What is the most likely diagnosis?A 75-year-old white man presents for a health maintenance checkup. The patient has stable hypertension but has not seen a physician in more than 2 years. He denies any particular problems. He lives alone. He takes an aspirin a day and is compliant with his blood pressure medication (hydrochlorothiazide). His son fears that his father is either experiencing a stroke or getting Alzheimer disease because his father is having trouble with speech discrimination and understanding what family members are saying during social events. The son reported no noticeable weakness or gait impairment. On physical examination, the patient’s blood pressure was 130/80 mm Hg. Examination of the ears showed no cerumen impaction and normal tympanic membranes. His general examination is normal. Laboratory studies, including thyroid-stimulating hormone (TSH), are normal.
What is the most likely diagnosis?
What is the next step?
Summary: A 75-year-old man who presents with loss of speech discrimination and complains of difficulty understanding speech and conversation in noisy areas.
• Most likely diagnosis: Presbycusis
• Next step: Presbycusis is a diagnosis of exclusion. Hearing aids are underused in presbycusis, but are potentially beneficial for most types of hearing loss, including sensorineural hearing loss. Consequently, referral to an audiologist for testing and consideration of amplification with a hearing aid may be an important next step.
1. Be familiar with geriatric health maintenance.
2. Be aware of the importance of geriatric screening.
The patient described in the case is a 75-year-old man who has difficulty with speech discrimination and complains of difficulty understanding speech and conversation in noisy areas. He most likely has presbycusis, which is an age-related sensorineural hearing loss typically associated with both selective high-frequency loss and difficulty with speech discrimination. Physical examination of the ears in patients with presbycusis is normal. Other conditions in the differential diagnosis include cerumen impaction, otosclerosis, and central auditory processing disorder. Cerumen impaction and otosclerosis can be diagnosed by otoscopy. Central auditory processing disorder is diagnosed when the patient can hear sounds without difficulty, but has difficulty in understanding spoken words.
PRESBYCUSIS: An age-related sensorineural hearing loss typically associated with both selective high-frequency loss and difficulty with speech discrimination.
FUNCTIONAL ASSESSMENT: An evaluation process that gauges a patient’s ability to manage tasks of self-care, household management, and mobility.
By the year 2030, the number of people aged 65 years and older is expected to double from what it was in 1999, increasing from 34 million to 69 million. Geriatric health maintenance provides screening and therapy with the goal of enhancing function and preserving health in the elderly. Screening is not indicated unless early therapy for the screened condition is more effective than late therapy or no therapy. Preventive services for the elderly include as goals the optimization of quality of life, satisfaction with life, and maintenance of independence and productivity. Most recommendations for patients older than age 65 years overlap recommendations for the general adult population. Certain categories are unique to older patients, including sensory perception and fall. The primary care physician can perform effective health screening using simple and relatively easily administered assessment tools (Figure 18–1).
Figure 18–1. Approach to geriatric health maintenance. ADL, activities of daily living; DNAR, do not attempt resuscitation; IADL, instrumental activities of daily living.
Functional assessment gauges a patient’s ability to manage tasks of self-care, household management, and mobility. Impairment in activities of daily living results in an increased risk of falls, hip fracture, depression, and institutionalization. An estimated 25% of patients older than age 65 years have impairments in their instrumental activities of daily living (IADL) or activities of daily living (ADL) (Table 18–1). Persons who are unable to perform IADL independently are far more likely to have dementia than their independent counterparts.
Table 18–1 • INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) AND ACTIVITIES OF DAILY LIVING (ADL)
Visual impairment is an independent risk factor for falls, which has a significant impact on quality of life. Direct visual testing with a Snellen chart or Jaeger card is the most sensitive and specific approach to visual screening. Referring all older people for a complete eye examination has the advantages of improving the quality of the examination and allowing for cataract and glaucoma screening. The majority of conditions leading to vision loss in the elderly are presbyopia, macular degeneration, glaucoma, cataract, and diabetic retinopathy.
