PD - Older adult & Disabled patient

"Demographic imperative"

for societies worldwide to maximize not only life span but also "health span", so that older adults maintain full function as long as possible

Elements of ideal geriatric primary care include:

- Assessment of functional status

- Frequent medication review

- Careful evaluation of benefits

- Benefits and burdens of any new test or treatment

- Frequent assessment of goals of care and prognosis

The most important geriatric syndromes in primary care:

- Falls

- Urinary incontinence

- Frailty

- Cognitive impairment

Primary aging

changes in physiologic reserves overtime that are independent of changes from disease

can lead to the development of multiple impairments such as decline in overall functional capacity, morbidity, and mortality

Alterations in primary aging tends to have the most impact during periods of stress:

Exposure to fluctuating temperatures - decreased vasoconstriction and sweat production (impaired response to heat)

Dehydration - decline in thirst (delayed recovery)

Shock - drop in maximum cardiac output, left ventricular filling and maximum heart rate

Blood Pressure Changes

- Systolic BP tends to rise

- Aorta and large arteries become less distensible (atherosclerosis) leading to a greater rise of systolic

- Diastolic tends to stop rising around the ages of 50-59

- Develop orthostatic hypotension

Heart rate/rhythm changes

resting heart rate unchanged, more likely to have abnormal heart rhythms

remain unchanged

as you age, respiratory rate and temperature usually ______

Skin, Nails and Hair changes

- Skin loses turgor/elasticity

- Dermis is less vascular (thin, fragile)

- Actinic purpura

- Nails may yellow and thicken

- Scalp hair looses pigment (gray)

- Hair loss, the number and diameter decreases

- Hair loss on body (trunk, pubic area)

Eyes and visual acuity changes

- Fat surrounding eyes may atrophy

- Pupils become smaller

- Fewer lacrimal secretions (dry eyes)

- Presbyopia

- Visual acuity diminishes rapidly after 70 yrs of age

- Increased risk for cataracts, glaucoma and macular degeneration

Presbyopia

age related farsightedness

Hearing changes

- Hearing acuity declines with age

- Early loss of high-pitched sounds

- Gradual loss of middle and lower range sounds

- Presbycusis (more evident after the age of 50)

Mouth, Teeth, and Lymph node changes

- Decreased salivary secretions and loss of taste

- Teeth may wear down or fall out due to periodontal disease

- Without teeth, lower portion of face looks small and sunken, with accentuated "purse-string" wrinkles radiating from mouth

- Angular cheilitis

- Cervical lymph nodes become less palpable but, submandibular glands become easier to feel

Angular cheilitis

maceration of the skin at the corners of the mouth

Thorax and Lung changes

- Loss of lung capacity

- Altered gas exchange

- Increase in closing volumes of small airways, predisposed to atelectasis and risk of pneumonia

- Diaphragmatic strength declines

- Mild decrease in arterial pO2 but O2 saturation normally remains above 90%

- Skeletal change, accentuate dorsal curve of the thoracic spine (kyphosis)

Neck changes

pulsatile mass due to kinking or buckling of the carotid artery low in the neck, caution not to mistake for carotid aneurysm which is true dilation of the artery!

systolic bruits heard in carotid artery/arteries indicate stenosis from atherosclerotic plaque (vs usually innocent in younger patients)

Cardiac output changes:

- modest drop in resting heart rate, but cardiac output in maintained due to increase in stroke volume

- significant drop in maximum heart rate during exercise

- increased myocardial stiffness and hypertrophy more notably in the left ventricle

- decreased early diastolic filling → diastolic dysfunction → greater dependence on atrial contraction

decreased ventricular filling

risk of heart failure increases with loss of atrial contraction and onset of atrial fibrillation due to ____________

Is S3 a normal heart sound to hear in the elderly? what about S4?

