The physical examination of the older adult should include all major systems but with particular attention to areas of concern identified during the history (see also Overview of Evaluation of the Older Adult Overview of Evaluation of the Older Adult 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... read more and History Taking in the Older Adult History-Taking in the Older Adult Attention to the medical history is particularly important in older adults because the history is often more complicated than in younger patients, and information may need to be gathered from... read more ).
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.
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, it 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 Orthostatic Hypotension Orthostatic (postural) hypotension is an excessive fall in blood pressure (BP) when an upright position is assumed. The consensus definition is a drop of > 20 mm Hg systolic, > 10 mm Hg... read more 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 respiratory rate for older adults differs based on health and living situation. The normal respiratory rate for older adults living independently is 12 to 18 breaths per minute, whereas the rate for those needing long-term care is 16 to 25 breaths per minute.
Skin and Nails
Initial observation includes color (normal rubor, pale, cyanotic). Examination includes a search for premalignant and malignant lesions, tissue ischemia, and pressure injuries Pressure Injuries Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more . In older patients, the following should be considered:
Ecchymoses may occur readily when skin is traumatized, often on the forearm, because the dermis thins with aging.
Uneven tanning may be normal because melanocytes are progressively lost with aging.
Longitudinal ridges on the nails and absence of the crescent-shaped lunula are normal age-related findings.
Nail plate fractures may occur because, with aging, the nail plate thins.
Black splinter hemorrhages in the middle or distal third of the fingernail are more likely to be due to trauma than to bacteremia.
A thickened, yellow toenail indicates , a fungal infection.
Toenail borders that curve in and down indicate (onychocryptosis).
Whitish nails that scale easily, sometimes with a pitted surface, indicate psoriasis Psoriasis Psoriasis is an inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with silvery scales. Multiple factors contribute, including... read more .
Head and Neck
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
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 Treatment Giant cell arteritis involves predominantly the thoracic aorta, large arteries emerging from the aorta in the neck, and extracranial branches of the carotid arteries. Symptoms of polymyalgia... read more , 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)
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 Evaluation of the Ophthalmologic Patient The eye can be examined with routine equipment, including a standard ophthalmoscope; thorough examination requires special equipment and evaluation by an ophthalmologist. History includes location... read more 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 Cataract A cataract is a congenital or degenerative opacity of the lens. The main symptom is gradual, painless vision blurring. Diagnosis is by ophthalmoscopy and slit-lamp examination. Treatment is... read more , optic nerve or macular degeneration Age-Related Macular Degeneration (AMD or ARMD) Age-related macular degeneration (AMD) is the most common cause of irreversible central vision loss in older patients. Dilated funduscopic findings are diagnostic; color photographs, fluorescein... read more , and evidence of glaucoma Overview of Glaucoma Glaucomas are a group of eye disorders characterized by progressive optic nerve damage in which an important part is a relative increase in intraocular pressure (IOP) that can lead to irreversible... read more , hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more , or diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more . 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 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–Screening Version Screening Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss ( 1). More than 10% of people in the US have some degree of hearing loss that compromises their... read more (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 Xerostomia Xerostomia is dry mouth caused by reduced or absent flow of saliva. This condition can result in discomfort, interfere with speech and swallowing, make wearing dentures difficult, cause halitosis... read more
Erythematous, edematous gingiva that bleeds easily: Usually indicating a gingival or periodontal disorder
Bad breath: Possibly indicating oral disorders (eg, caries Caries Caries is tooth decay, commonly called cavities. The symptoms—tender, painful teeth—appear late. Diagnosis is based on inspection, probing of the enamel surface with a fine metal instrument... read more , periodontitis Periodontitis Periodontitis is a chronic inflammatory oral disease that progressively destroys the tooth-supporting apparatus. It usually manifests as a worsening of gingivitis and then, if untreated, with... read more ), 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 (), 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 Amyloidosis Amyloidosis is any of a group of disparate conditions characterized by extracellular deposition of insoluble fibrils composed of misaggregated proteins. These proteins may accumulate locally... read more or hypothyroidism Hypothyroidism Hypothyroidism is thyroid hormone deficiency. Symptoms include cold intolerance, fatigue, and weight gain. Signs may include a typical facial appearance, hoarse slow speech, and dry skin. Diagnosis... read more . A smooth, painful tongue may indicate vitamin B12 deficiency Vitamin B12 Deficiency Dietary vitamin B12 deficiency usually results from inadequate absorption, but deficiency can develop in vegans who do not take vitamin supplements. Deficiency causes megaloblastic anemia, damage... read more .
