SCIENTIFIC
SECTION
Clinical assessment
of the elderly patient
The examination of an elderly patient often requires
special techniques and attention to the patient's
comfort and ease. This paper outlines a reasonable
approach to each phase of the interview and discusses
the particular medical problems of this age group.
Older people are often slow to bring their troubles to
medical attention because their symptoms are vague
or because they accept their disability as part of old
age. Sometimes they have difficulty in communicating
effectively with the physician. Simple patience can
ease an otherwise frustrating situation.
L'examen du patient Agb exige souvent des techniques
spAciales et requiert qu'on prOte attention au confort
et au bien-Otre du patient. Cet article expose les
grandes lignes d'une fagon raisonnable d'aborder cha-
cune des phases de l'entrevue et commente les
problAmes mAdicaux particuliers A ce groupe d'Age.
Les personnes Agbes sont souvent lentes A amener
leurs problAmes A I'attention du mbdecin parce que
leurs sympt6mes sont vagues ou qu'ils pergoivent leur
incapacit6 comme faisant partie de l'Age. Ils ont
parfois des difficult6s A communiquer efficacement
avec le mAdecin. La seule patience peut faciliter une
situation autrement p6nible.
As we prepare for inevitable changes in our society, the
special medical needs of the elderly are attracting ever
greater attention. Courses in geriatrics are becoming
established as part of the medical school curriculum.
For the practising physician, though, even the straight-
forward examination of an older patient can be complex
and frustrating. We offer a practical guide to dealing
with elderly men and women and their medical prob-
lems in a clinical examination.
Starting the interview
Nothing will do more to establish rapport with the
patient than to convey sincere interest in and respect for
From the division of geriatric and continuing care medicine,
department of medicine, Queen's University and St. Mary's of the
Lake Hospital, Kingston, Ont.
*
Resident
tAssistant professor
t Professor
§Associate professor at the time of writing; presently medical director,
Providence Villa and Hospital, Scarborough, Ont.
Reprint requests to: Dr. Gilbert M. Rosenberg, St. Mary's of the Lake
Hospital, 340 Union St., Kingston, Ont. K7L 5A2
Family Practice
ROLAND SKRASTINS,* B SC, MD
GEORGE M. MERRY,t B SC, MD, MCFP
GILBERT M. ROSENBERG,4 M SC, MD, FRCP[C], FACP
JOHN E. SCHUMAN,§ BA, MA, M SC, FRCP[C]
the patient as a person. If time is taken at the start to
gain his trust and ensure his comfort, the whole of the
interview will flow smoothly and at a relaxed pace.
If, however, the initial contact is hasty and disorgan-
ized, an atmosphere of tension and confrontation may
be created, in which extracting answers from the uneasy
patient may well be like pulling teeth. It will help if the
physician clearly identifies himself to the patient and
any family members present, and explains the nature of
the examination. This is particularly important for
consultants, who may be greeted with considerable
suspicion and withdrawal at their first meeting. Antici-
pation of any immediate needs of the patient, such as
assistance to the toilet before a prolonged interview, can
ease his growing discomfort, as would elevation of the
head of the bed to relieve orthopnea.
A quiet, undisturbed setting for the interview is
important. Privacy can be established by drawing cur-
tains around a hospital patient's bed. The distractions of
radio or television must be reduced. The examiner
should position himself close to the patient. The physical
contact of holding the patient's hand may improve
communication, especially if the patient has visual or
hearing impairments. It is discouraging to the patient to
be "talked down to", so eye contact should be main-
tained at a face-to-face level. This facilitates lip-reading
and will improve his attention and concentration. The
examiner should talk slowly and clearly, at a pitch and
loudness that are comfortable and comprehensible to the
patient. Unnecessary shouting can irreparably destroy
patient rapport.
