Skin

Wrinkles are mainly due to past exposure to ultraviolet light and hence are not usually seen in covered areas. The skin of the elderly bruises easily (senile purpura); some people have skin like transparent tissue paper, described as paparaceous, especially on the backs of the hands and the forearms (Figs 6.1 and 6.2). The skin around the eyes may show yellow plaques – Dubreuilh’s elastoma. Some solar-induced changes to be aware of include keratoacanthoma, basal cell carcinoma, squamous cell carcinoma and malignant melanoma. The most common skin lesion noted is the small red Campbell de Morgan spot, a benign lesion seen most often on the trunk and abdomen.

Figure 6.1 Transparent ‘paparaceous’ skin and senile purpura.

Figure 6.2 Transparent ‘paparaceous’ skin. The surface has broken with trivial trauma.

Leg ulcers resistant to healing are common in old age: 50% are due to venous stasis (Fig. 6.3), 10% to arterial disease and 30-40% are of mixed origin. Examination should include sensory (neuropathic ulcers) and vascular (ischaemia and varicose veins) examinations of the lower limbs. Measure the ankle and brachial blood pressures, using a Doppler meter and sphygmomanometer cuff, the Doppler meter being used instead of a stethoscope at the feet. The ankle–brachial pressure index (ABPI) is calculated using the formula:

Figure 6.3 Leg ulcers.

An ABPI of 1.0 is normal; an ABPI below 1.0 may indicate arterial disease. An ABPI <0.8 indicates compromised distal circulation, and so pressure bandaging for leg ulceration should be avoided.

Check cutaneous pressure areas, especially the heels, hips and sacrum, for signs of skin breakdown (pressure or decubitus ulcers).

Cardiovascular system

Cardiovascular examination in older patients is no different from that in younger adults, but there are a number of important factors to take into account. Bradyarrhythmias and tachyarrhythmias are common in sick, older patients and may lead to cardiovascular collapse despite simlar rates being well tolerated in the young. The increase in heart rate in response to stress (e.g. exercise, illness or pyrexia) is reduced in advanced old age, and this may be exacerbated by medications such as β-blockers and other antiarrhythmics.

A lying and standing (or sitting) blood pressure is extremely useful, but may not be obtainable in the more disabled patient. Postural hypotension, defined as a drop in systolic blood pressure on standing of more than 20 mmHg, is a considerable cause of morbidity in old age, often caused or exacerbated by medications. The sitting or standing blood pressue should be measured immediately prior to, and then 1, 3 and 5 minutes after, changing position. Age-related structural and functional changes in the cardiovascular system account for a slight increase in mean blood pressure with increasing age, although adult hypertensive guidelines should still be applied.

Heart valves, especially the aortic valve, can become less mobile, exacerbated by calcification. This is known as aortic sclerosis and is characterized by a non-radiating ejection systolic murmur, heard loudest in the aortic area. Degeneration and calcification of the mitral valve can result in either apical ejection murmurs or the more common pansystolic mitral regurgitant murmur (see Ch. 11).

Arterial abnormalities auch as an aortic aneurysm, arterial bruits and evidence of peripheral vascular disease should be sought. Palpation of the pulses can be difficult because of atheroma or oedema and, in the lower limbs, Doppler measurement (see above) may be necessary to assess the peripheral circulation. Assessment of retinal vessels for signs of disease, as in hypertension and diabetes, can prove difficult in old people owing to the frequent presence of cataracts.

Respiratory system

Kyphosis, owing to intervertebral disc degeneration and osteoporosis, and calcification of the costal cartilages make the chest wall more rigid and less expansible. A reduction in pulmonary elasticity with age may be responsible for some hyperinflation on a chest radiograph, but this is principally due to pathological hyperexpansion associated with chronic obstructive pulmonary disease (COPD). Generally, the physical signs of respiratory system disease are the same in the old as in the younger patient. Measurements of peak expiratory flow rate (PEFR) and vital capacity (VC) are reduced (see Table 6.1) but, despite these changes, normal oxygenation is maintained and the normal adult ranges for oxygen saturation should be used.

‘All that crackles is not necessarily heart failure or pneumonia.’ Coarse basal crackles caused by air trapping owing to loss of pulmonary elasticity can make the interpretation of breath sounds difficult. It is important to note their presence when the patient is well, so that inappropriate therapy is not initiated if and when he becomes ill. In this situation, a chest radiograph is essential, regardless of the presence or absence of other signs and symptoms of cardiopulmonary disease. Common changes on the chest radiograph include calcification from old tuberculosis, calcification in chondral cartilages and major blood vessels, pleural calcification from past pneumonia and old rib fractures. Pleural effusions, cardiomegaly, areas of collapse and consolidation, interstitial changes and pleural thickening should not be accepted as normal at any age.

