3. CGA in Primary Care Settings: Physical Assessment
Examination of older patients incorporates all the typical aspects of clinical examination, although there are some general considerations and emphases that should be borne in mind, and specific examinations that may be more relevant in older people. Many of these specific assessments have associated tools but there is no well-validated screening tool for general physical examination. The physical examination will guide which areas require more in-depth or systematised assessment.
Older people, particularly those with frailty, may find the clinical examination challenging or tiring. A thorough assessment may have to be split into more than one session or deferred, so initial prioritisation of the most relevant issues is important.
Within a single examination session, the patient with limitations of mobility, exertion or posture requires an adaptive approach, grouping examinations by position and opportunity rather than organ system or diagnosis and accepting less than ideal conditions. For example, a kyphosis or severe heart failure may limit the ability to lie flat and so examination of the abdomen and screening neurological examination of the legs could be done with the patient semi recumbent and consecutively to avoid having to return to this position later.
Assessment of the non-concordant patient
Patients with dementia, delirium, or psychiatric illness may not give consent or participate in examination. Consideration must be given to whether the patient has capacity to agree or refuse examination and, if not, assessment performed bearing in mind the best interests of the patient using provisions of mental capacity legislation. This is likely to be the case for most aspects of clinical examination which are unlikely to be burdensome, harmful or limiting to the person’s liberty – however if the patient has previously refused interventions and assessments it should not be assumed that a change in their ability to consent or refuse means that examination is now acceptable. Discussion with the patient’s advocate(s) or healthcare power of attorney is also important here.
Examination is a continuous process and information can be gleaned even when not formally examining – the walk into the examination room may give significant clues about gait and balance, while visual cues such as choice and fit of clothing (e.g. elasticated waistbands) can suggest functional difficulties with dressing, or recent weight change. Non-concordant patients examined under their best interests may be challenging to assess but with assistance, reassurance, and careful observation (eg a variety of purposeful movements in lieu of formal neurological testing of each muscle group) a large amount of information may be gleaned.
Hints and Tips
Subtle clues can be picked up about sensory deficiencies but these can often be compensated for (e.g. lip-reading in deafness) or concealed (giving non-committal responses at the end of poorly-heard sentences). Quick screens for sensory problems include:
- Whispering numbers in the ear and requesting their repetition.
- Cupping a hearing aid in the hand to check for feedback noise.
- Gross visual testing (number of fingers, read a line from a book).
Feet and footwear
Observation of foot condition is extremely important, often yielding actions which can improve balance and function. Choice of footwear, condition of skin and nails (especially toenail cutting and fungal infections), oedema, anatomical abnormalities and ulcers can all be picked up in seconds. Peripheral sensory testing frequently identifies unrecognised abnormalities although their clinical and functional significance can be difficult to interpret. Vibration testing at the joints, joint position sense, and light touch in the lower limbs may be contributory. Check perfusion in the feet in general - are they warm? If not look for pulses and/or capillary refill time (greater than five seconds might suggest ischaemia).
Gait and balance
Observation around the examination (on and off the chair and examination couch/bed, in and out of the room) is extremely useful. Timed up and go, number of steps to turn 180 degrees, or formal balance scoring (e.g. Berg Balance Scale) can be useful. All these are described in more detail in the Patients presenting with mobility and balance issues chapter.
Lying and standing blood pressure
This is high yield, giving clues about fluid status, medication effects, and causes of dizziness or falls. The patient must lie flat for at least five minutes, followed by a BP check when standing (supported if necessary) immediately, after one minute a further check at three minutes’ standing. Postural hypotension is said to be present with a drop in systolic BP of more than 20mmHg or to below 90mmHg associated with reported syncope or presyncope (although it may not be demonstrated on every occasion). It is important to note that some individuals can continue to have postural symptoms even if there appears to have been no change in BP. These may need referral to a local geriatrician for more formal testing.
Cognition and mood
Interactivity, alertness, vocabulary, ability to follow complex commands and recall can all be noted over the course of an assessment but should be followed up with formal testing - see chapter on Psychological components. Drowsiness, inattention or hypervigilance can be signs of acute delirium if acute (Check 4AT).
A full functional assessment is generally the preserve of specialist occupational therapists, but evidence of difficulties with personal care (hygiene, choice of attire) may be picked up leading to a fuller review.
Many older patients will deny pain or be unable to express it. Observation during movement or change in posture may yield clues that mobility or function may be limited by pain. Using alternative words when assessing movement (e.g. “stiffness”, “ache”) may elucidate further. Examination of joints commonly affected by osteoarthritis such as the fingers and knees with functional observation and gross checking of range of movement / crepitus is helpful. A more thorough assessment by a physiotherapist of joint function may then be indicated.
Weight and nutrition
Check and record weight consistently. Other evidence of weight loss such as poorly fitting clothes, or loose skin should be noted. General condition of hair and nails can yield clues about nutrition, and an observation of oral health (including checking of dentures) is useful.
PR and genitalia
Constipation is often missed, and can cause chronic reduction in appetite or recurrent abdominal pain as well as acute deterioration, nausea and overflow diarrhoea. Faecal incontinence can result from this or from other local rectal problems. A PR examination will reveal information regarding these often-missed issues and also assess for prostate size/shape, haemorrhoids, bleeding or rectal masses. Examination of the external genitalia should be done in a complete assessment, and a brief breast examination (irrespective of sex) in addition.
‘Normal’ age-related changes
It is generally best to avoid assuming that a change is ‘normal’ for age, although certain non-pathological changes are increasingly common in older adults. Skin changes such as uneven coloration and wrinkling/thinning, and neurological findings such as decreased or absent ankle reflexes and loss of vibration sense in the toes or subtle changes in eye movements may not be significant in older patients.