The Approach to the Elderly Patient

Mark E. Williams

CLINICAL PEARLS

Chronologic age and biologic age are not the same.
As we age we become more unique and differentiated, hence care must be individualized.
Because old age is counterpoised against the certainty of death, preventive strategies focus on the quality of remaining life rather than on extending the quantity of life.
The ability to live independently is a critical issue.
Elderly people often present with symptoms that must be managed even when the underlying cause is not clear.
A major barrier to a full observation is having things fall into familiar context (habit).
The clinical interview (taking the history) is the “physical examination” of the intellect.
Shoes tell the story of their owner.
Linguistic analysis can assist in determining intellectual vitality, mental status, educational attainment, and emotional state.

The increasing biologic uniqueness of older persons as they age requires that their medical care be individualized.
The physician must be aware of his or her own attitudes and beliefs regarding aging and death and how these views influence the physician-patient relationship. As physicians, we must understand how elderly people behave when they are ill and know how to interpret a changing constellation of multiple disease possibilities and interrelationships. The physician requires knowledge, skills (especially in physical diagnosis), and the willingness and discipline to carefully evaluate each situation and to formulate a specifically tailored care plan. Because of the magnitude and complexity of medical, psychological, and social problems in older persons, an effective physician must cooperate with other members of the health care team. The accumulation and constant refinement of these skills reflect the maturity and scientific grounding of the physician.

Elderly persons require an approach and a clinical perspective that differs substantially from the medical evaluation of younger persons. The spectrum of symptoms is broader, the manifestations of distress are more subtle, and the implications for maintaining independence are more compelling. Improvement is sometimes less dramatic and slower to appear. The differential diagnosis is often different in older patients compared to younger patients, and chronic illnesses are more common. In addition, the presentation of disease is frequently nonspecific in elderly people. The most common presenting complaints are mental status changes, behavioral changes, urinary incontinence, gait disturbance or a fall, and weight loss. As a result of this, nonspecific presentation symptoms are difficult to interpret.

The benefits of rehabilitation need to be emphasized when developing an effective, comprehensive plan of care for functionally impaired older persons. Most medical interventions during old age derive their value from their influence on the person’s maintenance of independent living. An older person’s ability to manage daily activities cannot be determined confidently from the length of the problem list. The crucial issue is the elderly person’s ability to function because the discomfort and disability produced by even incurable conditions may often be modified. A conventional disease-specific perspective may not lend itself to developing strategies that best serve the older patient.

REVIEWING OUR PERCEPTIONS OF AGING

The way we think about elderly people strongly influences the way we provide care to them. Because many of us have stereotypes about aging and elderly people, it is important for us to keep an open mind while we focus our current perceptions. The striking increase in average life expectancy during the 20th century rates as one of the major events of our time. We are in the midst of a social revolution, not in new ideology, but in our changing population pattern. For the first time in human history, infants in fortunate nations such as ours can expect to live well into their seventies and beyond. This demographic revolution increases pressure on resources because it also creates further social change and new opportunities for older persons. Such rapid changes have left most of us living with outdated, generally negative attitudes about aging and elderly people. Most of us still view old people as being physically decrepit or in rapid, inevitable decline. Mentally, they are viewed as forgetful or childish, with little ability to learn and adapt; socially and economically, they are often considered a burden. The same outmoded beliefs are embedded in many of our health care and social programs. With such stereotypes, where is the expectation and encouragement for their continuing capacity to enrich their own lives and to enrich society?

These deep-seated cultural stereotypes do not describe accurately the new wave of elderly persons or their potential contributions to society. Today’s aging individuals are mostly far from decrepit. Less than 25% experience any disability and <5% are in nursing homes. Intellectually, they thrive when given new opportunities to learn and grow. Given suitable occupation, they work with zest and competence well beyond the traditional age of retirement. Many have an emotional maturity and the kind of wisdom that comes only with age. In short, chronologic age has virtually lost its meaning as a useful index of individual capacity.

To be sure, many old people have special needs for health care and other supports. But these cannot be provided knowledgeably without abandoning the old stereotypes, creating a broader public understanding of today’s elderly population and its potential relationship to the rest of society. Such understanding will bring recognition of the many ways our later years can be more a culmination of life than a prelude to death.

GENERAL PRINCIPLES TO IMPROVE CARE OF ELDERLY PEOPLE

The fact that you are reading this chapter says a lot about your interest and commitment to improve your care for elderly people. It is important that you commit yourself to excellence. Mediocrity has no place in the care of elderly people. Your self-discipline is necessary to maintain focus and avoid distractions.

