INTRODUCTION
The medical and psychiatric history obtained from the patient and informant, together with the mental status assessment, provide the majority of the information required in the evaluation of the older person presenting to the old age psychiatrist. However, the physical examination retains a crucial role in the evaluation of the older person for several reasons (Table 22.1).
First, it is an expected component of the consultation by the patient and/or their relative or carer and assists in developing the doctor-patient relationship. Second, a particular physical sign or constellation of signs will increase or decrease the pretest probabilities in the differential diagnosis under consideration following the history. Third, a more rational and focused plan of investigation will be instituted. Fourth, serial examination over time allows the clinician to observe the course of the disease, assess the effectiveness of any treatments commenced, and, if necessary, reconsider the diagnosis in the light of these data. Fifth, on occasions, an adequate history may not be obtainable, for example in delirium. The physical examination therefore assumes greater weight in determining further management until such history becomes available. Finally, co-morbidity is the rule rather than the exception in the older person. Commonly, there will be several aetiologies for a particular presenting complaint. The old age psychiatrist assesses the older person in a variety of settings, including the home, clinic, hospital ward, or institution, and may be the first or only contact that person may have with a clinician. Therefore, the old age psychiatrist should have the skill and ability to perform a brief but thorough physical examination, interpret the findings, plan a logical series of investigations, and determine if referral to a specialist, including other members of the multidisciplinary team, is indicated1.
Table 22.1 Role of the physical examination in the older person
Expectation by patient and/or relative in consulting a doctor Provides additional, pertinent information to history obtained Allows judicious use of investigations and resource Repeated assessment permits observation of disease course and therapeutic effects Detection of contributory or important co-morbidity |
A number of differences between older and younger people are reflected in the pattern and presentation of illness (Table 22.2). First, diseases that commonly occur in older people have taken many years, sometimes decades, to develop. Examples of such chronic ‘degenerative’ diseases are atherosclerosis, cancer, degenerative joint disease, and neurodegenerative disorders, such as Parkinson’s and Alzheimer’s diseases.
Second, co-morbidity is common and interacts with normal physiological ageing changes of the body to modify presentation of disease. Impairment of physiological homeostatic mechanisms results in reduced capacity to cope with changes in the body (brought about by disease) or in the environment (such as absence of a carer or admission to hospital). Thus, the older person will be more severely affected by an insult that might be relatively minor to a younger adult. These ‘reduced reserves’ of older age also lead to slower recovery from an acute insult. For example, hospital length of stay is twice that of younger adults. However, even old, seriously ill individuals can recover if given sufficient time and support.
Third, in older people symptoms of disease often are less specific and uninformative, making the task of establishing the diagnosis/diagnoses more challenging for the clinician. This non-specific mode of presentation often takes the form of a ‘giant of geriatrics’ syndrome – instability (falls); immobility (‘off feet’ or ‘off legs’); incontinence; intellectual impairment (delirium and dementia). However, a thoughtful approach and careful attention during physical examination will frequently direct the choice of investigations and treatment.
Some practical considerations in the conduct of the physical examination should be kept in mind and will reap considerable reward in the information obtained (Table 22.3). Time and patience are necessary virtues of clinician and patient.
Table 22.2 Differences between older and younger people
Background of chronic disease Impaired homeostasis/physiological changes of ageing Less specific presentation of disease |
Table 22.3 Practice points when examining the older person
Older people may require longer, and need assistance, to:
The examination may also be limited by:
|
The student and doctor in training are encouraged to take the time to follow a standard scheme of examination for each body system and to repeat this scheme again and again not in a thoughtless way but with consideration to each point in the scheme, the finding elicited being examined for its significance in light of the other available data. Such an approach will produce a skilled clinician who can not only perform a rapid and seamless physical examination but also detect pertinent physical signs of relevance to the care of the older person.
During the Interview
Physical examination commences on first meeting the older person, continues during the interview, and concludes with the ‘formal’ examination. Observation is thus the key initial tool, later to be supplemented, to a greater or lesser degree, by inspection, palpation, percussion and auscultation. Brief mention is made of the carer. Attention to carer demeanour and their relationship with the patient is important. Mental and physical ill health in the carer may adversely impact on the patient.
The general appearance of the clothes, face and hands, including nails, may be the first clue to self-neglect or neglect or abuse from a carer, depression, or functional decline in completion of basic activities of daily living due to underlying disease(s). Body habitus may suggest malnourishment or cachexia.
The handshake allows closer inspection of hands and nails and will also permit observation of tremor, whether resting or action, wasting of the small muscles, joint swelling or stiffness, or loose jewellery, for example, that will assist in directing enquiry and subsequent examination. Ability to transfer, requirement for an aid or an arm, and gait provide information on functional ability and may suggest dysfunction at various levels of the musculoskeletal and neurological systems which will require more detailed scrutiny.
Observation of the face during the interview may reveal the blank appearance of Parkinson’s disease or the lack of expression and poor eye contact of depression. Asymmetry in facial appearance may indicate neurological dysfunction, for example due to stroke or Bell’s palsy. Less obvious, perhaps, are symmetrical changes in facial appearance, such as the pallor of anaemia, the fat deposition and telangiectasia of Cushing’s syndrome, or the proptosis and lid retraction of an overactive thyroid gland.
Abnormal movements may be noted during the interview. In the head and face, titubation, orofacial dyskinesia, facial tics or myoclonus, or fasciculation of the tongue all require explanation. Wincing or grimacing indicates uncontrolled pain, which requires evaluation and alleviation. In the limbs, tremor may again be apparent. The position and posture of the limbs may suggest current or previous musculoskeletal or neurological problems.
Speech will be assessed during the interview and might direct further testing to determine if there are one or more problems affecting comprehension, such as loss of hearing or receptive dysphasia; articulation and pronunciation, such as dysarthria, expressive dysphasia and dysphonia; or content, such as confusional states, delusional or psychotic disorders, or depression. Limitation of speech due to pain or dyspnoea indicates serious cardiovascular and/or respiratory compromise or perhaps profound anaemia.
Examination
The general examination continues from and expands on observations made during the interview. A general ‘head to toe’ inspection of the patient will take closer note of the hands, face, head and neck, nutritional and hydration status, and the presence of abnormal swellings and masses.
A systematic approach to the hands will inform the examiner on the presence of a multitude of systemic disorders. The nails may be pitted in psoriasis or clubbed in a number of respiratory, cardiac, gastrointestinal and other disorders. The pattern and distribution of swelling and deformity of the small joints may suggest the presence of osteoarthritis, rheumatoid arthritis or psoriatic arthropathy. Abnormal pigmentation of the skin may indicate anaemia if pale or chronic liver disease if jaundiced. Atrophy of the small muscles may be a marker of generalized weight loss and ill health or suggest median nerve entrapment at the wrist if isolated to the thenar eminence.
Related posts:
The Care Home Experience Alisoun Milne
The Nosology of Dementia Kenneth Rockwood
Behavioural Management: Non-Pharmacological Jiska Cohen-Mansfield
Depression After Stroke Peter Knapp and Allan House
Sleep and Ageing: Disorders and Management Helen Chiu and Joshua Tsoh
Training Requirements for Old Age Psychiatrists in the UK Susan Mary Benbow and Aparna Prasanna
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
