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Geriatric
advanced physical assessment
| Question | Answer |
|---|---|
| -there has been a decline in the percentage of older adults reporting functional limitations, from 49% in 1990 to 41% in 2010, even though up to | 56% report at least one chronic condition. |
| obesity may increase future levels of disability, especially in | African American and Hispanic adults aged 60 to 69 years. |
| New paradigms also highlight the importance of shifting assessment to geriatric syndromes that fall outside traditional disease models but are strongly linked to | activities of daily living (ADLs). |
| Geriatric syndromes are present in almost 50% of older adults and include | cognitive impairment, falls, incontinence, low body mass index (BMI), dizziness, impaired vision and hearing— |
| In aging, decreased cutaneous vasoconstriction and sweat production can impair responses to | heat |
| declines in thirst may delay recovery from dehydration; and the physiologic drops in maximum cardiac output, left ventricular filling, and maximum heart rate may impair the response to | shock. |
| In Western societies, systolic blood pressure tends to | rise with aging. |
| The aorta and large arteries stiffen and become atherosclerotic. As the aorta becomes less distensible, a given stroke volume causes a greater rise in systolic blood pressure | systolic hypertension with a widened pulse pressure (PP) often ensue (systolic-diastolic >40) |
| In older adults, resting heart rate remains | unchanged |
| There are declines in the pacemaker cells of the sinoatrial node and the maximal heart rate | which affect the response to exercise and physiologic stress. |
| Rhythm changes= | syncope |
| There may be purple patches or macules, termed | actinic purpura |
| The pupils become smaller, making it more difficult to examine the ocular fundi. The pupils may also become slightly irregular but | should continue to respond to light and show the near reaction |
| Visual acuity remains fairly constant between ages 20 and 50 years. It diminishes gradually until | approximately 70 years and then more rapidly. |
| Near vision begins to blur noticeably for virtually everyone, the lens gradually loses elasticity, with progressive loss of accommodation and the ability to focus on nearby objects | Ensuing presbyopia usually becomes noticeable during the fifth decade. |
| When a person fails to hear the higher tones of words but still hears lower tones, words sound distorted and difficult to understand, especially in noisy environments | presbycusis, becomes increasingly evident, usually after age 50 years. |
| Cervical lymph nodes harder to feel but | submandibular are easier |
| There is a decrease in arterial pO2, but the | O2 saturation normally remains above 90%. |
| Lengthening and tortuosity of the aorta and its branches occasionally result in | kinking or buckling of the carotid artery low in the neck, especially on the right. The resulting pulsatile mass, occurring chiefly in women with hypertension, may be mistaken for a carotid aneurysm—a true dilatation of the artery. |
| A tortuous aorta occasionally raises the pressure in the | jugular veins on the left side of the neck by impairing their drainage within the thorax. |
| Myocardial contraction is less responsive to stimulation from | β-adrenergic catecholamines. |
| There is a modest drop in resting heart rate, but a significant drop in the | maximum heart rate during exercise. Although heart rate drops, stroke volume increases, so cardiac output is maintained. |
| Diastolic dysfunction arises from decreased | early diastolic filling and greater dependence on atrial contraction. There is increased myocardial stiffness, notably in the left ventricle, which also hypertrophies. |
| Risk of heart failure increases with loss of atrial contraction and onset of atrial fibrillation due to | decreased ventricular filling. |
| A physiologic third heart sound, commonly heard in children and young adults, may persist as late as age | 40 years, especially in women. |
| After age 40 years, however, an S3 strongly suggests | heart failure from volume overload of the left ventricle in conditions like heart failure and valvular heart disease (e.g., mitral regurgitation). |
| a fourth heart sound is seldom heard in young adults other than well conditioned athletes. An S4 can often suggest | decreased ventricular compliance and impaired ventricular filling. |
| Middle-aged and older adults commonly have which type of murmur? | a systolic aortic murmur. |
| In most older adults, the process of fibrosis and calcification, known as aortic sclerosis, does not impede | blood flow. In some, the aortic valve leaflets become calcified and immobile= aortic stenosis and outflow obstruction. |
