Chapter III PHYSICAL ASSESSMENT AND
|Certain disorders commonly affect the elderly. When reviewing your elderly patient’s systems, note the following possibly pathological signs and symptoms:|
|SKIN:||Delayed wound healing, change in texture|
|NAILS:||Brittleness, clubbing, pitting|
|HEAD:||Facial pain or numbness|
|EYES:||Diplopia, tunnel vision, halo effect, glaucoma, cataracts|
|EARS:||Excessive wax formation, use of wax softeners|
|NOSE:||Epistaxis, allergic rhinitis|
|MOUTH/THROAT:||Sore tongue, problems with teeth or gums, gums bleeding at night, hoarseness|
|NECK:||Pain, swelling, restricted range of motion.|
|RESPIRATORY:||Tuberculosis, difficulty or painful breathing, excessive cough producing
excessive or blood-streaked sputum.
|BREASTS||Discharge, change in contour, nipples, gynecomastia, lumps.|
|CARDIOVASCULAR:||Chest pain on exertion, orthopnea, cyanosis, syncope, fatigue, murmur, leg cramps,
varicosities, coldness or numbness of extremities, hypertension, heart attack.
|RENAL:||Flank pain, dysuria, polyuria, nocturia, incontinence, enuresis, hematuria, renal or bladder infections or kidney or bladder stones.|
|REPRODUCTIVE:|| Male – Hernia, testicular pain, prostatic problems.
Female – Postmenopausal problems (bleeding, hot flashes).
|MUSCULOSKELETAL:||Pain, joint swelling, crepitus, restricted motion, arthritis, gout, lumbago,
|NERVOUS:|| Memory loss, loss of consciousness, nervousness, insomnia, changes in emotionas,
tremors, muscle weakness, paralysis, aphasia, speech changes, numbness.
When you assess the psychological status of an elderly patient, remember that he or she is probably dealing with complex and important changes at a time in his/her life when his/her ability to solve problems may be diminishing. If he/she tends to cope well with stress and views aging as a normal part of life, he/she should be able to adjust smoothly to the changes that aging brings.
Common psychological problems among elderly patients include organic brain syndrome, depression, grieving, substance abuse, adverse drug reactions, dementia, paranoia and anxiety. Of course these problems are not limited to the elderly patients. Their incidence, however, is much higher in this age group than in all other age groups.
1. ORGANIC BRAIN SYNDROME
Organic Brain Syndrome is the most common form of mental illness in the elderly population. It occurs in both an acute form (reversible cerebral destruction) and a chronic form (irreversible cerebral cellular destruction). Characteristics of both types include impaired memory (especially recent memory), disorientation, confusion and poor comprehension.
In the elderly person, acute organic brain syndrome may result from malnutrition, cerebrovascular accident, drugs, alcohol or head trauma. Restlessness and a fluctuating level of awareness, ranging from mild confusion to stupor, may signal this condition.
The cause of chronic organic brain syndrome is unknown. The major signs of this disorder include impaired intellectual functioning, poor attention span, memory loss using confabulation and varying moods.
Depression is the most common psychogenic problem found in elderly patients. Since the symptoms of depression span a wide range, consider it as a possibility in any elderly patient.
Depression may appear as:
- changes in behavior (apathy, self-depreciation, anger, inertia).
- changes in thought processes (confusion, disorientation, poor judgment).
- somatic complaints (appetite loss, constipation, insomnia).
If you observe any of these signs, question your patient in detail about recent losses. Also find out how he or she is coping with those losses. Assess their feelings carefully. Remember that an elderly patient’s attitude toward his/her own aging and death – and toward death and dying in general – will affect his/her chances for successful treatment of depression.
A common difficulty elderly patients’ face is adapting to loss. The grieving process regularly intrudes on their lives. Your patient may have to deal with losing a job, income, friends, family, health or even his home.
These losses and associated feelings of isolation and loneliness can cause stress that has physiological and psychologic consequences. For example, the loss of a spouse or other loved one can trigger profound sorrow. The resolution of this may be difficult. Unsuccessful resolution of grief can cause a pathologic grief reaction. This reaction may take the form of physical or mental illness.
Many elderly people today are turning to substance abuse and suicide in response to severe stress. Suspect possible substance abuse or thoughts of suicide if your patient is taking an unusual amount of medications. Also observe for such signs of alcohol abuse as jaundice and tremor.
CLINICAL DEPRESSION IN THE ELDERLY (Gerontology 1991)
We will use the term “client” and “patient” almost interchangeably. We understand that the terms “client” and “patient” tend to be used differently in different parts of the country. In the editor’s opinion these terms, in this text, can be used interchangeable.
