<p> Older adult assessment 1</p><p>MENNONITE COLLEGE OF NURSING AT ILLINOIS STATE UNIVERSITY</p><p>Diagnostic Reasoning for Advanced Practice Nursing 431</p><p>Older Adult Screening and Assessment</p><p> 27 million older adults in the U.S.; expected to reach 86 million by 2050  Life span at birth is 79 years for women and 74 years for men  Americans over age 85 projected to increase to 5% of population within 40 years  Goal - increase “health span” not just increase life span → full function, active life, healthy aging  Frailty is a common myth - 95% of Americans > 65 live in the community, 5% in LTC facility  Different approach from disease-oriented H&P of younger patient – support system, function assessment (the 6th vital sign), long-term health & safety</p><p>Health History 1. General guidelines a. Allow sufficient time. b. Use a comfortable, private, well-lit environment. c. Face the client at eye level. d. Use clear, non-rapid speech e. Use closed-ended questions, open-ended questions, and refocusing strategies as needed.</p><p>2. Basic information: name, address, telephone number, date of birth, gender, race, marital status, work status, living arrangements, notation about reliability of information</p><p>3. Presenting problem: the main symptom or cause of concern, phrased in the client’s own language</p><p>4. History of present illness: summary and symptom analysis</p><p>5. Past health status: childhood illnesses, immunizations, allergies, major accidents major adult illnesses, surgeries, fractures, hospitalizations, blood transfusions, obstetric history in women, exposure to environmental hazards-occupation, experience of living abroad or extensive foreign travel, STDs (syphilis)</p><p>6. Family history: general health statuses; ages at death; causes of death; presence of AIDS or related disorders, alcoholism, anemia, arthritis, cancer, cerebrovascular disease, developmental disability, diabetes mellitus, other endocrine disorders, headaches, heart disease, hypertension, psychiatric disorders, renal disorders, seizure disorders, tuberculosis, osteoporosis</p><p>7. Personal habits: alcohol consumption; tobacco use; caffeine consumption; use of prescription, over- the-counter, and herbal medications, use of street drugs; use of nutritional supplements; frequency of physical examinations</p><p>8. Review of systems: overall health (appetite, fatigue, weight changes, alcoholism, sleep, depression); HEENT (hearing loss, visual changes); cardiovascular system; respiratory system (cough, dyspnea); integumentary system; gastrointestinal system (constipation); genitourinary system (incontinence, frequency, nocturia); breasts and axillae; musculoskeletal system (joint stiffness, ROM, falling); neurologic system (balance, memory, confusion, headache, TIA symptoms); endocrine system, hematopoietic system. Older adult assessment 2</p><p>Physical Assessment</p><p>1. General considerations a. Face the client at eye level; explain what the examination will involve and approximately how long it will last b. Maintain the examining room at a temperature of 68-75oF and ensure that the client’s body is exposed for no longer than necessary because of the risk of hypothermia. c. Help the client to undress, if necessary, and provide a straight-back chair that can be used while removing shoes and underwear. d. Assist the client onto the scale and examining table. Do not leave the client unattended while sitting or lying on the examining table. e. Pad the examining table with a blanket if the client is thin; use pillows to aid breathing if necessary. f. Minimize the number of position changes that the client must make g. Schedule 2 separate examination sessions if the client lacks the energy for a complete examination in 1 session.</p><p>Note: In the past, considerable decline in major body systems was attributed to normal aging. However, it has become increasingly apparent that much of what was previously ascribed to aging is the result of disease or disuse.</p><p>Rule of thirds: Of changes in physiological function observed with advancing age, approximately 1/3 is due to disease, 1/3 to disuse, and 1/3 to normal aging.