CHAPTER 1 HISTORY AND PHYSICAL EXAMINATION Practice of Geriatrics SECTION I GENERAL ISSUES IN GERIATRIC PRACTICE CHAPTER 1 HISTORY AND

PHYSICAL EXAMINATION Edmund H. Duthie, Jr., M.D. Geriatrics and Geriatricians Goals of Geriatric Medicine Prelude to the Examination The Medical History Chief Complaint and History of Present Illness The Physical Examination The Assessment GERIATRICS AND GERIATRICIANS Geriatric medicine has been defined as a branch of medicine that concerns itself with the aging process; the prevention, diagnosis, and treatment of health care problems in the aged; and the social and economic conditions that affect the health care of the elderly.1 Arbitrarily, the aged or elderly population is defined as persons aged 65 years or older. The 1990 U.S. Census estimated the elderly population as 13% of the total population of the United States. Although this is an impressive number, even more noteworthy is the amount of health care resources used by elderly patients, including the amount of time spent by primary care physicians with older persons (e.g., internists, 30% of time), the percentage of total health care expenditures (25%), the percentage of visits to office-based physicians (24%), and the percentage of prescription drug use (25%). Given this use of resources, it is essential that any physician who cares for adult patients be conversant with the principles of geriatric medicine. Geriatricians (physicians who specialize in the care of elderly patients) are typically physicians who are certified in internal or family medicine and who have either completed fellowship training in geriatrics or have successfully passed the certificate of added qualifications examination offered by the American Board of Internal Medicine or the American Board of Family Practice. Geriatricians frequently find themselves caring for the oldest old (arbitrarily defined as people aged 85 and over, the old old being those aged 75 to 85). These patients are often frail, require an interdisciplinary team approach, and are receiving long-term care

services in the home, community, or nursing home. A major goal of geriatric medicine is to educate students and physicians about the principles of geriatric medicine and to discover new knowledge about aging and the diseases that disable elderly patients through research. As a result, geriatricians have achieved high visibility in medical schools and academic medical centers. Working in concert, geriatricians and other clinician colleagues strive to optimize the health and function of older persons. Fundamental to geriatric practice is the fact that there is tremendous heterogeneity among elderly people. Clinicians recognize that chronologic age is a poor descriptor of a patient's functional status. Therefore, basing treatment or management decisions on a patient's age may be fraught with error. Better determinants of outcome may be the natural history of illnesses and comorbidities within a patient, the patient's functional status, or the social context (e.g., economic resources, family support) of the patient's life. This is the paradox of geriatricsthe study and practice of medicine in the elderly population, which is considered a group and yet is so diverse. With this brief introduction, the remainder of this chapter will describe the clinical encounter with the elderly patient, emphasizing the medical interview and history, the physical examination, and the formulation of a treatment plan. GOALS OF GERIATRIC MEDICINE The goals of geriatric care are listed in Table 1-1. These goals occur in the context of a high prevalence of chronic illness in geriatric patients and focus on detecting and managing disease rather than on curing disease. Also paramount in geriatric practice is an emphasis on the measurement and promotion of function. For decades, medical practice has emphasized the diagnosis of illness and associated therapy. This approach remains essential to geriatric practice but must be complemented by an assessment of the impact of illness on the patient's life. Table 1-2 lists the common chronic conditions that occur in later life.

TABLE 1-1 GOALS OF GERIATRIC CARE

TABLE 1-2 COMMON CHRONIC CONDITIONS IN OLDER PERSONS (AGE 75 AND OVER)

In the young and middle-aged patient, disability resulting from illness is fairly obvious from the diagnosis. The aged patient frequently has multiple complex illnesses, and loss of function is the net effect of these interacting disease processes. Functional assessment must be part of the evaluation of any geriatric patient. When caring for older patients, clinicians must recognize that preventive practice is still necessary and can have an important impact on the quality of life in the later years. Finally, there is the inescapable finality of life in geriatric practice. No other age group has the mortality rates seen in the geriatric population. Issues germane to death and terminal illness (e.g., advanced directives or palliative care) must be addressed by the practitioner. Table 1-3 lists the primary cause of death for populations of varying ages. Many of these illnesses not only cause death but are associated with attendant suffering.