Depression has been shown to be the most frequent cause for hospitalization in the elderly. The nurse must be able to understand and then cope with this very common ailment in our elderly population. The depressed elderly man or woman represents a very challenging nursing problem. Depression in the elderly often manifests itself as a variety of symptoms, both physical and emotional. This life-threatening disorder should be treated aggressively; and the nurse can certainly play an important role in the overall treatment plan for the elderly client1.
Depression is defined by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, as a persistently dysphoric and sad mood with loss of pleasure in usual pastimes. Much of the chronic disability in the elderly can be related to depression.
Many researchers claim that 25 to 30 percent of the population over 65 years of age suffer from symptoms of clinical depression. Some researchers have also concluded that the elderly tend to have more frequent recurrence of depressive episodes; and that symptoms tend to be more severe in the elderly. However, as the person ages, it is increasingly difficult to identify and diagnoses this condition.
Persons over the age of 65 will vary often suffer from poly pharmacy, increasing number of illnesses, more personal losses and more nutritional changes. Retirement, loss of status, family losses and other conditions seen in the elderly may lead to an increased risk of depression which, as we stated, is often difficult to diagnose.
Again, here is where the nurse may plan an important role. Be aware of the client who comes to the doctor with symptoms of insomnia, anorexia, constipation and feelings of uselessness. These may often be regarded as merely physical signs of aging. The nurse may further assess the client and determine whether or not the patient may have an underlying depression. Many times medications are prescribed for these “minor symptoms”. Be aware that some of these medications prescribed for these illnesses can actually cause depression in the elderly person. Steroids, anti-hypertensive drugs, anticonvulsants, anti-inflammatory drugs, antihistamines, cytoxic drugs and many other drugs may actually cause depression.
Assessment of depression in the elderly is the most important aspect of the nursing care. An important part of the assessment is the nursing history. Be sure to take a complete psychosocial history from the patient and/or the family.
This text has an excellent assessment tool for the psychosocial areas. Be sure to assess the psychosocial history that includes the person’s “normal” characteristics and those characteristics that the person is now experiencing. The nurse needs to differentiate between a normal “blue spell” and a deep depression. Symptoms that persist for two weeks or more are signs of a severe depression. Be sure to complete a thorough physical assessment as well as the psychosocial areas. Assess diet, skin, hygiene, elimination pattern, sleep pattern, exercise pattern, medication history and emotional discomfort. The assessment tool in this text includes all of these aspects.
Depressed persons are likely to ignore hygiene. This can lead to skin problems and skin breakdown. Constipation is a complaint often seen in the depressed client. Insomnia is probably the most common sleep problem seen in the depressed person. Look for these signs and symptoms when performing your nursing assessment. Also, begin to assess for the barriers to treatment of the depressed patient. Be aware of the patients’ attitudes toward mental health services. Very often, the older person has very set ideas regarding the health care system and care-givers. They might be afraid of the doctor or the nurse for fear of being labeled as “crazy”. Also observe their reaction to strangers (the nurse). Many elderly persons are very fearful of trusting strangers, even if the stranger is their nurse. You might wish to determine the type of health insurance the person has. Their financial position many times will dictate their reluctance to seek treatment. Be alert to these and other such situations that might be an obstacle to treatment. Later on in the hospitalization these factors may plan an important part of the treatment plan.
The term “aggressive treatment” means that the patient needs “intensive” treatment. He/she might need powerful drugs or powerful treatments; but he/she also needs to be observed carefully.Finally, the treatment of depression in the elderly will usually involve some type of psychotherapy and/or counseling. Remember that depression in the elderly can be very serious. Symptoms of depression can be serious enough to lead to the death of the patient. Be sure that your facility can provide the type of services needed by the severely depressed patient. Many facilities lack the necessary trained staff to deal with severely depressed patients. Your assessment can be very important. Your assessment might lead you to inform the doctor that this client is very depressed and needs aggressive treatment.
Remember that depression in the elderly can be life-threatening. You, as the nurse, need to be aware of how depression develops in the elderly and the signs and symptoms. One of the nursing responsibilities is to educate the health care workers at your facility. Everyone on the health care team must be able to recognize depression and to alert the patient’s physician. You also need to know how to take the appropriate action; and take it quickly, if we as nurses are going to provide the best possible care to the depressed elderly patients.
3. ADVERSE DRUG REACTIONS
When you assess an elderly patient, consider that his/her psychological problems may result from undetected adverse drug reactions. The incidence of these reactions increases in older people because they use more drugs. They also may not take medications in the prescribed manner. Physiologic changes related to the aging process also may alter a patient’s reaction to drugs. Such routinely prescribed medications as tranquilizers and barbiturates can cause or increase depression. Other medications, including anticholinergics and diuretics, may cause confusion in elderly patients. Always include a detailed drug history in your psychological assessment.
