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Section 1. Basics of Geriatric Care
Chapter 3. History and Physical Examination
Topics:    Introduction | History | Physical Examination | Unusual Presentations of Illness

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Physical Examination

Geriatric Essentials

  • Valuable information about a patient's function can be gained by observing the patient and the patient's movements.
  • Physical examination should include all systems, particularly mental status, and may require 2 sessions.

Observing the patient and the patient's movements (eg, walking into the examination room, sitting in or rising from a chair, getting on and off an examination table, taking off or putting on socks and shoes) can provide valuable information about a patient's function. The patient's personal hygiene (eg, state of dress, cleanliness, smell) should be noted; it may provide information about mental status and the ability to care for self.

Two sessions may be needed for the physical examination because patients may become fatigued. Elderly patients may require additional time to undress and transfer to the examining table; they should not be rushed. The examining table is adjusted to a height that the patient can easily access; a footstool facilitates mounting. Frail patients must not be left alone on the table. Portions of the examination may be more comfortable if the patient sits in a chair.

The patient's general appearance is described (eg, comfortable, restless, malnourished, inattentive, pale, dyspneic, cyanotic). If the patient is examined at bedside, use of protective padding or a protective mattress, bedside rails (partial or full), restraints, a urinary catheter, or an adult diaper is noted.

Vital Signs

Weight should be recorded at each visit. During measurement of height and weight, patients with balance problems may need to grasp grab bars placed near or on the scale.

Temperature is recorded. Hypothermia can be missed if the thermometer cannot measure temperatures more than a few degrees lower than normal. Absence of fever does not exclude infection.

Pulses and BP are checked in both arms. The pulse is taken for 30 sec, and any irregularity is noted. Because many factors can alter BP, BP is measured several times after the patient has rested > 5 min.

BP may be overestimated in elderly patients because their arteries are stiff. This condition, called pseudohypertension, should be suspected if patients develop symptoms of dizziness when antihypertensive drug therapy is increased to treat elevated systolic BP.

All elderly patients are checked for orthostatic hypotension because it is common. BP is measured with the patient in the supine position, then after the patient has been standing for 3 to 5 min. If systolic BP falls >= 20 mm Hg, orthostatic hypotension is diagnosed. Caution is required when testing hypovolemic patients.

A normal respiratory rate in elderly patients may be as high as 25 breaths/min. A rate of > 25 breaths/min may be the first sign of a lower respiratory tract infection, heart failure, or another disorder.

Skin

Initial observation includes color (normal rubor, pale, cyanotic). Examination includes a search for premalignant and malignant lesions, tissue ischemia, and pressure ulcers. Unexplained bruises may indicate abuse. Because the dermis thins with age, ecchymoses may occur readily when skin is traumatized, often on the forearm. Uneven tanning may be normal because melanocytes are progressively lost with aging.

Longitudinal ridges on the nails and absence of the crescent-shaped lunula are normal age-related findings. With aging, the nail plate thins and becomes prone to fracture. Black splinter hemorrhages in the middle or distal 1/3 of the fingernail are more likely to be due to trauma than to bacteremia. A thickened, yellow toenail indicates onychomycosis, a fungal infection. Toenail borders that curve in and down indicate ingrown toenail (onychocryptosis). Whitish nails that scale easily, sometimes with a pitted surface, indicate psoriasis.

Head and Neck

Face: Normal age-related findings may include the following: eyebrows that drop below the superior orbital rim, descent of the chin, loss of the angle between the submandibular line and neck, wrinkles, and dry skin. Thick terminal hairs develop on the ears, nose, upper lip, and chin.

The temporal arteries should be palpated for tenderness and thickening, which may indicate giant cell arteritis.

Nose: Progressive descent of the nasal tip is a normal age-related finding. It may cause the upper and lower lateral cartilage to separate, enlarging and lengthening the nose.

Eyes: Loss of orbital fat is a normal age-related finding. It may cause gradual sinking of the eye backward into the orbit (enophthalmos). Thus, enophthalmos is not necessarily a sign of dehydration in the elderly. Enophthalmos is accompanied by deepening of the upper eyelid fold and slight obstruction of peripheral vision. Other normal findings include pseudoptosis (decreased size of the palpebral aperture), entropion (inversion of lower eyelid margins), ectropion (eversion of lower eyelid margins), and arcus senilis (a white ring at the limbus). With aging, presbyopia develops; the lens becomes less elastic and less able to change shape when focusing on close objects.