The examination of an acutely confused person
demands great patience and diagnostic skill. Anxiety
can be reduced by speaking in a calm, reassuring
manner and by eliminating distractions. The visible
presence of a close, trusted relative or a familiar health
professional, perhaps the patient's nurse, often improves
cooperation. Despite these efforts, tranquillizing medi-
cations may still be needed so that a proper examination
may be completed. A recent publication by Bayne'
describes a practical approach to these problems.
History-taking
Traditionally the clinical interview is an orderly
sequence of questioning that begins with identification
of the patient's reason for seeking medical help. This is
followed by a detailed account of the present problem,
CMA JOURNAL/AUGUST 1, 1982/VOL. 127 203
the past history, the family and social history, and a
systems review.
This line of questioning may be difficult for some
elderly patients to comprehend and follow, particularly
if they suffer from dysphasia, inattention, confusion or
memory loss. The key, then, is flexibility. The sequence
and content of questioning should be adjusted to suit the
individual's ability to communicate and respond. The
physician should be alert to signs of fatigue or discom-
fort in the patient during the questioning. Sometimes it
is best to stop the interview and resume it later.
Patient profile
Introductory conversation with the patient should be
relaxed and informal. Information should be gathered
regarding the patient's age, marital status, birthplace,
current residence and occupational history. This will
also permit a preliminary assessment of the patient's
mental state and reliability, which will guide the
approach to further questioning.
It may be useful to bring out the family and social
history earlier than usual in the interview to gain insight
into the family structure and support from auxiliary
services, such as Home Care, Victorian Order of Nurses
and Meals on Wheels. A brief assessment of the health
of the patient's spouse, siblings and children may be
appropriate at this point, but a more complete screening
for specific disorders, such as Alzheimer's disease,
should be done later in the interview.
Present illness
Identifying the major presenting symptom may not be
easy. Often, new symptoms are nonspecific and insidious
in onset, leading to considerable delay in seeking
medical attention. The key to success is to ascertain
what new problem has brought the patient to medical
attention at this time, rather than what developed weeks
or months ago, and to determine the extent to which it
has interfered with the patient's functioning.
A host of slowly progressive diseases, such as malig-
nant diseases, metabolic disorders and chronic infections
(e.g., tuberculosis), may manifest themselves simply as a
failure to thrive, with decreasing weight, loss of social
interests and inability to cope with such daily activities
as personal hygiene or the management of a household.
Confusion may be the only visible feature of acute
problems, such as dehydration, infections, heart failure,
cerebrovascular accidents and adverse drug reactions.
The inflammatory response to infections or necrosis
may be impaired, and the pain response, too, may be
lessened and poorly localized. Beyond the age of 75 it is
common for myocardial infarctions to occur without
pain, and therefore it becomes important to search out
such secondary symptoms as increased dyspnea or
fatigue. This is especially so for diabetic patients, in
whom peripheral neuropathy may have further dimin-
ished the sensitivity to pain.
Exertional symptoms may not be reported because of
the relative immobility of many older people. For
example, intermittent claudication may be absent de-
spite severe peripheral vascular disease.
The elderly may not complain about major discom-
forts and disabilities, accepting them as part of old age
204 CMA JOURNAL/AUGUST 1, 1982/VOL. 127
or incorrectly attributing new symptoms to known
chronic diseases. For instance, new joint pain from bony
metastases may be dismissed as a "touch of rheuma-
tism". Subtle changes in quality and severity of chronic
symptoms may point to an unrecognized problem.
There may be great difficulty in obtaining a descrip-
tion of the onset, duration and sequence of symptoms.
One can assist the patient by associating symptoms with
the seasons or important times in the year.
The physician must try to understand what the
patient means by vague terms such as "giddiness" or
"queer turns", and in turn should make sure that the
patient understands any medical terms used.
The patient's historical account ought to be con-
firmed with his relatives or friends, who can often
provide a perspective on the patient's disabilities.
Past medical history
Any major medical problems and surgical procedures
should be clearly documented, even though considerable
time may be lost in eliciting this information. The
physician may wish to review the details of past
problems in hospital and clinic charts.