| A brisk carotid upstroke can help distinguish aortic sclerosis from aortic stenosis, which has a delayed carotid upstroke | but clinically distinguishing these conditions is difficult. Both carry increased risk for cardiovascular morbidity and mortality. |
| Calcification of the mitral valve annulus, or valve ring, impedes normal valve closure during | systole, causing the systolic murmur of mitral regurgitation- may become pathologic as V/O increases in the left ventricle. |
| The peripheral arteries tend to lengthen, become tortuous, and feel | harder and less resilient. |
| There is increased arterial stiffness and decreased endothelial function. The trophic changes of the skin, nails, and hair discussed earlier occur | independently, although they may accompany arterial disease. |
| Although arterial and venous disorders, especially atherosclerosis, are more common in older adults, these are | not normal changes of aging. |
| after age 70 years, the temporal arteries may develop giant cell, or temporal, arteritis, leading to | loss of vision in 15% of patients and headache and jaw claudication. |
| androgen dependent proliferation of prostate epithelial and stromal tissue BPH begins in | he third decade, continues to the seventh decade, then appears to plateau |
| Sarcopenia is the loss of lean body mass and strength with aging | strength training |
| Unlike parkinsonian tremors, benign tremors are | slightly faster and disappear at rest, and there is no associated muscle rigidity |
| Older adults frequently lose some or all vibration sense in the | feet and ankles (but not in the fingers or over the shins). |
| Less commonly, position sense | may diminish or disappear. |
| The gag reflex may be | decreased or absent. |
| Abdominal reflexes may | diminish or disappear. |
| Ankle reflexes may be | symmetrically decreased or absent, even when reinforced- knee reflexes are similarly affected d/t musculoskeletal changes in the feet, the plantar responses become less obvious and more difficult to interpret. |
| If there are associated abnormal neurologic findings, or if atrophy and reflex changes are asymmetric | search for an explanation other than aging. |
| Older patients having a myocardial infarction are less likely to report | chest pain; symptoms of atypical or no chest pain, shortness of breath, palpitations, syncope, and confusion are more common |
| Older patients with hyperthyroidism and hypothyroidism have | fewer s/s- 1/3 hyperthyroidism present with fatigue, weight loss, and tachycardia instead of classic heat intolerance, sweating, and hyperreflexia & atrial fibrillation. |
| Hyperthyroidism increases the risk of | osteoporosis, and, in affected women, the risk of hip and vertebral fractures increases X3 |
| hypothyroidism is most commonly caused by | autoimmune thyroiditis (Hashimoto thyroiditis); fatigue, weakness, constipation, dry skin, and cold intolerance are often attributed to other conditions, medication side effects, or aging. |
| Geriatric syndromes are strongly linked to | functional decline. Examples include dizziness, as well as functional impairment, frailty, delirium, depression, cognitive impairment, falls, and urinary incontinence. |
| The ETHIC(S) mnemonic helps clinicians escape the pitfalls of | group-labeling by expanding individual history taking to include Explanation, Treatment, Healers, Negotiate, Intervention, Collaborate, and Spirituality. |
| drug–drug interactions- consult the | Beers criteria |
| Hospitalized older adults- risk factors for a/e meds | >4 comorbid conditions, Heart or renal failure, liver dz, ● ≥80 yo ● polypharmacy >8 ● warfarin, insulins, oral antiplatelet agents, oral hypoglycemic● hx drug rx● Hyperlipidemia ● inc WBC● antidiabetic agents ● LOS ≥ |
| Geriatric syndrome | Frailty- wt loss, exhaustion, weakness, slowness, and low physical activity; broader definition includes mood, cognition, and incontinence. |
| Osteoporotic Fractures | wt loss > 5% over 3 years, inability to do five chair stands, self-reported exhaustion. |
| “Do you often feel sad or depressed?” has a sensitivity of | 69% and specificity of 90% |
| “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” | 100% sensitive and 77% specific. |
| Dementia is “an acquired condition that is characterized by a decline in | at least two cognitive domains (loss of memory, attention, language, visuospatial or executive functioning) that is severe enough to affect social or occupational functioning. |
| Age-related Cognitive Decline ● This diagnosis is suggested by | mild forgetfulness, difficulty remembering names, mildly reduced concentration. ● S/s are sporadic and do not affect daily function. |
