Elderly:History and Physical

•  Falls
•  Incontinence
•  Delirium/dementia/depression
•  Polypharmacy
•  Vision and hearing impairments
•  Malnutrition
•  Dizziness and syncope
•  Sleep problems

• Bone Mineral Density At least once after age 65
• BP screening yearly
• DM screening every 3 when BP135/80
• Lipid screening yearly
• Obesity screening yearly
• Smoking cessation every visit

• AAA Once in men 65-75 who have ever smoked
• Alcohol abuse Periodically
• Depression yearly
• sigmoidoscopy/colonoscopy yrly/q5yr/q10yr 50-75
• Hearing impairment yearly
• Mammography,breast exam q 1-2 yrs
• PAP q 3 yrs until age 70
• Visual impairment yearly

• Herpes Zoster
• Once in immunocompetent elderly
• Flu
• Yearly
• Pneumonia
• Once after 65, or repeat if taken before age 65
• DT
• Every 10 yr, (but T-dap 18-64)

• Assesses Risk for Falls- do practice 1st time then time them the second time
• Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with arm rest. On the word, "Go", the patient is asked to do the following:
• 1. Stand up from the arm chair
• 2. Walk 3 meters (in a line)
• 3. Turn
• 4. Walk back to chair
• 5. Sit down

• Time the second effort.
• Observe patient for postural stability, steppage, stride length and sway.
• Scoring:
• Normal: completes task in < 10 seconds.
• Abnormal: completes task in >20 seconds
• Low scores correlate with good functional independence; high scores correlate with poor functional independence and higher risk of falls.

• Measures balance
• Measure of balance
• Difference, in inches, between arm's length and maximal forward reach, using a fixed base of support.
• 48-inch measuring device or "yardstick" used to measure reach from sitting or standing position
• A reach of less than or equal to 6 inches predicted fall

• IADLs
• Mobility
• Incontinence
• Affect/Mood
• Cognition (Memory)

• Knownage related changes
• Function
• Cohort and career 80s lived during polio epidemic, rheumatic fever, agent orange (babyboomers)
• E.g., childhood illnesses or exposures, wars
• Establishingbaseline or change from it

• Health beliefs and preferences
• DNR, advanced directives, durable POA
• Stressors and coping patterns
• Family! (Abuse screen)
• Recent losses, moves
• Finances
• Habits
• Drug use, sexually active

• Odor, clothing disheveled,poor fit
• Signs of neglect, abuse or falls
• General posture and gait
• Orthostatic BPs with each visit
• Weight change

• Sehorrheic keratosis sun exposed areas scabby raised
• Actinic keratosis shinnier with irregular border precancerous
• Senile lentigines liver spots
• Squanous cell CA

• Palpate temporal artery
• Internal eye exam may not be tolerated
• But look for blepharitis (inflammation of eyelid margins), entropion (rolling inwards of eyelid), ectropion (outward rotation of eyelid)
• Check for cerumen (ear wax)
• Inspectmouth and dentures

• Determines whether vertigo is triggered by certain head movements.
• observe any involuntary eye movements (nystagmus) that may occur during this test to determine if the cause of your vertigo is central or peripheral. Central vertigo=inside the brain
• peripheral vertigo=problem with the inner ear or the nerve leaving the inner ear.

• Kyphosiscan cause displacement of PMI
• Systolic murmur may be benign
• Diastolic murmur always abnormal
• Signs of arterial or venous insufficiency
• Pulmonary
• Impact of kyphosisand/or scoliosis
• Breast exam

• Pulses often diminished
• arteral and venous insufficiency

• MS screen to establish baseline:
• MiniCog
• GeriatricDepression Scale–Short Form
• CAM and CAM-ICU (CAM-ICU pt doesnt need to be able to speak or write to score)
• DTR and vibratory diminished

• All three present with similar symptoms and signs
• All three can occur simultaneously
• BUT consequences for each are much different, txdiffers

A syndrome of progression cognitive decline

Affective disorder of overwhelming sadness

• must have
• Disturbance of consciousness
• Impaired attention
• Change in cognition

• need at least 2 of these
• * develops acutely and fluctuates most common
• *sleep disturbances most common
• *evidence of underlying physiological cause
• *disturbed psychomotor behavior (ie hyper or hypoactive form..HYPO has worse outcome)
• *emotional disturbance
• *EEG abnormalities

• Multiple cognitive deficits with both
• Memory impairment
• One of the following:
• Aphasia –loss of ability to use language
• Apraxia–loss of ability to initiate mechanics of speach
• Agnosia–loss of ability to connect words to objects
• Disturbance in executive functioning –control of cognitive functions including planning, executing, anticipating, imagining
• Deficits cause significant impairment in daily life
• Gradual onset and progression
• Able to exclude delirium, depression and psychosis
• A diagnosis of exclusion

Loss of contact with reality (absent in dysthymic disorder)

• Loss of interest in previously enjoyed activities
• Weight loss, loss of appetite
• Fatigue, low energy
• Indecisiveness, poor concentration
• Hypersomniaor insomnia
• Psychomotor retardation or agitation
• Feelings of worthlessness, self reproach, excessive guilt
• Suicidal thoughts
• 10/16/2010Vermeersch
• 40

Dysthymia is a depressive mood disorder characterized by a chronic course and an insidious onset. Many people with dysthymia describe life-long depression.By definition, dysthymia is a chronic mood disorder with a duration of at least 2 years

• Virtually anything and usually a combination
• medication SE or toxicity
• hypoxia
• infection or other metabolic abnormality
• change in environment
• pain

• Age
• Pre-existing cognitive impairment
• Visual impairment
• Severe illness
• BUN/ Creatinineratio >18
• Immobility
• Hearing impairment
• Sleep disturbance

• Physical restraints
• Malnutrition
• >3 medications added
• Use of a bladder catheter
• Any iatrogenic event

• Age
• Female
• Family hx
• head injury
• education
• Down?s syndrome
• Genetic
• Early Onset
• PS (presenilin) 1 and 2 (14, 1)
• APP (21)
• Late Onset
• ApolipoproteinE4 (19)
• HTN (stroke)
• Atherosclerosis (stroke

• Normal life events + daily hassle > coping
• Suicide is more lethal in older adults
• Prior hx
• Medical illness
• Medications
• Social factors
• female
• poor social supports
• low income
• early traumatic experiences
• baby boomers

• Delirium
• 1.Rapid Onset
• 2.Attention Deficit
• 3.Fluctuation course
• 4.Unable to participate in cognitive screen
• 5.There is a likely source for delirium
• Dementia
• 1.slow onset
• 2. memory deficit
• 3.usually steady decline in function
• 4.makes up answers to cognitive screen
• 5.Unable to find source for MS changes-diagnosis of elimination
• Depression
• 1.uncertain onset
• 2.memory deficit
• 3.some decline but tends to hold steady
• 4."Idont know" replies to cognitive screen
• 5.Likely source is symptoms r/t losses,comorbidity