The eye examination should focus on testing visual acuity (eg, using a Snellen chart). Visual fields can be tested at the bedside by confrontation. The patient is asked to stare at the examiner so that the examiner can determine differences between the examiner's and the patient's visual field. However, such testing has low sensitivity for most visual disorders. Tonometry is occasionally done in primary care; however, it is usually done by ophthalmologists or optometrists as part of routine eye examinations or by ophthalmologists when a patient is referred to them because glaucoma is clinically suspected.

Ophthalmoscopy is done to check for cataracts, optic nerve or macular degeneration, and evidence of glaucoma, hypertension, or diabetes. Findings may be unremarkable unless a disorder is present because the retina's appearance may not change much with aging. In elderly patients, mildly to moderately elevated intracranial pressure may not result in papilledema because cortical atrophy occurs with aging; papilledema is more likely when pressure is markedly increased. Areas of black pigment or hemorrhages in and around the macula indicate macular degeneration. For all elderly patients, an eye examination by an ophthalmologist or optometrist is recommended every 1 to 2 yr because such an examination may be much more sensitive for certain common eye disorders (eg, glaucoma, cataracts, retinal disorders).

Ears: Tophi, a normal age-related finding, may be noted during inspection of the pinna. The external auditory canal is examined for cerumen, especially if a hearing problem is noted during the interview. If the patient wears a hearing aid, it is removed and examined. The ear mold and plastic tubing can become plugged with wax, or the battery may be dead, indicated by absence of a whistle (feedback) when the volume of the hearing aid is turned up.

To evaluate hearing, the examiner, with face out of the patient's view, whispers 3 to 6 random words or letters into each of the patient's ears. The hearing of a patient who correctly repeats at least half of these words for each ear is considered functional for one-on-one conversations. Patients with presbycusis (age-related, gradual, bilateral, symmetric, and predominantly high-frequency hearing deficits) are more likely to report difficulty in understanding speech than in hearing sounds. Evaluation with a portable audioscope, if available, is also recommended.

Mouth: The mouth is examined for bleeding or swollen gums, loose or broken teeth, fungal infections, and signs of cancer (eg, leukoplakia, erythroplakia, ulceration, mass). In patients with xerostomia, the mouth and tongue may be fissured, and the tongue blade may stick to the buccal mucosa. With aging, the teeth may darken because of extrinsic stains and less translucent enamel. Erythematous, edematous gingiva that bleeds easily usually indicates a gingival or periodontal disorder. Bad breath may indicate caries, periodontitis, another oral disorder, or sometimes a pulmonary disorder.

The dorsal and ventral surfaces of the tongue are examined. Common age-related changes include varicose veins on the ventral surface, erythema migrans (geographic tongue), and atrophied papillae on the sides of the tongue. In an edentulous patient, the tongue may enlarge to facilitate chewing; however, enlargement may also indicate amyloidosis or hypothyroidism. A smooth, painful tongue may indicate vitamin B12 deficiency.

Dentures should be removed before the mouth is examined. Dentures increase risk of oral candidiasis and resorption of the alveolar ridges. Inflammation of the palatal mucosa and ulcers of the alveolar ridges may result from poorly fitting dentures.

The interior of the mouth is palpated. A swollen, firm, and tender parotid gland may indicate parotitis, particularly in dehydrated patients; pus may be expressed from Stensen's duct.

Painful, inflamed, fissured lesions at the lip commissures (angular cheilitis) may be noted in edentulous patients who do not wear dentures; these lesions are usually accompanied by a fungal infection.

Temporomandibular joint: The temporomandibular joint should be evaluated for degeneration (osteoarthrosis), a common age-related change. The joint can degenerate as teeth are lost and compressive forces in the joint become excessive. Degeneration may be indicated by joint crepitus felt at the head of the condyle as the patient opens and closes the jaw, by painful jaw movements, or by both.