| Mild Cognitive Impairment (MCI) -Daily function is preserved, but modest cognitive decline in one or more cognitive domains | (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) Alertness and attention is preserved (unlike delirium). ● Other dementias are unlikely |
| Vascular dementia is suggested by | vascular risk factors or cerebrovascular disease causing cognitive impairment- decline in executive function, w/onset of cerebrovascular event, but consider this dementia -gait changes and focal findings. |
| Lewy body disease is suggested by evidence of | parkinsonism. Visual hallucinations, delusions, and gait d/o- EPS at times, fluctuating mental status, sensitivity to antipsychotic medications. |
| Frontotemporal lobar degeneration is suggested by | prominent behavioral or language disorders, impulsivity, aggression, and apathy, excessive eating and drinking-may occur before age 60 years. |
| 10-Minute Geriatric Screener | 3 important areas-cognitive, psychosocial, and physical function. It includes vision, hearing, and questions about urinary incontinence, an often hidden source of social isolation and distress. |
| To identify incontinence pneumonic■ DIAPERS: | Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals, Excess urine output from conditions like hyperglycemia or heart failure, Restricted mobility, and Stool impaction |
| To identify incontinence pneumonic ■ DDRRIIPP: | Delirium, Drug side effects, Retention of feces, Restricted mobility, Infection of urine, Inflammation, Polyuria, and Psychogenic |
| Joint National Committee (JNC8) recommends blood pressure targets of | ≤150/90 but notes that if tx results in SBP <140 and is okay treatment does not need to be adjusted. |
| those aged 80 years and older, other experts cite studies showing that blood pressure targets of | 140 -<150/70 - 80 appear optimal for notable reductions in stroke, cardiovascular events, and all-cause mortality |
| A red reflex is seen with | cataracts At +10 diopters, a cataract appears white |
| isolated systolic hypertension and a widened PP are cardiac risk factors, prompting a search for | left ventricular hypertrophy (LVH). |
| A tortuous atherosclerotic aorta can raise pressure in the | left jugular veins by impairing emptying into the right atrium, also kinking of carotid artery low in the neck on right, can be mistaken for a carotid aneurysm. |
| A sustained PMI is present in | LVH; a diffuse PMI and an S3 signal left ventricular dilatation from heart failure or cardiomyopathy. |
| An S4 often accompanies | hypertension. |
| A systolic crescendo–decrescendo murmur in the second right interspace suggests | aortic sclerosis or aortic stenosis= increased risk of cardiovascular disease and death |
| A harsh holosystolic murmur at the apex radiating to the axilla suggests | mitral regurgitation, the most common murmur in older adults. |
| Abdominal bruits are suspicious for | atherosclerotic vascular disease. |
| A widened aorta of ≥3 cm and pulsatile mass occur in | abdominal aortic aneurysm, especially in older male smokers. |
| Probable AD, based on DSM-5 criteria, consists of | evidence of a causative genetic mutation from family history or genetic testing, or the presence of cognitive decline in two or more cognitive domains, with all three features |
| AD features | (1) decline in memory/learning & @least one cognitive (2) steady progressive decline in cognition (3) no evidence of mixed etiology from other neurodegenerative, cerebrovascular, mental, or systemic disease. |
| Possible AD is diagnosed when the patient meets all three criteria by evidence from genetic testing or when family history is absent | Alertness and attention is preserved, Other dementias are unlikely AD |
| AD Memory difficulties may take the form of | repeating questions, losing objects, confusion when performing tasks (shopping). Later stages- impaired judgment, disorientation progressing to aphasia, apraxia, left–right confusion, dependence of IADLs. Psychosis and agitation |
| Carotid bruits can occur in | aortic stenosis. The presence of bruits from carotid stenosis increases risk of ipsilateral stroke. |
| A sustained PMI is present in | LVH; a diffuse PMI and an S3 signal left ventricular dilatation from heart failure or cardiomyopathy |
| An S4 often accompanies | hypertension. |
| A systolic crescendo–decrescendo murmur in the second right interspace suggests | aortic sclerosis or aortic stenosis- Both are associated with an increased risk of cardiovascular disease and death |
| A harsh holosystolic murmur at the apex radiating to the axilla suggests | mitral regurgitation, the most common murmur in older adults. |