TABLE 1-3 DEATHS BY AGE AND LEADING CAUSE

In summary, practitioners caring for adults are heavily involved with the care of persons over the age of 65. Geriatric practice is not simply the practice of internal medicine, surgery, psychiatry, or radiology in the old. Rather, geriatric practice is a comprehensive system of care of older patients that embodies the principles of

adult medicine, modifies these principles to accommodate changes related to aging (Table 1-4), and employs an interdisciplinary approach when needed. Care for patients should occur in the least restrictive environment possible that optimizes independence, function, and autonomy.

TABLE 1-4 UNIQUE FEATURES OF GERIATRIC PATIENTS

PRELUDE TO THE EXAMINATION Geriatric patients are cared for in a variety of settings: office, home, nursing home, adult day center, subacute unit, or acute care hospital. General principles of medical history-taking should be incorporated into each of these settings. Before seeing the patient, the physician should not be biased by the patient's age or location. It must be reemphasized that the patient's chronologic age provides little or no information. Every practitioner should examine his or her own views about aging and the aged. Negative prejudicial stereotypes of aging (ageism) are rampant. Years of training and clinical encounters with sick or frail elders may lead to the development of biases about elderly patients. Personal life experiences with aged relatives may also be a strong influence. The clinician must put aside prejudices about aging or certain aged patients and approach each patient with an open mind, focusing on the goals of geriatric care. On learning that an elderly patient resides in a nursing home or lives at home, the practitioner may begin to make assumptions about the patient. Given the rapidly changing health care scene, it is erroneous to draw conclusions about patients in any setting. Nursing home residents may be recuperating from an acute illness (e.g., hip fracture) and may be capable of a high level of functioning in a community setting once they are rehabilitated. Alternatively, patients at home may be very debilitated and capable of home residence only through family support with the aid of home health agencies, which can provide intense monitoring and assistance with modalities such as intravenous support or even ventilator management. In approaching the elderly patient, the practitioner should be aware that patients have their own biases and prejudices about their own aging. Patients may assume

that their symptoms are simply a normal part of aging and therefore do not seek medical attention. Alternatively, they may fear aging and seek out alternative medicine practitioners or therapies to maintain youthfulness. Clinicians should also keep in mind that old age or functional decline is not necessarily accompanied by a disinterest in life or medical treatments. Other issues that may influence the interview include the age gap between the patient and physician, which may make it difficult to establish rapport. This can be a particular problem for inexperienced young interviewers who become insecure when patients comment, You seem too young to be a doctor or when recounting the medical history remark, You're too young to remember that. Additionally, there are issues that affect the psychologic interplay between the patient and physician, such as the physician assuming the role of a child or grandchild in relation to the senior patient. Gender differences between patients and practitioners can also influence the patient-practitioner relationship in late life. Clinicians may have a tendency to infantilize older ill patients by assuming a paternal or maternal stance, thereby jeopardizing the therapeutic relationship. Third Party Interview Clinical encounters with geriatric patients often occur with family present. Frail elderly persons may rely on children or others for transportation. Children often take the time to accompany a parent to a medical visit to support the patient, to assist with the treatment plan, and to obtain information so that the optimum living situation can be determined and plans for the future can be made. Some research suggests that a third party is present as often as 15% to 20% of the time when the geriatric patient sees a physician. The practitioner should consider the role played by the family member in the encounter.2 The family presents a challenge and on opportunity in caring for the patient. The challenge is to maintain the patient's autonomy and keep the focus of the encounter on the practitioner-patient relationship. The patient should play the key role in determining what he or she wishes the family's involvement to be. Every visit should allow some private time for the clinician and patient to discuss the patient's condition. Sensitive issues such as failing cognition, urinary incontinence, sexual dysfunction, or elder abuse or neglect may be overlooked unless provision is made for private clinician-patient contact. However, care must be taken not to overtly exclude the family or caregivers because they are important allies of both patient and practitioner. When families are involved in the clinical encounter it is important that the patient not feel that any confidence or trust is being betrayed. Care should be exercised to avoid allowing the interview to proceed between the clinician and family to the exclusion of the patient. If during the interview the patient is spoken of in the third person, a lack of proper patient involvement in the interview exists. Families

