examination and evaluation of the older adult

chart review

different depending on the setting

- acute care = access on computer to all info, very extensive

- post acute = may be out of order and confusing

- OP = may have very little info, getting most from the patient

when doing a chart review for an older adult you are paying attention to what?

- cognition, meds, fall hx and risk of falls, vitals, medical comorbidities that will impact treatment

- special diets, fluid restrictions

- what language they speak, cognitive deficits will resort back to native language

what are you ultimately looking for in a chart review?

- diagnosis

- Dr. orders

- precautions

- medications/allergies

- imaging and labs

- cognition

- PMH/PSH

- social history

- previous therapy

subjective

different depending on the setting

- acute care = PLOF, home set up, safety

- home health = PLOF, home set up

- outpatient = PLOF, inc physiological reserve, d/c to HEP/community fitness program

subjective history

- review PMH, PSH, medications

- review current condition

- rule out red flags

- review home environment

- PLOF

- durable medical equipment (DME)

red flag questions

- new onset of bowel/bladder incontinence

- gain/lose significant weight recently

- history of cancer

- pain at night that cannot be changed with movement

- presence of saddle anesthesia

subjective history- history of falls

- number

- cause

- direction

- result in injury

- could they get back up

- fear of falling

the CDC recommends 3 questions to screen for falls

- # falls in the past year

- do you feel unsteady when standing/walking

- are you worried about falling

autonomy

important for patient centered care

- will inc your pts motivation and self-efficacy

- incorporate pt goals

clinical considerations

- you don't have a lot of time

- need to gently guide subjective to pertinent info without being rude

- it's not always easy

how long should a subjective take?

10-15 mins

- can incorporate into session too

systems review

- anthropometric characteristics

- cardiovascular

- pulmonary

- neurological

- cognition

- musculoskeletal

- hearing and vision

anthropometric characteristics

- height

- weight

- BMI

- waist circumference

abnormal waist circumference

- men = >40"

- women = >35"

waist to hip ratio

gives info about intra-abdominal fat

- men =

height is important regarding what?

osteoporosis

- most with osteoporosis have an asymptomatic compression fracture

- height difference can help aid in early detection

- >2cm height loss in a year OR historical height of 1.5 in = refer out

weight, BMI, waist circumference, and waist to hip ratio can tell you what?

info ab pt's health and used as an outcome measure if weight management is a goal

- taking waist circumference is a component of metabolic syndrome criteria

metabolic syndrome criteria

- large waist (measures at least 35 in for women and 40 in for men)

- high triglyceride level (150mg/dL or higher)

- reduced "good" or HDL cholesterol (

cardiovascular

- HR, BP, SpO2, RPE

- circulation

- ankle brachial index (ABI)

- edema

- intermittent claudication

- DVT/PE sn/sx

circulation

- feel temp

- palpate pulses

- capillary refill time (>3 secs is abnormal)

- rubor of dependency

rubor of dependency

gives info about arterial insufficiency

- raise foot in supine for 60s, then sit EOB with foot dangling off

- if it takes 30s for color to return AND color is bright red = arterial compromise

ankle brachial index

gives you info about circulation required for wound healing

- you need a doppler and BP cuff

- take BP of an arm and divide by systolic BP of ankle

- you want the number to be .1, if it's

edema

in geriatrics, caused from CHF or lymphedema

- can assess via edema pitting, circumferential measurements, and figure 8 measurements around the ankle

lymphedema vs CHF

- skin is thicker

- less likely to have pitting edema

- it's chronic

intermittent claudication

amount of time/distance tolerated and grading of pain

- vascular vs neurogenic (due to spinal stenosis)

- bicycle test of van gelderen, stoop test, 2 stage treadmill test to differentiate cause

assessing for DVT and PE

- wells criteria

- clinical reasoning skills

- if suspected, stop treatment and get the client seen

figure 8 method for ankle edema

- start midway between the tendon and tibialis anterior and lateral malleolus

- wrap distal to navicular tuberosity

- wrap proximal to base of the 5th MT

- wrap distal to medial malleolus

- wrap distal to lateral malleolus

intermittent claudication - bicycle test of van gelderen

- ride bike sitting upright + radicular pain

- leans forward + relief of pain

intermittent claudication - stoop test

walk upright and then walk flexed with improved symptoms

2 stage treadmill test

person walk on flat grade then 15% inc. in incline

- (+) if person can walk farther on incline

you get a point on the wells criteria if someone has what?

