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. (For screening recommendations in older people, see Prevention of Disease in Older Adults Prevention of Disease in Older Adults Disease prevention is treatment intended to prevent a disease from occurring or worsening. Independent, older people with minimal or no chronic disease, as well as older people with several... read more .)
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 ).
Early detection of problems can result in early intervention, which can prevent deterioration and improve quality of life Quality of Life in Older People Quality of life (QOL) is the degree to which a person is healthy, comfortable, and able to participate in or enjoy life events. It is critical for health care practitioners to take quality of... read more , 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 Comprehensive Geriatric Assessment Comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of older... read more , which includes evaluation of function and quality of life, best administered by an interdisciplinary team Geriatric Interdisciplinary Teams Every 4 years, the US Department of Health and Human Services (HHS) updates its strategic plan and defines its mission and goals. The current HHS strategic plan (2018-2022) includes the following... read more .
On average, older patients have 6 diagnosable disorders. 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 Delirium Delirium is an acute, transient, usually reversible, fluctuating disturbance in attention, cognition, and consciousness level. Causes include almost any disorder or drug. Diagnosis is clinical... read more , dizziness Dizziness and Vertigo Dizziness is an imprecise term patients often use to describe various related sensations, including Faintness (a feeling of impending syncope) Light-headedness Feeling of imbalance or unsteadiness... read more , syncope Syncope Syncope is a sudden, brief loss of consciousness with loss of postural tone followed by spontaneous revival. The patient is motionless and limp and usually has cool extremities, a weak pulse... read more , falling Falls in Older People A fall is defined as a person coming to rest on the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically, events caused by acute disorders... read more , mobility problems Gait Disorders in Older Adults Gait disorders encompass a number of issues, including slowing of gait speed and loss of smoothness, symmetry, or synchrony of body movement. For older adults, walking, standing up from a chair... read more , weight or appetite loss Involuntary Weight Loss Involuntary weight loss generally develops over weeks or months. It can be a sign of a significant physical or mental disorder and is associated with an increased risk for mortality. The causative... read more , urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem. The disorder is greatly underrecognized and underreported. Many... read more ) 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 Disorders More Common Among Older Adults ); 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 How to Assess Mental Status The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status ( see Examination... read more . 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.
Patients' prescription, over-the-counter, and recreational drugs (including marijuana) should be reviewed frequently, particularly to look for drug interactions and use of drugs considered inappropriate for older patients Drug Categories of Concern in Older Adults Some drug categories (eg, analgesics, anticoagulants, antihypertensives, antiparkinsonian drugs, diuretics, hypoglycemic drugs, psychoactive drugs) pose special risks for older adults. Some... read more . This review is especially important during care transitions when reconciliation of drugs is required to eliminate duplication, missed drugs, and errors in dosage and to identify drugs that may be no longer be needed.
Occasionally, problems of older patients are related to neglect or abuse by their caregiver Elder Abuse Elder abuse is physical or psychologic mistreatment, neglect, or financial exploitation of older adults. Common types of elder abuse include physical abuse, psychologic abuse, neglect, and financial... read more . 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
Frequent bruising, especially in difficult-to-reach areas (eg, middle of the back)
Grip bruises of the upper arms
Bruises of the genitals
Unexplained fearfulness of a caregiver in the patient