The Psychology of the Examiner

The psychology of the examiner is the first consideration. Careful geriatric clinicians must be able to focus their attention and awareness. The nature of the clinician’s inner state should be one of complete attention to the patient’s concerns and appreciating the special aspects of the moment. The examiner’s overall intention is to help and
to be of assistance to a person implicitly asking for relief from distress, for guidance, or for support. In addition, the clinician’s technique reflects his or her grounding and maturity. You must be totally focused on the patient, with no thoughts or inner dialogue on any other matter. You are giving the other person your most priceless possession, your undivided attention.

Increasing Your Perceptive Capacity

The second principle is to work hard to increase your perceptive capacity. This is not as easy as it sounds. There are three types of knowledge: General, specialized, and perceptive. General knowledge is what is in the textbook or encyclopedia. Take “basketball” as an example. If we look “basketball” up in an encyclopedia we get a particular type of information: The history of the game, number of players on a team, basic rules, referees’ signals, and a listing of championship teams in the past. Specialized knowledge is what an informed fan would know: Which teams had a good recruiting year, which team plays well against a particular opponent, whose star player has a nagging injury. This body of knowledge is not found in the encyclopedia. The third type of knowledge is perceptive knowledge: What is it like to be out on the basketball court with the ball in a game situation. This framework helps us appreciate that most health care education is either general or specialized knowledge: Lists, tables, flowcharts, algorithms, decision trees, or clinical pathways. This important information has its place in clinical care. But very little time is spent educating learners on how perceptions guide one on what to do.

One difficulty in sharing perceptive knowledge is that we have a limited perceptive vocabulary. It is cumbersome to describe perceptive insights without a descriptive vocabulary. Another factor limiting the sharing of perceptive knowledge is that there are few role models with the requisite experience who are also willing to communicate their techniques and expose their vulnerabilities to others. In geriatrics there has also been a lack of students with an interest in the perceptions gained through a caring relationship with an elderly patient.

Show Reverence for the Patient

Francis Ward Peabody said in a classic 1927 monograph in the Journal of the American Medical Association that the art of caring for the patient is to care for the patient. He also wrote, “The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.” This succinct advice epitomizes the need for the craftsmanship of caring.

One of my sons collects sports cards. Although I cannot tell the valuable cards from the common ones, I can sort them accurately by watching how he handles them. The rare rookie card of a star athlete is handled with a sense of reverence. In fact, we infer value by observing how people touch objects they perceive to be valuable. There is a precious delicacy of the touch, with attention to each nuance in movement. The pottery bowl (or a rare book, for example) commands total concentration and an obvious appreciation for value. In the same way, it is easy to tell the student (or resident or attending physician) who is “caring for the patient” by how he or she takes the patient’s hand to begin the physical examination. Again, there is a sense of conscious appreciation, respect, and reverence.

Creating a Healing Atmosphere

Conscientious information gathering requires awareness of the premise and dynamics of the clinical encounter and structuring the environment to facilitate communication. The attitudes of physicians and other health care personnel strongly influence the quality of information available from the history. The premise of the clinical relationship is the expectation of reducing morbidity and improving function and quality of life by whatever means possible. It is important to emphasize the premise, which is not necessarily to eliminate the cause of the distress (which may be impossible in many circumstances) but to help relieve the distress itself, because the presence of disease and the development of symptoms are not always closely related. This key insight frees health care providers from the frustration, anxiety, and sense of vulnerability that results from cure-oriented expectations.

Attention to a few specific environmental considerations can improve communication by facilitating sensory input to the older person and putting them at ease. Because some older people have visual impairments, techniques to improve nonverbal cues become useful. For example, to improve visual information, physicians should avoid having a strong light behind them (such as a window) because it puts the face in silhouette. Another useful technique is to reduce the distance between participants. As a rule of thumb, the optimal distance is that at which the interviewer begins to feel uncomfortably close. For individuals with hearing impairment, the volume of the voice must be raised without raising the pitch. Shouting, which raises the pitch, defeats the purpose because high-frequency sounds are characteristically affected more profoundly than lower-frequency sounds in the aging ear. Shouting can also produce significant discomfort because the failing ear may become more sensitive to loud sounds.

