The Older Adult Patient Chapter 26 The Older Adult Patient

Competencies Describe the structural and physiological variations of the older adult compared with a nongeriatric patient. Discuss techniques that facilitate the health history interview of the older adult. (continues)

Competencies Discuss various tools that can be used to assess functional status and cognition in the older adult. Describe modifications of the physical examination techniques for use within the older adult population. (continues)

Competencies Perform inspection, palpation, percussion, and auscultation in a head-to-toe examination of the older adult. Document a complete health history and physical examination of the older adult.

Epidemiology Trend toward an increased population of adults > 65 years old Sub-classifications for older adult population Young-old: 65–75 years of age Old: 75–85 years of age Old-old: 85 years of age and older

Issues in Presentation Chronic conditions and comorbid diseases increase with age Older adult is more susceptible to disease and disability (continues)

Issues in Presentation Most common complaints are vague May erroneously attribute symptoms to normal aging and delay seeking treatment More common to experience absent or atypical symptoms of disease (continues)

Issues in Presentation Issues compromising recognition of symptoms Gradual onset and vague symptoms Stoicism Fears related to loss of independence, expense, physical discomfort Cognitive impairment

Anatomy and Physiology: Age-related Changes Vital signs Respiration Pulse Temperature Blood pressure (continues)

Anatomy and Physiology: Age-related Changes Skin Wrinkles Thinning of the epidermis Decreased vascularity Altered thermoregulation Predisposed to dryness and itching (continues)

Anatomy and Physiology: Age-related Changes Hair Nails Head, neck, and regional lymph nodes Appearance Function (continues)

Anatomy and Physiology: Age-related Changes Eyes Lens cortex becomes more dense Presbyopia Decrease in aqueous humor secretion Diminished peripheral vision Decreased corneal sensitivity Decreased corneal reflex (continues)

Anatomy and Physiology: Age-related Changes Ears Hearing loss Increased risk of balance and equilibrium deficits Nose Diminished sense of smell (continues)

Anatomy and Physiology: Age-related Changes Mouth and throat Decreased saliva production Decreased number and function of taste buds Breast and regional nodes Adipose tissue atrophies Breast tissue mass decreases Increased incidence of breast cancer (continues)

Anatomy and Physiology: Age-related Changes Thorax and lungs Anatomic changes Alveolar gas exchange Regulation of ventilation Lung defense mechanisms (continues)

Anatomy and Physiology: Age-related Changes Heart Decreased heart size Cardiac output decreases Greater risk for heart murmurs (continues)

Anatomy and Physiology: Age-related Changes Peripheral vasculature Arterial blood vessels become fibrotic Thickening of the intimal lining of the veins (continues)

Anatomy and Physiology: Age-related Changes Abdomen Decreased abdominal muscle mass and tone Decreased esophageal motility Decreased pancreatic enzymatic and hormonal secretions Decreased intestinal motility (continues)

Anatomy and Physiology: Age-related Changes Musculoskeletal system Decreased bone density Muscle is replaced by fibrous connective tissue Muscle atrophy and loss of muscle strength Increased fat content (continues)

Anatomy and Physiology: Age-related Changes Mental status and neurological system Myelin sheath degenerates Total brain weight, the number of synapses, and the number of neurons are decreased (continues)

Anatomy and Physiology: Age-related Changes Mental status and neurological system (cont’d) Decreased mental flexibility, abstract thinking, recall, and visual spatial ability Recognition, attention, and language skills remain unchanged (continues)

Anatomy and Physiology: Age-related Changes Renal Decreased glomerular filtration rate Bladder Reduced elasticity and muscle tone Weakened urinary sphincter Increased risk for nocturia (continues)

Anatomy and Physiology: Age-related Changes Female genitalia Menopause Atrophy of the external and internal organs Pelvic muscles atrophy (continues)

Anatomy and Physiology: Age-related Changes Male genitalia Normal spermatogenesis continues until 70 years of age Decreased testosterone levels (continues)

Anatomy and Physiology: Age-related Changes Anus, rectum, and prostate Loss of muscle elasticity in the rectum Greater risk for rectal prolapse, constipation, and fecal incontinence Enlarged prostate after 40 years old

Interview of the Older Adult Modify approach based on limitations Health history covers same areas as for a younger patient Past health history (continues)

Interview of the Older Adult Medications Role of family history Current living situation (continues)

Interview of the Older Adult Ability to cope with changes Assess for depression, personality changes, or other signs of cognitive decline

Special Examinations Developmental Cultural Spiritual (continues)

Special Examinations Geriatric syndromes Nutritional assessment Sleep assessment Falls assessment Pain assessment

