Evaluating Older Patients: What You Dont Want to Miss

1
Evaluating Older Patients What You Dont Want
to Miss

• Richard W. Besdine, MD,FACP
• Professor of Medicine
• Greer Professor of Geriatric Medicine
• Director, Division of Geriatrics
• Director, Center for Gerontology and Healthcare
  Research

2
Maybe Aging isnt so Bad
Foofie Harlan age 75 (or 80?)
3
Learning Objectives Today

• Identify important differences in the medical
  interview for older adults
• Demonstrate communication skills for patients
  with hearing or cognitive impairment
• Identify important differences in the physical
  examination for older adults
• Demonstrate understanding of the critical
  importance of function for elders

4
Easy to Miss Land Mines in Elders

• Mild (or not mild!) cognitive impairment
• Elder abuse
• Depression
• Undernutrition
• Incontinence
• Falls
• Hearing and vision impairment
• Alcohol or medication misuse
• Orthostatic hypotension
• Chronic pain
• Malignant skin lesions

5
Meeting Your Patient

• Greet with a smile and touch a gentle handshake
  or a touch on the shoulder say something kind
• Use formal address until patient asks otherwise
  Mr., Mrs., Miss, Dr. and always introduce
  yourself by name, even on return visits
• Chairs should have a high seat or mechanical
  lift step stool with handrail, short drapes

6
Be Careful About Courtesy to Elders

• They may be old and slow, but they are our
  history and heritage
• They are the 5th commandment
• They also can bring wisdom and experience to
  problems
• And, if for no other reason, it is safer

7
Dont Mess with Grandma!
8
Taking the History1

• Determine first if the patient can hear you
• 50 80 have presbycusis, but 50 do not so
  dont shout
• Consonants most difficult - high-tone loss
• Lower-than-usually-pitched voice
• Face the patient to allow lip reading
• Eyeglasses (enhance lip reading), dentures
  (enhance patient's speech) and hearing aid (with
  a functional battery)

9
Taking the History2

• Reliability Check mental status (answers you
  know e.g., time and place, previous health care
  contacts, biographical data, current events,
  driving directions)
• Are you having trouble with your memory?
• Even when severe impairment, current symptom
  inquiry will give useful information
• Beware the answering daughter see patient alone
  or insist patient answers all questions

10
The History - Format, Approach

• Begin with an open-ended functional question
  e.g., What do you feel interferes most with your
  day-to-day activities?
• Occams razor rarely works - single or chief
  complaint is uncommon multiple diseases and
  problems usually present with multiple symptoms
  and complaints
• Standard CC, HPI, PMH can be frustrating
• Organize history around a problem list

11
The History Medications

• Identify every medication - duplicate,
  overlapping, conflicting drugs are common - from
  multiple prescribers and OTC
• Include questions about herbals, hypnotics,
  vitamins, supplements, analgesics, laxatives,
  meds from friends and family
• Gather medications and pill bottles from
  bathroom, bedside table, purse, kitchen drawer,
  friends and relatives

12
The History - Social

• Living arrangements - being alone in late life is
  a risk for multiple bad outcomes (functional
  decline, hospitalization, death, NH admission)
• Who is available to help out at home or in the
  local community? Is there a plan in case of
  illness or functional decline?
• Extent of social relationships is a powerful
  predictor of functional status and mortality
• Family History AD, depression, caregiving
• Is there evidence suggesting elder abuse?

13
The History - Nutrition

• Have you lost 10 lb in past 6 months?
• Independent elders usually adequately nourished
• Under-nutrition increases in vulnerable and frail
  older persons most often unrecognized
• Chronic diseases (DM, CA), oral or GI disorders,
  drug effects, systemic illness, psychiatric
  disease dementia all increase risk for
  inadequate nutrition
• Screening - diet (past day or two) recent
  weight shopping, cooking habits history of
  eating disorders sites of eating, company
  skipped meals
• Best longitudinal measure is weight over time

14
The History - Substance Use/Abuse

• Alcohol misuse often overlooked effects
  attributed to common diseases in old age
• Alcohol-related hospitalizations as frequent as
  for AMI in older adults
• CAGE (Cut down, Annoyed, Guilty feelings,
  Eye-opener) valid in elders
• Tobacco cessation is beneficial at any age, and
  counseling is mandatory
• Elders use recreational drugs watch out for the
  Boomers

15
Discussing Sex and Death with Elders

• Most older persons are sexually active if they
  are healthy and can find a partner, but they
  dont talk about it
• The same is true about death
• Most often, elders have thought about it
• Most often, they dont want to upset their nice
  young doctors or their children
• Most often, they are grateful if you raise it
• Be matter-of-fact, open-ended Have you thought
  about what you would want if?

