Examination starts at the first contact and continues throughout the consultation. Useful information may be gathered at any point in your assessment, particu-larly with regard to functional abilities and cognition.
The examination of an older person should be thorough, appropriate and respectful but may be limited by the patient’s disability or cognitive impair-ment or by lack of appropriate privacy. Be guided by the principle of ‘appropriateness and need’. For example, a frail, severely disabled or cognitively impaired patient will find it very difficult to cooperate with a formal neurological assessment and will tire rapidly. The examination thus becomes impossible, invalid and inappropriate. Likewise, a digital rectal examination may normally be considered part of a comprehensive examination but may simply be inappropriate or impossible in such patients. The answer to the question ‘How will this part of the examination contribute to the management of this
patient?’ should then direct further assessment. Figure 7.1 Transparent ‘paparaceous’ skin and senile purpura.
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Check cutaneous pressure areas, especially the heels, hips and sacrum, for signs of skin breakdown (pressure or decubitus ulcers).
Cardiovascular system
Cardiovascular examination in older patients is no different from that in younger adults, but there are a number of important factors to take into account.
Bradyarrhythmias and tachyarrhythmias are common in sick, older patients and may lead to cardiovascular collapse despite similar rates being well tolerated in the young. The increase in heart rate in response to stress (e.g. exercise, illness or pyrexia) is reduced in advanced old age, and this may be exacerbated by medications such as β-blockers and other antiarrhythmics.
A lying and standing (or sitting) blood pressure is extremely useful, but may not be obtainable in the more disabled patient. Postural hypotension, defined as a drop in systolic blood pressure of more than 20 mmHg on standing, is a considerable cause of morbidity in old age, often caused or exacerbated by medications. The sitting or standing blood pressure should be measured immediately prior to and then 1, 3 and 5 minutes after changing position. Age-related structural and functional changes in the cardiovascular system account for a slight increase in mean blood pressure with increasing age, although adult hyper-tensive guidelines should still be applied.
Heart valves, especially the aortic valve, can become less mobile, exacerbated by calcification. This is known as aortic sclerosis and is characterized by a non-radiating ejection systolic murmur, heard loudest in the aortic area. Degeneration and calcification of the mitral valve can result in either apical ejection murmurs or the more common pansystolic mitral regurgitant murmur (see Ch. 11).
Arterial abnormalities such as an aortic aneurysm, arterial bruits and evidence of peripheral vascular disease should be sought. Palpation of the pulses can be difficult because of atheroma or oedema and, in the lower limbs, Doppler measurement (see above) may be necessary to assess the peripheral circulation.
Assessment of retinal vessels for signs of disease, as in hypertension and diabetes, can prove difficult in old people owing to the frequent presence of cataracts.
Respiratory system
Kyphosis, resulting from intervertebral disc degenera-tion and osteoporosis, and calcificadegenera-tion of the costal cartilages make the chest wall more rigid and less expansible. A reduction in pulmonary elasticity with age may be responsible for some hyperinflation on a chest radiograph, but this is principally due to pathological hyperexpansion associated with chronic obstructive pulmonary disease (COPD). Generally, the physical signs of respiratory system disease are the same in the old as in the younger patient.
Examination should include sensory (neuropathic ulcers) and vascular (ischaemia and varicose veins) examinations of the lower limbs. Measure the ankle and brachial blood pressures using a Doppler meter and sphygmomanometer cuff, the Doppler meter being used instead of a stethoscope at the feet. The ankle–brachial pressure index (ABPI) is calculated using the formula:
ABPI Ankle systolic pressure Brachial systolic pressure
=
An ABPI of 1.0 is normal; an ABPI below 1.0 may indicate arterial disease. An ABPI <0.8 indicates compromised distal circulation, and so pressure bandaging for leg ulceration should be avoided.
Figure 7.2 Transparent ‘paparaceous’ skin. The surface has been broken by trivial trauma.
Figure 7.3 Leg ulcers.
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Nervous system
Central nervous system examination should routinely include an assessment of higher cortical function (language, perception and memory). If cognitive impairment is suspected, assess the mental state early in the interview before the patient tires and record the result in the clinical notes (see below). As well as the Abbreviated Mental Test Score (AMTS) and Mini-Mental State Examination (MMSE) (see below), use the ‘clock test’. The patient is presented with a drawn circle, about 10-15 cm in diameter, and asked to fill in the numbers of a clock face (Fig. 7.4).
Abnormalities may be due to visual impairment, agnosia (owing to right parietal lobe lesions) or cognitive impairment. This test is easily reproducible and less influenced by cultural and language problems than the AMTS or MMSE. A newer test, the Test Your Memory (TYM), has recently been introduced for patients attending diagnostic memory clinics or outpatient clinics to fill in prior to being seen by medical staff.