provide the opportunity to reinforce information about the patient's illness, provide corroboration of the medical history, assist with the treatment plan, and help to set and achieve the goals of medical care. To summarize, the clinician is often faced with a geriatric patient accompanied by his or her family. Family involvement should be negotiated with the patient, individualized according to the clinical circumstances, and reflect a balance between patient autonomy and the dependence caused by illness. THE MEDICAL HISTORY Traditionally, the medical history is thought to be the cornerstone of the clinical encounter. This remains true in geriatric medicine. There are, however, challenges in geriatric medical history-taking that must be anticipated and overcome. The history begins in the usual fashion with introductions and an explanation of the manner of the examination. The interviewer should assume that the patient is cogent. Unless directed otherwise by the patient, the patient should be referred to by his or her surname. There is a very real tendency for health providers to address elderly persons by their first name, particularly sick or frail elderly patients. This is probably a manifestation of the tendency toward infantilization referred to previously. As is customary in medical interviews, the clinician should anticipate immediate patient needs such as the patient's comfort, the need to urinate or defecate, or the pressure of competing activities such as meals, therapeutic programs, or diagnostic studies.

Communication Issues The setting of the interview should be quiet and undisturbed and should ensure privacy. Hospitals, nursing homes, and day care centers may lack this proper environment, impeding the interview. Sensory loss (eyesight and hearing) is ubiquitous in late life and should be anticipated. Quiet rooms that reduce extraneous noise (e.g., music, conversation, machine or appliance noise, overhead pages, and so on) will greatly facilitate history-taking. Patients who use eyeglasses, hearing aids, or dentures should be instructed before-hand to bring these to the interview so that optimal communication can occur. If communication appears to be problematic during the initial stages of the interview, a solution should be sought before one proceeds further. Some geriatric clinics have office staff who screen patients for these problems and take action, such as inspecting the ear canals and removing cerumen impactions before the clinician meets the patient. Some practitioners own pocket amplifiers and provide these to hearing-impaired patients to facilitate the interview. Hearing aids should be tested by the office staff and batteries replaced if they are no longer working.

Generally, it is a good idea for the examiner to be on the same level as the patient. Lighting should be adequate to highlight the interviewer's face. Indirect light that avoids both glare and shadow is best. Turning away from the patient when speaking or leaving the patient's visual field may reduce visual cues used by the patient to assist with communication. When speaking, slow clear enunciation is helpful. The pace of speech should not be modified excessively, and shouting should be avoided, particularly into one ear (which is often out of the patient's visual field). Geriatric patients may have other special communication problems. Patients who are edentulous may articulate poorly and should be advised to wear dentures to the interview or, in hospitals or nursing homes, to insert them. Patients with aphasia need further analysis of the type of aphasia to determine the future conduct of the interview. Some of these patients are able to answer simple yes or no questions adequately. Patients with delirium or dementia need to have another person present to corroborate the history. Reliability of Historian Assessment of a historian's reliability is important in geriatrics. As noted previously, the assumption is that the patient is reliable. It is generally assumed that mental status testing is part of any medical interview, and this is particularly true in geriatrics. Such testing can be done early in the interview and should be tactfully and appropriately introduced. This approach will assist in assessing the reliability of the patient's history and in detecting subclinical cognitive deficits. If found, such deficits will also alert the practitioner to the need to reinforce to relatives or caregivers instructions about the patient's condition or therapy. History-Taking Issues It does appear that more skill is needed to extract a medical history from the aged patient than from other adults. Table 1-5 summarizes some of the reasons why more skill may be required in taking a geriatric history. The implications are that more time is invariably required to extract and record a medical history from a geriatric patient.