Gastrointestinal system

The older patient should be weighed at every visit. As in younger patients, nutritional assessment includes estimation of the body mass index (BMI): weight (kg)/height (m²). Because of osteoporotic vertebral collapse and other age-related changes, height may reduce in the old and so trends in weight are a more useful benchmark. If a true nutritional assessment is required, skin folds at the biceps, triceps, waist and thigh should also be measured.

The majority of older people are edentulous. If dentures are used, they should be worn during the examination so that problems with fit, for example poor speech or eating difficulties, can be corrected early. Oral candidiasis is common in the unwell older patient and is easily treatable. Leukoplakia appears as small white patches on the oral mucosa. It is associated with repeated mucosal trauma and may become malignant. Varicosities on the underside of the tongue are seen in about 40% of older people; their significance is unknown, but vitamin C deficiency has been implicated.

Abdominal examination may be limited by patients’ orthopnoea, kyphoscoliosis or other disabilities. However, always try to perform an appropriate assessment. If abdominal examination is limited by such disabilities, the patient will also find it difficult to lie supine for investigations such as computed tomography (CT) scanning or colonoscopy. The indications for digital rectal examination are the same as for younger patients, but this may not be feasible or appropriate, particularly in the very disabled or frail older patient. Constipation severe enough to cause faecal impaction is not uncommon and can have serious consequences (Box 6.6). This is often iatrogenic, but if of recent onset should be investigated appropriately.

Nervous system

Central nervous system examination should routinely include an assessment of higher cortical function (language, perception and memory). If cognitive impairment is suspected, assess the mental state early in the interview before the patient tires and record the result in the clinical notes (see below). As well as the Abbreviated Mental Test Score (AMTS) and Mini-Mental State Examination (MMSE) (see below), use the ‘clock test’. The patient is presented with a drawn circle, about 10-15 cm in diameter, and asked to fill in the numbers of a clock face (Fig. 6.4). Abnormalities may be due to visual impairment, agnosia (owing to right parietal lobe lesions) or cognitive impairment. This test is easily reproducible and less influenced by cultural and language problems than the AMTS or MMSE. A newer test, the Test Your Memory (TYM), has recently been introduced for patients attending diagnostic memory clinics or outpatient clinics, to fill in prior to be seen by medical staff.

Figure 6.4 Clock-face drawing.

It is important to recognize difficulties with communication. Communication is a two-way process that involves understanding and comprehension, as well as the production of appropriate speech. Communication problems can be considered in terms of:

disorders of language (dysphasia)

disorders of articulation (dyspraxia, dysarthria)

disorders of voice (dysphonia) or of fluency (dysfluency).

Dysphasia, i.e. difficulty in encoding and decoding language, is usually associated with a left hemisphere lesion (see Ch. 14). Dyspraxia is difficulty initiating and carrying out voluntary movements, for example of the tongue, and hence can affect speech. Dysarthria has many causes, including local factors in the mouth and dentition, stroke, Parkinson’s disease and other neurological disorders. Dysphonia, an abnormality of the quality of the voice (e.g. hoarseness), can be due to anxiety, vocal abuse, local disease of the larynx and pharynx or hypothyroidism. It is common after surgery to the throat and intubation. Dysfluency (stammer) is found in people of all ages.

The formal assessment of the peripheral nervous system by examining muscle bulk, tone, power, sensation and tendon reflexes is something the inexperienced clinician often finds difficult. In older, disabled patients, where judgements about normality and abnormality may be more subjective, this can be especially difficult. As with all clinical skills, such judgement is only acquired with practice. As part of this assessment, it is useful to ask the patient to hold his upper limbs fully extended and supinated, at shoulder height, with his eyes closed. Observe for pronator drift, which is a sign of pyramidal weakness. The reflexes should be examined in the normal manner. It is not uncommon for the ankle jerks to be diminished or hard to elicit in very old people but, as with all clinical signs, this should be viewed in the context of other findings and not in isolation.

