Assessment of Older Adult PatientsChapter 13

Introduction

• This chapter introduces age-related changes• Gradual decline and chronic illness

characterize aging• Communicating with the aged can be

challenging but if successful can lead to better outcomes

Introduction (cont’d)

• Older adults have depressed immune systems and often present with atypical signs and symptoms

• The “graying of America” increases the importance of understanding the special needs of this population

The Importance ofPatient-Clinician Interaction

• Principles of communication• Avoid ageism: discrimination against the

aged• This can cause practitioners to not listen

well to older patients• Treat the aged with compassion

The Importance of Patient-Clinician Interaction (cont’d)

• Communication barriers: • Sensory deficits of hearing or visual

impairment• Speech may be impaired by poor fitting

dentures, stroke, head injury, or Alzheimer’s disease• Emotional barriers such as depression• Bridging these barriers facilitates

communication

The Importance of Patient-Clinician Interaction (cont’d)

• Reduce communication barriers • Always approach patient in a caring manner• Address by last name and appropriate title• Avoid condescending terms: “sweetie,” “dear”

• Adjust heat, lights, etc. for patient comfort• Introduce yourself and explain your purpose• Eliminate background noise and interruptions • Do not rush the patient

Age-Related Sensory Deficit

• Hearing impairment • Presbycusis: age-related, progressive

hearing loss often causing diminished functional independence• This condition affects:• 23% of adults between ages 65 and 75• 50% of adults between ages 70 and 80

• Assess hearing impairment by whispering a simple question while out of view but close to the patient

Age-Related Sensory Deficit (cont’d)

• Vision impairment• Presbyopia: age-related change to the

lens of the eye• Typically results in correctable

farsightedness• More serious disorders include cataracts,

glaucoma, diabetic retinopathy, macular degeneration• Age is a major factor in the development of

cateracts• Places patients at high risk for falls

Age-Related Sensory Deficit (cont’d)

• Compensating for vision loss/impairment• Leave everything where patient wants it• Patients memorize where items are

• If eyeglasses are used, make sure they are clean and properly positioned• Verbal communication more important• Speak clearly and explain procedure

thoroughly• If patient must move, offer an arm of

support

Aging of Organ Systems

• Cardiovascular system• Cardiovascular diseases common in elderly• Normal CV changes include:• Increased LV afterload results in LV wall

thickening• 1/3 of patients older than 70 years of

age have calcium deposits in the aortic or mitral valves• The occurrence of CHF doubles for each

decade of life between 45 and 75 years

Aging of Organ Systems (cont’d)

• Normal pulmonary system changes include:• Smooth muscle progressively replaced with

fibrous connective tissue• Alveolar septa gradually deteriorate reducing

surface area for gas exchange• Lungs have less elastic recoil; chest wall more

rigid: result is increased FRC and RV• At ~55 years respiratory muscles begin to weaken• Epithelial lining of tracheobronchial tree

degenerates, ciliary action slows, and phagocytic activity decreases

Aging of Organ Systems (cont’d)

• Immunity• Aged have a reduced cell-mediated

immunity•May impair ability to fight infections

placing them at greater risk for pneumonia, sepsis, etc. • Increased frequency of reactivation

tuberculosis• Diminished response to vaccines

Video

• http://www.medcomrn.com/mtsac/• 113. VIDM267A-T How the Body Ages,

Part 1: Cardiovascular, Respiratory, and Musculoskeletal Systems (w/Video)

Unusual Presentation of Illness

• Presentation of older person with specific illness often different from younger person• Could be due to a number of reasons• Patients may just consider it “old age”• Peripheral sensitivity decreases, diminishes

pain• Tachycardic response to hypoxia/sepsis

reduced• Aging organ systems may lose their ability to

compensate for other systems• Diminished inflammatory response

Unusual Presentation of Illness (cont’d)

• Pneumonia may present with:• Reduced appetite, fatigue, decreased ability to

perform daily activities, weakness• Nausea, vomiting, diarrhea, myalgia, arthralgia • Most sensitive sign of pneumonia is increased

respiratory rate (>28 beats/min)• Chest radiograph may not show infiltrate if

patient dehydrated (detectable 24-48 hr after rehydration)• Lack of fever!• Consider bronchoscopy to identify cause

Unusual Presentation of Illness (cont’d)

• Heart failure: leading cause for hospitalization in adults >65• 50% of people older than 75 years die of an MI• They often have atypical presentation of MI• What is the most common complaint from a

patient suffering from a MI?• Complaints of shoulder, throat, or abdominal

pain• Bilateral elbow pain • Syncope, acute confusion, weakness, and fatigue• Dyspnea or dizziness may be only complaints• Cough, wheezing and hemoptysis

Unusual Presentation of Illness (cont’d)

• Asthma often misdiagnosed • Typically considered a childhood disease• Should be considered in elderly patients

with wheezing or dyspnea even if they do not have:• Nocturnal or early morning symptoms• History of allergies• Immediate response to bronchodilators