TABLE 1-5 ISSUES IN GERIATRIC HISTORY-TAKING

CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS There is general agreement that the concept of a chief complaint is often not applicable to geriatric patients. These patients frequently have multiple complex problems that are interacting. The patient may emphasize issues that seem trivial to the practitioner and unrelated to the manifest disease processes, but the clinician must address the patient's concerns or risk losing his or her confidence and adherence to the treatment plan. The history of the present illness should develop chronologically the sequence of events that have led to the patient's current condition. Each medical condition has its own chronology. The interviewer must recognize the problems of underreporting of illness and the atypical nature of some symptoms when interpreting the history (see Table 1-5). It may be useful for the clinician to prioritize complaints by asking questions like, If we could do one thing for you, what would it be? to focus the priorities of the patient with multiple complex problems. Another strategy might be to ask for a description of a typical day to get a sense of the impact of the medical condition on daily life and the social support available to the patient. Medication use deserves special mention. Patients should be encouraged to bring their medications to each visit for review. This allows the physician to review the therapy and helps to emphasize the importance of adherence to the regimen. Specific inquiry about over-the-counter medicine usage is mandatory. Functional Assessment as Part of the History Functional assessment should to be part of the evaluation of the geriatric patient. Often this assessment is accomplished through the history and could occur as part of the history of the present illness. Table 1-6 is an example of one instrument that measures function; many others have been used and are advocated for use among geriatric patients. At a minimum, the activities of daily living (see Table 2-1) should be assessed. Assessment of the instrumental activities of daily living (see Table 2-2) provides further insight into the patient's abilities and the effects of illness. Functional assessment also serves as a benchmark that allows the effects of illness or intervention to be monitored. In certain long-term care settings, functional assessment may be available as part of an admission data base (e.g., the Minimum Data Set in nursing homes). In some cases, the clinician may believe that observation of function is needed and request occupational therapy, speech therapy, physical therapy, or nursing assistance to help make an accurate determination.

TABLE 1-6 BARTHEL SELF-CARE INDEX (BI)DEFINITION AND DISCUSSION OF SCORING

Past Medical History Obtaining the past medical history may be a particular challenge in geriatric patients. The use of forms that are completed prior to the encounter may expedite this process and enhance reliability. An effort should be made to obtain primary sources of data such as office records from prior practitioners, clinic notes, hospital or nursing home notes, and discharge summaries. These data may be voluminous and may take considerable time to read, but they can be essential for patient management and to avoid repeat testing or evaluation. Special efforts should be made to review data on prior hospitalizations, nursing home stays, and surgical procedures. The relevance of childhood illnesses to geriatric patients has been questioned. A history of exposure to tuberculosis or a diagnosis of tuberculosis remains important into late life. Since rheumatic heart disease may become manifest initially in geriatric patients, a history of rheumatic or scarlet fever could be important. Family History Like childhood illness, the family history may have little relevance to the management of patients in their seventies and beyond. One suggestion has been that, rather than focusing on ancestors, the family history should go forward to review the health of subsequent generations. Germane to geriatric practice are issues relating to neurodegenerative disorders or mood disorders. Social History This portion of the history is particularly important in the practice of geriatrics. It serves as a focal point through which the clinician can get to know the patient better as a person. Through the occupational history the patient's exposure to health hazards (noise, toxins, and so on) can be uncovered. Living arrangements and dependence on family or others for assistance should be identified. Issues of abuse or neglect, caregiver stress, and advance directives merit review at this time.

Generally, it will become apparent that losses are ubiquitous in late life, and loss of job, spouse, friends, adult children, income, domicile, and recreational opportunities may be recounted. How the patient has coped with these losses provides important insights into patient management. As part of this assessment, issues centering on transportation and driving should be addressed. This section of the history is also where questions about alcohol use, tobacco use, and, on occasion, illicit drug use can be raised. Social workers may be needed to assist with further assessment and implementation of a plan when the situation is complex, and they are frequently involved in the management of patients in hospitals or nursing homes. Review of Systems Though often a tedious portion of the history, some key issues in geriatrics merit special attention and may not arise in caring for other groups of adult patients. These are listed in Table 1-7.

TABLE 1-7 SPECIAL CONSIDERATIONS IN GERIATRIC SYSTEMS REVIEW

Summary of Medical History In summary, the medical history remains the foundation of medical care for the geriatric patient. The history may be extensive and may require multiple visits before it can be completed. Previsit questionnaires; records from health care providers, agencies, hospitals, nursing homes, and pharmacies; auxiliary historians (family, friends, caregivers); and a hands on medication review can all assist in the collection of a complete and reliable data base. Computers and facsimile machines should help with data collection. The principles of sound medical history taking, augmented by an emphasis on some unique features of geriatrics discussed earlier, should ensure optimal medical assessment. THE PHYSICAL EXAMINATION