The incidence of presbyopia increases with age. Patients have difficulty focusing on near objects while their distant vision remains intact. Age-related macular degeneration (AMD) is the leading cause of severe vision loss in the elderly. AMD is characterized by atrophy of cells in the central macular region of the retinal pigment epithelium, resulting in the loss of central vision. Glaucoma is characterized by a group of optic neuropathies that can occur in all ages. Although glaucoma is most often associated with elevated intraocular pressure, it is the optic neuropathy that defines the disease. Cataract is any opacification of the lens. Age-related, or senile, cataracts account for 90% of all cataracts. Cataract disease is the most common cause of blindness worldwide. Diabetic retinopathy is the leading cause of blindness in working-age adults in the United States. It is important to consider diabetic retinopathy in geriatric vision screening.
More than one-third of persons older than age 65 years and half of those older than age 85 years have some hearing loss. This deficit is correlated with social isolation and depression. The whispered voice test has sensitivities and specificities ranging from 70% to 100%. The initial office screening for general hearing loss can be reliably performed with questionnaire such as the HHIE-S (Hearing Handicap Inventory for the Elderly). Limited office-based pure-tone audiometry is more accurate in identifying patients who would benefit from a more formal audiometry.
The majority of patients with hearing impairment will present with complaints unrelated to their sensory deficit. In a quiet examination room with face-to-face conversation, patients can overcome significant hearing loss and avoid detection from a physician. Family members are often more concerned about the hearing loss than the patient. Common causes of geriatric hearing impairments are presbycusis, noise-induced hearing loss, cerumen impaction, otosclerosis, and central auditory processing disorder. Presbycusis is age-related sensorineural hearing loss usually associated with both selective high-frequency loss and difficulty with speech discrimination. Presbycusis is the most common form of hearing loss in the elderly. Because it often goes unrecognized, exact prevalence data are lacking. Presbycusis is a diagnosis of exclusion. Complete deafness is not an expected end result of presbycusis. Noise-induced hearing loss is essentially a wear and tear phenomenon that can occur with either industrial or recreational noise exposure. Patients will typically present with tinnitus, difficulty with speech discrimination, and problems hearing background noise. Cerumen impaction in the external auditory canal is a common, frequently overlooked problem in the elderly that may produce a transient, mild conductive hearing loss. It is estimated that 25% to 35% of institutionalized or hospitalized elderly are affected by impacted cerumen. Otosclerosis is an autosomal dominant disorder of the bones in the inner ear. It results in progressive conductive hearing loss with onset most commonly in the late twenties to the early forties. Speech discrimination is typically preserved. Geriatric patients with hearing loss may have otosclerosis complicating their presentation. Central auditory processing disorder (CAPD) is the general term for conditions involving hearing impairment that results from CNS dysfunction. The patient with CAPD will have difficulty understanding spoken language, but may be able to hear sounds well.
Falls are the leading cause of nonfatal injuries in the elderly. The associated complications are the leading cause of death from injury in those older than age 65 years. Hip fractures are common precursors to functional impairment and nursing home placement. Approximately 30% of the noninstitutionalized elderly fall each year. The annual incidence of falls approaches 50% in patients older than 80 years of age. Factors contributing to falls include age-related postural changes, alterations in visual ability, certain medications, and diseases affecting muscle strength and coordination. Every older person should be asked about falls, as many will not volunteer such information. Gait impairments commonly coexist with falls.
The prevalence of dementia doubles every 5 years after age 60, so that by age 85 approximately 30% to 50% of individuals have some degree of impairment. Patients with mild or early dementia frequently remain undiagnosed because their social graces are retained. The combination of the “clock draw” and the “three-item recall” is a rapid and fairly reliable office-based screening for dementia. When patients fail either of these screening tests, further testing with the Folstein Mini-Mental State questionnaire should be performed.
Incontinence in the elderly is common. Incontinence is estimated to affect 11% to 34% of elderly men and 17% to 55% of elderly women. Continence problems are frequently treatable, have major social and emotional consequences, but are often not raised by patients as a concern.