16
The History - Completed

• Family History AD, depression, caregiving
• Sexual History direct, open-ended question
  most older adults are sexually active
• Preferences for Care - end-of-life
  decision-making, advance directives
• Functional Status - screening questions about
  independence and self-care

17
Validated Function Screens

• Have you fallen in the past year?
• Vision - Do you have trouble?
• Hearing Audioscope, whispered voice
• Leg strength, balance Up and Go Test
• Urinary incontinence Do you wet 6 days/mo?
• Nutrition 10 lb. wt. Loss in 6 mo. or lbs.?
• Memory Do you have trouble? Mini-cog
• Mood/affect Do you often feel depressed? GDS
• Formal assessment in any domain that screens

Moore, Siu. Am J Med. 1996 100440
18
Validated Function Screens

• Have you fallen in the past year?
• Vision - Do you have trouble?
• Hearing Audioscope, whispered voice
• Leg strength, balance Up and Go Test
• Urinary incontinence Do you wet 6 days/mo?
• Nutrition 10 lb. wt. Loss in 6 mo. or lbs.?
• Memory Do you have trouble? Mini-cog
• Mood/affect Do you often feel depressed? GDS
• Formal assessment in any domain that screens

Moore, Siu. Am J Med. 1996 100440
19
Lawton ADL Scale
Scores range from 0 to 6
20
Lawton IADL Scale Scores 0-8
21
Mini-Cog Assessment

• 3- item recall with a clock draw test (CDT)
• Scoring
• 1 point for each recalled word after CDT (0-3)
• 2 points for a normal clock draw test, 0 for
  abnormal CDT
• 5 point total maximum (0-5)
• Interpretation 2 or less is abnormal

22

• MINI-COG ASSESSMENT - Combines 3-item recall test
  with a clock-drawing test (CDT) about 3 min, no
  equipment, little effect of education or
  language.
• Administration
• 1. Instruct patient to listen carefully to
  remember 3 (unrelated) words, then repeat back to
  you (to be sure the patient heard them)
• 2. Instruct the patient to draw the face of a
  clock (blank page or with circle already on it)
  with the numbers inside the circle.
• 3. After patient puts numbers on clock face, ask
  pt. to draw hands of clock to read 820. No
  further instructions to be given. If after 3
  min, the CDT is not finished, go to next step.
• 4. Ask pt. to repeat the 3 previously presented
  words.
• Scoring - 1 point for each recalled word after
  CDT 03 for recall. 2 points for normal CDT (all
  numbers depicted once, in correct order and
  position, hands show requested time), 0 for
  abnormal CDT. Add recall and CDT scores to get
  Mini-Cog Score- 0-5.
• Interpretation 3 or more normal, 2 or less
  abnormal

23

Draw a Clock Face at 3 O'clock
MMSE27
24
Up and Go Test

• The patient sits in an armless chair
• Instruction is to stand without using hands, walk
  to a mark 10 feet away, turn, walk back to the
  chair, and sit again
• The patient is told that she will be timed
• This is a validated performance measure time 9
  seconds indicates a 2-fold fall risk
• Much can be learned observing the patient

25
GERIATRIC DEPRESSION SCALE - GDS

• Choose the best answer for how you felt over the
  past week
• 1. Are you basically satisfied with your life?
  yes/no     
• 2. Have you dropped many activities and
  interests? yes/no
• 3. Do you feel that your life is empty? yes/no
      
