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advanced physical assessment

-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