No, auscultating S3 strongly suggests heart failure from volume overload of the LV or valvular heart disease in the older adult

S4 in rarely normal, may suggest decreased ventricular compliance and impaired ventricular filling

Cardiac murmurs heard in the elderly:

Aortic Stenosis - fibrotic changes thicken the bases of the aortic cusps, calcifications follow and result in audible vibrations

Mitral Regurgitation - calcifications of mitral valve annulus

Peripheral Vascular System changes

peripheral arteries tend to lengthen, become tortuous, firmer, and less resilient

increased arterial stiffness, decreased endothelial function

Females - Breast and Axillae changes

Glandular tissues of breast atrophy, breasts are smaller more flaccid, more pendulous

Axillary hair diminishes

gynecomastia

elderly males may develop _______ due to obesity or hormonal changes

Abdomen changes

- muscles weaken

- decreased activity of lipoprotein lipase

- fat accumulation in lower abdomen and near the hips

- manifestation of acute abdomen may be blunted due to less severe complaint of pain (diminished or absent guarding and rebound tenderness - peritoneal inflammation)

Female genitourinary system changes

- estrogen falls, resulting in symptoms such as hot flashes, palpitations, chills, anxiety, sleep disruption, and mood changes

- ovarian function usually declines during fifth decade

- vagina narrows and shortens, mucosa becomes thin, pale and dry

- within 10 years after menopause, ovaries no longer palpable

Male genitourinary system changes

- penis decreases in size and testicles drop in the scrotum

- sexual interest remains intact, but intercourse frequently declines after age 75

Urinary incontinence

decreased innervation and contractility of the detrusor muscle and loss of bladder capacity, urinary flow rate, and ability to inhibit voiding

Benign Prostatic Hyperplasia (BPH)

benign growth of cells within the prostate gland, patient will report symptoms such as urinary hesitancy, dribbling and incomplete emptying

Musculoskeletal system changes

loss of bone mass, increased risk for fracture

- especially in women after menopause

- bone density scan (DEXA) to diagnose osteoporosis

Sarcopenia

loss of lean body mass and strength with aging

Mental Status Changes

- retrieve and process data more slowly, ability to perform complex tasks may diminish

- early Alzheimer disease vs. "benign senescent forgetfulness"

- more susceptible to delirium

what could be contributing to changes in mood of elderly patients?

death of friends, retirement, decreased income, social isolation

Motor system changes

- move and react slower, skeletal muscles decrease in bulk

- signs of muscle atrophy (hands, arms, legs)

- essential tremors (benign, faster, stop at rest, no muscle rigidity)

Position and Vibratory Sense/Reflexes:

- lose some or all vibratory sense in feet and ankles

- decreased reflexes → gag, knee, ankle etc.

Recognizing geriatric syndrome:

multifactorial condition of identifiable situation - specific stressors & underlying age-related risk factors:

- incontinence

- falls

- pressure ulcers

- delirium

- functional decline

Interaction between geriatric syndromes & age-related risk factors can result in poor outcomes

Importance of addressing cultural dimensions of aging

culture shapes beliefs about aging, medications, health care proxies, end of life decisions

alcohol recommendation

recommend limit of 2 drinks in one day or 7 drinks in a week

clues of alcohol consumption: memory loss, depression, neglect of hygiene/appearance etc.

true, only 30-40% of elderly meet recommended guidelines for daily intake of fruit and vegetables

t/f prevalence of under nutrition increases with age

ADLs (activities of daily living): 6 basic self-care abilities

Bathing

Dressing

Toileting

Transferring

Continence

Feeding

IADLs (instrumental activities of daily living): higher level functions

Using the telephone

Shopping

Preparing food

Housekeeping

Laundry

Transportation

Taking medicine

Managing money

Level of Assistance

- Independent

- Needs some assistance

- Total assistance (dependence)

what is polypharmacy and why should it be avoided?

suboptimal prescribing, concurrent use of multiple drugs, inappropriate use and nonadherence

major cause of morbidity!! try to keep the number of drugs to a minimum

Medication Management

- perform a thorough medication history (name, dose, frequency & patient's explanation of reason for taking each drug)

- review all bottles, including OTC and herbal supplements

- new medication dosing: "start low and go slow"

- assess medication for drug interactions

- avoid polypharmacy

true

t/f medications are the single most common modifiable risk factor associated with falls

Assessment of Pain - Acute & persistent pain

- Address each visit

- Onset (distinct vs > 3 months)

- Pathology

- Duration

- Causes

- Analgesic history (effectiveness, satisfaction)

- Quantitative assessment: Standard pain scale (FACES pain scale)

Advance care planning

providing information, clarifying the patient's preferences and identifying the surrogate decision makers

