Assessment of

Elder Patients & Age

related Changes

By: Mr. TAUQEER AHMED

LECTURER: FUCN
Date: January 05, 2021
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)
• Elders have depressed immune systems
and often present with atypical signs and
symptoms

• The “graying of Elders” increases the

importance of understanding the special
needs of this population
The Importance of
Patient-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
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 (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
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
• PFTs may require extra time for such elder
patients.
• 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