Dentures Denture problems Teeth may be lost to dental caries, periodontal disease, or trauma or may be removed when treatment fails. Missing teeth may cause cosmetic, phonation, and occlusal problems and may allow movement... read more 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 Cheilitis (lip inflammation) Lip inflammation may be generalized, or localized to one or more ulcers or lesions. Although some swelling may be present, the main manifestation is discomfort. Lip swelling with little or no... read more ) may be noted in edentulous patients who do not wear dentures; these lesions are usually accompanied by a fungal infection.
This joint should be evaluated for degeneration Osteoarthritis Infectious arthritis, traumatic arthritis, osteoarthritis, rheumatoid arthritis, and secondary degenerative arthritis can affect the temporomandibular joint. (See also Overview of Temporomandibular... read more (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 Carotid pulses Complete examination of all systems is essential to detect peripheral and systemic effects of cardiac disorders and evidence of noncardiac disorders that might affect the heart. Examination... read more 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.
In men and women, the breasts can be considered for annual examination, but there is no strong evidence of benefit (ie, in decreasing mortality from breast cancer), which limits the recommendations made by both the American Cancer Society and the U.S. Preventive Services Task Force. 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 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 Atrial Fibrillation Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form... read more .
In older adults, a systolic murmur Systolic murmurs Auscultation of the heart requires excellent hearing and the ability to distinguish subtle differences in pitch and timing. Hearing-impaired health care practitioners can use amplified stethoscopes... read more 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 Aortic Stenosis Aortic stenosis (AS) is narrowing of the aortic valve, obstructing blood flow from the left ventricle to the ascending aorta during systole. Causes include a congenital bicuspid valve, idiopathic... read more and need for treatment.
However, systolic murmurs Systolic murmurs Auscultation of the heart requires excellent hearing and the ability to distinguish subtle differences in pitch and timing. Hearing-impaired health care practitioners can use amplified stethoscopes... read more may be due to other disorders, which should be identified:
Aortic valve stenosis Aortic Stenosis Aortic stenosis (AS) is narrowing of the aortic valve, obstructing blood flow from the left ventricle to the ascending aorta during systole. Causes include a congenital bicuspid valve, idiopathic... read more : 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 Mitral Regurgitation Mitral regurgitation (MR) is incompetency of the mitral valve causing flow from the left ventricle (LV) into the left atrium during ventricular systole. MR can be primary (common causes are... read more : This murmur is usually loudest at the apex and radiates to the axilla.
Hypertrophic obstructive cardiomyopathy Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy is a congenital or acquired disorder characterized by marked ventricular hypertrophy with diastolic dysfunction (eg, due to valvular aortic stenosis, coarctation... read more : This murmur intensifies when patients do a Valsalva maneuver.
Diastolic murmurs Diastolic murmurs Auscultation of the heart requires excellent hearing and the ability to distinguish subtle differences in pitch and timing. Hearing-impaired health care practitioners can use amplified stethoscopes... read more are abnormal in people of any age.
Fourth heart sounds Diastolic heart sounds Auscultation of the heart requires excellent hearing and the ability to distinguish subtle differences in pitch and timing. Hearing-impaired health care practitioners can use amplified stethoscopes... read more 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 Orthostatic Hypotension Orthostatic (postural) hypotension is an excessive fall in blood pressure (BP) when an upright position is assumed. The consensus definition is a drop of > 20 mm Hg systolic, > 10 mm Hg... read more and heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more is required. These symptoms and signs may be due to loss of atrioventricular synchrony.
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 Abdominal Aortic Aneurysms (AAA) Abdominal aortic diameter ≥ 3 cm typically constitutes an abdominal aortic aneurysm. The cause is multifactorial, but atherosclerosis is often involved. Most aneurysms grow slowly (~10%/year)... read more 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. Screening recommendations for colorectal cancer Screening tests Colorectal cancer is extremely common. Symptoms include blood in the stool and change in bowel habits. Screening using one of several methods is recommended for appropriate populations. Diagnosis... read more are important to review.
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 may provide a qualitative estimate of prostate volume. Most professional organizations do not recommend DRE as a screening tool for prostate cancer. Screening recommendations for prostate cancer are discussed elsewhere (see prostate cancer screening Screening Prostate cancer is usually adenocarcinoma. Symptoms are typically absent until tumor growth causes hematuria and/or obstruction with pain. Diagnosis is suggested by digital rectal examination... read more .)
The genital area should be examined for signs of sexually transmitted infections (STIs), other infections, and abnormalities.
Female Reproductive System
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.
Some health care practitioners recommend that patients ≥ 21 have screening pelvic examinations Physical Examination Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. Gynecologic evaluation may be necessary... read more annually. Others recommend an interval of 3 years until age 65. 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 individualized.