Advance directives

includes DNR, DNI, do not hospitalize, do not provide artificial hydration or nutrition, do not administer antibiotics

Health care proxy, durable power of attorney (DPOA)

person who makes decisions reflecting patient's wishes

Palliative care

alleviation of pain and suffering and the promotion of optimal quality of life across all phases of treatment, including curative interventions and rehabilitation (advanced or terminal illnesses)

Assessing Functional Status

- ability to perform tasks and fulfill social roles associated w/ daily living

- baseline for making interventions and identifying geriatric syndrome

- 10 minute Geriatric Screener

10 minute geriatric screener

includes vision, hearing, incontinence, nutrition, memory, depression, leg mobility (timed get up & go test), and physical disability.

target blood pressure

recommendation for >60 yrs: <150/90 (80 years and older 140-150/70-80)

orthostatic hypotension

defined as the drop in systolic of >20 mmHg or diastolic of >10 mmHg within 3 minutes of standing

true

t/f apical heart rate allows for better detection of arrhythmias compared to radial pulse

Overall Physical Exam of the Older Adult:

- Assessing Functional Status (10 min geriatric screener)

- Vital Signs (BP, HR, RR, Temp, Height, Weight, BMI)

- General Survey

- Skin

- Snellen chart (visual acuity), eyelids, bony orbit, pupillary constriction, ophthalmic exam

- Ears (whisper or audio scope)

- Mouth/teeth

- Neck (thyroid & lymph exam)

- Thorax/Lungs

- Cardiovascular system

- Peripheral Vascular System

- Abdomen

- Breasts and Axillae

- GU

- MSK

- Nervous System

General Survey

observing gait, posture changes (kyphosis), involuntary movements, nutrition, flat effect (depression, Parkinson disease, Alzheimer disease), and hygiene

Skin Exam

- Physiologic changes (thinning, loss of turgor, dry, flaky, rough)

- Interosseous atrophy (space between metacarpals)

- Actinic purpura

- Pressure ulcers in bed bound patients

- Hair and scalp

- Nails

Actinic Keratoses

sun damage, pre cancerous, superficial flattened patches covered by a dry scale (crusty) often found on hands, ears, lips, neck and shoulders

Seborrheic keratoses

barnacles of old age, benign raised yellowish lesions that feel greasy and velvety, or warty, often found on head, back, or neck

Senile ptosis

both eyelids drooping due to old age, caused by weakening, relaxation, increased weight

Entropion

lower lid eyelashes directed toward the eye

Extropian

sagging and outward turning of lower eyelid and eyelashes

Glaucoma

increased intraocular pressure, loss of peripheral vision, disc cupping

Cataracts

opacity of eye lens

Macular degeneration

atrophy of cells in central macular region of retina

Ear exam

whisper test or audio scope, inspect canals for cerumen

Mouth/Teeth exam

examine oral cavity for odor, appearance of gingival mucosa, carries, adequacy of saliva, inspect for lesion. remove dentures!

Neck exam

thyroid and lymph node exam

Thorax/Lung exam

observe for subtle signs of change in pulmonary function

increased AP diameter, purse-lipped breathing, dyspnea w/ talking = COPD

Cardiovascular Exam

- JVP inspection and palpate carotid upstrokes, auscultate for bruits

- PMI, S1, S2, S3, S4

- Cardiac murmurs

Mitral regurgitation

most common murmur in older adults, harsh holosystolic murmur at the apex, radiating to the axilla

Peripheral Vascular System Exam

diminished or absent pulses seen in PAD - confirm diagnosis with Ankle-Brachial Index (ABI)

Abdomen Exam

assess for bruits (aortic, renal, iliac, femoral), masses, aortic pulsations, width of the aorta

Ascites

abdominal accumulation of fluid in peritoneal cavity (liver disease, cancer)

Atherosclerosis

plaque, cholesterol buildup to inner lining of artery (thickening/hardening)

Abdominal Aortic Aneurysm

swelling/enlargement of aorta

Breast and Axillae Exam

- Inspect nipples

- Atrophy, glandular tissues replace with fat, flaccid, pendulous breasts

- Males may develop gynecomastia

- Palpate for lumps or masses in older adults

- Ducts more easily palpable

- Mammogram?