• 4. Do you often get bored? yes/no     
• 5. Are you in good spirits most of the time?
  yes/no     
• 6. Are you afraid something bad will happen to
  you? yes/no     
• 7. Do you feel happy most of the time? yes/no
• 8. Do you often feel helpless? yes/no

26
GERIATRIC DEPRESSION SCALE GDS2

• Choose best answer for how you felt over the past
  week
• 9. Do you prefer to stay at home, rather than
  going out and doing new things? yes/no
• 10. Do you feel you have more problems with
  memory than most? yes/no
• 11. Do you think it is wonderful to be alive
  now? yes/no
• 12. Do you feel pretty worthless the way you are
  now? yes/no
• 13. Do you feel full of energy? yes/no     
• 14. Do you feel that your situation is hopeless?
  yes/no
• 15. Do you think that most people are better off
  than you are? y/no
• Scoring 1 point for answers. Normal 05 5
  suggests depression

27
What is Different About Physical Exam?

• Unique findings rare, but many abnormal findings
  are more common in older persons (wrinkles,
  proliferative skin lesions, BPH, SEM, stiff
  palpable arteries, S4)
• Some findings that indicate pathology in the
  young are usually innocent in elders (SEM,
  keratoses, Kaposis, absent bilateral gag or
  ankle jerk reflex, mild cardiac enlargement)
• Even the healthiest elders are a treasure trove
  of physical findings

28
General Appearance

• Vitality, markedly youthful or aged-appearing
• Indicators of frailty
• Odor of urine or stool
• Signs of abuse, neglect or poverty
• Hygiene and grooming
• How long it takes, any help to undress
• Sense of humor!

29
Vital Signs - No Change with Age

• Temperature is unchanged, but hypo- and
  hyperthermia are more common use low-reading
  thermometer in winter
• Always check BP standing after supine for 10
  minutes
• Both atrial and ventricular premature beats are
  to be expected very rarely need Rx
• Blunting of baroreflex mechanism with aging makes
  cardio-acceleration a late and unreliable sign of
  hypovolemia

30
Vital Signs2

• Tachypnea 25/min is reliable sign of lower
  respiratory illness, usually infection (but
  beware PE), even in very old patients
• Weight is most reliable longitudinal measure of
  nutritional state in older outpatients evaluate
  10 lb loss
• Assessment of general or localized pain is 5th
  vital sign use uniform scale (0-10)

31
Skin

• Sun and age produce dehydration, thinning
  elastic tissue loss wrinkling results more from
  sun and cigarettes than from aging
• All proliferative lesions are more common on
  sun-exposed skin, but also occur elsewhere
• Benign Seborrheic keratosis, seborrheic
  dermatitis, angioma, flat nevus
• Pre-malignant Solar (actinic keratosis) very
  common on bald heads, arms, face

32
Skin2

• Malignant basal cell, squamous cell, melanoma
  (ABCD - Asymmetry, Borders irregular, Color
  variegated, red, blue, black, Diameter/depth,
  Elevation/thickness)
• All skin should be examined, exposed to sun or
  not, for tumors and pressure sores
• Skin turgor is not a reliable sign of hydration
  status in skin of elders
• Ecchymoses should also be noted - purpura of thin
  old skin, unreported trauma consider abuse

33
Head and Neck

• Identify skin lesions palpation of temporal
  arteries insensitive for TA/PMR
• Visual acuity - pocket Snellen predicts
  mortality
• Whispered voice as sensitive as audioscope, but
  latter best to follow over time remove cerumen

34
Head and Neck2

• Combined impairment of hearing and vision confers
  high risk of 10-year functional dependence
• Oral exam - sores, tooth and gum health, oral
  cancers inspect, palpate (dentures out) -
  early malignant oral lesions are red and
  painless after two weeks, biopsy
• Neck noises usually from vessels other than
  carotid bruits as often identify contralateral
  stroke, coronary risk - also ipsilateral stroke

35
Heart

• Atrial, ventricular ectopy common - usually
  innocent except in setting of ischemia/AMI
• S4 common without disease, but S3 indicates heart
  failure (diastolic systolic over 65)
• SEM common without stenosis, but aortic sclerosis
  is not innocent - increased risk for AMI, CHF,
  stroke and CV death without outflow obstruction

36
SEM Stenosis or Sclerosis

• Stenosis - loud murmur, diminished A2, narrow
  pulse pressure, dampened carotid upstroke but
  each may be absent and falsely reassuring
• Stenosis can be detected by pulse delay between
  brachial and radial arteries
• Moderate to severe stenosis associated with 3 of
  these 4 findings 1) slow carotid upstroke 2)
  reduced carotid artery volume 3) maximal murmur
  intensity at 2nd right intercostal space 4)
  reduced A2 intensity
• But if any doubt, get an echo!