Environmental conditions can improve communication by relaxing and comforting the older person. Office equipment should be practical and comfortable. Plush furniture may be stylish and handsome but dysfunctional for persons with painful backs, hips, or knees. Older persons often prefer a simple straight-backed chair with armrests (for possible assistance in standing). Another important way to improve communication is to sit down. The importance of sitting is inversely proportional to the time available for the encounter: The less the time
available, the greater the importance of sitting. In addition to providing a common level for eye contact, sitting helps neutralize the appearance of impatience and haste. The appearance of impatience inhibits communication by magnifying a hierarchic relationship (physician over patient) rather than establishing a partnership to solve problems. The professional may nonverbally communicate that he or she is more interested in the problem or disease than in the person who is experiencing the distress.

Biological and Psychological Uniqueness Increases with Aging

As we age, we become more unique and differentiated and less like one another. There is more biologic variability among octogenarians than neonates. Anyone who has attended a high school or college reunion can attest to the fact that some individuals age very slowly over a 10-year period while other individuals seem to have aged several decades. Because of this increasing biologic variability with aging, our approach must be individualized. A “one-size-fits-all” strategy will not fit an older person.

CLINICALLY RELEVANT DIFFERENCES BETWEEN YOUNG AND OLD PEOPLE

What is aging? Aging is a nearly ubiquitous biologic process characterized by progressive, predictable, inevitable evolution and maturation until death. Aging is not the accumulation of disease, although aging and disease are related in subtle and complex ways. A fundamental principle is that biologic age and chronologic age are not the same. Different individuals age at different rates, and aging occurs in different organ systems at different rates, influenced primarily by the individual’s socioeconomic status and lifestyle choices. For example, smoking cigarettes seems to accelerate aging in the pulmonary and cardiovascular systems.

Normal aging in the absence of disease is a remarkably benign process. In physiologic terms, normal aging involves the steady erosion of organ system reserves and homeostatic controls. This erosion is evident only during periods of maximal exertion or stress. The limits of homeostatic maintenance eventually reach a critical point (usually in advanced age), such that relatively minimal insults cannot be overcome, resulting in the person’s death over a relatively short time. Consequently, any morbidity apparent to the person is compressed into the last period of life. Deviations from this ideal represent the effects of superimposed disease.

Aging also causes important changes in body composition and in the structural elements of tissues. Between age 25 and 75, the lipid compartment expands from 14% to 30% of the total body weight, whereas the total body water (mainly extracellular water) and lean muscle mass decline. This change in body composition has important implications for nutritional planning, metabolic activity, and the use of drugs by older persons. For example, the lipid-soluble drugs such as diazepam remain in the bodies of older persons for a much longer time than they remain in younger persons. Aging changes have also been documented in connective tissue and the isomeric forms of structural proteins.

How the Body Ages

Difficulties in making health care decisions result when normal aging changes are not appreciated or are misinterpreted. Because of this, a knowledge of the anatomy of aging is fundamental to our care.

Changes in Height

All individuals lose height as they age but with great variability both in the age of onset and the rate of loss. On average, approximately 5 cm are lost by the age of 80. Changes in posture, changes in the growth of vertebrae, a forward bending of the spine, and compression of the disks between the vertebrae cause a loss in trunk length. Increased curvature of the hips and knees, along with decreased joint space in the trunk and extremities, contributes to a loss of structure. In the feet, joint changes and a flattening of the arches can also contribute to the loss of standing height.

Body Composition

Lean body mass is lost with age; this reduction is mainly a decrease in muscle mass, with some decrease in bone and viscera. Hormonal changes seem to influence these losses. The fall in the level of estrogen (and adrenal androgens) is proportionally much greater in women than that in the level of total androgen (adrenal plus testicular) in men. Other organs also show losses: The liver and kidneys, for example, lose approximately a third of their weight between age 30 and 90. The prostate differs; it doubles in weight between age 20 and 90.

Skin and Connective Tissue

Little change occurs with aging in the outer layer of the skin called the stratum corneum. The contact area between the dermis and the epidermis decreases, and the number of deeper basal cells and pigment-producing cells, called melanocytes, is reduced. With advancing age, the number of Langerhans cells, which come from the bone marrow and provide assistance to the immune system, is also modestly reduced. The reduction of these cells is striking in the skin that has been exposed to sunlight; this reduction is thought to contribute to the development of sun-related skin cancers.

The content of collagen, a basic chemical building block of skin, decreases with age, which results in less skin elasticity. The collagen fibers in younger skin exhibit an orderly arrangement similar to fibers in a rope. These fibers become coarser and random with aging, resembling a mass of unstirred spaghetti. Alterations in elastic tissue cause a loss of resiliency and produce wrinkles.