Depressive symptoms are more common in the elderly despite major depressive disorder being slightly lower in prevalence when compared with younger populations. Unlike dementia, depression is usually treatable. Depression significantly increases morbidity and mortality, and is often overlooked by physicians. A simple two-question screen (Have you felt down/depressed/hopeless in the last 2 weeks? and Have you felt little interest or pleasure in doing things?) shows high sensitivity. Positive responses can be followed up with a Geriatric Depression Scale, a 30-question instrument that is sensitive, specific, and reliable for the diagnosis of depression in the elderly.
Approximately 15% of older outpatients and half of the hospitalized elderly are malnourished. A combination of serial weight measurements obtained in the office and inquiry about changing appetite are likely the most useful methods of assessing nutritional status in the elderly. Adequate calcium intake for women is advised. Supplementation with a multivitamin formulated at about 100% daily value can decrease the prevalence of suboptimal vitamin status in older adults and improve their micronutrient status to levels associated with reduced risk for several chronic diseases. Malnutrition is common in nursing homes, and protein undernutrition has a prevalence of 17% to 56% in this setting. Protein undernutrition is associated with an increased risk of infections, anemia, orthostatic hypotension, and decubitus ulcers.
Treatment of hypertension is of substantial benefit in the elderly. Heart disease and cerebrovascular disease are leading causes of death in the elderly. Treatment of hypertension has contributed to a reduction in mortality from both stroke and coronary artery disease. Lifestyle modifications are recommended for all hypertensive patients. Thiazides are the drugs of choice unless a comorbid condition makes another choice preferable.
The incidence of stroke in older adults roughly doubles with each 10 years of age. The greatest risk factor is hypertension followed by atrial fibrillation. Anticoagulation with warfarin reduces the risk of strokes in people with atrial fibrillation, but many elderly patients are not anticoagulated because of the fear of injuries from falls. In most instances, the benefits of anticoagulation are likely to outweigh the increased risk of fall-related bleeding, unless the patient has multiple falls, high-risk falls, or a very low risk of stroke.
Screening elderly men for prostate cancer is not routinely recommended, as it has not been definitively shown to prolong life and because of the risk of incontinence or erectile dysfunction caused by the treatments. An older woman should undergo annual mammography until her life expectancy falls below 5 to 10 years. Screening for colon cancer (either with colonoscopy every 10 years or with annual fecal occult testing plus flexible sigmoidoscopy every 5 years) can be stopped when a patient’s life expectancy is less than 5 to 10 years. Screening for cervical cancer can be stopped in women older than 65 to 70 who have had three normal Papanicolaou smears over the preceding 10 years.
The prevalence of low bone mineral density in the elderly is high, with osteopenia found in 37% of postmenopausal women. Primary prevention of osteoporosis begins with identification of risk factors (older age, female gender, white or Asian race, low calcium intake, smoking, excessive alcohol use, and chronic glucocorticoid use). Calcium carbonate (500 mg three times daily) and vitamin D (400-800 IU/d) reduce the risk of osteoporotic fractures in both men and women. Bone mineral density testing using dual-energy x-ray absorptiometry (DEXA) of patients with multiple risk factors may uncover asymptomatic osteoporosis.
Everyone over the age of 6 months should receive annual influenza vaccination. Persons older than age 65 should receive at least one pneumococcal immunization and a single booster dose of tetanus and diphtheria vaccine. One dose of herpes zoster vaccine is recommended at age 60 or older.
Well-informed, competent adults have a right to refuse medical intervention, even if refusal is likely to result in death. To further patient autonomy, physicians are obligated to inform patients about the risks, benefits, alternatives, and expected outcomes of end-of-life medical interventions such as cardiopulmonary resuscitation, intubation and mechanical ventilation, vasopressor medication, hospitalization and ICU care, and artificial nutrition and hydration. Advance directives are oral or written statements made by patients when they are competent that are intended to guide care should they become incompetent. Advance directives allow patients to project their autonomy. Although oral statements about these matters are ethically binding, they are not legally binding in all states. Written advance directives are essential so as to give effect to the patient’s wishes in these matters.
