Health Articles

Symptoms and signs of hyperthyroidism may be subtle in very old patients, and classic eye findings and an enlarged thyroid gland may not be present (see HYPERTHYROIDISM in Ch. 79). Symptoms include weight loss, palpitations, and weakness; clinical signs include fine skin, tremor, atrial fibrillation, and tachycardia. Patients may have an apathetic rather than a hyperkinetic appearance. Those with hypothyroidism may present with weight loss rather than weight gain and may have cognitive loss, heart failure, or constipation.
Patients with hyperparathyroidism often do not have any of the characteristic symptoms. The clinical picture may be nonspecific: fatigue, decreased intellectual capacity, emotional instability, anorexia, constipation, and hypertension (see HYPERCALCEMIA in Ch. 82).
Instead of presenting with the classic manifestations of headache, jaw claudication, or blindness, patients with giant cell arteritis or polymyalgia rheumatica may present with respiratory tract symptoms (eg, cough, sore throat, hoarseness) or mental changes (see Ch. 74). They may complain of head pain in the frontal, vertex, or occipital areas rather than in the temporal area.
Elderly patients with systemic lupus erythematosus have a lower incidence of Raynaud’s phenomenon, malar rash, nephritis, and neuro-psychiatric disease than do younger patients (see SYSTEMIC LUPUS ERYTHEMATOSUS in Ch. 75). However, the incidence of pneumonitis, interstitial fibrosis, subcutaneous nodules, and discoid lupus is higher in the elderly. Patients may present with the symptoms of a systemic illness (eg, fever, weight loss, arthritis).
Elderly patients with fibromyalgia syndrome are less likely than younger patients to have chronic headaches, anxiety, and symptoms aggravated by weather factors, mental stress, or poor sleep.
The clinical manifestations of sarcoidosis in the elderly are variable. Presenting symptoms include shortness of breath, blurred vision, myopathy, adenopathy, and fatigue.
Elderly patients with bacteremia may not be febrile, demonstrating instead nonspecific findings such as general malaise or an unexplained change in mental status.
The elderly patient with urinary tract infection may be afebrile and may not complain of dysuria, frequency, or urgency (see Ch. 65). Dizziness, confusion, anorexia, fatigue, or weakness may occur.
At initial presentation, the elderly patient with meningitis may not have symptoms of meningeal irritation (see Ch. 92). The patient may have fever and a change in mental status without headache or nuchal rigidity.
The older patient with pneumonia may present with malaise, anorexia, or confusion. Although tachycardia and tachypnea are common, fever may be absent. Coughing may be mild and without copious,purulent sputum. Coexisting illnesses may alter the presentation of tuberculosis. Symptoms may be nonspecific (eg, fever, weakness, confusion, anorexia). Pneumonia and tuberculosis are discussed in Ch. 46.
Older patients with appendicitis may complain of diffuse abdominal pain that is not followed by localization to the right lower quadrant (see DISORDERS OF THE APPENDIX in Ch. 62). However, tenderness in this quadrant is a significant early physical sign.
Elderly patients with biliary disease may present with nonspecific mental and physical deterioration (malaise, confusion, loss of mobility) without jaundice, fever, or abdominal pain. Abnormal liver function tests may be the only indication that biliary disease is present (see DISORDERS OF THE GALLBLADDER AND BILIARY TREE in Ch. 62).
Patients with acute bowel infarction may not have the characteristic abdominal pain and tenderness. These patients may present with acute confusion.
Nonsteroidal anti-inflammatory drugs can mask the pain of peptic ulcer disease in elderly patients, who may present with anorexia (see PEPTIC ULCER DISEASE in Ch. 62). Gastrointestinal bleeding may be painless in the elderly.
Patients with myocardial infarction may present with dyspnea, syncope, weakness, vomiting, or confusion, rather than with chest pain (see Ch. 37).
Instead of complaining of dyspnea, an elderly patient with heart failure may present with confusion, agitation, anorexia, weakness, insomnia, or lethargy (see also Ch. 41). Orthopnea may cause nocturnal agitation in demented patients with heart failure.
Irritability may be the primary affective symptom of depression (see Ch. 95). Cognitive loss, often called pseudodementia, is another atypical presentation of depression (see Ch. 90).

Many of the measurements commonly performed when assessing nutritional status may be unreliable in the elderly. Aging can alter height, weight, and body composition (lean body mass and fat content). Arm span is a reliable estimate of height when calculating body mass index in the elderly. Use of multiple sites instead of only the triceps may provide more reliable skinfold measurements.