Neck: The thyroid gland, which is located low in the neck of elderly people, often beneath the sternum, is examined for enlargement and nodules.

Carotid bruits due to transmitted heart murmurs can be differentiated from those due to carotid artery stenosis by moving the stethoscope up the neck: A transmitted heart murmur becomes softer; the bruit of carotid artery stenosis becomes louder. Bruits due to carotid artery stenosis suggest systemic atherosclerosis. Whether asymptomatic patients with carotid bruits require evaluation or treatment for cerebrovascular disease is unclear.

The neck is checked for flexibility. Resistance to passive flexion, extension, and lateral rotation of the neck may indicate a cervical spine disorder. Resistance to flexion and extension can also occur in patients with meningitis, but in patients with meningitis and without a cervical spine disorder, the neck can be rotated passively from side to side without resistance.

Chest and Back

All areas of the lungs are examined by percussion and auscultation. Basilar rales may be heard in the lungs of healthy patients but should disappear after patients take a few deep breaths. The extent of respiratory excursions (movement of the diaphragm and ability to expand the chest) should be noted.

The back is examined for scoliosis and tenderness. Severe low back, hip, and leg pain with marked sacral tenderness may indicate spontaneous osteoporotic fractures of the sacrum, which can occur in elderly patients.

Breasts: In men and women, the breasts should be examined annually for irregularities or nodules. For women, monthly self-examinations are also recommended, as is annual screening mammography, especially for women with a family history of breast cancer. If nipples are retracted, pressure should be applied around the nipples; pressure everts the nipples when retraction is due to aging but not when it is due to an underlying lesion.

Heart: Heart size can usually be assessed by palpating the apex. However, displacement caused by kyphoscoliosis may make assessment difficult.

Auscultation should be done systematically. In elderly patients, a systolic murmur most commonly indicates aortic valve sclerosis, which typically is not hemodynamically significant. This murmur peaks early during systole and is rarely heard in the carotid arteries. In contrast, the murmur of aortic valve stenosis typically peaks later during systole, is transmitted to the carotid arteries, and is loud (> grade 2); the 2nd heart sound is dampened, pulse pressure is narrow, and the carotid upstroke is slowed. However, in elderly patients, the murmur of aortic valve stenosis may be difficult to identify because it may be softer, a 2nd heart sound is rarely audible, and narrow pulse pressures are uncommon. Also, in many elderly patients with aortic valve stenosis, the carotid upstroke does not slow because vascular compliance is diminished.

Systolic murmurs may be due to other disorders, which should be identified. The murmur of mitral regurgitation is usually loudest at the apex and radiates to the axilla. The murmur of hypertrophic obstructive cardiomyopathy intensifies when the patient performs a Valsalva maneuver.

Fourth heart sounds are common among elderly people without evidence of a cardiovascular disorder and are commonly absent among elderly people with evidence of a cardiovascular disorder. Diastolic murmurs are abnormal in people of any age. Unexplained and asymptomatic sinus bradycardia in apparently healthy elderly people may not be clinically important.

If new neurologic or cardiovascular symptoms develop in patients with a pacemaker, evaluation for variable heart sounds, murmurs, and pulses and for hypotension and heart failure is required. These symptoms and signs may be due to loss of atrioventricular synchrony.

GI System

The abdomen is palpated to check for weak abdominal muscles, which are common among elderly people and which may result in hernias. Most abdominal aortic aneurysms are palpable; however, only their lateral width can be assessed during physical examination. A pulsatile mass located in front of the aorta does not expand laterally. The liver and spleen are palpated for enlargement. Frequency and quality of bowel sounds are checked, and the suprapubic area is percussed for tenderness, discomfort, and evidence of urinary retention.

The anorectal area is examined externally for fissures, hemorrhoids, and other lesions. Sensation and the anal wink reflex are tested. A digital rectal examination (DRE) to detect a mass, stricture, tenderness, or fecal impaction is done in men and women.

Male GU System

The prostate gland is palpated for nodules and consistency. Estimating prostate size by DRE is inaccurate, and size does not correlate with urethral obstruction; however, DRE provides a qualitative evaluation.

