This is an overview of the things to look out for during examination of the older patient.

1. Assessment of the
Elderly
Marc Evans M. Abat, M.D.,
FPCP, FPCGM
Internal Medicine-Geriatric
Medicine

2. Outline
• Introduction
• Interviewing and History Taking
• Physiologic Changes with Aging
• Geriatric Assessment Tools
• Examples of Pitfalls That May be Encountered in
Physical Assessment

3. Geriatric Assessment
• include non-medical domains
• emphasize functional ability and quality of life,
• Rely on interdisciplinary teams
• improve care and clinical outcomes
– greater diagnostic accuracy
– improved functional and mental status
– reduced mortality
– decreased use of nursing homes and acute care hospitals
– greater satisfaction with care

4. Geriatric Essentials
• Unless corrected, sensory deficits, especially
hearing deficits, may interfere with history-
taking.
• Many disorders in the elderly manifest solely
as functional decline.

5. • Health care practitioners must often interview
caregivers to obtain the history of functionally
dependent elderly patients.
• Frail elderly patients with complex conditions (eg,
multiple disorders, use of several drugs) often
require assessment by an interdisciplinary team.

6. Approach to the interview
• Asking patients to
describe a typical day
– establishes a rapport
• Have the patient wear
their eyeglasses,
dentures, hearing aids,
etc.

7. • Interview patient
directly as much as
possible

8. Medical history
• Previous diseases including allergies
• Previous surgeries
• Past treatment regimens
• Review of old medical records if available
• Thorough systems review

9. Drug history
• Patient’s drug list
• If possible visually inspect all
available medications
• Do not overlook
– Over-the-counter (OTC)
medications
– Vitamins and supplements
– Herbal medications
– Topical medications
• Ability to take the medications

10. Tobacco, alcohol and drug use
• Sensitive topic; may need to
interview relatives or
caregivers
• Unusual preparations of
above substances
– “nganga”
– Snuff or chewed tabacco
– Unusual sources of alcohol

11. Nutrition History
• Type, variety, quantity and frequency of feeding
• Special diets or diet fads
• Use of vitamins and supplements
• Weight changes
• Amount of money spent on food
• Accessibility of kitchen and food storage
• Problems with chewing, taste and smell

12. Mental Health
• Insomnia, changes in sleep patterns, constipation,
cognitive dysfunction, anorexia, weight loss, fatigue,
preoccupation with bodily functions, and increased
alcohol consumption
• ask about delusions and hallucinations, past mental
health care, use of psychoactive drugs, and recent
changes in circumstances
• Mood changes or cognitive changes may indicate
depression

13. Social History
• Evaluation of living arrangements
• Describe typical daily activities
– Hobbies, leisure activities
– Socialization activities and contacts, pastoral or spiritual
activities
– Driving activities
• Caregiver and support systems
• Marital status, sexual history, educational and
financial status

14. Physiologic Changes with Aging
Vital Signs
• BP may be
overestimated due to stiff
arteries
• normal respiratory rate in
elderly patients may be
as high as 25
breaths/min

15. Skin
• dermis thins by 20% with
age, ecchymoses may
occur readily when skin is
traumatized
• melanocytes are
progressively lost
uneven tanning may
be normal

16. • Linear nail growth decreased by 50%
• Decreased number and function of eccrine and
apocrine sweat glands
• Decreased thermoregulation

17. Vision
• Atrophy of periorbital tissues
– May lead to ectropion or entropion
• Lacrimal gland function, tear
production and goblet cell
production decrease
• Atrophy and yellowing of the
conjunctiva
• Decreased corneal sensitivity by
50%
• Iris becomes more rigid and
sluggish

18. • Vitreous humor and body also
shrink
– Separation of the liquid and solid
components”flashes of light”
• Thinning of the retina
• All these changes lead to
presbyopia
– Distance to focus near objects
increases
– Decline in static and dynamic visual
acuity
– Slower adaptation to light
– Decline in contrast sensitivity

