Physical health assessment

Chapter 15 PHYSICAL HEALTH ASSESSMENT



INTRODUCTION


As general medical conditions increase sharply in prevalence with advancing age, many people referred to older persons’ mental health services (OPMHS), and many of their carers, will have one or more such conditions. Common conditions in later life include gastro-oesophageal reflux disorder, hypertension, ischaemic heart disease, type 2 diabetes mellitus, stroke, cancer, osteoarthritis, osteoporosis, chronic obstructive lung disease, impaired vision due to cataracts or macular degeneration, and impaired hearing (presbyacusis). Mental health problems can interact with physical health problems in various ways to increase the person’s level of disability. For instance, some mental health problems, such as dementia or schizophrenia, can lead to reduced adherence with prescribed medications for general medical problems.


Because of its necessary use of technical medical language, this chapter is likely to be most relevant to clinical nurse specialists and junior medical personnel. It is beyond the scope of this book to go into great detail on physical examination. However, those interested in pursuing the matter further are advised to consult one of a number of excellent books on the subject (e.g. Talley & O’Connor 2005). For a shorter treatment of the subject, consult the brief article on physical examination in psychiatric practice by Garden (2005).



MEDICAL HISTORY


Much of the medical history, including past surgical and obstetric and gynaecological history, should be available from the person themselves and from records of the person’s general practitioner (GP). However, it is worth running through a short list of general medical problems that are directly relevant to mental health. These include: hypertension, hypercholesterolaemia, atrial fibrillation, diabetes, myocardial infarction (heart attack), transient ischaemic attack (TIA), stroke, seizures, falls, head injury, syncope, other episodes of loss of consciousness, and surgical procedures involving cardiopulmonary bypass and general anaesthesia.


In older people certain ‘geriatric syndromes’ are common precipitants of medical presentations. These include confusion, falls and incontinence. These are not disease entities in themselves, but rather the final common pathways for a large number of disease states. Thus, the clinician must think broadly when confronted with one of these common syndromes.


There is a strong interaction between mental and physical health problems in that people with chronic physical health problems are more likely to develop mental health problems, and vice versa. For example, chronic physical ill health is a powerful predictor of both depression and anxiety symptoms in older people. In addition, certain acute medical conditions are commonly associated with depression. These include stroke and acute coronary syndrome. In addition, when older people with mental health problems are treated with psychotropic medication, this medication can lead to physical health problems. An example of this is drug-induced Parkinsonism, which can present as either falls or incontinence. Falls occur because of impaired gait and ‘incontinence’ because the older person cannot get to the toilet in time.



PERSONNEL INVOLVED IN THE PHYSICAL EXAMINATION


A general physical examination is an important component of the work-up of older people suspected of having a mental health problem. Ideally, the person’s GP should carry this out prior to the person’s referral to the OPMHS, or should accompany the mental health workers to the person’s residence, but sometimes this is not feasible. As a consequence, staff of the OPMHS must either be able to undertake a general physical examination themselves or have access to an outside medical practitioner who is able to do one. Although GPs have a long history of performing brief physical examinations in people’s homes, these seem to happen less commonly nowadays. If the OPMHS does not have its own medical personnel to undertake such examinations on home visits, consideration should be given to arranging for the older person to attend the GP’s office or the local hospital outpatients department or emergency department for a physical examination. The person’s case manager or the mental health workers doing the initial assessment may need to accompany the person to the doctor to request a physical examination. This is often also a suitable opportunity for blood to be drawn for screening laboratory tests and for an electrocardiogram to be performed (see below).


In better resourced OPMHS, the initial assessment can be done by two mental health workers, one of whom should be a medical officer who can undertake a screening physical examination. In some settings, experienced registered nurses carry out screening physical examinations. A screening physical examination should be informed by the history obtained from the older person and other informants, and what is already known about the person’s general health. However, at a minimum, it is important to examine the person’s level of consciousness, general appearance, vital signs (temperature, pulse rate, blood pressure, respiratory rate), eyesight, hearing, gait, speech, and cardiorespiratory and neurological status. All of these can be roughly assessed without having the person completely disrobe and most can be assessed with the person seated in a chair. Most mental health services now use a physical examination template to provide structure to screening examinations.



EQUIPMENT NEEDED FOR THE PHYSICAL EXAMINATION


Basic equipment needed for a physical examination includes:


• a thermometer

• a sphygmomanometer

• a stethoscope

• a watch with a sweep hand

• a tendon hammer

• a Snellen chart

• a tape measure

• a small torch

• urinalysis strips, and

• portable scales.

Additional equipment may include:


• an ophthalmoscope

• an auroscope

• a tuning fork (256 Hz)

• disposable tongue depressors

• disposable gloves

• a pulse oximeter

• a portable electrocardiogram (ECG) machine, and

• an alcometer.


FACTORS TO BE CONSIDERED IN THE PHYSICAL EXAMINATION



Consent


At common law, a physical examination without consent could constitute assault. Thus, the mental health worker should obtain the consent of the person, or their substitute decision maker, before undertaking a physical examination. This is particularly so when planning to do a physical examination during a domiciliary visit, as consent under these circumstances should not be assumed. When a substitute decision maker has given consent, the examiner should still attempt to obtain the person’s assent.



