeing in dim light harder. Also, the lens yellows, resulting in loss of contrast and changes in the way colors are perceived.

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).

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 health care professionals 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–Screening Version (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.

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

• Darkened teeth: Due to extrinsic stains and less translucent enamel, which occur with aging

• Fissures in the mouth and tongue and a tongue that sticks to the buccal mucosa: Due to xerostomia

• Erythematous, edematous gingiva that bleeds easily: Usually indicating a gingival or periodontal disorder

• Bad breath: Possibly indicating oral disorders (eg, caries, periodontitis), another infection (eg, sinus), 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 patients without teeth, 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 patients with dehydration; 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 patients without teeth who do not wear dentures; these lesions are usually accompanied by a fungal infection.

The temporomandibular 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.

The thyroid gland, which is located in the front of the neck, wrapped around the trachea, 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 and predict a higher risk of ischemic heart disease than of stroke-(1). 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.

1. 1. Chambers BR, Norris JW: Outcome in patients with asymptomatic neck bruits. N Engl J Med 315 (14):860–865, 1986. doi: 10.1056/NEJM198610023151404

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. Although some clinicians screen for breast cancer by physical examination, major specialty societies do not agree about whether breast examination should be done to screen for breast cancer.

(See also Cardiovascular Examination.)

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

• 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:

• 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.

• Mitral regurgitation: This murmur is usually loudest at the apex and radiates to the axilla.

• 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 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. Neurologic symptoms (eg, syncope, cognitive impairment, vertigo, dizziness, rarely stroke) may occur, usually secondary to atrioventricular asynchrony or intracardiac blood flow stasis leading to embolism.

Evaluation of the cranial nerves may be complex.

Older adults 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 adults, 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 medications that decrease salivation.

Visual and hearing deficits may result from abnormalities in the eyes and ears rather than in nerve pathways.

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.

Older adults, particularly those who do not do resistance training regularly, may appear weak during routine muscle strength 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 adults; however, jerky movements during examination and cogwheel rigidity are abnormal.

Sarcopenia (a decrease in muscle mass) is a common age-related finding. It is not always pathologic and may not cause 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.

Motor coordination is tested. Coordination decreases because of changes in central mechanisms and can be measured in the neurologic examination; this decrease is usually subtle and does not impair usual function.

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. Fall risk assessment is recommended yearly for all adults age 65 or older.

Normal age-related findings may include the following:

• Shorter steps, possibly because calf muscles are weak or because balance is poor

• Reduced gait velocity in patients > 70 because steps are shorter

• Increased time in double stance (when both feet are on the ground), which may be due to impaired balance or fear of falling

• Reduced motion in some joints (eg, ankle plantar flexion just before the back foot lifts off, pelvic motion in the frontal and transverse planes)

• 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 adults walk upright unless a disorder is present (see table).

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.

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 findings are 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.

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 adults 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.

A mental status examination is important for people ≥ 65 years or for younger people with concerns about cognitive decline. 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, dysarthria, speech apraxia, aphasia) can be difficult (see also How To Assess Mental Status).

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).