Age-Specific Examination
Special Populations and Older Adults
Examination Guidelines
Variability exists in knowledge, experience, cognitive abilities, and personality among patients. These differences can affect your interaction. Persons with disabilities and older adults may experience some decline in their abilities, and these changes may not all occur at the same rate. Adaptation to patients’ needs with disabling physical, intellectual, or emotional states (e.g., acute disabling illness, deafness, blindness, depression, psychosis, developmental delays, or neurologic impairments) is necessary.
Some patients may have sensory losses, such as hearing, that make communication more difficult. Position yourself so that the patient can see your face. Speak clearly and slowly;shouting magnifies the problem by distorting consonants and vowels. For deaf patients who use sign language, use of a sign language interpreter is best. Impaired vision and difficulties with light-dark adaptation are a problem with written interview forms. Large print and lighting that does not glare or reflect in the eyes or individualized assistance is helpful.
The patient has most often learned the best way to be transferred from a wheelchair or bed to another site or to a different position. Consult patient about this.
Let a hearing-, speech-, or vision-impaired patient guide you to the best communication system for your mutual purposes.
Bowel and bladder concerns are common to many individuals with disabilities and should be given the necessary attention during the examination process.
Cognitive Assessment
Some older adults or individuals with intellectual delay may be confused or experience memory loss, particularly for recent events. Take whatever extra time is needed. Ask short (but not leading) questions, and keep your language simple. Consult other family members to clarify discrepancies or to fill in the gaps. When necessary, use other health care professionals involved in care and the patient’s record as resources for a more complete background.
Mental status is assessed continuously throughout the entire interaction with a patient by evaluating the patient’s alertness, orientation, cognitive abilities, and mood. Observe the patient’s physical appearance, behavior, and responses to questions asked during the history (see figure, p. 276). Evaluate the patient’s mental status throughout the encounter (see Chapter 3).
Testing Memory in Visually Impaired Patients
When a patient is visually impaired, test recent memory with unrelated words rather than observed objects. Pick four unrelated words that sound distinctly different, such as “green,” “daffodil,” “hero,” and “sofa” or “bird,” “carpet,” “treasure,” and “orange.” Tell the patient to remember these words. After 5 minutes, ask the patient to list the four words.
Cognitive impairment that deprives ability to join in decision-making processes underscores the need for advance directives, which document the patient’s wishes regarding extraordinary means of life support (e.g., ventilation assistance and feeding tubes). These documents should be complemented by a surrogate (e.g., spouse, child, sibling, or other person with a close relationship) who has a legally executed durable power of attorney for health care.
Multiple problems that require multiple medications increase risk for iatrogenic disorders and issues related to interactions. A medication history with attention to interactions of drugs, diseases, and aging is needed for prescribed and over-the-counter medications and herbal preparations.
Aging, disability, a debilitating illness, and the onset of frailty increase dependency on others, worry about tomorrow, and grieving for what has been lost. Recognize these vast concerns and the sense of loss in both the patient and the immediate caregiver. Maintaining function is a compelling concern of older adults.
Functional Assessment
Functional assessment is an evaluation of a patient’s ability to achieve the basic activities of daily living (ADLs). Questions concerning the ability to take care of one’s daily needs are part of the review of systems.
Activities of Daily Living
The ability to perform instrumental ADLs, or the ability to live independently, is an important assessment. Determine the patient’s ability to perform the following:
The personal and social history should include other dimensions of functional capacity such as social, spiritual, and economic resources; recreational activity; sleep patterns; environmental control; and use of the health care system.
Functional assessment should be given to anyone limited by disease or disability and includes:
Any limitations will affect a patient’s independence and autonomy, and increase reliance on other people and on assistive devices.
In older patients, these limitations indicate the loss of physical reserve and the potential loss of physical function and independence that indicate the onset of frailty.
Frailty is an at-risk state caused by the age-associated accumulation of deficits. With multisystem dysregulation, decreased physiologic reserves, and increased vulnerability to stressors, frailty shares features of normal aging (Fedarko, 2011; Rockwood and Mitnitski, 2011), but age and frailty are not necessarily synonymous.