</p><p>2. Important areas of assessment in elderly clients a. General observation (1) Observe posture and gait; stooped posture and slow or altered gait may be present (2) Listen for unusual sounds; wheezing during respiration may indicate illness (3) Check for presence of involuntary movements (e.g., tremors) (4) Observe general cleanliness and grooming (5) Check for unusual odors; breath or body odors may indicate illness (6) Observe facial expression and affect</p><p> b. Skin and Nails (1) Observe color (2) Take temperature (3) Assess texture (4) Check skin turgor, which may be decreased, with sagging, drooping, or wrinkling (5) Check for presence of commonly occurring lesions or rashes (e.g., cherry angiomas, senile lentigines, seborrheic or actinic keratoses, cutaneous skin tags, vitiligo, purpuric lesions) (6) Inspect for presence of reddening at pressure areas, which may indicate tissue breakdown (7) Inspect veins for varicosities (8) Check nails for presence of fungus, cyanosis, and clubbing (9) Check capillary refill time</p><p>Normal aging of the skin</p><p>What happens: wrinkling, sagging of subcutaneous support, hair loss and graying, and increased frequency of benign and malignant skin conditions Older adult assessment 3</p><p>Sequence of changes: sagging of the lateral aspects of the eyebrows  wrinkling of the forehead  horizontal skin lines at the lateral canthus of the eye  sagging of the tip of the nose  perioral wrinkling  fat absorption of the buccal and temporal areas</p><p> c. Head and neck (1) Check hair; color, texture, amount, distribution, cleanliness, presence of itching, lesions, or soreness. (2) Observe facial area (a) Proportion and symmetry (b) Function of facial and trigeminal nerves during smiling, clenching teeth, lifting eyebrows (c) Presence of pain with movement of temporomandibular joint (TMJ) (d) Palpate temporal areas for tenderness (3) Inspect eyes (a) Alignment and symmetry (b) Presence of lid lag and inflammation (c) Color of sclera and conjunctiva (d) Pupils that are equal, round, and reactive to light and accommodation (PERRLA) (e) Presence of corneal irritation and opacities (f) Presence of lens opacities (g) Moisture and tearing (4) Assess ears (a) Presence of tenderness, swelling, or nodules on auricle (b) Presence of cerumen, lesions, or discharge in auditory canal (c) Color and landmarks of tympanic membrane (d) Auditory acuity; if any problems consider Audiology referral (5) Check nose (a) Symmetry, shape, size, and color (b) Presence of masses (c) Presence of discharge or flaring of nares (d) Sense of smell (have the client identify strong odor (6) Palpate frontal and maxillary sinuses for tenderness (7) Assess mouth and oropharynx (a) Presence of lesions on lips and in mouth (b) Condition of teeth for occlusion, number, color, and surface characteristics (c) Condition of gums – gingivitis = heart disease? (d) Fit of dentures (e) Swallowing and chewing abilities (f) Condition of mucous membranes (g) Function of gag reflex – be selective (swallowing problems, voice change, etc.) (h) Condition of buccal mucosa for color and texture and presence of lesions (i) Uvula midline (j) Tongue deviation (k) Presence of coating, redness, white patches, or lesions on tongue – thrush? (8) Assess neck (a) Range of motion (b) Function of spinal accessory nerve (ability to shrug shoulders) (c) Presence of enlargement or tenderness in lymph nodes (d) Enlargement of thyroid or presence of nodules Older adult assessment 4</p><p>(e) Presence of jugular vein distention</p><p>Normal Aging of the Special Senses</p><p>Normal visual changes in aging include presbyopia (gradual loss of lens elasticity, resulting in diminished ability of the lens to accommodate for near vision, usually in early 40s), reduced contract sensitivity, impaired adaptation to darkness or daylight, and delayed recovery from glare.</p><p>Modest lens opacification scatters light, leading to glare sensitivity. Severe lens opacification is called a cataract. </p><p>A nearly universal finding in older persons is high-frequency hearing loss, termed presbycusis. </p><p> d. Thorax and lungs (1) Check symmetry of thorax (2) Note respiratory rhythm, rate, and symmetry (3) Test position and range of movement of diaphragm during inspiration and expiration (4) Listen to breath sounds</p><p>Normal Aging of the Pulmonary System</p><p>There is decreased elasticity of the lungs, decreased ciliary action, weakening of respiratory muscles, decreased coughing reflex, calcification of costal cartilages.</p><p>Physiological reserves are so great that aging alone rarely leads to significant impairment.</p><p> e. Breasts and axillae (1) Check symmetry and contour (2) Check for presence of masses or tenderness (3) Observe nipple for discharge and inversion (4) Assess for gynecomastia in males</p><p> f. Heart (1) Evaluate for presence of thrills or abnormal pulsations (2) Assess rhythm and rate (3) Check for presence of murmurs or other abnormal sounds (4) Palpate point of maximal impulse (PMI)</p><p> g. Peripheral vascular system (1) Measure blood pressure (2) Assess coloring and warmth of extremities (3) Check for presence of varicosities or ulceration</p><p>Normal Aging of Cardiovascular System</p><p>Disease rather than normal aging appears to lead to most dysfunction.