Female Reproductive System

Regular pelvic examinations are recommended, with a Papanicolaou (Pap) test every 2 to 3 yr until age 70. At age 70, testing can be stopped if results of the previous 2 consecutive tests were normal. If women >= 70 have not had regular Pap tests, they should have at least 2 negative tests, 1 yr apart, before testing is stopped. Once Pap testing has been stopped, it is restarted only if new symptoms or signs of a possible disorder develop. If women have had a hysterectomy, Pap tests are required only if cervical tissue remains.

For pelvic examination, a patient who lacks hip mobility may lie on her left side. Postmenopausal reduction of estrogen leads to atrophy of the vaginal and urethral mucosa; the vaginal mucosa appears dry and lacks rugal folds. The ovaries should not be palpable; palpable ovaries suggest cancer. The patient should be examined for evidence of prolapse of the urethra, vagina, cervix, and uterus. The patient is asked to cough to check for urine leakage and intermittent prolapse.

Musculoskeletal System

Joints are examined for tenderness, swelling, subluxation, crepitus, warmth, and redness. Heberden's nodes (bony overgrowths at the distal interphalangeal joints) or Bouchard's nodes (bony overgrowths at the proximal interphalangeal joints) can occur in patients with osteoarthritis. Subluxation of the metacarpophalangeal joints with ulnar deviation of the fingers may indicate chronic RA. Hyperextension of the proximal interphalangeal joint and flexion of the distal interphalangeal joint (swan-neck deformity) and hyperextension of the distal interphalangeal joint and flexion of the proximal interphalangeal joint (boutonnière deformity) suggest RA. These deformities may interfere with functioning or usual activities.

Active and passive range of joint motion should be determined. The presence of contractures should be noted. Variable resistance to passive manipulation of the extremities (gegenhalten) sometimes occurs with aging.

Feet: Diagnosis and treatment of foot problems, which are common with aging, help elderly people maintain their independence. Common age-related findings include hallux valgus, medial prominence of the 1st metatarsal head with lateral deviation and rotation of the big toe, and lateral deviation of the 5th metatarsal head. Hyperflexion of the proximal interphalangeal joint (hammer toe), which may occur in RA, and hyperflexion of the proximal and distal interphalangeal toe joints (claw toe) may interfere with functioning and daily activities. Patients with foot problems should be referred to a podiatrist for regular evaluation and treatment.

Neurologic System

Neurologic examination for elderly patients, similar to that for any adult, includes evaluation of cranial nerves, motor function, sensory function, and mental status. However, nonneurologic disorders that are common among elderly people may complicate this examination. For example, visual and hearing deficits may impede evaluation of cranial nerves, and periarthritis (inflammation of tissues around a joint) affecting certain joints, especially shoulders and hips, may interfere with evaluation of motor function.

Signs detected during the examination must be considered in light of the patient's age, history, and other findings. Symmetric findings unaccompanied by functional loss and other neurologic symptoms and signs may be noted in elderly patients. The physician must decide whether these findings justify a detailed evaluation for a neurologic lesion. Patients should be reevaluated periodically for functional changes, asymmetry, and new symptoms.

Cranial nerves: Evaluation may be complex. Elderly people often have small pupils; their pupillary light reflex may be sluggish, and their pupillary mitotic response to near vision may be diminished. Upward gaze and, to a lesser extent, downward gaze are slightly limited. Eye movements, when tracking a physician's finger during evaluation of visual fields, may appear jerky and irregular. Bell's phenomenon (reflex upward movement of the eyes during closure) is sometimes absent.

In many elderly people, sense of smell is diminished because they have fewer olfactory neurons, have had numerous upper respiratory infections, or have chronic rhinitis. However, asymmetric loss (loss of smell in one nostril) is abnormal. Taste may be altered because the sense of smell is diminished or because patients take drugs that decrease salivation.

Visual and hearing deficits may result from abnormalities in the eyes and ears rather than in nerve pathways.

Motor function: Strength, coordination, gait, and reflexes are evaluated. Elderly people, particularly those who do not do resistance training regularly, may appear weak during routine testing. For example, during the physical examination, the physician may easily straighten a patient's elbow despite the patient's effort to sustain a contraction. If weakness is symmetric, does not bother the patient, and has not changed the patient's function or activity level, it is likely to be clinically insignificant. Increased muscle tone, measured by flexing and extending the elbow or knee, is a normal finding in elderly people; however, jerky movements during examination and cogwheel rigidity are abnormal.