Evaluation of language function includes assessing spontaneous speech, comprehension of spoken language (performance of verbal commands, yes or no answers to questions, pointing to objects), repetition of words and phrases, word-finding ability, comprehension of written material, and writing. In assessing spontaneous speech, pay attention to the rate of word output, the effort involved in initiating speech, and the length of phrases (see TABLE 16-2). In testing word-finding ability, ask the patient to name objects and parts of objects.
The patient with dysarthria may have weakness or poor coordination of the lips, tongue, palate, vocal cords, or respiratory muscles, which interferes with speech production. The patient produces approximate sounds in the correct arrangement. Dysarthria may occur in patients with neurologic diseases (eg, cranial nerve palsies) or lesions that affect the speech mechanism, such as vocal cord tumors. Note speech rhythm and articulation (see TABLE 16-3). Since language function is intact, the dysarthric patient is able to read and write.
The patient with speech apraxia is able to move the muscles involved in speech and understands what needs to be done but has difficulty speaking. He can perform overlearned acts (eg, counting) and write sentences without a problem. In contrast, the patient with aphasia has difficulty speaking or writing (see TABLE 16-2). Previously acquired language ability is lost. Depressed patients may speak slowly and softly, but language function is intact. Speech arrest may be associated with seizures.

Assessment of mental status, a key component of the history and physical examination, is discussed in Ch. 89.
The patient may resent the mental status examination and needs to be reassured that it is routine. The patient must be able to hear the examiner. Pure word deafness, an isolated inability to understand speech, may be mistaken for cognitive dysfunction. Assessing the mental status of a patient who has a speech or language disorder (eg, mutism, dysarthria, aphasia, or speech apraxia—see below) is difficult.
Although the speed with which information is processed and memories are retrieved may decline, abnormalities of consciousness, orientation, judgment, calculations, speech, language, or praxis cannot be attributed simply to age. Questions of orientation alone fail to detect many cases of dementia. Loss of short-term memory is a sensitive indicator of cognitive impairment and can be used as a screening test. Such screening can be followed later by a formal test of mental status.

Measure the patient’s height and weight. Grab bars near or on the scale are helpful for patients with balance problems. When recording the temperature, be aware that hypothermia can be missed if the thermometer does not measure low temperatures. Febrile elderly patients in an ambulatory setting are more likely than younger patients to have a serious disease, but the absence of fever does not exclude infection.
Pulses and blood pressure should be checked in both arms. Since many factors can alter blood pressure, take several measurements under resting conditions (see also Ch. 35). Blood pressure may be overestimated in elderly patients because of arterial stiffness. This pseudohypertension is suspected in patients with elevated systolic and diastolic blood pressure but no end-organ damage from hypertension. In patients with pseudohypertension, the brachial or radial artery is still palpable after the blood pressure cuff is inflated to a point greater than the systolic pressure (Osier’s sign). However, Osier’s maneuver is subject to observer error; its accuracy in predicting pseudohypertension is not known.
Checking for orthostatic hypotension is worthwhile, even though it is unclear whether prevalence increases with age in patients who are not hypertensive. Observe the patient for at least 3 min in the standing position, but exercise caution when testing volume-depleted patients. A postprandial fall in blood pressure with virtually no compensatory increase in pulse rate has been observed in institutionalized patients (see also Ch. 36).
Respiratory rate in elderly patients is 16 to 25 breaths/min. A rate > 25 breaths/min may signal a lower respiratory tract infection before other clinical signs appear.

Ask if the patient wants a relative or aide in the room during the examination. Portions of the examination may be more comfortable if the patient is allowed to sit in a chair. Lower the examining table to a height that allows easy access; a footstool facilitates mounting. Be aware of examining gowns that are too long and may cause the patient to trip. Do not leave the patient alone on the table. Maintain his dignity and ensure his privacy; if the examination is conducted in a hospital room and a roommate is present, the curtains must be drawn.
Does the patient appear uncomfortable, restless, malnourished, inattentive, pale, dyspneic, or cyanotic? The patient may look older or younger than the stated age. Preliminarily assess the patient’s functioning by, for example, observing his clothing and personal hygiene. If the patient is examined at bedside, note the use of a water mattress, a sheepskin, or restraints, as well as the use of a urinary catheter or adult diaper.