</p><p>Systolic blood pressure tends to rise with age, intrinsic cardiac contractile function declines, and cardiac reserve diminishes in non-diseased subjects. Older adult assessment 5</p><p>The CV system rarely fails, however, except as a result of disease or a severe physical challenge, such as perioperative overhydration.</p><p> h. Abdomen (1) Assess contour (maximum height at level of umbilicus) (2) Determine size of liver by palpating upper and lower border (3) Palpate for presence of masses or tenderness (4) Auscultate bowel sounds</p><p>Normal Aging of the Gastrointestinal System</p><p>Dental changes, particularly gum recession and tooth loss.</p><p>Peristalsis is diminished throughout the GI tract, but symptoms of constipation rarely arise in the absence of poor diet, drug effects, decreased mobility, or disease.</p><p>Gastric acid secretion is reduced (many elderly are achlorhydric), and moderate villous atrophy is present in the small intestine, but significant malabsorption does not occur in health elderly on adequate diets. Consider effect of medications and diabetic gastroparesis. </p><p> i. Musculoskeletal system (1) Assess body symmetry. (2) Assess muscle strength and atrophy. (3) Determine range of joint motion (e.g., flexion, extension, abduction, rotation). (4) Palpate joints for presence of tenderness, warmth, swelling, deformity, or crepitation (crackling)</p><p>Normal Aging of the Musculoskeletal System</p><p>Average loss of 2 inches between ages 40 and 80. Muscle mass decreases by 30%, and decreases occurring in muscle strength, endurance, and bulk.</p><p>Decline in bone density: peak bone mass is achieved during the 30s or early 40s, after which there is a gradual decline. More rapid among women than men, with the most rapid demineralization occurring during the 5 years immediately following menopause. Kyphosis?</p><p>Osteoarthritis: occur in most weight-bearing joints and in the hands; result from a wearing down of the articular bony surfaces that get frequent use. Reactive bone growth follows, with new bone extending laterally. This extra bone growth is visible radiographically as spurs.</p><p> j. Nervous system (1) Assess mental status (2) Test function of cranial nerves: sense of smell, hearing, taste, corneal reflexes, facial muscles, peripheral vision, near vision, and movement of eyes. (3) Test motor nerve function: gait; equilibrium; coordination; hand grip; and presence of muscular atrophy, fasciculations, or involuntary movements. (4) Test sensory nerve function: perception of touch, temperature, pain, and vibration. Older adult assessment 6</p><p>Normal Aging of the Nervous System</p><p>Cerebral blood flow reduced by 20%, brain weight reduced by 7%.</p><p>Declines in performance measures (handwriting speed, hand grip strength, vibratory sensation, foot reaction time & peripheral vision – consider driving safety?)</p><p> k. Male genitalia (1) Inspect scrotum for symmetry, inflammation, edema, masses, or lesions (2) Check rectum and anus for presence of inflammation, rash, lesions, hemorrhoids, masses; check stool for occult blood. (3) Check muscle tone of sphincter (4) Check prostate for enlargement, consistency l. Female genitalia and pelvis (1) Check vulva for inflammation, edema, tenderness, or masses. (2) Inspect vagina for color, odor, hydration status, lesions, mucosal bulging, excessive discharge, abnormal bleeding, and muscle tone. (3) Check for signs of prolapsed uterus – lying & standing. (4) Palpate size and consistency of ovaries. (5) Check rectum and anus for presence of inflammation, rash, lesions, hemorrhoids, masses. (6) Evaluate muscle tone of sphincter</p><p>Normal Aging of the Reproductive System</p><p>Postmenopausal women often experience thinning of the vaginal mucosa and diminished vaginal secretions, largely as a result of estrogen deficiency.</p><p>Erectile dysfunction, ranging from inability to maintain an erection to complete impotence, increases with age among men and is aggravated by many medications.</p><p>Among men, prostatic hypertrophy is nearly universal, and with it come increased nocturia, urinary hesitancy, and decreased urinary stream. Prostatic cancer?</p><p>Functional Status Screening</p><p>Purpose: To assess performance in key functional areas to determine the client’s ability to live independently</p><p>Activities of Daily Living (ADL)  Eating/feeding  Bathing  Grooming  Dressing  Transferring  Ambulation  Toileting</p><p>Instrumental Activities of Daily Living (IADL) Older adult assessment 7</p><p> Preparing meals  Shopping  Housekeeping/yard work  Doing laundry  Managing money and finances  Taking medications  Using the telephone  Driving/transportation</p><p>Psychosocial Assessment: Folstein Mini Mental State Examination (MMSE), Geriatric Depression Scale, Michigan Alcoholism Screening Test, etc.