Physical Examination General approach Maintain warm, comfortable environment Direct questions to the older adult, even if others are present Facilitate independence during examination Ensure that assistive devices are clean and working (continues)

Physical Examination General approach (cont’d) Provide option for caregiver to stay during exam Use evidence-based examination tools Ask open-ended questions; avoid “yes/no” questions Allow time for the older adult to ask questions (continues)

Physical Examination Functional ability Mobility Nutrition Assess ability to perform activities of daily living (ADLs) Mobility Nutrition (continues)

Physical Examination Vision Hearing Cognition Depression (continues)

Physical Examination Equipment Vital signs Weight and height Pulse Temperature Blood pressure Weight and height Recent changes (continues)

Physical Examination Skin Common changes Temperature Hydration Lesions Bruising Turgor Color and pigmentation Skin cancer (continues)

Physical Examination Hair Nails Head and neck Range of motion (continues)

Physical Examination Eyes Common changes Graying of eyebrows and eyelashes Diminished tearing Loss of pigment in the iris Diminished or absent corneal reflex Decreased peripheral vision Altered color perception (continues)

Physical Examination Eyes (cont’d) Anterior chamber and lens Pupil Posterior segment structure (continues)

Physical Examination Ears Nose Mouth and throat Auditory testing Internal ear External ear Nose Mouth and throat (continues)

Physical Examination Breasts Thorax and lungs Changes in shape, consistency of tissue, nipples Masses or lesions Thorax and lungs Decreased chest wall expansion (continues)

Physical Examination Heart and peripheral vasculature Apical pulse may be displaced S4 heart sound is common Decreased pulse volume (continues)

Physical Examination Abdomen Diminished mass and tone Increased incidence of urinary and fecal incontinence (continues)

Physical Examination Musculoskeletal system Mobility Fine and gross motor skills Activities of daily living Decreased muscle mass and loss of strength Joints (continues)

Physical Examination Mental status Decline in short-term memory Increased incidence of depression (continues)

Physical Examination Neurological system Sensory Cranial nerves Cerebellar function Deep tendon reflexes (continues)

Physical Examination Female genitalia Smaller clitoris and labia Decreased amount of pubic hair Ovaries, fallopian tubes, uterus, cervix, and vagina become smaller Decreased vaginal secretions (continues)

Physical Examination Male genitalia Anus, rectum, prostate Testicles and penis atrophy Anus, rectum, prostate

Normal Findings Normal range for pulse is same as younger adults Temperature may be decreased Increased systolic and diastolic pressures Widened pulse pressure (continues)

Normal Findings Height and weight may be decreased Skin Drier, thinner, and wrinkled Liver spots (solar lentigo), sebaceous hyperplasia, sebaceous keratoses, and senile purpura are common findings (continues)

Normal Findings Hair may become thin and coarse Facial hair may grow on women Nails become thicker, hard, and yellowish Neck maintains full ROM (continues)

Normal Findings Eyes Graying of eyebrows and eyelashes Diminished tear production Diminished or absent corneal reflex Decreased peripheral vision (continues)

Normal Findings Eyes (cont’d) Altered color perception Arcus senilis may be present Decreased pupil size with slow accommodation (continues)

Normal Findings Ears Nose Some hearing loss is common Tympanic membrane may appear white, opaque, and thickened Nose Increased size of nose due to increased cartilage formation Decreased sense of smell (continues)

Normal Findings Mouth and throat Buccal mucosa thins Decreased saliva production Diminished taste sensation (continues)

Normal Findings Breasts Thorax and lungs May appear flattened and elongated Nipples may be smaller and flatter Inframammary ridge thickness is increased Thorax and lungs Chest wall expansion is decreased Inspiratory effort is increased (continues)

Normal Findings Heart and peripheral vasculature Abdomen Apical impulse may be displaced Systolic ejection murmur may be auscultated Abdomen Diminished muscle tone and mass Decreased liver size Increased deposition of fat (continues)

Normal Findings Musculoskeletal system Joints Center of gravity is changed Step height is reduced Gait may be unsteady Reduced muscle mass and loss of strength Joints Decreased ROM Crepitus may be present (continues)

Normal Findings Mental status Sensory perception Slight decline in short-term memory Minimal cognitive decline Sensory perception Reduced sensation of cold/heat, touch discrimination Decreased proprioception (continues)

Normal Findings Cerebellar function Deep tendon reflexes Balance, gait, and coordination may be altered Deep tendon reflexes Decreased reflexes, Achilles reflex may be extinguished (continues)

Normal Findings Female genitalia Male genitalia Ovaries, fallopian tubes, uterus may not be palpable Decreased vaginal secretions Male genitalia Penis and testes may atrophy