After completing the medical history, the clinician proceeds to the examination of the patient. An astute clinician will have already made observations such as grip strength when shaking hands, skin pallor, obvious tremor, speech disturbances, obvious sensory deficits, or neuromuscular deformities. Age-related changes and commonly found abnormalities should be recognized and distinguished from other pathologies. Frail, ill geriatric patients who are bedbound present a special challenge because they may not be able to cooperate fully with an examination. This requires the examiner to be resourceful in finding ways to complete the examination. On occasion, compromise may be necessary, for example, examining the patient in a wheelchair rather than on a table or in bed. Limited examinations are better than no examination, but the examiner must be mindful of missing important findings such as decubitus ulcers or dependent edema. Patient comfort must be anticipated. Cool examining rooms are a source of patient tension, and the availability of blankets may help. Spinal deformities from arthritis or osteoporosis may require the adjustment of pillows so that the examination can proceed comfortably. Adaptive devices to assist with ambulation (e.g., canes, walkers, wheelchairs, and so on) should be available during the examination. This permits the examiner to inventory these devices (many of which are obtained or used without medical input) and to see how the patient functions with their help. Adequate space to accommodate these devices and to perform a gait evaluation can be a problem in some practice settings. Vital Signs The examination begins with assessment of the patient's weight, pulse, temperature, respiration, and blood pressure. Problems of overweight and underweight are common among older patients, requiring weight measurement with each visit. Weight appears to plateau in middle life and then decline slightly in the later years. It is important to remember that with aging, there is a relative increase in body fat and a decrease in lean body mass. Therefore, even a stable weight does not imply the presence of similar body composition from the middle years into late life. Pulse rate should not be significantly affected by age. Arteriosclerotic changes of the blood vessel walls may tend to make the arterial pulse more forceful or bounding in geriatric patients. This tendency toward a forceful pulse may mask such classic findings as the pulsus parvus et tardus seen in aortic stenosis. Careful detection of all pulses is important because atherosclerotic blockages can lead to significant pathology in elderly patients such as peripheral vascular disease with amputation, subclavian steal syndrome with dizziness and falls, or cerebrovascular disease with ischemia or stroke.

Stiffened blood vessels also have implications for blood pressure determination in late life. Systolic blood pressure rises throughout life in Western populations, whereas diastolic pressure peaks and plateaus in middle age and later life. Normal blood pressure has been defined by determining the cardiovascular risk associated with a given blood pressure (see Chapter 35). The presence of an isolated rise in the systolic pressure without a diastolic rise (isolated systolic hypertension) is fairly unique to older patients and, unlike younger patients, does not necessarily imply anemia, thyrotoxicosis, or aortic insufficiency, which can cause a bounding pulse and wide pulse pressure in the young. Determination of orthostatic blood pressure should be routinely performed in geriatric patients. Although a number of factors, such as declining baroreceptor sensitivity, diminished arterial compliance, increased venous tortuosity, decreased renal sodium conservation, and diminished plasma volume, could combine to cause a drop in orthostatic blood pressure among older patients, there is no clear evidence that the pressure drops solely as a function of age. However, a blood pressure drop when changing from the supine to the upright position is common among geriatric patients (possibly as many as 30% of unselected patients may experience a 20-mmHg or more drop in systolic pressure). Diseases and medications that cause the problem should be sought (see Chapter 5). Stiff and noncompressible blood vessels in older patients have been thought to contribute to the entity called pseudohypertension. This condition is an elevated blood pressure detected by sphygmomanometer with little target organ damage, sensitivity to antihypertensive medications, and normal intra-arterial pressure. Attempts to distinguish patients with pseudohypertension from true hypertensives using bedside clinical maneuvers have not been particularly reproducible. Temperature determination in the aged is the same as it is in other patients. Norms for fever or hypothermia have not been adjusted for age. Elderly people do have a tendency toward disturbances of temperature regulation (hypothermia or hyperthermia). It is possible that some elderly patients, like others, may present with serious infections that do not produce much temperature rise. It is difficult to generalize too much about this observation. Respiratory rate and patterns do not change significantly with age. A raised respiratory rate may be a subtle clue to a serious medical illness (e.g., acidosis, hypoxia, central nervous system disturbance) and should be detected and pursued as in any other patient. Head and Neck Examination The head of the geriatric patient should be inspected for gross deformities that might give a clue to Paget's disease, a condition that has a higher prevalence in older adults. Hair loss and graying of the hair occur with aging. The temporal arteries should be palpated routinely, since temporal arteritis is another condition