It is essential to observe the walking or gait pattern wherever possible. This may reveal subtle evidence of hemiparesis, poor balance (Box 6.7) or the furniture-clutching gait of the patient with longstanding mobility problems. When observing the gait, always have someone walk alongside the patient to offer a helping hand in case he stumbles or falls. Occasionally patients claim that they are capable of carrying out activities when in reality they cannot. Always check the feet for chiropody problems (e.g. onychogryphosis), which cause a ‘painful’ or antalgic gait.

Vision and the eyes

Age-related loss of periorbital fat may give the eyes a sunken appearance; this may be severe enough to cause drooping of the upper lid (ptosis) and redundant skin at the lateral borders. The loss of fat can also cause the lower eyelid to curl in (entropion) and irritate the cornea, causing redness and watering (epiphora) or to fall outwards slightly (ectropion). A whitish rim around the iris (arcus senilis) is a zone of lipid deposition around the periphery of the cornea.

Visual acuity should be assessed and any loss of vision noted, together with the history of development of the visual disorder. Acute and chronic causes of loss of vision should be considered during the examination (Box 6.8). If the patient wears glasses, ask to see them. A state of disrepair may be an indication of cognitive impairment and/or their underuse, thereby explaining falls and misinterpretation of the environment. The visual fields should always be assessed. It is common to see irregular, asymetrical pupils due to previous iridotomy. Pupillary responses are normal in the well, older patient, but stroke and medication may cause abnormal size and responses. Abnormalities such as Horner’s syndrome and palsies of the third, fourth and sixth cranial nerves are relatively common in the elderly, related to stroke and neoplastic disease. Funduscopy should be attempted wherever necessary, but may be difficult when there are cataracts.

Hearing

Communication is often compromised in the older patient by hearing impairment. Patients are described as confused when in fact they are simply hearing impaired. If deafness is detected, the external ear should be inspected for wax. This should be softened with bicarbonate drops and then removed by gently syringing the external auditory canal. Hearing loss is often due to presbyacusis, an age-related degeneration of the cochlear hair cells. If a hearing aid is being worn, make sure it is switched on. This is easily tested by placing one’s hand over the aid. If it is on, it will let out a shrill whistle. Communication is aided by raising your voice (but not by shouting), obtaining attention, sitting face to face, reducing background noise and speaking slowly and clearly. When the patient has severe hearing impairment, you may need to use written communication, provided his vision is good enough.

Immobility

Impaired mobility is one of the most common clinical presentations in the elderly. It is almost invariably multifactorial, and frequently the patient has several other medical problems. A careful history is necessary to elucidate the likely underlying issues and in separating cause from effect. The essential information is the onset of symptoms. Sudden immobility should be straightforward to diagnose, yet stroke and impacted subcapital femoral fractures are easily missed. A steady deterioration in mobility over several years implies a chronic process, for example Parkinson’s disease or osteoarthrosis. A stepwise decline indicates a disease that has periods of exacerbation and remission, for example recurrent strokes or rheumatoid arthritis. Rapid deterioration from full mobility to total immobility over a few days indicates a serious acute medical problem. The most difficult patients are those in whom the disease process caused immobility a long time ago and the clinical picture has become clouded by the complications of immobility.

Within the bounds of common sense, the patient should be asked or helped to stand up and attempt a few steps, during which the gait can also be assessed (see above). Always have someone in close attendance in case of falls. The patient may be able to mobilize but unable to get out of a chair or bed unaided. Look for signs of distress on standing that may not have been mentioned by the patient. Tentative steps or clutching helpers may indicate loss of confidence or apraxia. Sometimes a diagnostic gait pattern is found (Box 6.9).

Instability/falls

It is said that ‘young people trip, but old people fall’. With age, muscle strength is lost and postural reflexes become impaired. Falls are therefore common in old age, especially in the very old. Several causes may coexist (see Box 6.7). Even a single fall should lead to a detailed history and examination, and a corroborative history sought from spouse or friends. In a patient who was previously well, a search should be made for new acute illness. If none is present, the fall may be deemed ‘accidental’ due to environmental or mechanical factors, although this is a diagnosis of exclusion. Information about the pattern of any previous falls can be helpful: frequency, relationship to posture, activity or time of day, prewarning and residual symptoms following the fall, and any avoiding steps taken by the patient should be ascertained. The absence of any warning implies a sudden event, usually neurological or cardiovascular in nature. Sinister symptoms associated with falling include loss of consciousness (although, notoriously, this is poorly reported), focal neurological deficit, features of seizure, chest pain, palpitations or other cardiorespiratory symptoms. The most useful clinical investigation in older fallers is to watch them walking. Patients may also require 24-hour ambulatory electrocardiograph monitoring, a CT head scan and sometimes tilt-table testing.