Patients can be evaluated for tremor during handshaking and other simple activities. If tremor is detected, amplitude, rhythm, distribution, frequency, and time of occurrence (at rest, with action, or with intention) are noted.

A decrease in muscle mass (sarcopenia) is a common age-related finding. It is insignificant unless accompanied by a decline or change in function (eg, a patient is no longer able to rise from a chair without using chair arms). Sarcopenia affects the hand muscles (eg, interosseous and thenar muscles) in particular. Weak extensor muscles of the wrist, fingers, and thumb are common among patients who use wheelchairs because compression of the upper arm against the armrest injures the radial nerve. Arm function can be tested by having the patient pick up an eating utensil or touch the back of the head with both hands.

Motor reaction time and motor coordination are tested. Reaction time often increases with aging, partly because conduction of signals along peripheral nerves slows. Coordination decreases because of changes in central mechanisms, but this decrease is usually subtle and does not impair function.

The deep tendon reflexes are checked. Aging usually has little effect on them. However, eliciting the Achilles tendon reflex may require special techniques (eg, testing while the patient kneels with the feet over the edge of a bed and with the hands clasped). A diminished or absent reflex, present in nearly ½ of elderly patients, may be normal. It occurs because tendon elasticity decreases and nerve conduction in the tendon's long reflex arc slows. Asymmetric Achilles tendon reflexes may indicate sciatica.

Overall postural control is evaluated using the Romberg test (patients stand with feet together and eyes closed). With aging, postural control is often impaired, and postural sway (movement in the anteroposterior plane when the patient remains stationary and upright) may increase.

Cortical release reflexes (known as pathologic reflexes), which include snout, sucking, and palmomental reflexes, occasionally occur in elderly patients who have no detectable brain disorders (eg, dementia). Babinski's reflex (extensor plantar response) in elderly patients is abnormal; it indicates an upper motor neuron lesion, which is often cervical spondylosis with partial cord compression.

Sensation: Evaluation of sensation includes touch (using a skin prick test), cortical sensory function, temperature sense, proprioception (joint position sense), and vibration sense testing. Aging has limited effects on sensation. Many elderly patients report numbness, especially in the feet. It may result from a decrease in size of fibers in the peripheral nerves, particularly the large fibers. Nonetheless, patients with numbness should be checked for peripheral neuropathies. In many patients, no cause of numbness can be identified.

Many elderly people lose vibratory sensation below the knees. This loss occurs because small vessels in the posterior column of the spinal cord change. However, proprioception, which is thought to use a similar pathway, is unaffected.

Mental status: A mental status examination is a key component of evaluation. A patient who is disturbed by such a test should be reassured that it is routine. The examiner must make sure that the patient can hear; hearing deficits that prevent a patient from hearing and understanding questions may be mistaken for cognitive dysfunction. Evaluating the mental status of a patient who has a speech or language disorder (eg, mutism, dysarthria, speech apraxia, aphasia) can be difficult.

Orientation may be normal in many patients with dementia or other cognitive disorders. Thus, evaluation may require questions that identify abnormalities in consciousness, judgment, calculations, speech, language, praxis, executive function, or memory, as well as orientation. Abnormalities in these areas cannot be attributed solely to age, and if abnormalities are noted, further evaluation, including a formal test of mental status, is needed. With aging, information processing and memory retrieval slow but are essentially unimpaired. With extra time and encouragement, patients perform such tasks satisfactorily.

Nutritional Status

Aging changes the interpretation of many measurements that reflect nutritional status in younger people. For example, aging can alter height. Weight changes can reflect alterations in nutrition, fluid balance, or both. The proportion of lean body mass and body fat content changes. Despite these age-related changes, body mass index is still useful in elderly patients. Thorough nutritional evaluation, including laboratory measurements, is indicated if patients have an abnormal nutrition history (eg, weight loss, suspected deficiencies in essential nutrients) or body mass index.

This topic was last updated June 2006.

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