It is important to recognize difficulties with com-munication. Communication is a two-way process that involves understanding and comprehension as well as the production of appropriate speech. Com-munication problems can be considered in terms of:
■ disorders of language (dysphasia)
■ disorders of articulation (dyspraxia, dysarthria)
■ disorders of voice (dysphonia) or of fluency (dysfluency).
Measurements of peak expiratory flow rate (PEFR) and vital capacity (VC) are reduced (see Table 7.1) but, despite these changes, normal oxygenation is maintained and the normal adult ranges for oxygen saturation should be used.
‘All that crackles is not necessarily heart failure or pneumonia.’ Coarse basal crackles caused by air trapping owing to loss of pulmonary elasticity can make the interpretation of breath sounds difficult. It is important to note their presence when the patient is well so that inappropriate therapy is not initiated if and when he becomes ill. In this situation, a chest radiograph is essential, regardless of the presence or absence of other signs and symptoms of cardiopul-monary disease. Common changes on the chest radiograph include calcification from old tuberculosis, calcification in chondral cartilages and major blood vessels, pleural calcification from past pneumonia and old rib fractures. Pleural effusions, cardiomegaly, areas of collapse and consolidation, interstitial changes and pleural thickening should not be accepted as normal at any age.
Gastrointestinal system
The older patient should be weighed at every visit.
As in younger patients, nutritional assessment includes estimation of the body mass index (BMI): weight (kg)/height (m2). Because of osteoporotic vertebral collapse and other age-related changes, height may reduce in the old and so trends in weight are a more useful benchmark. If a true nutritional assessment is required, skin folds at the biceps, triceps, waist and thigh should also be measured.
The majority of older people are edentulous. If dentures are used, they should be worn during the examination so that problems with fit, for example poor speech or eating difficulties, can be corrected early. Oral candidiasis is common in the unwell older patient and is easily treatable. Leukoplakia appears as small white patches on the oral mucosa. It is associated with repeated mucosal trauma and may become malignant. Varicosities on the underside of the tongue are seen in about 40% of older people;
their significance is unknown, but vitamin C deficiency has been implicated.
Abdominal examination may be limited by patients’
orthopnoea, kyphoscoliosis or other disabilities.
However, always try to perform an appropriate assessment. If abdominal examination is limited by such disabilities, the patient will also find it difficult to lie supine for investigations such as computed tomography (CT) scanning or colonoscopy. The indications for digital rectal examination are the same as for younger patients, but this may not be feasible or appropriate, particularly in the very disabled or frail older patient. Constipation severe enough to cause faecal impaction is not uncommon and can have serious consequences (Box 7.6). This is often iatrogenic but if of recent onset should be investigated appropriately.
Box 7.6 Faecal impaction may cause
■ Faecal incontinence (ball-valve effect, with spurious diarrhoea)
■ Intestinal obstruction
■ Restlessness and agitation in the confused (but never itself causes confusion)
Figure 7.4 Clock-face drawing.
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Dysphasia, that is difficulty in encoding and decod-ing language, is usually associated with a left hemi-sphere lesion (see Ch. 16). Dyspraxia is difficulty initiating and carrying out voluntary movements, for example of the tongue, and hence can affect speech.
Dysarthria has many causes, including local factors in the mouth and dentition, stroke, Parkinson’s disease and other neurological disorders. Dysphonia, an abnormality of the quality of the voice (e.g. hoarse-ness), can be due to anxiety, vocal abuse, local disease of the larynx and pharynx or hypothyroidism. It is common after throat surgery and intubation. Dysflu-ency (stammer) is found in people of all ages.
The formal assessment of the peripheral nervous system by examining muscle bulk, tone, power, sensation and tendon reflexes is something the inexperienced clinician often finds difficult. In older, disabled patients, where judgements about normality and abnormality may be more subjective, this can be especially difficult. As with all clinical skills, such judgement is acquired only with practice. As part of this assessment, it is useful to ask the patient to hold his upper limbs fully extended and supinated, at shoulder height, with his eyes closed. Observe for pronator drift, which is a sign of pyramidal weakness. The reflexes should be examined in the normal manner. It is not uncommon for the ankle jerks to be diminished or hard to elicit in very old people but, as with all clinical signs, this should be viewed in the context of other findings and not in isolation.
It is essential to observe the walking or gait pattern wherever possible. This may reveal subtle evidence of hemiparesis, poor balance (Box 7.7) or the furniture-clutching gait of the patient with long-standing mobility problems. When observing the gait, always have someone walk alongside the patient to offer a helping hand in case he stumbles or falls.
Occasionally patients claim that they are capable of carrying out activities when in reality they cannot.
Always check the feet for chiropody problems (e.g. onychogryphosis), which cause a ‘painful’ or antalgic gait.
Vision and the eyes
Age-related loss of periorbital fat may give the eyes a sunken appearance; this may be severe enough to cause drooping of the upper lid (ptosis) and redundant skin at the lateral borders. The loss of fat can also cause the lower eyelid to curl in (entropion) and irritate the cornea, causing redness and watering (epiphora) or to fall outwards slightly (ectropion).