that has a predilection for older people. Facial skin may be wrinkled and lax, lack turgor, and appear pale because of diminished vascularity. Lesions such as lentigines, seborrheic keratoses, actinic keratoses, seborrheic dermatitis, and carcinomas are all common and should be noted (see Chapter 43). Associated with facial skin changes is a change in the appearance of the eyes in older patients. The eye tends to recede into the orbit, and the lids become lax and may bulge. Lid laxity may give the appearance of ptosis. In advanced situations, frank lid ectropion (eversion) or entropion (inversion) may be seen. The hair of the eyebrows does become thinner, but this does not necessarily represent any pathology. The pupillary orifice becomes smaller over the years and does not dilate to the same degree in geriatric patients as in younger persons. This may be due to structural changes in the iris and autonomic receptors in the eye. A graying of the limbus where the outer cornea meets the sclera has been termed arcus senilis. This finding is common in older patients and has no special significance. Cataract surgery is very common among older patients, and evidence of this surgery (e.g., the presence of implants, subcapsular contacts, iridectomies) should be noted. The lens of the eye becomes thicker and yellower with age. Accommodation can be affected. Some evaluation of visual acuity is worthwhile among geriatric patients. Cataracts occur in as many as one third of patients in their eighties and should be recognized. On funduscopic examination, the arterioles of geriatric patients appear narrow, pale, straight, and less brilliant than the vessels of the young. The fundus should be inspected for evidence of macular degeneration, the most common cause of irreversible eyesight loss in late life (see Chapter 42). The clinician should specifically ask the geriatric patient about eye care. He or she should not assume that eyeglass use means that an eye specialist has seen the patient. Patients may use spectacles that they obtain from relatives or friends, or they may purchase clear lenses over the counter that have little therapeutic benefit. Examination of the ears should include some screening of hearing ability. Bedside maneuvers such as whispering, giving the Weber-Rinne test, and giving commands outside the patient's visual field (e.g., behind the patient) can be used. More formal screening procedures including the use of questionnaires, the audioscope, and bedside measures may be more sensitive in detecting the hearing deficits that are so common in late life (see Chapter 41). Cerumen impactions are common in older patients and require treatment. When examining the mouth, it is important to remove dentures so that the mucosa can be properly inspected. This is especially important for patients with a history of tobacco use or significant alcohol intake. Inspection of dental appliances can give the examiner some idea of the patient's oral hygiene. Dry mouth should not be attributed to normal aging (see Chapter 44). Dilated veins beneath the tongue,

termed a caviar tongue, are seen more frequently in geriatric patients than in younger patients. The mechanism for the development of these varicosities has not been established. Inexperienced examiners can mistake this finding for petechiae or the lesions of Kaposi's sarcoma. With aging of the immune system, lymphatic atrophy develops. Tonsillar tissue frequently recedes in geriatric patients. Palpable nodes in the neck or an enlarged tonsil should raise a suspicion of some underlying pathology. Ptotic submandibular salivary glands can sometimes be easily felt in geriatric patients and may be mistaken for masses. Geriatric patients may have limited mobility during examination of the neck owing to degenerative changes of the disks and facet joints. Palpation of the thyroid gland is important, as it is in any age group, but it can be challenging in older adults. With aortic uncoiling and tortuosity, arterial pulsations can be seen on inspection and felt on palpation; they must to be distinguished from arterial aneurysms. Neck vein inspection may be more reliable on the right side of the neck because venous inflow may be impeded on the left side because of dilated, tortuous large arteries. With advancing age, atherosclerosis increases in prevalence; it may result in a carotid bruit. Since systolic heart murmurs are so common in older patients (see later section, Cardiovascular Examination), particularly at the base, a bruit in the neck must be distinguished from a transmitted heart murmur. Chest Examination The chest should be inspected for evidence of kyphosis, which may be a clue to the presence of osteoporosis. Although a number of changes in pulmonary function occur with age, these generally do not influence the clinical lung examination. In older women, an increasing incidence of breast cancer has been documented through the ninth decade. Therefore, detection of breast cancer remains an important issue for elderly women. Glandular atrophy occurs after menopause, and some elongation of the breast or a pendulous appearance may be seen. Palpable masses need an explanation. Cardiovascular Examination Examination of the blood pressure, pulse, neck veins, and carotid pulse has already been reviewed. Frequently, the apical impulse and point of maximal intensity are difficult to locate in a geriatric patient. Palpable thrills, especially over the aortic area, should be sought because of the frequency of systolic murmurs. Splitting of the second heart sound may be difficult to detect in older patients. The presence of a third heart sound is not physiologic in elderly patients, as it is in young adults. Debate exists about whether a fourth heart sound may be accepted as normal in aged patients. My own view is that because heart disease is so common in older persons, it is not surprising that fourth heart sounds are frequently reported. This does not mean, however, that a fourth sound is the inevitable consequence of

