Mrs. T., an 82 year old nursing home resident, fell twice during a 24 hour period. She had no history of gait abnormalities or balance problems, and no history of falls. Her vital signs were unchanged, and she had no other complaints except for decreased appetite. The following day, she complained of dizziness, and her blood pressure had fallen to 80/40 with orthostatic changes. She was evaluated in a nearby emergency room, where her physical examination revealed absent bowel sounds but no abdominal tenderness. Abdominal X-rays showed evidence of a perforated viscus, and ultimately she was found to have a peritonitis secondary to a perforated diverticulum.

This case illustrates a non-specific clinical presentation of a serious illness in an older patient. This woman presented with vague, nonspecific symptoms.

Q: Can you think of some other types of altered disease presentations that occur in older people?

Click here for answer.

In addition to the non-specificity of disease presentations, other factors may further complicate the assessment of older patients:

• Communication problems
  • older patients often slower to respond
  • hearing problems
  • dysarthria or aphasia
• Multiple complaints
  • the new complaint may be obscured by a "background" of other complaints (an unfavorable "signal-to-noise ratio")
  • Interactions between multiple problems and medications (see Polypharmacy for further discussion)

Obtaining a History - Alterations for Frail Elderly Patients

• Alterations in approach for visual or hearing-impaired patients (see Physiology of Aging: Approach to Visual/Hearing-Impaired Older People)
• Determine the patient's functional status
• Asking is the most important step
• Functional assessment: ask about activities of daily living (ADL's):
  • basic ADL's
  • bathing, dressing, transfers, hygiene, continence, ambulation, feeding
  • examples:
    • "How far can you walk?" "Has this gotten worse lately?"
    • "Can you get out of bed and into your wheelchair w/o help?"
    • "Do you have trouble holding your urine?"
    • "Can you get dressed without help?"
  • "instrumental" ADL's
  • shopping, transportation, cooking, household chores, finances, telephoning, employment, etc.
  • examples:
    • "Do you do your own shopping?" "Housework?" "Cooking?"
    • "How often do you leave your house?" "Do you drive?" " Take the bus?"
• Try to determine baseline functional status
  • Any recent changes?
  • A change in function may be only indication of acute illness
  • acute/subacute loss of function suggests the possibility of either an acute illness or a worsening of a chronic illness
• Inquire about any caregivers that assist with ADL's
  • "who would you call if you needed help with your daily activities?"
• Sources of information regarding functional status:
  • The patient; family/caregivers; direct observation
  • Each source has its own biases
    • patients often overestimate capabilities
    • family may underestimate, especially if they are "enabling" the person to be dependent by helping with activities the person can actually do without assistance.
    • Direct observation by the practitioner usually occurs outside the patient's own milieu, where s/he may be able to perform best
• Comprehensive geriatric assessment involves other "domains" in addition to ADL's
  • Other "domains": psychological, social, environmental, nutritional, sensory, cognitive, etc.
  • Examples of relevant questions that may help screen for problems in these other domains
    • Psychological
      • "Do you often feel sad or blue?"
      • "Does life still seem worthwhile?"
      • "What do you like to do for fun?"
    • Cognitive
      • Test recall of 3 objects at 1 minute
      • Full Folstein Mini-Mental Status Exam is useful as part of a complete physical exam
    • Vision
      • "Do you have trouble seeing well enough to drive? Read? Watch TV?"
    • Hearing
      • Whisper simple question in each ear, e.g., "what is your name?"
      • Social - an adequate support system is often the key to an older person's ability to live in the community

Physical Exam - Alterations for Elderly Patient

• General
  • Exam interpretation made more difficult by multiple pathology superimposed on age-related changes, e.g., evaluation of hydration status is more difficult
    • Age-related changes include decreased skin turgor and postural reflexes (poor skin turgor, mild orthostatic blood pressure drop may not indicate intravascular volume depletion)
    • Venous insufficiency common - edema doesn't necessarily indicate excessive intravascular volume status 
  • Poor grooming/hygiene may reflect poor functional status
  • Lungs: rales may be due to atelectasis, fibrotic changes of the lungs not necessarily due to congestive heart failure or significant lung disease

   

• Cardiovascular
  • arrhythmias relatively common in asymptomatic patient; seldom need specific evaluation/treatment if no other symptoms
  • systolic murmurs: very common, usually benign

   

• Gait/balance evaluation may be critical
  • falls often devastating
  • "Get Up and Go" test: a quick functional evaluation for changes in gait, balance, lower extremity strength, and fall risk:
    • arise from a chair (without using arms to assist if possible), stand still momentarily, walk forward 10 feet, turn around, walk back to chair, turn and sit down
    • observe:
      • sitting balance
      • transfers from sitting to standing
      • stability on first standing
      • gait stability, symmetry, step height and length
      • self-selected walking speed
      • ability to turn without staggering

• Cognitive
  • Delayed, slow responses may be due to age-related changes or disease (e.g., Parkinson's disease, depression)
  • Confusion, depressed affect may need intervention

• Observe surroundings
  • General clutter
  • Is stair-climbing required to enter/leave home?
  • Signs of neglect
  • old food in refrigerator? Unwashed dishes?

• Obvious safety hazards

Click below to link to Home Page for
University of Washington, Division of Gerontology and Geriatric Medicine

Copyright 1999, 2000 David A. Gruenewald, M.D. and Kayla I. Brodkin, M.D. All rights reserved.