JC PD Geri

BP changes in elderly*

vessels stiffen d/t atherosclerosis

→ systolic HTN or orthostatic hypotension

HR/rhythm changes in elderly*

pacemaker cells decline → afib or dysrhythmias

temp changes in elderly*

inc susceptibility to hypothermia

skin changes in elderly

• Decreased dermal vascularity

• Wrinkles and laxity

• Thin, fragile, loose skin

• Abdominal fat distribution changes

• Macules and actinic purpura

• Actinic keratosis, seborrheic keratosis, leukoplakia, nummular eczema 

hair/nails changes in elderly

• Nails dull, yellow, and thicken

• Hair grays

• Axillary hair diminishes

• Alopecia

breast changes in elderly

• Females → increased nodularity, become smaller/more flaccid as glandular tissue atrophies and is replaced by fat

• Males → develop gynecomastia d/t meds, obesity and/or hormonal changes

eye changes in elderly

• Pupils become smaller

• Presbyopia (loss of near vision)

• Decrease in overall visual acuity

• Increased risk of cataracts, glaucoma (acute angle glaucoma), macular degeneration

ear changes in elderly

presbycusis (hearing loss)

neck changes in elderly

• Neck vessels → tortuosity, cervical bruits, increased pressure of the jugular veins, increased risk of aneurysm 

• Cervical lymph nodes less palpable

throat/nose/mouth changes in elderly

• Submandibular glands more palpable

• Angular cheilitis → maceration d/t overclosure of jaw

• Dental loss/orthodontic disease

• Decreased salivation

• Decreased olfaction

heart changes in elderly (long)

• Myocardial contraction less responsive and stiff

• Risk of heart failure increases

• S3 and S4 heart sounds

  • Systolic aortic murmurs

  • Valve concerns, mitral regurgitation 

• Aortic sclerosis and increased risk of stenosis

peripheral vascular changes in elderly

• Concern for peripheral vascular disease

• Concern for aneurysm

• Chronic effects of lifestyle → smoking, ETOH, obesity, DM

• Temporal arteritis

genitalia changes in elderly

• Females → menopause (45-52), diminished vaginal lubrication, libido unchanged 

• Males → 50% experience ED, increased risk of prostate cancer d/t age, libido unchanged but frequency of intercources declines after 75

MSK changes in elderly

• Loss of muscle/bone mass (osteoporosis)

• Loss of height

• Loss of ligament tensile strength, ROM diminishes

  • Strength training can reverse/slow process

mental status changes in elderly

• Short term memory loss

• Increased susceptibility to MS changes

• Risk of dementia, Alzheimer's, functional decline

motor sensory changes in elderly

• Motor system changes, tremors

• Diminished reflexes

• Diminished vibration sensory testing

functional capacity definition*

Ability to perform activities necessary or desirable to daily life

basic ADLs (DEATHS)

• Dressing

• Eating

• Toileting / Transfering

• Shower/Bathing

instrumental ADLs (SHAFFFTTT)

• Shopping

• Housework

• Farmaceuticals

• Finances

• Food (cooking)

• Transportation

• Tech

Ability to keep a schedule of activities

fall risk with elderly

• Gait speed → predicts functional decline and early mortality;

• higher risk of future falls and decreased independence

• tug test (timed up and go test - time it takes for a person to rise from chair, walk 3 M turn around and sit down)

cognition screening in elderly

• Basic cognitive screens can lead to detailed mental status examination, neuropsychiatric testing and/or medical testing

• Screening for dementia  → Montreal cognitive assessment, mini cog

mood changes in elderly - what 2 questions to ask?

• Late-life unipolar depression remains underdiagnosed

• 2 questions

  • During the past month have you been bothered by feeling down, depressed or hopeless

  • During the past month have you been bothered by little interest or pleasure in doing things 

• Can open up further testing and further discussions

polypharmacy changes in elderly

• Increased risk of drug-drug interactions

• Have them bring in medications and review them during each visit

• Ask about alternative medical therapy (OTC meds, vitamins, herbs, and supplements)

social support in elderly

early identification and intervention

identify caregiver burnout

watch for elder abuse

goal of care for elderly

• Positive and personal health goals, independence goals, social goals, functional goals 

• Clinical tools is: goal assessment scaling but can be and usually is informal

advanced care preferences in elderly

•  do this early while pt has cognitive capacity

  • Choosing appropriate decision maker → power of attorney/health care proxy 

  • Clarify values and preferences over time

  • Help guide desired therapy if pt is unable to speak for themselves

  • DNR orders

  • Palliative care preferences

nutrition/weight changes in elderly

• Undernutrition increases w/ age

  • Assess nutrition from food choice, preparation and personal/cultural significance, to swallowing, digestion, and bowel regularity 

• Nutrition screening tools

urinary incontinence in elderly - can lead to, conerns?

• Can lead to skin maceration/infection

• Social isolation

• Concerns for hygiene

causes of urinary incontinence

DIAPERS

→ Delirium, infection, atrophic vaginitis/urethritis, pharm, excess output, restricted mobility, stool impactions

sexual function changes in elderly

• Libido intact among elderly

• May need access to lubrication and tx for ED

• Can still have risk for STIs

• Concern for elder abuse

alcohol + med changes in elderly - threshold, inc risk for?