Medications
Some of the many medications elderly patients take
may contribute to poor health. The patient should bring
in all his prescription and nonprescription medications,
so that the staff can examine the containers themselves
and check prescribed dosages and compliance. It is
essential that the patient be made to understand the
dosages of all his drugs and the reasons for taking them.
Any history of adverse drug reactions or allergies
should be described as clearly as possible, keeping in
mind that a patient who refers to a "penicillin allergy"
may in fact be describing an adverse gastrointestinal
effect. The amount of smoking and alcohol consumption
should also be recorded.
Systems review
This essential component of history-taking is often
neglected. One should be looking for problems that the
patient may have accepted for years as a part of
growing old. Specific enquiries directed at common
problems, such as visual and hearing disturbances, poor
dentition, urinary incontinence or urgency, falling at-
tacks, joint pain, depression and early impairment of
memory, can be productive.
An elderly patient may have difficulty answering long
lists of questions that are asked in rapid succession, and
may find it easier to understand and respond if these are
asked at the time the particular organ system is being
examined.
Physical examination
It has sometimes been suggested that the sequence of
the physical examination be altered for the elderly
patient. Wright,2 for instance, suggested beginning with
the patient's back. Such an approach risks missing a
vital area because of deviation from the routine. We still
feel that the traditional "head to toes" approach is best.
However, it may be impossible to position the patient
"properly" for all aspects of the examination because of
painful flexion contractures, neurologic deficits or or- Atrophic change in the oral mucosa and bony ridges
thopnea, and examining techniques may have to be occurs after the loss of teeth and may contribute to the
modified to permit as complete a work-up as possible. development of oral candidiasis. This infection along
Before starting the physical examination the physi- with temporomandibular arthritis, dental sepsis and
cian should reassess the patient's comfort and privacy. malocclusion of dentures should be identified. These
Enough bed sheets should be provided to keep the may be factors contributing to weight loss because
patient warm, and anatomic regions not under examina- eating is painful. A smooth, shiny tongue or angular
tion should be left covered. Washing one's hands with stomatitis may indicate vitamin deficiencies. Because
warm water and warming the stethoscope are small mouth-breathing is common, a dry tongue is not as
measures of thoughtfulness that will be appreciated. reliable an indicator of dehydration as is a dry sulcus
One of the major difficulties in examining the elderly between the mandible and the lower lip.
patient is to differentiate abnormal findings of clinical Examination of the neck should be directed at ruling
significance from the changes of normal ageing and out thyroid enlargement, abnormal nodules and supra-
from isolated signs that are not of functional or clavicular lymphadenopathy that may result from tu-
diagnostic significance. mour metastases.
General appearance Thorax
This should be assessed while taking the history, with Ageing results in weakening of the thoracic wall
attention to nutritional state, grooming, facial expres- muscles, reduction of costal cartilage elasticity and
sions, posture and involuntary movements. coalescence of alveoli. Chest expansion and vital capaci-
Because of muscle atrophy and loss of subcutaneous ty are decreased, leaving the patient more susceptible to
tissue, a normal elderly patient may appear sornewhat pneumonia. More pronounced respiratory difficulty may
wasted and malnourished. More severe generalized result from kyphoscoliosis, chronic obstructive pulmo-
wasting and cachexia, though, raise the possibility of an nary disease or bronchial carcinoma. Scattered basal
underlying chronic or malignant disease. crepitations are common and are not necessarily as-
sociated with congestive heart failure.