A durable power of attorney for health care (DPOA-HC) allows the patient to designate a surrogate decision maker. The responsibility of the surrogate is to provide “substituted judgment” to decide as the patient would, not as the surrogate wants. In the absence of a designated surrogate, physicians turn to family members or next of kin, under the assumption that they know the patient’s wishes.
Physicians should encourage patients to express their preferences for the use of cardiopulmonary resuscitation (CPR). Despite the favorable portrayal of CPR in the media, only approximately 15% of all patients who undergo CPR in the hospital survive to hospital discharge. DNAR (“do not attempt resuscitation”) is the preferred term over DNR (“do not resuscitate”) to emphasize the low likelihood of successful resuscitation. In addition to mortality statistics, patients deciding about CPR preferences should also be informed about the possible consequences of surviving a CPR attempt. CPR may result in fractured ribs, lacerated internal organs, and neurologic disability. There is also a high likelihood of requiring other aggressive interventions if CPR is successful. For some patients at the end of life, decisions about CPR may not be about whether they will live but about how they will die.
18.1 A third-year medical student is researching various recommendations for the care of the geriatric patient. Which of the following statements is most accurate?
A. The American Urological Association (AUA) and United States Preventive Services Task Force (USPSTF) recommend annual prostate cancer screening with digital rectal examination (DRE) and prostate-specific antigen (PSA).
B. All men older than age 50 years should have a PSA drawn each year, regardless of other health conditions.
C. The United States Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for prostate cancer with digital rectal examination (DRE) and prostate-specific antigen (PSA).
D. Transrectal ultrasound offers the greatest sensitivity and specificity for detecting prostate cancer.
E. For healthy men older than age 70 years, the AUA discourages any prostate cancer screening.
18.2 A 70-year-old man is having difficulty hearing his family members’ conversations. He is diagnosed with presbycusis. Which of the following statements regarding his condition is most accurate?
A. Presbycusis does not respond to hearing aid use.
B. Presbycusis is usually caused by a conductive disorder.
C. Presbycusis usually results in loss of speech discrimination.
D. Presbycusis usually results in unilateral hearing loss.
E. Presbycusis usually results in low-frequency hearing loss.
18.3 Which of the following is the leading cause of blindness worldwide?
A. Glaucoma
B. Vitamin A deficiency
C. Age-related, or senile, cataracts
D. Diabetic retinopathy
18.1 C. The combination of DRE and PSA is known to increase the sensitivity and specificity of prostate cancer detection. However, the benefit of routine use of checking prostate-specific antigen and rectal examination to detect prostate cancer is questionable. It is a Category I recommendation.
18.2 C. Up to one-third of persons older than age 65 years suffer from hearing loss. Presbycusis typically presents with symmetric high-frequency hearing loss. There is loss of speech discrimination, so that patients complain of difficulty understanding rapid speech, foreign accents, and conversation in noisy areas. The mechanism is sensorineural rather than a conductive problem.
18.3 C. The vast majority of cataracts are age related, although there are other causes. Cataracts are the leading cause of blindness worldwide. Diabetic retinopathy is the leading cause of blindness in working-age adults in the United States. Age-related macular degeneration is the most common cause of severe vision loss in the elderly.
Protein undernutrition is associated with an increased risk of infections, anemia, orthostatic hypotension, and decubitus ulcers.
Smoking is associated with osteoporosis.
If “osteoporotic” fractures, such as vertebral compression fractures, occur in conjunction with osteopenia on x-ray, the diagnosis of osteoporosis is almost certain.
Hearing loss, and sensory impairments in general, can be confused with cognitive impairment or an affective disorder.
Presbyopia, macular degeneration, glaucoma, cataracts, and diabetic retinopathy account for the majority of conditions leading to vision loss in the elderly.
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