37
Musculoskeletal Exam

• Brief screen if no complaints or loss of
  function
• Upper extremity, "Touch the back of your head
  with your hands, Pick up spoon," are sensitive,
  specific
• Gait and mobility - timed "Up and Go" (rise from
  chair, walk 3 meters, turn, walk back, sit down)
  adding each foot off the floor" predicts
  functional deficits better than detailed
  neuromuscular exam
• Simple tests stance, balance, timed 8-foot
  walk, timed chair rise and sit down 5X - predict
  disability
• Deficits detected in screen require more detailed
  evaluation consider inclusion of PT

38
Female Genitalia

• Labia thin, wrinkled, pale, dry clitoral
  enlargement
• Vagina - atrophy, friable, shrinkage, less
  secretion (pH up), loss of rugae and squamous
  maturation
• Cervix shrinks, os obscured uterus small
• Urethra - functional length,closing pressure
  diminished mucosal atrophy
• Atrophic vaginitis UI, itching, dyspareunia
  topical ERT absorbed low dose, brief

39
Female Genitalia2

• Ovaries or uterus palpable 10 years
  post-menopause suggests tumor adnexal mass often
  malignant
• Consider exam with patient on her side, knees
  drawn up allows speculum and Pap smear bimanual
  exam supine
• Signs of abuse may be discovered on pelvic
  examination

40
)
Male Urogenital Aging

• External genitalia - scrotal thinning, pallor,
  gray and thin pubic hair mild gynecomastia
• Benign prostatic hyperplasia
• Urethra - closing pressure diminished
• Mild changes in semen (?volume, more abnormal
  spermatozoa, less motility), but men remain
  fertile lifelong
• Erectile changes - ?duration, firmness,
  frequency longer refractory period

41
Age Changes in Neurologic Exam1

• Abnormalities in 20-50, but not pure aging
  doesnt happen to everyone
• Frontal release - snout, palmo-mental, root,
  suck, grasp said to identify dementia, but found
  in 10-35 with normal cognition
• Ankle jerks more difficult to elicit, and absent
  in 10
• Vibration loss in toes common, position nl
• Hand force control, hand foot speed ?

42
Age Changes in Neurologic Exam2

• Pure aging it happens to everyone
• Decreased amplitude of tendon reflexes
• Hand force control ? - measures steadiness and
  fine motor control
• Hand- and foot-tapping speed ?
• Gait changes ?arm swing, shorter steps
• Restricted upward gaze

43
Asymptomatic Brain MRI Findings

• 2000 persons (mean age 63 46-97),
  population-based Rotterdam Study of healthy
  volunteers
• High-res brain MRI (1.5 T) trained reviewers
  recorded abnormalities previously not detected,
  potential clinical relevance unrelated to exam
  cause
• Infarct, 7.2 aneurysm, 1.8 benign tumors,
  1.6
• Prevalence of asymptomatic infarcts, meningiomas,
  volume of white-matter lesions increased with
  age
• Incidental important brain MRI findings,
  including sub-clinical vascular pathology, are
  common
• Information on their course over time is needed

• N Engl J Med 20073571821-8.

44
Benefits last longer than cholinesterase
inhibition, fewer side effects, lower cost
45

• Jeanne Louise Calment
• Born in Arles, France 2/21/1875 died at 122 in
  Arles, 8/4/1997. She met Van Gogh in her father's
  shop. Her mother at died 86, father at 94,. She
  rode a bicycle until age 100. She ate 2 pounds of
  dark chocolate each week until she turned 119.
• A kind God forgot me