19. Hearing
• Atrophy of the external
auditory canal
• Drier, more tenacious
cerumen
• Thicker tympanic
membrane
• Degenerative changes in
the ossicles
• Changes in the inner
earloss of high- and low-
frequency audition

20. Taste and Smell
• Decrease in the
lingual papillae
• Olfactory detection
threshold increase
by 50% and
recognition of
smells decreases
by 15%

21. Head and Neck
• Loss of fat and
connective tissue 
shrunken appearance
• Loss of teeth
• Prominence of neck
vessels

22. Respiratory
• Decreased cough reflex
• Increase in diameter of
the trachea and central
bronchi
• Calcification of tracheal
cartilage
• Hypertrophy of mucous
glands

23. • ↓decreased elastic recoil
(decreased lung elasticity)
• chest wall expands and
stiffness increases, increasing
expiration work of breathing
• Presence of basilar rales in
normal patientsdisappears
on deep inspiration
• Elevated closing volumes-
inability to drain certain lung
areas
• respiratory muscle endurance
decreases

24. • Diaphragm may be at a
mechanically suboptimal
position
• Mucociliary clearance
slower and less effective
• Forced vital capacity
decreases by 0.15-0.3 liters
per decade
• Forced expiratory volume in
1 sec decreases by 0.2-0.3
per decade

25. Cardiac
• Low-normal to normal heart
rate but poor heart rate
response with effort
• Lower cardiovascular reserve
• ↑vascular stiffness
• ↑ventricular stiffness
• Early reliance on the Starling
curve to maintain cardiac
output

26. • Recovery after exertion
more prolonged
• Conduction system
degeneration
• Valvular degeneration
• ↓β-adrenergic
responsiveness
• ↓baroreceptor sensitivity
• ↓SA node automaticity

27. Gastrointestinal/Hepatic
• Oral mucosa thins with age
• Small decrease in acinar
cells of salivary glands
• subtle decrease in saliva
production
• Less effective chewing
whether or not teeth are
intact
• Preserved esophageal
motility and sphincter tone

28. • Decreased acid
production
• Adaptive relaxation is
impaired
• Moderate atrophy of
small intestine villi
• Some lost of myenteric
plexi throughout the GI
tract
• Decreased absorption of
iron, calcium, vitamin D
• Decreased lactase levels

29. • Slowed transit and altered
contraction of the colon
• Increased colonic opioid
receptors
• Decreased liver mass
• Decreased hepatic blood
flow by 10% per decade
• Higher lithogenic index of
bile

30. Renal
• Decreased renal mass by 25-30%
• Renal fibrosis and fatty infiltration
• Nephron loss, preferably those with the longest
loops
• Diffuse sclerosis of glomeruli

31. • Loss of capillary loops
• Thickening of the basement
membrane
• Decrease in creatinine clearance by
7.5-10.0 ml per decade
• No significant change in serum
creatinine due to loss of muscle
mass
• Reduction in urine acidification
• Impairment of urine dilution
• Impaired ability to retain amino acids
and glucose
• Vitamin D hydroxylation is impaired.

32. Musculoskeletal
• ↓skeletal muscle mass in
relation to body weight by
30-40%
– Non-linear
– Accelerates with age
– Decrease in fiber number
and size
– Accompanied by altered
innervation

33. • Loss of muscle strength
– Up to 60% loss of grip
strength
– Slower time to peak tension
and slower relaxation
– Important role of activity
• Decrease in muscle
glycolytic enzymes with age

34. • Decreased bone density
• Degenerative joint changes
• Joint cartilage changes
– Decrease in tensile strength
– Bound water content decreases
– Decrease in proteoglycan units
and fragmentation of polymers
• Variable resistance to
manipulation

35. Hematopoietic System
• Decreased bone marrow mass, increased marrow fat
• Response to phlebotomy or hypoxia is slower
• WBC generation of free radicals and enzymes is
reduced
• Tissue macrophage is decreased

36. Endocrine
• Increased postprandial
glucose levels
• Decreased insulin
secretion
• Decreased insulin
sensitivity
• Decreased thyroid volume
with fibrosis
• Decreased conversion of
T4 to T3
• Increased ADH response
to osmotic stimuli