Hair changes play a prominent role in the perception of age. Hair graying results from a progressive loss of melanocytes from the hair bulbs. The loss of these pigment cells is more rapid in the hair than in the skin, possibly because of the rapid proliferation of cells during hair growth. The graying of hair in the axilla is thought to be one of the most reliable signs of aging. There is a decease in the number of hair follicles on the scalp. Changes in the growth rate of hair depend upon the site. The growth rate of scalp, pubic, and armpit hair declines; however, possibly because of hormonal changes, an increase in growth of facial hair is sometimes seen in elderly women. An increased growth of eyebrow, nostril, and ear hair occurs in elderly men.

Musculoskeletal Changes

A decrease in muscle weight relative to total body weight characterizes advanced age. Aging changes in the muscles include a decrease in muscle strength, endurance, size, and weight relative to total body weight. However, the late onset of these changes and their unpredictable rate of appearance suggest that they may not be due to aging but rather due to inactivity, nutritional deficiency, disease, or other long-standing conditions. Curiously, both the diaphragm and the heart, two muscles that work continuously, appear to be relatively unchanged by aging. Age-related chemical changes occur in the cartilage, the substance that provides the lubricating surface of most joints. Because cartilage contains no blood vessels, it depends upon the blood supply of the synovium (the tissue that produces joint fluid) for nutrients that pass through the joint fluid. The water content of cartilage decreases, and changes in the deeper structures such as the underlying bone may influence the cartilage and may reduce its ability to adapt to repetitive stress.

Bone loss is a universal aspect of aging that occurs at highly individual rates. Aging affects and reduces the bone cells that produce bone more severely than those cells that reabsorb bone. Although bone remodeling occurs throughout life, the balance between the amount of bone reabsorbed and the amount of bone formed is impaired with aging; the growth of bone slows and the bone begins to thin and become more porous. The internal latticework of bones loses its horizontal supports, which significantly compromises its strength.

The skull appears to thicken with age. All the skull dimensions increase, but greater increases are noted deep in the skull and in the frontal sinuses. Bone growth has also been demonstrated well into advanced age in the ribs, fingers, and femur. These changes in the hip may be important because growth in the mid portion of the bone results in a wider but weaker bone.

Conditioning, nutrition, vascular and neurologic abnormalities, and hormones influence the degeneration in the muscles and bones. Conditioning is the most significant influence because disuse or underuse produces marked declines in bone and muscle structures. Nutrition affects bone and mineral metabolism, and blood vessel and neurologic abnormalities accelerate muscle degeneration. In addition, a variety of hormones—growth hormone, estrogens, androgens, and many others—modify the musculoskeletal integrity.

Changes in the Nervous System

The brain’s weight declines with age, but this decline appears to be in a few specific places rather than overall. Atrophy of the gray matter is usually moderate in healthy older people, as compared with a more extensive loss of cells in older people with dementia. From age 30 to 70, the blood flow to the brain decreases by 15% to 20%. With aging, there is a loss of neurons in the gray matter, cerebellum, and hippocampus that seems to be involved in some aspects of memory function. Less dramatic losses occur in deeper brain structures. For some nerves, the density of their interconnections seems to be reduced with aging. However, there is a slow and continued growth of the terminal dendritic connections between nerves, which suggests a possible repatterning of the nervous system.

Age-related changes in certain neurotransmitters occur in specific parts of the central nervous system. The catalyzing and synthesizing enzymes of acetylcholine, acetylcholinesterase and choline acetyltransferase decline significantly with age. These decreases are most prominent in the caudate nucleus. Changes in glutamic acid decarboxylase have also been reported. The decrements are significant and also seem to affect the caudate nucleus. A 40% loss of binding sites for dopamine agonists and antagonists occurs with age. Similar aging changes have been observed in cortical and pineal β-adrenergic receptors. Changes in membrane fluidity with age may impair receptor function. Binding sites for serotonin in the frontal cortex and hippocampus are reduced with age.

Aging changes in brain structure and biochemistry do not necessarily affect thinking and behavior. Basic language skills and sustained attention are not altered with aging, but some aspects of cognitive ability do seem to change, the earliest being the ability to retain large amounts of information over a long period. Naming tasks and abstraction are altered late in life. However, none of these changes develops uniformly or inevitably, and many older people continue to perform at levels that are comparable to, or even exceed, those of much younger people.

