Health Concerns in the Elderly

Aka: Health Concerns in the Elderly, Health Maintenance in Older Adults, Geriatrics, Geriatric Health Maintenance Exam, Geriatric Assessment, Comprehensive Geriatric Assessment, Medicare Annual Wellness Visit, Health Care of the Elderly

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II. Epidemiology

  1. See Life Expectancy
  2. Prevalence (U.S. Census 2020): 55.8 Million over age 65 years (17% of U.S. population)
    1. Represents a 40% increase from the 40.3 Million from the 2010 U.S. Census

III. Approach: Communication with Older Patients

  1. Although these points apply to all patients, ageism is common in the care of older patients
  2. General
    1. Address patients formally unless they wish to be addressed otherwise
    2. Face the patient and make eye contact
    3. Listen to patients without interruption as much as possible, Hearing their concerns
    4. Keep in mind Impairments that interfere with communication (vision Impairment, Hearing Impairment, cognitive deficits)
    5. Speak clearly with language and pace appropriate for specific patient understanding
  3. Clinic Visits
    1. Schedule longer visits at quieter times of day
    2. Facilitate a quiet and comfortable waiting area and minimize wait times
    3. Encourage a welcoming clinic environment focused on positive staff-patient interactions
    4. Assist patients navigating the physical clinic space and visit logistics
  4. Organize the visit agenda with the patient's priorities in mind
    1. Identify the list of patient concerns early in the encounter
    2. Address one concern at a time, starting with the concern most important to them
    3. Communicate empathetically and with appropriate honesty and realism
    4. Encourage the patient to make decisions about the plan of care
    5. Look for safe options for patients to maintain their independence and quality of life
    6. Make use of learning aids (e.g. visual diagrams) when explaining medical conditions and their treatment
    7. Provide resources (e.g. written education, videos) for additional guidance following the visit
  5. References
    1. Walling (2024) Am Fam Physician 110(1):87-9

IV. Associated Conditions: Common Medical Conditions affecting patients over age 75

  1. Osteoarthritis and other Rheumatologic Conditions
    1. See Rheumatologic Conditions in the Elderly
  2. Cardiovascular Disease (36%)
    1. Coronary Artery Disease
    2. Congestive Heart Failure
  3. Diabetes Mellitus (20%)
  4. Hypertension (29%)
  5. Cerebrovascular Disease (14%)
  6. COPD (11%)
  7. Decreased Visual Acuity
  8. Hearing
    1. See Hearing Loss in Older Adults
    2. See Hearing Handicap Inventory for the Elderly
  9. Hypothyroidism
  10. References
    1. Van Lankveld (2004) Arthritis Rheum 51:299 [PubMed]

V. Associated Conditions: Common Syndromes in the Elderly

  1. Dementia
    1. Concerns regarding decreased cognition by friends, family
    2. See Mini-Cog
    3. See SLUMS Exam
  2. Urinary Incontinence
    1. In the past year, have you ever lost your urine and gotten wet?
    2. Have you lost your urine on at least 6 separate days
  3. Fall Prevention in the Elderly
    1. Falls in the last year?
      1. Associated with 2.8 fold increased risk of falls in the next year
      2. Ganz (2007) JAMA 297(1):77-86 [PubMed]
    2. See Get Up and Go Test
    3. Consider Home Safety Self-Assessment Tool
  4. Polypharmacy
    1. See Medication Use in the Elderly
    2. See Drug-Drug Interactions in the Elderly
    3. Consider Deprescribing at every encounter

VI. Associated Conditions: Psychosocial Concerns

  1. Nutrition
    1. See Geriatric Nutrition Checklist
    2. Have you lost weight in the previous 6 months?
  2. Activity in the Elderly
    1. Activities of Daily Living (e.g. dressing, toileting, bathing, eating, walking)
    2. Activities of Daily Living Scale
    3. Instrumental Activities of Daily Living (e.g. shopping, managing medications, finances)
  3. Elder Abuse
  4. Driving Assessment
  5. Behavioral risks
    1. Alcohol Abuse (and other agents, such as opiods, Benzodiazepines)
    2. Tobacco Abuse
    3. New sexual partners
  6. Geriatric Depression
    1. See Geriatric Depression Scale
    2. See Five-Item Geriatric Depression Scale
    3. See Patient Health Questionaire 9 (PHQ-9)

VII. History

  1. Self assessment of health status (excellent, good, fair, poor)
  2. Update recent medical events (emergency department visits, hospitalizations, surgeries)
  3. Family History of longevity, Cognitive Impairment
  4. Medication reconciliation
    1. See Medication Use in the Elderly (includes Beers Criteria and STOPP)
    2. See Polypharmacy