• “Alcoholism threshold” → 7 drinks/week after age 65 

• Increase risk for cognitive and health regulatory complications → memory, esophagitis, sleep disorders, HTN

• Risk for med complications → warfarin, DM, etc

• Increased risk for other addictive substances 

vision/hearing tests for elderly

• 10 minute geriatric screener

• Eye chart

• Whisper test

• Increase referral testing if warranted

dentition changes in elderly

• Dental hygiene dependent on ADLs

• Can complicate and be complicated by comorbid conditions such as HTN, DM, polypharmacy

• Xerostomia (dry mouth)

• Prosthetic devices, dentures

pain changes in elderly - acute vs. persistent pain

• Acute pain → distinct onset, short duration, obvious pathology

• Persistent pain (>3 m) → psychological and/or functional impairment, fluctuates in character intensity, range of causes

living situation changes in elderly - household safety and fall prevention

• Adequate alarms systems and plans for care/evaluation, access to 911

• Removal of tripping hazards

• Adequate lighting and accessibility 

• Adequate grab bars and safety rails, ramps for walking, etc

immunizations in elderly

• Influenza A & B

• Pneumococcal

• Zoster (shingles) → contraindicated in HIV, leukemia, lymphoma, neoplasms affecting bone marrow or lymphatic system 

• Tb & Tdap → q 10 years

2 most common geriatric murmurs?

aortic sclerosis

mitral regurg/insuff

cancer screening changes in elderly (breast, colon, lung, cervical, prostate, skin)

• Breast cancer → 50-74y

• Colorectal cancer → 50-75y; FOBT yearly and colonoscopy q 10 years

• Lung cancer → 55-80; annual screening w/ low dose CT if smoking history, discontinue after >15y smoke free

• Cervical cancer → no recommendation if low risk and neg pap

• Prostate cancer → PSA no longer recommended

• Skin cancer → insufficient evidence to warrant routine whole body routine skin eval

spirituality awareness when working w/ elderly

• be open to all beliefs

• be aware of cultural/personal/gender in faith

• be aware beliefs can change

initial survey of elderly

• bp target <150/90

• hypothermia, fever

• weight loss, undernutrition

• balance, gait irregularities

• mood/affect

• involuntary mvmt

• frailty, motor

• speech

• RR, O2, BMI, HR

depigmented patches of skin = ?

pseudoscars

skin inspection in elderly

• Note age related skin changes: skin dryness, flakiness, wrinkling

• watch skin coloration (actinic purpura)

• depigmented patches = pseudoscars

• watch for basal cell carcinoma, squamous cell carcinoma, melanomas

• actinic lentigines (liver spots), actinic keratosis, seborrheic keratoses

• painful vesicular lesion → suspect varicela zoster

• detect pressure ulcers

eye inspection in elderly

watch for yellow of sclera, arcus senilis (white ring around limbus) or senile ptosis

test visual acuity, note presbyopia (loss of near vision), EOMs, pupil constriction

red reflex, cataracts, disc cupping = glaucoma, drusen = macular degeneration

drusen = ?

macular degeneration

disc cupping = ?

glaucoma

ear check for elderly

occlude one year and use whispered voice

check for cerumen

consider audiometry

mouth check in elderly

dryness, quality of salivary prod

look for lesion, tumors, dental sores, caries, gingivitis

look for angular cheilitis

neck inspection for elderly

jvp

carotid upstrokes

carotid bruits

goiters (thyroid)

examine lymph node extends to clavicular nodes

lungs review with elderly

review smoking hx

assess talking, exertional effort

coughing, wheezing

auscultate all fields

spirometry

cardiac assessment in elderly

auscultate s1 and s2 at PMI, listen for S3 S4

listen for murmurs

_ HR gives better detection of arrythmias than radial pulse

apical

what should you confirm diminished pulse findings with? why?

ABI

to intervene early if peripheral vascular disease

breast/axilla exam in elderly

lumps, masses

paget’s disease

breast exam

tail of _ extends into the axilla

spence

the breast exam should always include the _ area

axillary

eczema-like scaling around the nipple = ?

paget’s disease

abdomen assessment in elderly

• Inspect for masses, pulsations

• Palpate right and left of midline for pulsations, assess width of aorta

• Auscultate for bruits: aorta, renal and femoral arteries

female assessment in elderly

• Inspect for age related changes

• Inspect urethra for caruncles, bulging d/t urethrocele or urethral diverticulum

• clitoral enlargement

• atrophy, discharge, mucus (prolapse, cystocele, urethrocele, mass)

• bimanual/rectovaginal exam (colorectal cancer)

• vervical/uterine/adnexal tenderness

• enlarging uterine fibroids

enlarging uterine fibroids may be?

malignant leiomyosarcomas

estrogen stimulated mucus is seen w?

HRT

endometrial hyperplasia

estrogen tumors

female ob/gyn masses names

condylomata, (wart like growth)

fibromas,

leiomyomas,

sebaceous cysts

lipomas

male genitalia assessment

• Examine penis, scrotum, testicles, epididymis

• Perform digital rectal exam to evaluate prostate for symmetry, nodularity, size and evaluation of masses

  • Rectal masses suggest colorectal cancer

  • r/o prostate cancer if prostate nodules or dissymmetry are present

if male has rectal mass, suspect?

colorectal cancer

MSK assessment in elderly

• Mobility screening tests

  • TUG test

  • 10 min Geriatric Screener

• Look for degenerative joint changes/arthritis

• Consider increased bone fragility d/t osteoporosis and compression fractures of the spine 

nervous system assessment in elderly

• Assess memory, affect and changes in cognition

• Evaluate changes in gait and balance 

  • Widening of gate, slowing and lengthening of stride, difficulty turning, etc

• Evaluate for parkinsons

sx of parkinson’s

• Pill rolling tremor and resting tremor

• Rigidity

• Akinesia (loss of muscle movement)

• Postural instability

highest prevalence of conditions in geriatrics

PNA

UTI (highest risk of delirium)

other names for essential tremor

intention tremor

what exam condition that may need to be accommodated with elderly individual with motility issue?

exam pt where they are

annual wellness visit was signed into law by?

obama