- active cancer

- paralysis

- bedridden or recent surgery

- localized tenderness

- swelling

- pitting edema

- collateral superficial veins

- previous DVT

someone gets -2 pts on the wells criteria if they have what?

another diagnosis that could be the reason for the symptoms

- ex: gout

what score on the wells indicates a referral?

>2 points, DVT is likely

-

wells criteria for a PE, you add points for what?

- clinical signs of a DVT

- PE is most likely diagnosis

- tachycardia

- immobilization

- recent surgery

- previous DVT or PE

- coughing blood (hemoptysis)

- active cancer

what score on the wells criteria for PE warrents a referral?

>4 pts, PE is likely

- 0-4pts, PE is unlikely

pulmonary

- SpO2

- breath sounds

- respiratory rate (RR)

- effort

- symptoms = SOB, cyanosis, diaphoresis

- can use dyspnea scales

neurological tests to do every time to give info about balance

- light touch to dermatomes

- proprioception

- myotomes

specific tests you can do

- pinprick for pain, temperature, vibration, pressure

- can assess graphesthesia, stereognosis, 2 point discrimination

- can assess CNs

graphesthesia vs stereognosis

- graphesthesia = recognition of movements drawn on the skin

- stereognosis = recognition of solid objects through touch

- indicate deficits in somatosensory cortex

neurological exam

- reflexes

- tone

- peripheral neuropathy

- coordination

- communication

- pain, temp, vibration, pressure

- stereognosis/graphesthesia/2 point discrimination

- cranial nerve testing

tests you can use for different diagnoses

- modified ashworth - tone

- monofilament testing - peripheral neuropathy

- finger to nose/thumb opposition, rapid alt mvmts - coordination

communication deficits

- expressive aphasia (brocas)

- receptive aphasia (wernicke's)

- global aphasia (both)

cognition

alert and oriented

- mini-mental status exam (MMSE)

- mini-cog

- saint louis university mental status (SLUMS)

- montreal cognitive assessment (MoCA)

what do cognitive tests tell you?

- if someone has a mild cognitive impairment vs dementia

- are the deficits seen age related in nature or pathological

musculoskeletal

- visual inspection

- range of motion

- strength

visual MSK systems review

common to see contractures, hand/foot deformities

- claw foot

- hammer toes

- pes planus

- arthritic changes in hands

ways to assess strength

- MMT

- dynamometer

- exercise specific tests

- functional performance tests

standing heel-rise test

mean number of reps of heel raise completed by age and gender are

- males 61-80yo = 4.1

- females 61-80yo = 2.7

- healthy 20-59 yo = 25 reps (normal)

MSK- posture

- visual and manual assessment of the body

- spinal assessments

what things should you look for in a posture assessment

- kyphosis

- forward head

- scoliosis

- compression fractures

- leg length discrepencies

ways to objectively assess the spine

- flexicurve ruler

- wall occiput test

- rib cage pelvis distance test

flexicurve rules to assess the spine

- entire kyphosis is measured and traced onto graph paper, length and width of thoracic and lordotic curves are measured and ratio is calculated

- clinically significant kyphosis >13

- use of flexicurve allows you to track change in kyphosis or lordosis over time

wall-occiput distance

- stand heels and back to the wall, fully elongate cervical spine

- distance between occipital prominence and wall is measured

- inability to touch wall with back of head is (+) finding

wall-occiput distance significance

- >7 cm women = rules in thoracic compression fx with high degree of accuracy

- 0cm reduces change of thoracic fracture

wall-occiput distance significance via Medbridge

- >0-4 cm = poor posture

- >4cm - fracture risk

rib-pelvis distance

patient stands in erect posture with the UEs raised parallel to the floor

- examiner stands behind the patient and places fingers horizontally between the inferior margin of the ribs and superior surface of the ilium in the mid-axillary line

rib-pelvis distance results

- (+) test = distance ≤ 2 finger widths, suggesting further evaluation be performed