A whitish rim around the iris (arcus senilis) is a zone of lipid deposition around the periphery of the cornea.
Visual acuity should be assessed and any loss of vision noted, together with the history of development of the visual disorder. Acute and chronic causes of loss of vision should be considered during the exami-nation (Box 7.8). If the patient wears glasses, ask to see them. A state of disrepair may be an indication
Box 7.7 The causes of falls in elderly people Premonitory
■ Forerunner of acute, usually infectious, illness Medication
■ Multiple drug therapy
■ Psychotropic drugs
■ L-dopa
■ Autonomic failure/dysfunction Neurological disease
■ Neurocardiogenic syncope
■ Multiple strokes
■ Transient ischaemic attack
■ Parkinson’s disease
■ Cerebellar disease
■ Epilepsy
■ Age-related loss of postural reflexes
■ Spastic paraparesis (usually due to cervical spondylosis)
■ Peripheral sensory or motor neuropathy
■ Situational and postprandial syncope Cardiovascular disease
■ Carotid sinus syndrome
■ Brady- and tachyarrhythmia: second-degree and complete heart block, sick sinus syndrome, atrial and ventricular tachyarrhythmias
■ Structural abnormalities: valvular stenosis and regurgitation, hypertrophic obstructive cardiomyopathy
■ Myocardial infarction and ischaemia Musculoskeletal disease
■ General muscle weakness (e.g. due to systemic malignancy)
■ Muscular wasting due to arthritis
■ Unstable knee joints
■ Myopathy (e.g. osteomalacia) Miscellaneous
■ Drop attacks
■ Hypoglycaemia
■ Cervical spondylosis
■ Alcohol
■ Elder abuse (e.g. physical mistreatment)
■ Poor vision
■ Multisensory deprivation:
– deafness – poor vision – labyrinthine disorder – peripheral neuropathy
Older people 93
Immobility
Impaired mobility is one of the most common clinical presentations in the elderly. It is almost invariably multifactorial, and frequently the patient has several other medical problems. A careful history is necessary to elucidate the likely underlying issues and in separat-ing cause from effect. The essential information is the onset of symptoms. Sudden immobility should be straightforward to diagnose, yet stroke and impacted subcapital femoral fractures are easily missed. A steady deterioration in mobility over several years implies a chronic process, for example Parkinson’s disease or osteoarthrosis. A stepwise decline indicates a disease that has periods of exacerbation and remission, for example recurrent strokes or rheumatoid arthritis.
Rapid deterioration from full mobility to total immobility over a few days indicates a serious acute medical problem. The most difficult patients are those in whom the disease process caused immobility a long time ago and the clinical picture has become clouded by the complications of immobility.
Within the bounds of common sense, the patient should be asked or helped to stand up and attempt a few steps, during which the gait can also be assessed (see above). Always have someone in close attendance in case of falls. The patient may be able to mobilize but unable to get out of a chair or bed unaided. Look for signs of distress on standing that may not have been mentioned by the patient. Tentative steps or clutching helpers may indicate loss of confidence or apraxia. Sometimes a diagnostic gait pattern is found (Box 7.9).
Instability/falls
It is said that ‘young people trip, but old people fall’.
With age, muscle strength is lost and postural reflexes become impaired. Falls are therefore common in old age, especially in the very old. Several causes may coexist (see Box 7.7). Even a single fall should lead to a detailed history and examination, and a corrobora-tive history sought from spouse or friends. In a patient who was previously well, a search should be made of cognitive impairment and/or their underuse, thereby
explaining falls and misinterpretation of the environ-ment. The visual fields should always be assessed. It is common to see irregular, asymmetrical pupils due to previous iridotomy. Pupillary responses are normal in the well, older patient, but stroke and medication may cause abnormal size and responses. Abnormalities such as Horner’s syndrome and palsies of the third, fourth and sixth cranial nerves are relatively common in the elderly, related to stroke and neoplastic disease.
Funduscopy should be attempted wherever necessary but may be difficult when there are cataracts.
Hearing
Communication is often compromised in the older patient by hearing impairment. Patients are described as confused when in fact they are simply hearing impaired. If deafness is detected, the external ear should be inspected for wax. This should be softened with bicarbonate drops and then removed by gently syringing the external auditory canal. Hearing loss is often due to presbycusis an age-related degeneration of the cochlear hair cells. If a hearing aid is being worn, make sure it is switched on. This is easily tested by placing one’s hand over the aid. If it is on, it will let out a shrill whistle. Communication is aided by raising your voice (but not by shouting), obtaining attention, sitting face to face, reducing background noise and speaking slowly and clearly. When the patient has severe hearing impairment, you may need to use written communication, provided his vision is good enough.