Skin Breast lumps may become more apparent in the
With the usual degeneration of collagen and elastin, elderly through atrophy of overlying tissue. Advanced
atrophy of the epidermal structures, loss of subcutane- tumours are not uncommon in women who have long
ous fat and increased vascular fragility it is common to been reluctant to seek medical attention. The axillae
find dryness, thinning and wrinkling of the skin, senile should be checked for metastatic lymphadenopathy.
purpura, loss of scalp, axillary and pubic hair, and loss With time the aorta and its major branches stretch
of skin turgor over the extremities. It is more appropri- and lose their elasticity. Dilatation of the subclavian
ate, then, to pinch-fold the skin over the forehead rather artery may obstruct venous return on the left side of the
than the extremities when looking for isotonic dehydra- neck, resulting in unilateral jugular distension.
tion. Other "normal" findings include small papular Systolic murmurs, usually reflecting aortic sclerosis
lesions (cherry angiomas) and coarse facial hairs in or mild mitral insufficiency, are very common in the
women. elderly and are of little clinical significance. Calcific
Common skin conditions requiring treatment include aortic stenosis and rheumatic valvular heart disease can
abrasions, infections, herpes zoster, onychogryphoses, against valveofreplacement.5
be treated, course, but the patient's age may argue
paronychiae, senile keratoses and lesions suggestive of An irregular rhythm is often due to chronic atrial
squamous or basal cell carcinoma. Especially in bedrid-
den patients the heels, sacral region, greater trochanters, fibrillation, which may be well tolerated in the absence
shoulders and malleoli may be sites of decubitus ulcers. of rapid ventricular response or congestive heart failure.
Systolic hypertension is common in the elderly, but
Head and neck the level requiring treatment is unknown, and the
The loss of orbital fat results in a sunken appearance sphygmomanometer may not properly measure the
intra-arterial pressure.'
of the eyes and senile ptosis. Degenerative changes in other hand, may reflect volume Postural hypotension, on the
the muscles of accommodation and the iris may result in neuropathy or be a side effect of depletion or autonomic
contracted, irregular, unequal pupils, and the pupillary diuretic. This is a common cause aofdrug, falls.
especially a
can be
response to light may be sluggish. Arcus senilis and detected by recording blood pressure and pulseItwhen the
some degree of presbyopia are usually present. Eye
patient is supine, sitting
troubles that may be found include entropion, ectropion, minutes between each change in and standing, with 2 or 3
position
glaucoma, cataract, diabetic retinopathy, retinal detach- measurement. A fall in the systolic pressure of more and the
ment and senile macular degeneration. The visual fields than 15 mm
should be assessed for homonymous hemianopsia. Hg with standing should be considered
Some degree of hearing loss, almost universal in the abnormal.
elderly, can lead to severe psychologic effects through Abdomen
social isolation, and yet is one of the problems for which Examination may be difficult if the patient is unable
the elderly most commonly fail to seek help.3'4 Degenera- to relax the abdominal musculature. The skin tempera-
tion of the organ of Corti and of the neuronal pathways ture should be noted, since coolness may suggest hypo-
may impair high-tone hearing, cortical sound discrimi- thermia. A transverse abdominal skin crease could have
nation and perception of speech. resulted from severe kyphosis or a collapsed vertebra.
CMA JOURNAL/AUGUST 1, 1982/VOL. 127 205
 The normal-sized aorta is commonly palpable as a
pulsatile mass; it is more apparent in the elderly because
of loss of subcutaneous tissue. The presence of an
abdominal aortic aneurysm, a common cause of disabili-
ty and death in the elderly that may be amenable to
surgery,7 should be excluded.
Abdominal "masses" often consist of scybala (firm
feces) in the transverse or descending colon; they need
to be reassessed following an enema. The presence of
hepatomegaly or splenomegaly should initiate a search
for an occult malignant disease.
A rectal examination should be performed in every
elderly patient to seek evidence of fecal impaction,
rectal carcinoma, benign prostatic hypertrophy or pro-
static carcinoma. "Normal" findings may include some
laxity in the tone of the anal sphincter and small pellets
of feces in the rectum.
Genitourinary system
Urinary incontinence secondary to chronic painless
retention may be a problem, and the suprapubic region
should be percussed for bladder distension. Men should
be assessed for inguinal hernias and penile lesions. Some
degree of atrophic vaginitis is common in older women,
but other causes of perineal discomfort should be
considered.
Musculoskeletal system
Loss of muscle bulk and strength and impaired
balance make falls likely. Bony deformities may have
resulted from old fractures, especially those involving
the neck of the femur.