</p><p>Age-related changes in common laboratory values</p><p>Hematology tests  Hemoglobin: slightly decreased because of reduced hematopoiesis in men and women and decreased androgen levels in men  Males over age 70: 10-17 g/100 ml (standard value 13.5-18 g/100 ml)  Females over age 70: 9-17 g/100 ml (standard value 12-16 g/100 ml)  Hematocrit: slightly decreased because of reduced hematopoiesis  Males: 38-54% (standard 40-54%)  Females: 35-49% (standard 38-47%)  Leukocytes: decreased because of a decrease in T and B lymphocytes and reduced hematopoiesis  Males: 3,600-12,700 (standard 4,500-11,000)  Females: 3,100-12,000 (standard 4,500-11,000)  Sedimentation rate: slightly increased  Males: < 22 mm/hour (standard < 15 mm/hr)  Females: < 22 mm/hour (standard < 20 mm/hr)  Note: Persistent elevations > 40 mm should be investigated)</p><p>Blood chemistry tests  Blood urea nitrogen (BUN): increased because of decreased glomerular filtration rate and reduced renal tubular secretion  Creatinine: increased due to decreased kidney size  Creatinine clearance: must be calculated to take into account age-related decrease in glomerular filtration rate  (140-age) X body weight (kg) serum creatinine X 72 kg  Male (above), female x 0.8  Calcium: slightly decreased perhaps due to inadequate intake  Fasting glucose: increased renal threshold for glucose  Glucose tolerance: Higher peak at 2 hours with slower decline; rise at 1 hour equals 9 mg/100 ml +/- 5 mg/100 ml for each decade of life; AIC?  Potassium: slightly increased  Thyroxine (T4): decreased because converted from T3 at a lower rate in elderly Older adult assessment 8</p><p>Appropriateness of Various Preventive Screening Techniques In Elderly Persons Widely Accepted  Blood pressure measurement  Mammogram – recommendations vary based on history and age  Breast examination  Pap smear unless previously normal  Cervical cancer is comparatively rare in old age, and older women with previously normal Pap smears rarely develop it. Women with a record of normal Pap smears and at low risk may not need screening beyond age 70.  Tetanus/diphtheria immunization  Influenza immunization  Pneumococcal immunization  Herpes Zoster immunization  Hearing tests  Vision screens  Dental examinations  Smoking history and education  Weight measurement and education  Diet history and education  Physical exercise education  Skin cancer examination  Oral cancer examination  Digital rectal examination  Stool for occult blood</p><p>Controversial  Cholesterol measurement  Research has not clearly demonstrated that treatment is beneficial in asymptomatic persons over age 65  However, NCEP advises that all adults without evidence of coronary heart disease (i.e., history of MI or angina pectoris) should have a screening measurement of total cholesterol and HDL cholesterol at least once every 5 years  Cholesterol screening for the primary prevention of CHD is not recommended for those 75 years of age and older, according to the American College of Physicians.  Prostate specific antigen  ACS recommends that men aged 40 and over should have a DRE annually. Men aged 50 and over should also have an annual PSA blood test, which may be discontinued when the client’s life expectancy is less than 10 years.  Routine estrogen use  Oral – after surgical or natural menopause if symptoms  Vaginal – dryness, frequent URIs  Thyroid function tests  In the US, thyroid dysfunction occurs in up to 4% of adults, with women, older adults, and individuals with a family history of thyroid disease being at greatest risk.  In older adults, thyroid disease often manifests itself insidiously, causing atypical symptoms that are assumed to be part of normal aging. Older adult assessment 9</p><p> Hypothyroidism: May be nonspecific symptoms such as fatigue, lethargy, memory loss, depression, and constipation.  Hyperthyroidism: May experience weight loss, insomnia, weakness, apathy, congestive heart failure, and atrial fibrillation.  Screening for AAA for men >65 who have ever smoked  Blood/urine sugar  Colon/sigmoid endoscopy  The ACS recommends annual performance of a digital rectal exam after age 40 and a fecal occult blood test after age 50. In addition, a flexible sigmoidoscopy examination is advised every 3-5 years after age 50 or colonoscopy every 10 years.  Medicare will pay for one screening FOB test annually and one flexible sigmoidoscopy every 4 years for individuals over 50.</p>