VIII. Exam: Vitals

  1. Weight
    1. Unintentional Weight Loss
      1. Cancer
      2. Major Depression
    2. Weight gain
      1. Congestive Heart Failure
  2. Blood Pressure
    1. Orthostasis (Autonomic Dysfunction, Beta Blockers, Coronary Artery Disease)
  3. Heart Rate
    1. Bradycardia (Beta Blockers, Heart Block)
    2. Atrial Fibrillation
  4. Respiratory Rate increased >24
    1. COPD
    2. Congestive Heart Failure
    3. Pneumonia
  5. Temperature high or low Temperature
    1. See Infections in Older Adults
    2. Hypothyroidism or Hypothyroidism

IX. Exam: Head and Neck

  1. Face
    1. Facial asymmetry (e.g. neurovascular disease)
    2. Frontal bossing (Paget's Disease)
  2. Eyes
    1. Vision Loss (Macular Degeneration, Cataracts, Glaucoma)
  3. Ears
    1. Hearing Loss
  4. Mouth
    1. Oral Lesions (denture fit, Leukoplakia)
    2. Xerostomia (e.g. Diabetes Mellitus, Sjogren's Syndrome, Anticholinergic Medications)
  5. Neck
    1. Carotid Bruit
    2. Thyroid mass

X. Exam: Trunk

  1. Heart Exam
  2. Lung Exam
  3. Abdomen
    1. Abdominal Aortic Aneurysm
    2. Constipation (drug-related, Colon Cancer, Dehydration)
    3. Fecal Incontinence (e.g. Fecal Impaction)
    4. Rectal Bleeding
  4. Genitourinary
    1. Vaginal Atrophy
    2. Prostate enlargement
    3. Urinary Incontinence

XI. Exam: Extremity

  1. Feet
    1. Bunions, Callus, and non-healing sores
    2. Peripheral Vascular Disease
    3. Venous Insufficiency
  2. Joints
    1. Painful range of motion
    2. Antalgic Gait
  3. Neurologic
    1. Get Up and Go Test
    2. Ataxia
    3. Parkinsonian Tremor
    4. Cognition

XII. Prevention: Counseling for over age 65 years

  1. Tobacco Cessation
    1. Quitting as late as age 65 still increases Life Expectancy 1-3 years
    2. Taylor (2002) Am J Public Health 92(6): 990-6 [PubMed]
  2. Heart Healthy Diet (e.g. Mediterranean Diet)
  3. Exercise in the Elderly
  4. Weight management
  5. Nutrition
  6. Home Adaptations for the Elderly
  7. Advance Care Planning
    1. Long-term care
    2. Advanced Directives (e.g. POLST, Living Will)
    3. Durable Power of Attorney
  8. Vaccination
    1. Influenza Vaccine annually
    2. Tdap at least once, and then Tetanus Vaccine every 10 years
    3. Prevnar-13 Vaccine at age 65 years and PneumovaxVaccine at age 66 years
    4. Herpes Zoster Vaccine (Shingrix) at age 50 years old (if immunocompetent)

XIII. Prevention: Screening

  1. See Health Maintenance in Adults
  2. Precautions
    1. Take Life Expectancy into account when discussing cancer screening
    2. Breast and Colorectal Cancer Screening is not recommend if <10 year Life Expectancy
    3. Paradoxically, the healthiest patients are screened less than those in with the lowest Life Expectancy
  3. Abdominal Aortic Aneurysm Screening with Abdominal Ultrasound
    1. Screen men between ages 65 to 75 if any history of Tobacco Abuse (consider in women)
  4. Breast Cancer Screening with Mammograms
    1. Every other year in women up to age 75 AND
    2. May continue based on Shared Decision Making IF at least 10 years Life Expectancy
  5. Cervical Cancer Screening with Pap Smears
    1. May be discontinued after age 65 unless dysplasia history or inadequate prior screening
  6. Colorectal Cancer Screening
    1. See Colon Cancer Screening with Colonoscopy for recommended intervals
    2. Routine screening until age 75 years and may be considered in age 76 to 85 years
    3. Stop screening when Life Expectancy <10 years
  7. Prostate Cancer Screening
    1. Controversial at any age
    2. Avoid screening over age 70 years OR Life Expectancy <10 to 15 years
  8. Osteoporosis Screening
    1. See Osteoporosis Screening
  9. Lung Cancer Screening CT Chest (guidelines updated 2021)
    1. Adults 50 to 80 years old with >20 pack year history of smoking AND
    2. Currently smoking or quit within last 15 years

XIV. Resources

  1. See Community Services for the Elderly

XV. References

  1. Dial (2003) AAFP Board Review Lecture, Seattle
  2. Elsawy (2011) Am Fam Physician 83:48-56 [PubMed]
  3. Salzman (2016) Am Fam Physician 93(8): 659-67 [PubMed]
  4. Spalding (2008) Am Fam Physician 78(2): 206-15 [PubMed]
  5. Tatum (2018) Am Fam Physician 97(12): 776-84 [PubMed]

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