4. PARANOIA IN THE ELDERLY
Paranoia is defined as an unreasonable fear that they are in danger. Paranoia may be one symptom of psychosis, depression or dementia. It can also be a discreet illness, characterized by a slow, gradual development of a rigid delusional system in a patient who otherwise has clear thought processes.
If you detect signs of paranoia during the mental status examination, try to determine whether they are a result of sensory-loss problems (which may be corrected by glasses or a hearing aid), psychological problems or a realistic fear of attack or robbery. Make certain that you rule out the possibility that the “paranoia” is justified. In today’s society, many elderly are in fear of their lives. In some cases this may be true. Crime has become so prevalent and vicious that the nurse must make a decision. Is this person’s fear justified? Or are they paranoid?
5. THE EFFECTS OF ANXIETY
In an elderly patient, the need to adjust to physical, emotional and socioeconomic changes (such as hospitalization, loneliness or moving to a new neighborhood) can cause an acute anxiety reaction. These changes may raise the anxiety level to the point of temporary confusion and disorientation. Often an elderly person’s condition can be mislabeled as senility or as organic brain syndrome. Actually the condition should be considered a psychogenic disorder (Tom 1976).
Dementia is the loss of intellectual abilities, especially those higher order functions measured by memory, judgment, abstract thinking and visual-spatial relations, in the context of preserved alertness. Dementia is different from delirium, which is a clouding of consciousness with decreased awareness of both external and internal environment and a decrease in the ability to sustain attention manifested by disordered thinking and agitation (Wetle 1982).
Fifteen percent of persons over 65 have some degree of dementia. Less than 5 percent are severely impaired due to dementia. There are many terms that are commonly interchanged by the public. The nurse must be sure to use the correct terminology after assessing the condition of the patient. These terms often used interchangeably are: senile dementia, primary neuronal degeneration, chronic brain syndrome, Alzheimer’s disease and primary degenerative dementia.
Once the condition has been accurately diagnosed by the physician, the treatment plan can be set to most effectively deal with the problem. Many times the underlying problem is Alzheimer’s disease. Other times the diagnosis will be Parkinson’s or other disease conditions. Whichever is the case, the nursing responsibility is to accurately assess and report history and symptoms of the illness in order to expedite the correct treatment plan.
Senile dementia induced by Alzheimer’s disease is usually slow in onset. Women are more often affected by this type of dementia than are men. The patients tend to be of advanced years and the Alzheimer’s dementia has a slow linear progression. These patients tend to have a flat affect (show little emotion) and no other organic disease conditions can be identified (they are ruled out by lab tests ad by examination). Most other types of dementia (from brain disorders) tend to afflict younger old people and usually have an abrupt onset.
1. NORMAL AGING CHANGES
Aging is characterized by the loss of some body cells and reduced metabolism of others. These conditions cause loss of bodily function and changes in body composition. Adipose tissue store usually increases with age. Lean body mass and bone mineral contents usually decrease with age.
A person’s protein, vitamin and mineral requirements usually remain the same as he or she ages. Whereas caloric needs of the elderly are decreased. Decreased activity may lower energy requirements about 200 calories per day for men and women aged 51 to 75; 400 calories per day for women over the age of 75; and 500 calories per day for men over the age of 75.
Other physiologic changes that can affect nutrition in an elderly patient include:
- Decreased renal function, causing greater susceptibility to dehydration and formation of renal calculi.
- Loss of calcium and nitrogen (in patients who are not ambulatory).
- Decreased enzyme activity and gastric secretions.
- Decreased salivary flow and diminished sense of taste, which may reduce the person’s appetite and increase consumption of sweet and spicy foods.
- Decreased intestinal motility.
2. PATIENT HISOTRY
Disabilities, chronic diseases and surgical procedures (for example, gastrectomy) commonly affect an elderly patient’s nutritional status, therefore, to be sure to record them in your patient history. Drug or substances taken by your patient for a medical condition may also affect nutritional requirements. For example, mineral oil, which many elderly persons use to correct constipation, may impair gastrointestinal absorption of vitamin A.
Some common conditions found in elderly persons can affect nutritional status by limiting the patient’s mobility. Therefore, the ability to obtain and prepare food or feed him or herself could be compromised. Among such disorders are conditions such as degenerative joint disease, paralysis and impaired vision (from cataracts or glaucoma).
Gastrointestinal complaints, especially constipation and stool incontinence, commonly occur in older patients. A decrease in intestinal motility characteristically accompanies aging. Constipation may also be related to poor dietary intake, physical inactivity or emotional stress. Constipation may also occur as a side effect of certain drugs. Elderly patients often consume nutritionally inadequate diets consisting of soft, refined foods that are low in residue and dietary fiber. Laxative abuse, another common problem in elderly patients, results in the rapid transport of food through the gastrointestinal tract and subsequent decreased periods of digestion and absorption.