Observation of the patient's posture, gait and locomo-
tion is essential. Particular attention should be paid to
the ease with which he moves from supine and sitting to
standing positions and to the appropriate use of a cane
or a walker. Home visits by the physician or other
professionals are invaluable in assessing the patient's
capacity to cope with the activities of daily living.
In the hand, osteoarthritic changes often involve the
proximal and distal interphalangeal joints (Bouchard's
and Heberden's nodes) and should not be confused with
rheumatoid deformities. New joint effusions should
not be dismissed lightly, as there is a high incidence of
septic arthritis in patients with rheumatoid arthritis.
Bony tenderness, especially in the ribs and spine, may
be a sign of metastatic carcinoma. Proximal muscle
discomfort and temporal artery tenderness should be
assessed to rule out temporal arteritis with or without
polymyalgia rheumatica.
The feet deserve special emphasis in the elderly
patient, as they may produce severe pain and impair
function. Corns, calluses, bunions, ingrown toenails and
fungal infections should be identified and treatment
planned. The insole of the shoes will show the points of
weight-bearing and suggest corrective footwear.
Nervous system
Isolated neurologic findings of dubious significance
are very common and include impaired upward gaze
without diplopia, absence of deep tendon reflexes (espe-
cially ankle jerks), absence of vibration or position sense
in the feet, and wasting of the first dorsal interossei of
the hands.8
206 CMA JOURNAL/AUGUST 1, 1982/VOL. 127
Primitive reflexes, such as the grasp, glabellar tap,
snout, suck and Hoffmann's, should be documented as
evidence suggesting frontal lobe dysfunction (most com-
monly found in senile dementia of the Alzheimer type).
However, sometimes patients may show these signs as a
variation of normal.9
Asymmetry of muscle power and tone, together with
unilateral sensory deficits, may point to an old, often
unrecognized, cerebrovascular accident.
An important treatable cause of neurologic dysfunc-
tion is Parkinson's disease. However, benign senile
tremor in the hands is another common finding; it may
or may not respond to therapy.'0
Mental status
This is commonly documented at the end of the
work-up, but it should be analysed throughout the
interview and examination. The patient's behaviour,
judgement and insight should be noted and specific
attention paid to depression, a very common problem
that may appear as "pseudodementia"."
To test for specific features of dementia a more
formal neuropsychiatric assessment should be done,
preferably when the patient is well rested and coopera-
tive, perhaps in a second visit. The assessment should
include tests for concentration, attention span, short-
and long-term memory, orientation, expressive and
receptive speech, apraxias and higher cognitive func-
tions. Various "dementia scales" are available to docu-
ment the abnormal findings. In a recent review Ropper'2
described a rational approach to the problem of demen-
tia in the elderly.
Conclusion
One can expect the examination of an elderly patient
to take longer than usual, because communication may
be difficult and symptoms obscure. The physician may
have to rearrange and repeat his questions and then
probe the answers to arrive at a satisfactory understand-
ing of the patient's condition. He will have to be alert to
subtle changes in chronic complaints, yet be able to
judge which symptoms are of no diagnostic or clinical
significance. Through anticipation of the patient's prob-
able needs and disabilities, the examination of an elderly
person can become a rewarding experience.
References
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l39-141
2. WRIGHT WB: Geriatrics is medicine - How to examine an old person, Lancet 1977; 1:
1145-1146
3. LOwTHER CP, MACLEOD RDM, WILLIAMSON J: Evaluation of early diagnostic
servicea for the elderly. Br Med J 1970; 3: 275-277
4. PIKE LA: Screening the elderly in general practice. J R CoIl .Qen Pract 1976; 26:
698-703
5. JAMIESON WRE, THOMPSON DM, MUNRO Al: Cardiac valve replacement in elderly
patients. Can Med Assoc J 1980; 123: 628-632
6. CAPE RD: Aging: Its Complex Management, Har-Row, Hageratown, Md, 1978: 30
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