aging; rather, it reflects the high prevalence of cardiac disease in the geriatric population. Systolic heart murmurs have been reported in as many as a third to a half of octogenarians. These murmurs may be due to aortic sclerosis, aortic stenosis, mitral regurgitation from numerous causes, mitral valve prolapse, idiopathic hypertrophic subaortic stenosis, tricuspid regurgitation, or atrial septal defect. Clinicians examining geriatric patients should, therefore, expect to hear systolic heart murmurs often and be prepared to assess patients further through maneuvers and associated findings to determine the cause of the murmurs. Innocent murmurs, described in children or young adults, are not found in the geriatric age group. Valvular pathology and cardiac dysfunction are the likely explanations of a murmur in a geriatric patient. Abdominal Examination There is no great difference between the abdominal examination of a geriatric patient and that of a younger patient. In geriatric patients with severe scoliosis or kyphosis, the abdominal examination can be difficult owing to compression of the visceral contents by the musculoskeletal deformities. Skin atrophy and wrinkling can mask prior surgical scars; therefore, the examiner must be alert in looking for these and should query patients about scars that are located. Patients who are inactive can develop marked wasting of the abdominal musculature. As a result, palpation can detect viscera, vessels, or masses that would not otherwise be palpable in younger patients. For example, palpation of a normal aorta may be mistaken for an aneurysm, or stool in the colon may raise a suspicion of a mass. These palpable findings require serial examinations and sometimes adjunctive radiologic testing to make a precise diagnosis. The acute surgical abdomen in the geriatric patient can be a diagnostic challenge. Inexperienced examiners who expect to find the textbook characteristics of tenderness or rigidity that occur in young patients with ischemic viscera, an inflamed or perforated viscus, or peritonitis may dismiss a geriatric patient with minimal tenderness and a soft abdomen. As a result, diagnosis in the geriatric patient with serious surgical intra-abdominal disease may be delayed, and significant morbidity may ensue. Genitourinary Examination In aged men and women public hair decreases in amount and becomes gray. Prostate assessment is important in elderly men with urinary complaints. The digital rectal examination has significant limitations in both sensitivity and specificity for conditions such as cancer or hyperplasia. In women, estrogen loss results in atrophy of the labia and vaginal mucus. Mild eversion of the urethral mucosa (caruncle) is common in older women and may be present in as many as 50% of patients. Inspection of the vulva for skin abnormalities, especially squamous cell carcinoma,

is important. The cervix can be difficult to identify on speculum examination. On palpation, uterine and ovarian atrophy can make palpation of these organs difficult. In fact, the presence of a palpable ovary in an elderly women should raise a suspicion of some pathology, especially malignancy. Elderly women with urinary incontinence need to undergo a gynecologic examination as part of their assessment. The examiner requires an appropriate examination table, space, light, and equipment to perform a pelvic examination successfully. Orthopedic or neurologic deformities can make the examination difficult. A small speculum may be needed for women with significant atrophy and a small introitus. Proper preparation of the patient, allowance of adequate time, and the presence of an experienced attendant who can assist with the examination increase the likelihood of success in performing a gynecologic examination that will assist with patient management. Musculoskeletal Examination Since arthritis is a leading chronic illness among elderly people (see Table 1-2), a careful musculoskeletal examination is required. Findings of osteoarthritis should be sought and documented. Evidence of arthritis other than osteoarthritis (e.g., gout, pseudogout, rheumatoid arthritis), periarticular problems (e.g., tendonitis or bursitis), or neural dysfunction (e.g., neuropathy or radiculopathy) can be commonly found and should be distinguished from osteoarthritis. Careful inspection of the feet is especially important. Deformities resulting from degenerative disease are common. Pulses should be routinely palpated. Evidence of neuropathy or ischemia should alert the examiner to the need for special footwear, care, and vigilance so that amputation can be avoided. Neurologic Examination Testing of higher cortical functions (mental status) should be done formally and routinely in every geriatric patient. Healthy older people should be cognitively intact. Failure to test mental status formally will result in missed diagnoses and failed patient management. In examination of the cranial nerves, testing of sensory function (especially eyesight and hearing) must be reemphasized. Olfactory acuity, though rarely formally tested, does decline with advancing age. As a result, detection of flavors, which depends on olfaction, may also be affected. On testing extraocular muscle movements, clinicians often find that geriatric patients can have difficulty in raising their eyes upward to the same degree as younger patients. Testing of the gag reflex is appropriate but has limited value in predicting speech or swallowing function. In motor testing, orthopedic deformity, neural disease, and disuse may all combine to result in atrophy. Interosseous wasting is commonly described and may be related to any number of the just-mentioned abnormalities. Muscle does atrophy as