The social history includes assessment of the patient’s living arrangements: number of rooms, plumbing, availability of elevators, heat, and air conditioning. Discuss home features that could lead to falls, such as poor lighting, slippery bathtubs, and unanchored small rugs, and how to remedy them. A home visit is the best way to assess the situation. In addition, valuable information can be gleaned from having the patient describe a typical day, touching upon activities such as reading, television viewing, work, exercise, and hobbies. The patient may also talk about the frequency and nature of meals, social contacts, family visits, and availability of transportation. As the number of older drivers increases, the physician’s role in examining patients for impairments that may affect driving ability becomes more important (see Ch. 112).
Identify caregivers and support services available to the patient. Determine the family’s ability to assist the patient; a full-time job, traveling time to the patient’s home, and the health of family members all play a role (see also SOCIAL SUPPORTS AND FAMILY CAREGIVING in Ch. 110). Probe the patient’s attitude toward the family and the family’s attitude toward the patient. Note the patient’s social network (friends or religious or senior citizens’ groups) and status (single, married, widowed, or living in a relationship without marriage). Inquire about sexual practices and satisfaction in order to diagnose sexual problems. Although the questioning must be sensitive and tactful, it should be thorough, exploring the number and sex of sexual partners and the risk of sexually transmitted diseases (see Ch. 68).
An elderly person suffers many losses that may affect health and well-being. The patient may have experienced the loss of a spouse, sibling, child, friend, or pet. Retirement may lead to a loss in income. Economic difficulties brought about by inflation and a fixed income need to be addressed. Financial or health problems may result in loss of a home, social status, or independence. The relationship with a longtime physician may have been lost, either because the physician retired or died or because the patient moved to a new residence.
The social history includes questions about tobacco and alcohol use. Remind the patient about the hazards of smoking; if the patient continues to smoke, be especially careful to warn against smoking in bed. Although alcoholism is a serious problem in the elderly, it is often not diagnosed. Signs of alcoholism may include confusion, anger, hostility, alcohol odor on the breath, and tremors. The CAGE (Cut down, Annoyed, Guilty, Eye-opener) screening questionnaire effectively identifies elderly patients with a history of drinking problems (see also Ch. 99).
Discuss and document the patient’s wishes regarding heroic measures for prolonging life in acute or chronic care settings. Determine whether the patient has provided for surrogate decision making in case of incapacity .

Evaluate the patient’s mobility, continence, self-sufficiency, and mentation. The patient may walk independently or may need a cane, walker, or another person’s assistance. Ask about difficulty with stairs. Assess the patient’s ability to walk, transfer, toilet, groom, bathe, dress, and feed himself (activities of daily living) as well as his ability to cook, use the phone, do laundry, clean, shop, or manage money (instrumental activities of daily living); see also Ch. 17. Input from a caregiver and clinical observation may be necessary to evaluate a very disabled patient.

Psychiatric problems in the elderly may not be detected as easily as those in younger patients. Insomnia or changes in sleep patterns, constipation, changes in cognition, anorexia, weight loss, fatigue, increased preoccupation with bodily functions, increased alcohol consumption, and somatic complaints are common signs (see also Ch. 94). Ask the patient about feelings of sadness, depression, and hopelessness. Episodes of crying may indicate depression. Deafness may contribute to depression. Determine if the patient suffers from delusions or hallucinations. Elicit any history of psychiatric care, including psychotherapy, institutionalization, electroconvulsive therapy, and the use of psychoactive drugs or antidepressants.
Discuss such events as the recent loss of a loved one. Suicide risk is not increased by asking about thoughts of suicide (see Suicide in Ch. 94), and plans (eg, medications, gun) need to be discovered. The sooner suicidal thoughts are discovered, the more likely suicide can be prevented.

Ask what kind of food, how much, and how often the patient eats, including the number of hot meals eaten weekly. Address the patient’s ability to eat (eg, ask how well he can chew and swallow). Xerostomia (dry mouth) may impair mastication and swallowing. Find out if another physician has prescribed a special diet (eg, a low salt or low carbohydrate diet) or if the patient follows a self-prescribed fad diet. Inquire about the intake of alcohol, dietary fiber, and OTC vitamin preparations, as well as the type of snacks consumed.
The amount of money spent on food and the accessibility of food stores are important issues. A patient may be unable to prepare meals if proper kitchen facilities are unavailable. Others have difficulty prepar-jng meals or feeding themselves because of visual limitations, arthritis, immobility, or tremors. A decreased sense of taste or smell may reduce the pleasure of eating. Patients who are worried about urinary incontinence may reduce their fluid intake, which may lead to poor food intake.