Chaperone


It is generally prudent to have a chaperone present for all but the most superficial physical examinations. This advice holds true for female as well as male examiners and for male as well as female people who are being examined. The chaperone can assist with positioning the person and maintaining their dignity and privacy during the examination. The chaperone can also help minimise the risk of physical assault on the examiner in the case of an agitated, delusional or manic person, and can act as a witness to proceedings for the protection of both the person and the examiner.



Safety


The mental health worker should be alert to factors that might compromise their own safety and that of the older person, particularly when undertaking physical examinations on domiciliary visits with unfamiliar patients. Sometimes, discretion is the better part of valour and the physical examination should be put off until another day. See also Chapter 18.



Evidence of elder abuse


The physical examination provides an opportunity to observe signs of physical abuse or neglect, which may be present if the older person has been the victim of domestic violence or some other type of physical abuse or neglect. Bruises of differing ages are a pointer to elder abuse just as they are to child abuse. Neglect may lead to chronic undernutrition with weight loss and vitamin deficiencies.



Evidence of substance use


Some older people abuse alcohol over a long period and develop the normal sequelae of this. Some older people use illicit drugs, including amphetamines and cannabis. See also Chapter 24.



Level of consciousness


Assess whether the older person is fully conscious and alert or whether they exhibit a reduced level of consciousness. Reduced consciousness starts with clouding of consciousness (reduced awareness) and ends with coma and death. If the level of consciousness appears reduced, the Glasgow Coma Scale (GCS) (Teasdale & Jennett 1974) can be used to document the extent of conscious impairment. Reduced level of consciousness is often a medical emergency, requiring immediate action by the mental health worker.



General appearance


Assess the following:


• cachexia or obesity

• clothing (Is clothing appropriate for the climate? Are there any unusual features, such as clothes on back to front, too many layers, street clothes on over pyjamas in warm weather, or insufficient clothing in very cold weather?)

• personal hygiene (e.g. hair, nails and general dishevelment)

• dentition

• foot care, and

• height and weight.


Eyesight


Test each eye separately with the other eye covered using a Snellen chart (at 6 metres) or mini-Snellen chart (various distances, depending upon the font of the letters on the chart) for an estimate of visual acuity. The person should wear their usual spectacles during testing. If a Snellen chart is not available, ask the older person to read from a magazine or a newspaper, or ask the person to read the labels on their medicine bottles. Refer people with previously undiagnosed visual impairment for formal testing. Inquire about navigational difficulties that might be due to visual field defects.



Hearing


Whisper into each ear with the other ear covered by a hand for an estimate of hearing acuity. The person should wear their usual hearing aids during testing. Refer people with previously undiagnosed hearing impairment for formal testing.



Speech and language


Engage the older person in conversation and note any abnormalities of speech or language. Common abnormalities include dysarthria (slurred speech, which is often due to stroke or intoxication) and dysphasia (reduced ability to generate speech or understand speech, which may be expressive or receptive dysphasia, and is often due to stroke or dementia). A less common problem is dysprosody (loss of the musical quality or rhythm of speech, which is often due to stroke, head injury or Parkinson’s disease). Dysprosody sometimes gives the clinician the impression that the person is speaking with a foreign accent. Other types of speech and language disorders are associated with longstanding mental illness, including the formal thought disorder associated with early-onset schizophrenia (see Ch 13).



Posture and gait


Note the seated posture of the older person. Ask the person to stand up, walk several metres, turn around, walk back and resume their seat. Look for abnormal seated posture, which might be due, for instance, to pain or discomfort, arthritis or other skeletal abnormality, stroke, Parkinson’s disease or other neurological abnormality, or voluntary adoption of an abnormal posture. Look for abnormal gait, such as the shuffling gait, festination (shortening of stride and quickening of gait) and the absent arm swing of Parkinson’s disease, the small stepping gait associated with deep white matter ischaemic changes in the brain, or the choreoathetoid movements and the so-called ‘dancing gait’ of Huntington’s disease. The ‘get up and go test’ is also a straightforward test of locomotion.



Neurological examination


There may be clues to a neurological problem from the older person’s speech and language function and their posture and gait. However, a more detailed neurological screening examination is warranted in all first presentations of mental health problems, including dementia, in later life.


The twelve cranial nerves can be screened quite simply and efficiently, as follows:































I Ask the person about their sense of smell.
II Test the person’s eyesight with a Snellen chart.
III, IV and VI Test the person’s eye movements.
V Test facial sensation by soft touch.
VII Ask the person to smile and close their eyes tightly.
VIII Test hearing and balance (ask them to heel–toe walk or stand on one leg).
IX and X Ask the person to speak, to swallow, to say ‘Ah’ (look at their soft palate) and test their gag reflex with a tongue depressor.
XI Ask the person to shrug their shoulders and turn their head.
XII Ask the person to poke out their tongue.

The pyramidal tract can be screened by testing:


• the power in both arms and legs by asking the person to move them against resistance (this can be estimated even if the person is seated)

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Aug 6, 2016 | Posted by in GERIATRICS | Comments Off on Physical health assessment

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