Incontinence

Incontinence is an involuntary and inappropriate voiding or leakage of urine or faeces. Continence depends on intact sphincter mechanisms and the functional ability to toilet oneself, or at least to acknowledge the need for toileting. Age-associated changes in the lower urinary tract predispose older people to incontinence but, despite these changes, most well older people are continent. Incontinence should not be regarded as a normal part of ageing and is more specifically associated with sphincteric damage, loss of neurological control mechanisms, especially in dementia or stroke, and with severe disability, chronic illness and frailty. Among the institutionalized older population, as many as 50% may suffer urinary and/or faecal incontinence.

When taking a history of urinary of faecal incontinence, try to differentiate between loss of ability to control voiding and failure to identify or reach an acceptable place. Find out how socially disabling the incontinence has become: many patients become isolated or afraid to go out because of the associated anxiety and potential embarrassment. Clinical examination should include rectal and vaginal examinations, assessment of the prostate gland, evaluation of the pelvic floor muscles and culture of a mid-stream specimen of urine. An incontinence chart kept for a few days may suggest a recognizable pattern of urinary and/or faecal incontinence. The specialist help of a continence adviser is often useful. Causes of urinary incontinence are shown in Box 6.10.

Faecal incontinence is relatively rare in well older men, but is principally associated with severe chronic disability or cognitive impairment. In women, it is more frequent relatively, but still rare. It may result from pelvic floor weakness. In both sexes, it may occur with carcinoma of the rectum, diverticular disease, laxative abuse and excess, faecal overloading with impaction, and neurogenic bowel.

Pressure ulcers

The mean capillary pressure in the skin of healthy young adults is approximately 25 mmHg. A bedridden patient or a person lying on the floor generates pressures in the skin in excess of 100 mmHg, especially over the sacrum, heels and greater trochanters (96% of ‘decubitus’ pressure ulcers occur below the level of the waist). Such pressures lead to occlusion of cutaneous blood vessels, causing the surrounding tissues, including the skin, to become hypoxic. In such circumstances, necrosis of the skin, adipose tissue and muscle may develop in as little as 4 hours. About 80% of pressure ulcers are superficial (Fig. 6.5). They occur mainly in dehydrated, immobile and incontinent patients exposed to sustained pressure. People with impaired sensation, or with diabetes, are especially vulnerable. Decubitus ulcers are always potentially preventable, but will occur in any setting if skin care is disregarded. Any superficial ulcer will deepen if the pressure is not relieved. Deep ulcers (Fig. 6.6) are formed when localized high pressure applied to the skin cuts off a wedge-shaped area of tissue, usually adjacent to a bony prominence.

Figure 6.5 Superficial pressure ulcers.

Figure 6.6 Deep pressure ulcers.

All at-risk patients should have active skin care management, including good nursing care and adequate hydration, started immediately a new illness or injury occurs, whether at home or in hospital. All pressure area sites must be inspected at the first clinical assessment, and again at regular intervals during the illness. An alternating-pressure air mattress (APAM), in which horizontal air cells (Fig. 6.7) inflate and deflate over a short cycle, constantly supporting the patient, provides periods of low pressure at all pressure sites, and good protection.

Figure 6.7 An alternating-pressure air mattress (APAM).

The confused older patient

‘Patient confused, no history available’ is a phrase that should never be used. It is crucial to establish whether the patient is orientated in place, time and person, and whether they are alert. A corroborative history from a friend or relative, and thorough clinical examination, will help decide whether the confusional state is acute or chronic. It is important to use a standard test of mental function (Box 6.11). Explain to the patient that you wish to test his memory. With experience, it is possible to check most of the items in the mental test score by working them into your introductory conversation. Hearing and speech impairments (such as nominal dysphasia) can make people appear very cognitively impaired, but should be easy to recognize. Depressed patients tend to perform poorly on mental test scores. If a problem is detected with a simple test, proceed to a more in-depth assessment using the MMSE (see Ch. 7). Assessment of mental state is most valuable when applied serially over a period of time.

Management of suspected dementia should aim to confirm the diagnosis, to identify potentially reversible causes and to determine a management plan with the patient and carers. This is best achieved in a diagnostic memory clinic, where a multidisciplinary approach involving a geriatrician, psychiatrist, psychologist and nurse specialist may be taken. As with any other group of patients, examination and investigation should be appropriate and directed towards helping with the management plan.