| Benign masses include | condylomata, fibromas, leiomyomas, and sebaceous cysts. Bulges and Swellings of the Vulva, Vagina, and Urethra |
| Erythema with satellite lesions results from | Candida infection; erythema with ulceration or a necrotic center =vulvar carcinoma. Multifocal reddened lesions w/white scaling plaques occur in extramammary Paget disease, a form of intraepithelial adenocarcinoma. |
| The thin patchy atrophic white plaques of lichen sclerosus | may be precancerous |
| Estrogen-stimulated cervical mucus with ferning is seen in | use of hormone replacement therapy, endometrial hyperplasia, and estrogen-producing tumors. |
| Mobility of the cervix is restricted with | inflammation, malignancy, or surgical adhesion. |
| Enlarging uterine fibroids, or leiomyomas, can be normal or | malignant leiomyosarcoma; ovarian masses or enlargement are seen in ovarian cancer. |
| Rectal masses are found in | colorectal cancer. |
| Examples of age-related abnormalities include | unequal pupil size, decreased arm swing and spontaneous movements, increased leg rigidity and abnormal gait, snout and grasp reflexes, ↓ toe vibratory sense. |
| several of the most common features of Parkinson disease | Tremor, Rigidity, Akinesia, and Postural instability, or TRAP- Also bradykinesia, the most characteristic clinical sign, micrographia, shuffling “freezing” gait, difficulty rising from a chair. |
| Memory impairment in delirium vs dementia | Immediate and recent memory impaired vs Recent memory and new learning especially impaired |
| Test- frailty | Characterized by age-related, lack of adaptive physiological capacity occurring by an age-identifiable illness- three elements: Weight loss of more than 5% over 3 years, Inability to do five chair stands, Self-reported exhaustion. |
| Palliative care | Takes into consideration well-being for both Patients & Families: Physical, Mental, Social, Spiritual |
| Dementia and cognition definition | Definition- “An acquired condition that is characterized by a decline in at least two cognitive domains & affects social or occupational functioning: Memory, Attention, Language, Visuospatial (Executive Function) |
| Influenza-Tri/Quadrivalent -Adults 50+ | once a year |
| Pneumococcal- PVC 13-Adults 65+ | at least 1x |
| Zoster Vaccine-Adults 60+ | or younger if they have CVD, pulmonary disease, DM, immunosupressed, immunocompromised, caregivers, high dose steroids |
| Tdap-60 + /every | 10 yrs |
| Breast CA-Mammography | Annually at age 40-75 ACOG |
| Cervical CA-PAP- | Over age 65 USPSTF & ACOG recommends against screening unless the pt has had a recent abnormal pap. |
| Colorectal CA-Colonscopy | Every q 10 years or sigmoidoscopy every 5 yrs w/FOBTs. Recommends against routine screening for those 76-85 due to poor net benefit. Do not screen if life expectancy is less than 10 yrs. |
| Prostate CA-PSA | USPSTF & AAFP-Against all use of the PSA citing harm>benefit. |
| Lung CA- | Low-Dose CT-USPSTF & AAFP recommend the use of LD CT for patients with a 30-pack/yr smoking hx or those who have quit within the past 15 years. |
| Skin CA-Whole-Body Skin Exam- | Both USPSTF & AAFP given no recommendation for routine screening. |
| PHQ2 | 2 questions- Question 1- Sensitivity 69% Specificity 90%- Combined-Sensitivity 100% and 77% Specificity |
| Dementia is an umbrella term for what? | Alzheimer’s, Vascular Dementia, Frontotemporal Dementia, Dementia with Lewy Bodies, Parkinson w/dementia, Dementia of Mixed Etiology |
| You’re more likely to get dementia if | 1st degree relative has it |
| Mild cognitive impairment | decline in Memory, attention, Language, Visuospatial (Executive Function)- daily fx is okay |
| Alzheimer’s criteria | >2 Memory, Attention, Language, Visuospatial (Executive Function) plus ↓memory & learning,Steady, progressive ↓ in cognition w/o other cause or mixed etiology from another neurodegenerative , CV, mental, or systemic dz. |
| Dementia and sleep | lose night and day perception- sleep fragmented |
| MMSE s&s | Best-91% Sensitivity & 86% Specificity |
| Function | economic, environmental, cognitive, medical, affective, social support, spirituality |
| orthostatic B/P changes | <20 systolic or <10 diastolic? |
| Normal Aging Changes | Unequal pupil size, ↓arm swing, Spontaneous movements, ↑ leg rigidity, Gait abnormality, ↓ toe vibratory sense |
| 10-Minute Geriatric Screener | Vision-Visual Acuity 20/60on Snellen, Hearing-Cannot hear Whisper voice either ear. Audiometry if done. Leg Mobility-Scored 9 seconds on Timed Get-Up & Go Test. Urinary Incontinence-no self wetted in 20/30 days. |
Created by:
arsho453
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