• Underdiagnosis may relate to underuse of objective measurement by spirometers and peak flowmeters

Patient Assessment

• Vital signs in the elderly• Temperature• Tends to be lower, >90 years may be 96˚ to

97˚ F• Obtaining a temperature may be difficult• Aged may not be able to keep mouth closed• Axillary method may not be accurate due to

muscle wasting• Rectal method is accurate but not tolerated well• Tympanic method, expensive but accurate and

fast

Patient Assessment (cont’d)

• Vital signs in the elderly• Pulse• Healthy older adults may have normal

resting pulse• Inactive older adults may have resting pulse

of 50 to 55 beats/min• Arrhythmias with rapid pulse are poorly

tolerated• Any changes in pulse should be immediately

investigated

Patient Assessment (cont’d)

• Vital signs in the elderly• Blood pressure (BP)• Generally rises with age, particularly systole • 60% of older adults have elevated systolic or

diastolic blood pressure• Risk of CV disease doubles with every 20/10

increment • It is key to control HTN

Patient Assessment (cont’d)

• Vital signs in the elderly• Respiratory rate (RR)• Normal RR is 16 to 25 breaths/min• Tachypnea may be due to:• Ambulation• Anxiety• Hypoxemia, acidemia, or pneumonia

• Bradypnea may be due to:• Medication or being asleep• Alkalosis or hypothermia

Patient Assessment (cont’d)

• Inspection of the elderly• Skin turgor (assess hydration)• Tenting cannot be used because muscle

wasting provides a false positive• Condition of tongue better indicates

dehydration • Clubbing• Elderly have higher incidence of chronic

diseases thus also have higher incidence of clubbing• May indicate connective tissue disease

Patient Assessment (cont’d)

• Inspection of the elderly• Edema• Often peripheral edema indicates CHF or

DVTs• Not always a reliable indicator of CHF

• A gain of more than 5 lb in one week may indicate fluid retention

• Jugular venous distention (JVD)• JVD is indicative of right heart failure

Patient Assessment (cont’d)

• Pulmonary auscultation • May not be able to sustain deep breathing• Best effort may produce 3 or 4 breaths

followed by rest • Start posterior basal portions first • Breath sounds may be reduced even if

healthy making vesicular sounds hard to hear• Adventitious breath sounds will be just as

with other patient groups

Diagnostic Tests

• Gas exchange in the elderly• Reduced VC and PEF• Slight reduction in PaO2 secondary to loss

of alveolar surface area and increased V/Q mismatch

Diagnostic Tests (cont’d)

• Arterial blood gases • PaO2 decreases with age, roughly –0.245 mm

Hg/year (see Table 13-2)• Blood gas drawn from supine patient has

PaO2 of 5 mm Hg less than if patient sitting• After age 75 PaO2 tends to be higher in males • PaO2 should be adequate in absence of

disease• Hypercapnia occasional in healthy aged• Not predictable and usually mild

http://www.rtmagazine.com/issues/articles/2006-02_04.asp

Diagnostic Tests (cont’d)

• Pulse oximetry (SpO2) • The lower PaO2 common in elderly results in

a slightly lower SpO2 (93% to 94%)• If the PaO2 stays at 60 mm Hg or greater the

fall in SpO2 will not be clinically significant • A good, measurable pulse is essential to

measure SpO2 • Some older patients have poor circulation, so

obtaining a reading can be a problem

Diagnostic Tests (cont’d)

• Pulmonary function studies (PFTs) • After age 25, pulmonary function declines• Residual volume almost doubles with older age

• Important to use age-appropriate norms• FVC and FEV1 diminish by approximately 30

ml/yr for men and 23 ml/yr for women• DLCO decline not linear but worse after age 40 • PFTs may require extra time• Talk to the pulmonologist about the patient’s

level of comprehension and performance

Comprehensive Geriatric Assessment

• Important goal: improve functional ability • Quantified by activities of daily living (ADL)• Personal hygiene, feed self, use toilet, dress self

• Instrumental activities of daily living (IADL)• A way of quantifying the complex ADL• Money management, telephone use, writing skills,

ability to shop• Deterioration of functional ability: early sign of

illness; noting this may maintain quality of life

Summary

• Effective communication will improve patient care • Taking extra time with older adults is worth the

effort• Disease presentation is often atypical in the

elderly• Vital signs and functional anatomy are often

altered in the aged• Preventive interventions to keep older patients

healthy and functional and at home is the best medical care we can offer

The End

Diagnostic Tests

• Gas exchange in the elderly• Reduced VC and PEF• Increased closing volume reduces

ventilation to bases while increases ventilation of upper lung fields • Results in an increased V/Q ratio

• Slight reduction in PaO2 secondary to loss of alveolar surface area and increased V/Q mismatch