a function of age, even with sustained use. Bedside testing of strength should be normal in healthy older patients, although some sophisticated laboratory measures are more sensitive in detecting age-related decrements of strength. Deep tendon reflexes at the ankle are absent in a significant minority of elderly persons. Controversy exists about whether this reflects common neural pathology in late life or is a normal variant. On examination the sense of touch should be intact to pin prick, light touch, and position. Like absent ankle reflexes, lost vibratory sensation is frequently encountered in older people in the distal lower extremities. Once again, this may reflect some subclinical pathology. Gait testing should be performed in every geriatric patient. Office space frequently limits the ability to assess the gait properly. A simple screening test could include having the patient arise from a chair without using his or her arms, walking normally, standing with the feet together with the eyes open and then closed, supporting body weight on the heels and then the toes, and then sitting back down. With aging, the gait changes. Patients have more flexion at the elbows, waist, and hips. There is diminished arm swing. Step length is shorter, and foot lift is less than that seen in the young (Fig. 1-1).

Figure 1-1 The characteristic gait pattern of an elderly man (left) compared with that of a younger man (right). (From: Murray MP, Kory RC, Clarkson BH: Walking patterns in healthy old men. J Gerontol 24:176, 1969.)

Assessment of function has been previously emphasized. Historical data can be supplemented by asking the patient to raise the arms over the head and undress or dress without assistance but under observation to check for fine motor abilities. THE ASSESSMENT After performing a detailed history and physical examination, the clinician formulates a problem list together with the appropriate diagnostic and therapeutic strategies. Since a multitude of problems is likely, prioritization is frequently

needed. The problems that contribute most to the patient's dysfunction should be given highest priority. Readily reversible or treatable problems also merit prompt attention. Serial determination of functional assessment can help to gauge the impact of therapies. The benefits and risks of intervention need careful attention. Geriatric patients are often more prone to the complications accompanying invasive diagnostic procedures and surgical interventions. Pharmacotherapy also is more problematic in elderly patients than in young patients, and adverse drug reactions are more likely as the number of drugs taken by a patient increases. Clinical judgment is the key in knowing when patients can tolerate an intervention and are likely to benefit and when complications and serious morbidity are a significant reality. The clinician should not deny effective treatment when it can benefit a patient nor initiate an evaluation or treatment when it will not result in a significantly improved outcome for the patient. Balancing these priorities requires experience and an in-depth knowledge of the literature on clinical trials in aged patients. This is the challenge presented by geriatric practice for the practitioner. CHAPTER REFERENCES

1. Federated Council for Internal Medicine: Geriatric medicine: A statement from the Federated Council for Internal Medicine. Ann Intern Med 1981;95:372376.

2. Green MG, Majerouitz SD, Adelman RO, Rizzo C: The effects of the presence of a third person on the physician-older patient medical interview. J Am Geriatr Soc 1994;42:413419. ADDITIONAL READINGS Gastel B: Working with Your Older Patient: A Clinician's Handbook. Bethesda, MD, National Institute on Aging, National Institutes of Health, 1994. Schneiderman H: Physical examination of the aged patient. Conn Med 1993;57(5):3 10. Schwartz MH: The geriatric patient. In Schwartz MH (ed): Textbook of Physical Diagnosis. Philadelphia, WB Saunders, 1994, pp. 584597.