- (-) test = 2 finger widths rules out lumbar vertebral fractures with high degree of certainty

integumentary

visual inspection

- irritation/open areas

- any vascular changes

- moles (ABCDE)

- nails (slow growing/thicker, gives insight into nutrition)

integumentary visual assessment

- high pressure areas: heels, back, sacrum, elbows

- irritation, open areas, maceration, deep tendon injury, signs of infection or scars

integumentary vascular changes

signs of arterial or venous chnages

ABCDE

- asymmetry

- border

- color

- diameter

- evolving

integumentary - nails

- older adults grow slower and thicker nails

- dec mobility which causes dec ability to cut their own nails

- may need a referral to a podiatrist

- can give info of nutrition

integumentary - arterial disease vs venous disease

- arterial disease = atrophic skin changes, shiny/hairless skin, red, swollen

- venous disease = dry scaly skin, hemosiderin staining, bluish/purple in color

pressure injury stages

- stage 1 = ulcers are red and non blanchable but have not broken through the skin

- stage 2 = ulcers have broken through the top layers of skin but not adipose tissue

- stage 3 = ulcers have broken through top layers AND adipose tissue

- stage 4 = ulcers have broken through top layers of skin, fatty tissue, muscles, tendons, ligaments, and/or bone

what is an unstaged wound?

one that you can't tell the depth of the ulcer bc it is obscured by slough or eschar

deep tendon injury

a purple or maroon dislocation under the skin

pressure injury stages never do what?

change stages

- healed stage IV, not stage III

nail nutritional deficiencies

- white spots = zinc deficiency

- horizontal bands across nail = protein deficiency

- clubbing = hypoxemia

- spoon shaped nails = anemia

hearing

sensorineural vs conductive

- rinne and weber tests

Rinne test

place the base of a struck tuning fork on the mastoid bone behind the ear

- have the pt indicate when sound is no longer heard

- move fork beside ear and ask if now audible

- in a normal test AC>BC, pt can hear fork at ear

Rinne test with conductive hearing loss

BC (bone) > AC (air)

- patient will not hear fork at ear

Weber test

- place the base of a struck tuning fork on the bridge of the forehead, nose, or teeth

- normal test = no lateralization of sound

Weber test with conductive loss

sound lateralizes towards affected ear

Weber test with sensorineural loss

sound lateralizes to normal or better-hearing side

visual

- acuity (snellen chart)

- visual field (cover one eye and hold fingers up)

functional assessment in acute care and post acute care

- bed mobility

- transfers (STS, SPT, toilet, car)

- gait (safety, quality, endurance)

- stairs

- balance

- floor to stand

functional assessment of balance

- standing without holding on

- picking up something from the floor or a cabinet

- dynamic gait movements (with head turns, changes in speed/direction, over obstacles)

functional assessment in OP

pt independent with basic mobility

- want to hone in on functional impairments pt complains of

- use of PFPS

- ex: curb negotiation, walking on uneven surfaces, picking up heavy objects, shopping, etc)

tests and measures

used to objectify impairments

- one of which HAS to be an applicable fall risk assessment

the most common tests and measures

- TUG

- gait speed

- chair rise tests

- BERG

- DGI/FGA

- 6 min walk test

evaluation

taking in all the info you got and being able to interpret it into meaningful impairments and developing a POC

what is a good way to complete your evaluation

using the ICF model

- body functions

- activities

- participation

- environmental factors

- personal factors

the Movement Framework for Older Adults (MFOA)

- looks beyond impairment based models toward a more comprehensive, person-centered strategy

- takes into consideration the medical, cognitive, pharmacological, and psychosocial complexities that define geriatric care

- augments the ICF/PCM models

- rooted in the geriatric 5 Ms

geriatric 5 Ms

- mind (cognitive, delirium, dementia, mental health, expectations)

- mobility (safety/fall risk, injury recovery, declining function, gait and mobility limitations)

- medication (polypharmacy, adverse effects, etc)

- multi complexity (SDOH, frailty)

- matters most (pts perspective and beliefs)