Changes in the Special Senses

Vision

With age, the tissues around the eyes atrophy and fat around the eye is lost; this may result in the upper lid drooping and the lower lid turning inward or outward. The decreased production of tears combined with atrophy around the eye increases the chances of eye infection. Changes in the cornea can also occur, although they are usually related to disease and not aging. The iris becomes more rigid, the pupil becomes smaller, and changes occur around the lens, predisposing the person to glaucoma. As newer lens fibers proliferate at the periphery, older fibers migrate to the center to form a denser central section. This process is like continually forming a ball of yarn. The lens progressively accumulates yellow substances, possibly from a chemical reaction involving sunlight and the amino acids in the lens. These substances reduce the amount of light and color entering the eye, and this yellow filtering causes the lens to become less transparent to the blue part of the color spectrum. To older eyes, blue appears greenish blue.

Changes in the retina have not been clearly identified, although blood vessel disease involving the retina is common. Changes in the blood supply to the retina and possibly the pigmented layer of the retina can cause macular degeneration, one of the most common causes of vision loss in older people.

The most common change in vision associated with aging is called presbyopia, a condition in which it becomes harder to focus on nearby objects. This is mainly due to decreased elasticity of the lens and atrophy of the ciliary muscle that controls the lens shape. Presbyopia affects men and women equally and begins in the early twenties, although it is usually not noticeable until 20 or 30 years later. Eyeglasses usually correct the problem. As individuals age, they adapt more slowly to abrupt changes from light to dark areas. So consistent is this correlation with age that a person’s age may be predicted to within 3 years on the basis of this performance. These changes are not trivial—after 2 minutes of reduced illumination, young people’s eyes are almost five times more sensitive than older people’s eyes; after 40 minutes, there is a 240-fold difference.

Hearing

The external auditory canal atrophies, resulting in thin walls and decreased cerumen production. The tympanic membrane thickens and often appears dull and white. Ossicular joints can develop degenerative changes. Significant inner ear changes take place, such as loss of hair cells in the organ of Corti, loss of cochlear neurons (especially at the basal end), capillary thickening in stria vascularis, and degeneration of the spiral ligament. Whether aging in the absence of excessive noise exposure can produce these changes is unknown.

Hearing loss for pure tones, presbycusis, increases with age in both men and women. Higher frequencies are more affected than lower frequencies. Overall, the loss is slightly milder for women than for men. Decrements occur with aging not only in the absolute threshold of tones of varying frequency but also in the differential threshold—the point at which changes in pitch are detectable. Between age 25 and 55, pitch discrimination declines linearly; but after the age of 55 the decline is steeper, especially for very high and low frequencies. Pitch discrimination plays an important role in speech perception. Speech discrimination declines with age, even when pure tone hearing loss is taken into account. Speech intelligibility declines by <5% from age 6 to 59, but deteriorates rapidly thereafter, dropping by >25% from peak levels after age 80. With ambient noise or indistinct speech, older people hear even less.

Taste

The evidence regarding taste sensitivity is inconclusive and varies both among individuals and the substance tested. The tongue atrophies with age, which may result in diminished taste sensation; however, the number of taste buds remains unchanged, and the responsiveness of these taste buds appears to be unaltered.

Smell

The sense of smell declines rapidly after the age of 50 for both men and women, and the parts of the brain that are involved in smell degenerate significantly. By age 80, the detection of smell is almost 50% poorer than that at the peak capacity. Taste and smell work together to make the discrimination and enjoyment of food possible. As individuals age, they may have trouble recognizing a variety of blended foods by taste and smell.

Touch

In general, the response to painful stimuli diminishes with aging. Sensitivity of the cornea of the eye to light touch declines after the age of 50 (touch sensitivity to the nose begins to decline by age 15). Pressure touch thresholds on the index finger and the big toe decline more in men than in women.

Changes in the Cardiovascular System

With aging, the heart tends to show disease in the heart muscle, heart valves, and coronary arteries. It is unclear whether any age-related changes of the heart occur in the absence of disease. The cells responsible for producing heartbeats become infiltrated with connective tissue and fat. Similar but less dramatic changes occur in other parts of the heart’s electric system. Poor blood supply does not seem to be an underlying cause. Age-related declines in
cardiac contractility include a prolonged contraction time, decreased response to various medications that ordinarily stimulate the heart, and increased resistance to electric stimulation (normally these changes do not result in disease). The elastic properties of the heart muscle are altered.

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