Neither a Papanicolaou (Pap) test nor a human papillomavirus (HPV) test is recommended for women ≥ age 65 who have had normal test results in the preceding 10 years.
The genital area should be examined for signs of STIs, other infections, and abnormalities.
Joints are examined for tenderness, swelling, subluxation, crepitus, warmth, redness, and other abnormalities. 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.
Certain abnormalities, particularly those in the hands, may suggest a specific disorder:
(bony overgrowths at the distal interphalangeal joints) or (bony overgrowths at the proximal interphalangeal joints): Osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy (osteophyte formation). Symptoms... read more
Subluxation of the metacarpophalangeal joints with ulnar deviation of the fingers: Chronic rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more
(hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint) and (hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint): Rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more
These deformities may interfere with functioning or usual activities.
Common age-related joint 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. (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 Overview of Foot and Ankle Disorders Most foot problems result from anatomic disorders or abnormal function of articular or extra-articular structures (see figure Bones of the foot). Less commonly, foot problems reflect a systemic... read more indicate other systemic disorders (see table Foot Manifestations of Systemic Disorders Foot Manifestations of Systemic Disorders ). For example, palpation of the dorsalis pedis and posterior tibial pulses are important elements of the cardiovascular examination, and finding edema may suggest venous insufficiency or cardiac, liver, or kidney dysfunction.
Patients with foot problems should be referred to a podiatrist for regular evaluation and treatment.
Neurologic examination Introduction to the Neurologic Examination The neurologic examination begins with careful observation of the patient entering the examination area and continues during history taking. The patient should be assisted as little as possible... read more 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, such as diminished ankle jerks and decreased distal vibration sensation, 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.
Evaluation of the cranial nerves How to Assess the Cranial Nerves (See also Neuro-ophthalmologic and Cranial Nerve Disorders and Introduction to the Neurologic Examination.) Smell, a function of the 1st (olfactory) cranial nerve, is usually evaluated only... read more 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.
Patients can be evaluated for tremor Tremor Tremors are involuntary, rhythmic, oscillatory movements of reciprocal, antagonistic muscle groups, typically involving the hands, head, face, vocal cords, trunk, or legs. Diagnosis is clinical... read more 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 people, particularly those who do not do resistance training regularly, may appear weak during routine muscle strength testing How to Assess Muscle Strength Patients who report weakness may mean fatigue, clumsiness, or true muscle weakness. Thus, the examiner must define the precise character of symptoms, including exact location, time of occurrence... read more . 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.
Motor coordination is tested How to Assess Gait, Stance, and Coordination Normal gait, stance, and coordination require integrity of the motor, vestibular, cerebellar, and proprioceptive pathways ( see also Movement and Cerebellar Disorders). A lesion in any of the... read more . 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 function.
Gait and posture
All components of gait should be assessed How to Assess Gait, Stance, and Coordination Normal gait, stance, and coordination require integrity of the motor, vestibular, cerebellar, and proprioceptive pathways ( see also Movement and Cerebellar Disorders). A lesion in any of the... read more ; 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 Evaluation 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 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 people walk upright unless a disorder is present (see table Some Causes of Gait Dysfunction ).
Overall postural control is evaluated using the (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 Deep tendon reflexes (See also Introduction to the Neurologic Examination) Deep tendon (muscle stretch) reflex testing evaluates afferent nerves, synaptic connections within the spinal cord, motor nerves, and descending... read more . 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 Sciatica Sciatica is pain along the sciatic nerve. It usually results from compression of lumbar nerve roots in the lower back. Common causes include intervertebral disk herniation, osteophytes, and... read more ).
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 Dementia Dementia is chronic, global, usually irreversible deterioration of cognition. Diagnosis is clinical; laboratory and imaging tests are usually used to identify treatable causes. Treatment is... read more ). 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 How to Assess Sensation For the ability to sense a sharp object, the best screening test uses a safety pin or other sharp object to lightly prick the face, torso, and 4 limbs; the patient is asked whether the pinprick... read more 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 Peripheral Neuropathy Peripheral neuropathy is dysfunction of one or more peripheral nerves (the part of a nerve distal to the root and plexus). It includes numerous syndromes characterized by varying degrees of... read more . 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.
A mental status examination Examination of Mental Status 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.
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).
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 Diagnosis Obesity is excess body weight, defined as a body mass index (BMI) of ≥ 30 kg/m2. Complications include cardiovascular disorders (particularly in people with excess abdominal fat)... read more (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.
Valuable information about a patient’s function can be gained by observing the patient.
Physical examination should include all systems, particularly mental status, and may require 2 sessions.