Socioeconomic and psychological factors that affect nutritional status include loneliness, decline of the elderly person’s importance to the family, susceptibility to nutritional quackery and lack of money to purchase nutritionally beneficial foods.
3. ASSESSMENT TECHNIQUES
Currently, the adult standards for nutritional assessment are used for the elderly. These standards, however, are not as reliable for the elderly age group. Further research is needed to develop tools for assessing the nutritional requirements of elderly persons.
Measures you can use to assess such a patient’s nutritional status include:
- Common sense.
- Consideration of factors that place any patient at nutritional risk.
- The dietary history.
- Your objective data (keeping their limitations in mind).
- Monitoring of the patient’s intake (if hospitalized).
Remember, protein-calorie malnutrition is a major nutritional problem in patients over 75 years of age and contributes significantly to this age group’s mortality (Goldman 1971) (Health Assessment Handbook 1992).
MUSCULOSKELETAL SYSTEM1. SPECIAL HISTORY QUESTIONS
Biographical data are significant for the elderly, because osteoporosis commonly occurs after the age of 50.
If your patient’s chief complaint is pain associated with a fall, determine if the pain preceded the fall. Pain present before a fall may indicate a pathological fracture. Also, ask if your patient has noticed any vision or coordination changes that may make him or her more susceptible to falling.
When recording the patient’s past history, determine if he or she has had:
- Asthma (treatment with steroids can lead to osteoporosis).
- Arthritis (which produces joint instability).
- Pernicious anemia (inadequate absorption of vitamin B12 in pernicious anemia leads to loss of vibratory sensation and proprioception, resulting in falls).
- Cancer of the breast, prostate, thyroid, kidney or bladder may metastasize to bone.
- Hyperparathyroidism leads to bone decalcification and osteoporosis.
- Hormone imbalance can result in postmenopausal osteoporosis.
2. PHYSICAL EXAMINATION FINDINGS
Your examination of the elderly individual with a suspected musculoskeletal disorder is the same as for a younger adult. However, older patients may need more time or assistance with such tests as range of motion and gait assessment. This is due to muscle weakness and decreased coordination.
Disorders of motor and sensory function, manifested by muscle weakness, spasticity, tremors, rigidity and various types of sensory disturbances are common in the elderly. Damaging falls may result from difficulty in maintaining equilibrium and from uncertain gait.
Be sure to differentiate gait changes caused by joint disability, pain or stiffness from those caused by neurologic impairment or another disorder. Bone softening from demineralization (senile osteoporosis) causes abnormal susceptibility to major fractures. Most patients, over the age of 60, have some degree of degenerative joint disease. This can cause joint pain and limits spinal movement (Health Assessment Handbook 1987) (Stosky 1968).
1. ENDOCRINE SIGNS AND SYMPTOMS
Many endocrine disorders cause signs and symptoms in the elderly that are similar to changes that normally occur with aging. For this reason, these disorders are easily overlooked during the assessment. In an adult patient with hypothyroidism, for example, mental status changes and physical deterioration, including weight loss, dry skin, and hair loss, occur. Yet these same signs and symptoms characterize the normal aging process.
Other endocrine abnormalities may complicate your assessment because their signs and symptoms are different in the elderly than in other age groups. Hyperthyroidism, for example, will usually cause nervousness and anxiety, but a few geriatric patients may instead experience depression or apathy (a condition known as apathetic hyperthyroidism of the elderly). In addition, an elderly patient with Grave’s Disease may initially have signs and symptoms of congestive heart failure or atrial fibrillation rather than classic manifestations associated with this disorder.
2. NORMAL VARIATIONS IN ENDOCRINE FUNCTION
A very common and important endocrine change in the elderly is a decreased ability to tolerate stress. The most obvious and serious indication of this diminished stress response occurs in glucose metabolism. Normally, fasting blood sugar levels are not significantly different in young and old adults. However, when stress stimulates the older person’s pancreas, the blood sugar concentration increase is greater and lasts longer than in a younger adult. This decreased glucose tolerance occurs as a normal part of aging. Therefore, keep this fact in mind when you are evaluating an elderly patient for possible diabetes.
During menopause, a normal part of the aging process in women, ovarian senescence causes permanent cessation of menstrual activity. Changes in endocrine function during menopause varies from woman to woman. However, estrogen levels usually diminish and follicle-stimulating hormone production increases. This estrogen deficiency may result in either or both of two key metabolic effects; coronary thrombosis and osteoporosis. Remember, too, that some symptoms characteristic of menopause (such as depression, insomnia, headaches, fatigue, palpations and irritability) may also be associated with endocrine disorders. In men, the climacteric stage causes a decrease in testosterone levels and in seminal fluid production.