37. • GH levels decline with
age
• Delayed negative
feedback with ACTH
and cortisol levels
• Decrease in DHEA by
10% per decade

38. Reproductive System
• Decrease in ovarian size
• Decreased estrogen and
progesterone production;
testosterone and androstenedione
production also decreased
• Atrophy of uterus and vagina
• Reduced vaginal secretions
• Involution of breast glandular and
ductal tissue
• Ligamentous support of breasts
relaxes

39. • Gradual decline but no
total loss of male
reproductive ability
• Decreased sperm
production and quality
• Decreased in total, free
and available testosterone
• Benign prostatic
hyperplasia

40. Nervous System
• Decreased brain weight, age-
related neuronal loss
– Not uniform
– Tends to occur in the largest
neurons
• Cerebellum: more for the
Purkinje cells
• Subcortical regions: locus
ceruleus, substantia nigra
• Decreased blood flow by 20%
• Alteration in cerebral
autoregulation

41. • In general, decreased dendritic
density of the remaining neurons
– May have a compensatory increase
in some areas
• Decrease in myelin in the white
matter
• Significant loss in the anterior horn
cells
• Finger thermal threshold increases
with age

42. • Decreased muscle strength
• Increased reaction time
• Decrease in size of peripheral
nerves decreased
sensation
• with aging, information
processing and memory
retrieval slow but are
essentially unimpaired
– With extra time and
encouragement, patients
perform such tasks
satisfactorily

46. Timed Get Up and Go Test
• Prepare the following:
– Armless chair
– A marker 10 feet away from the chair
• Procedure:
10 ft.
Rise downchair
Sit from again Walk to the marker chair floor
Return to the on the Turn

50. Pitfalls

51. Fever
• Amplitude of normal circadian temperature
fluctuations is lower
• Reduced mean baseline temperature in the elderly
(mean oral temperature 36.7°C)
• in those who initially present with a blunted or
absent febrile response, fever may occur over time.
– onset of pyrexia was delayed several hours in a
significant number of patients; delayed >12 hours in
12% of patients
Clinical Infectious Diseases 2000;31:148–51

52. • fever in the elderly can be
defined:
– Persistent oral or TM
temperature >37.27C or;
– Persistent rectal
temperature>37.57C
– Moreover, an increase over
baseline temperature >1.3°C,
independent of site measured or
device used
Clinical Infectious Diseases 2000;31:148–51

53. • sensitivity for detecting an infection increased to
83% when 37.2°C became the threshold, but the
specificity dropped to 89%
• specificity was 99.7% when 38.5°C was the
threshold and 98.3% when 37.8°C was used
Clinical Infectious Diseases 2000;31:148–51

54. • a blunted fever response to a serious bacterial,
viral, or fungal infection suggests a poorer
prognosis than does a robust fever response
– 20%–30% of elderly persons
– lower baseline temperatures observed in the elderly may
lower the maximum temperature of a fever response to
an infection
Clinical Infectious Diseases 2000;31:148–51

55. • Possible mechanism(s) for the blunted temperature
responses to infection
– Diminished thermoregulatory responses, such as
sudomotor and vasomotor responses
– quantitative and qualitative abnormalities in both the
production of and response to endogenous pyrogens,
such as IL-1, IL-6, and TNF
– limit the ability of the hypothalamic circumventricular
organs to allow endogenous pyrogens to cross from the
blood stream to exert their effect on the CNS
Clinical Infectious Diseases 2000;31:148–51

56. PEARLS:
In a patient with an acute change in sensorium or
functionality, always rule out an infection even if
without a fever at the onset
Fever is not just defined as temperature across a
certain threshold but also a significant change from
baseline
Fever will almost always appear in the course of the
disease

57. Crackles
Age-Related Pulmonary Crackles (Rales) in
Asymptomatic Cardiovascular Patients
• 274 participants, in whom the heart was structurally
(based on Doppler echocardiography) and
functionally (B-type natriuretic peptide <80 pg/mL)
normal and the lung (X-ray evaluation) was normal,
were eligible for the analysis.
Ann Fam Med. 2008. 6(3): 239-245.