Mammogram Recommendation

USPSTF recommends every 2 years for women 50-74 years old

Female genitalia exam

raise head of table, caution with arthritis/spinal deformities while placing in lithotomy position

inspect for labial masses/ulcers, vulvar atrophy/erythema, prolapse (urethrocele, cystocele), rectovaginal exam

Male genitalia exam

inspect penis, scrotum, testes, epididymis, implant, rectal tone, rectal masses, enlarged prostate

Leg mobility - "Time to Get up and Go" or TUG Test

tests for gait and balance, and risk for falling

asking patient to get up from a chair, walk 10 feet, turn and walk back to the chair and sit back down

Nervous System Exam

- 10 minute geriatric screener assess memory and affect

- Gait, balance and stride characteristics

- Examine for TRAP

TRAP

Tremor

Rigidity

Akinesia

Postural instability

(commonly seen in Parkinson disease)

Causes of transient incontinence - DIAPPERS

Delirium

Infection (UTI)

Atrophic urethritis or vaginitis

Pharmaceuticals (diuretics, anticholinergics, CCB, opioids, sedatives, alcohol)

Psychological disorders (depression)

Excessive urine output (heart failure, uncontrolled DM)

Restricted mobility (hip fracture environmental barriers, restraints)

Stool impaction

Benefits of Exercise in Older Patients

- Decrease all-cause mortality (HTN, DM, colorectal/breast cancer, cardiac events)

- Improve cognitive function

- Improve physical function (gait speed, balance, performance of ADLs)

- Fall prevention

Exercise recommendation

150 minutes of moderate-intensity aerobic activity every week + muscle strengthening activities 2+ days a week = promotes healthy aging

Immunization recommendations

COVID - one or more doses of updated

Influenza inactivated or influenza recombinant - one dose annually

Tetanus, diphtheria, pertussis - 1 dose Tdap, then Td or Tdap booster every 10 years

Zoster recombinant (RZV) - 2 doses

Lung Cancer Screening

50-80 years old need screening IF 20 pack yr hx or current smoker or quit within the last 15 years

Low dose CT of lungs

Detecting the 3 D's

delirium, dementia, depression

Delirium

an acute brain dysfunction or confused state characterized by sudden onset, fluctuating course, inattention and at times alteration of consciousness, it can be reversed

screen at risk patients using confusion assessment method (CAM)

Dementia

an acquired condition characterized by a decline in memory & cognitive ability that interfere with activities of daily living

most common types: Alzheimer disease, Lewy body dementia, frontotemporal dementia, vascular dementia

Depression

mental disorder that presents with depressed mood, loss of interest of pleasure, feeling of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration

screening: patient health questionnaire (PHQ) and geriatric depression scale

Elder Mistreatment & Abuse

-abuse, neglect, exploitation, abandonment

- increased prevalence among older adults w/ depression & dementia

- highly undetected

- no valid, reliable screening tools

- careful history & high index of suspicion are important!

Approach to a Disable Patient:

- affirm impression of history with attention to the patient's ability to follow commands and perform functional tasks

- "improvise" examination techniques, as many patients are severely limited by their underlying disability

- allow for additional time and utilize appropriate instruments

Examples of Disabilities:

Mobility impairments - can affect ability to move or control limbs

Sensory impairments - can affect ability to hear or see

Cognitive impairments - can affect ability to think, reason or process information

Communication impairments - can affect ability to communicate effectively

Clinical pearls to keep in mind when examining patients with disabilities:

Communication

Positioning

Sensory consideration

Flexibility

Transfer methods

- Cradle

- Stand and Pivot

- Two-person (pivot, side-to-side, dependent)

- Patient lifts (Hoyer, Sara)

- Slide Board transfer

Transfer guidelines - Lifter

- Allow the patient to direct transfer

- Do not overestimate ability to lift

- Not all non-ambulatory people need assistance

- Keep back straight, bend at knees and lift with legs

- Be aware of jewelry, clothing, tubing or equipment which might catch

Exam of the hospitalized patient

- Adjust approach to the examination

- Identify areas that should be assessed at the beginning (review chart, what are they here for?)

- Principles for condensing or expanding parts of physical exam depend on the patient condition/alertness/cooperation

Perform an evaluation of the lower extremity on all hospitalized patients!