Evaluation of older adults usually differs from a standard medical evaluation. For older patients, especially those who are very old or frail, history-taking and physical examination may have to be done at different times, and physical examination may require 2 sessions because patients become fatigued. (For screening recommendations in older adults, see Prevention of Disease in Older Adults.)
Older adults also have different, often more complicated health care problems, such as multiple disorders, which may require use of many medications (sometimes called polypharmacy) and thus greater likelihood of a high-risk medication being prescribed (see table Potentially Inappropriate Medications in Older Adults).
Early detection of problems can result in early intervention, which can prevent deterioration and improve quality of life, often through relatively minor, inexpensive interventions (eg, lifestyle changes). Thus, some older patients, particularly the frail or chronically ill, are best evaluated using a comprehensive geriatric assessment, which includes evaluation of function and quality of life, best administered by an interdisciplinary team.
Multiple disorders
On average, older patients have 6 diagnosable disorders. A disorder in one organ system can impair another system, exacerbating the deterioration of both and leading to disability, dependence, and, without intervention, death. Multiple disorders complicate diagnosis and treatment, and effects of the disorders are magnified by social disadvantage (eg, isolation) and poverty (as patients outlive their resources and supportive peers) and by functional and financial problems.
Clinicians should also pay particular attention to certain common geriatric symptoms (eg, delirium, dizziness, syncope, falling, mobility problems, weight or appetite loss, urinary incontinence) because they may result from disorders of multiple organ systems.
If patients have multiple disorders, treatments (eg, bed rest, surgery, medications) must be well-integrated; treating one disorder without treating associated disorders may accelerate decline. Also, careful monitoring is needed to avoid iatrogenic consequences. For example, with complete bed rest, older patients can lose 1 to 3% of muscle mass and strength each day (causing sarcopenia and sharply reduced mobility), and effects of bed rest alone can ultimately result in death.
Missed or delayed diagnosis
Disorders that are common among older adults are frequently missed, or the diagnosis is delayed. Clinicians should use the history, physical examination, and simple laboratory tests to actively screen for disorders that occur only or more commonly in older patients (see table Some Disorders More Common Among Older Adults); when diagnosed early, these disorders can often be more easily treated. Early diagnosis frequently depends on the clinician’s familiarity with the patient’s behavior and history, including mental status. Commonly, the first signs of a physical disorder are behavioral, mental, or emotional. If clinicians are unaware of this possibility and attribute these signs to dementia, diagnosis and treatment can be delayed.
Some Disorders More Common Among Older Adults
Disorders |
|---|
Diabetic hyperosmolar nonketotic coma Foot disorders interfering with mobility Hearing and vision abnormalities Oral disorders interfering with eating |
Polypharmacy
Patients' prescription, over-the-counter, and illicit drugs (including marijuana) should be reviewed frequently, particularly to look for drug interactions and use of medications considered inappropriate for older patients. This review is especially important during care transitions when reconciliation of medications is required to eliminate duplication, missed medications, and errors in dosage and to identify medications that may be no longer be needed.
Caregiver problems
Occasionally, problems of older patients are related to neglect or abuse by their caregiver. Clinicians should consider the possibility of patient abuse and drug abuse by the caregiver if circumstances and findings suggest it. Certain injury patterns or patient behaviors are particularly suggestive, including
Frequent bruising, especially in difficult-to-reach areas (eg, middle of the back)
Grip bruises of the upper arms
Bruises of the genitals
Peculiar burns
Unexplained fearfulness of a caregiver in the patient