58. • prevalence of crackles among
patients
– low age(45-64 years; n = 97; 11%;
95% CI, 5%-18%),
– Medium age (65-79 years; n = 121;
34%; 95% CI, 27%-40%)
– high age (80-95 years; n = 56;
70%; 95% CI, 58%-82%)
– p <.001
Ann Fam Med. 2008. 6(3): 239-245.

59. • crackles in such patients
– fine
– almost always restricted to an area localized to the lower
quadrant of the lung field.
– diffuse basal crackles involving the bilateral hemithorax
were exceptional
– not considered clinically significant over the medium-
term follow-up
Ann Fam Med. 2008. 6(3): 239-245.

60. • risk ratio of pulmonary crackles increases
approximately threefold every 10 years after 45
years of age in patients with cardiovascular disease
and apparently normal heart function
• Minimal interstitial changes in some patients with
crackles were found with high-resolution CT
Ann Fam Med. 2008. 6(3): 239-245.

61. Diagnosing Pneumonia in the
Elderly
• the utility of the physical
examination alone in
predicting pulmonary disease
or in distinguishing among
pulmonary conditions
• 52 male patients, who were
generally elderly
– 24 had pneumonia confirmed by
chest radiographs
Arch Intern Med May 24, 1999;159:1082-7

62. • 2 most frequent abnormal findings in all patients
were rales in the sitting position (22 to 65%) and
bronchial breath sounds (8 to 43%)
• sensitivity and specificity of physical findings varied
considerably among physicians, as well as for a
given physician in eliciting findings between the
right and left lungs
Arch Intern Med May 24, 1999;159:1082-7

63. PEARLS:
Recognition of age-related crackles is important
because such clinically unimportant crackles are so
common among elderly patients-consider other
signs and symptoms, functionality.
Their existence might interfere with the physician’s
management of patients with suspected heart
failure or presumable pulmonary disease.

64. Hydration Status
Axillary sweating in clinical
assessment of dehydration
in ill elderly patients
• Dehydration is difficult to
assess clinically in older
patients
– collagen changes reduce skin
turgor
– tongue may be dry from mouth
breathing
– eyes may be sunken due to
reduced periorbital fat
BMJ 1994;308:1271 (14 May)

65. • Value of axillary moisture to assess hydration
• 38 men and 62 women (age 70-98 (mean 80.2)
years)
• preweighed tissue paper to the patients' right axilla
for 15 minutes, then weight measured again
• Sensitivity 50%, specificity 84%

66. Ann Emerg Med. 2005;45:327-329.

67. PEARLS:
Need to use multiple modalities, both clinical and
laboratory parameters, to assess hydration status.
Some PE findings like hypotension, decreasing urine
output and tachycardia may be late findings.
If in doubt and the benefit outweigh possible risks,
carefully rehydrate and evaluate frequently.

68. Acute Abdominal Pain
• Abdominal musculature is often thin in elderly
patients, leading to less guarding and rigidity even
in the presence of frank peritonitis
• detailed search for hernias
• rectal examination
• General physical examination also important
Emerg Med Clin N Am. 24 (2006) 371–388

69. Acute abdominal pain among elderly patients
• 557 patients aged 65-79 years and 274 patients
aged > or = 80 years
• older patients were more often misdiagnosed than
control patients (52 vs. 45%; p = 0.002)
• Rebound tenderness (p < 0.0001), local rigidity (p =
0.003) and rectal tenderness (p = 0.004) were less
common in the older than in the control patients
with peritonitis
Gerontology. 2006;52(6):339-44. Epub 2006 Aug 11.

70. PEARLS
Need to have a very high index of suspicion for
causes of acute abdominal pain.
Extensive use of physical examination, both general
and abdominal to determine the cause.
Lower threshold for use of other modalities for
diagnosis.