Clinicians are tasked with evaluating a patient including performing a history and physical examination, initiating a diagnostic workup when appropriate, and determining what medically reasonable options are appropriate given the patient’s unique situation. Clinicians must then explore the patient’s goals and share in the decision making to assure that the chosen treatments align with the patient’s goals.
The clinical interview is an important element of the decision-making process. It can be used to establish a diagnosis and monitor treatment and prognosis. The altered, often attenuated, presentation of diseases, the coexistence of multiple processes, and the underreporting of symptoms and conditions in older patients mandate a reordering of the importance of various components of the history. The chief complaint, the cornerstone of history-taking in younger patients, has decreased relevance in older persons. Indeed, overreliance on the chief complaint leads to the oft cited, though inaccurate comment that older persons are “vague” or “poor historians.” Rather, they may be accurately reporting the often vague, nonspecific manner in which they experience their illnesses.
Social history is of paramount importance in the care of older adults. Knowing a person’s living arrangements and financial situation as well as the organization of their support system is essential in decision making with older adults. Problems in these domains are prevalent among older adults. Indeed, these factors are central when discussing major decisions around increased support at home versus institutionalization.
Review of symptoms and syndromes
The review of systems takes on greater importance in older persons and is often the vehicle by which treatable health conditions are revealed. Complementary to the conventional review of systems, physicians should perform a review of syndromes, targeting modifiable multifactorial geriatric syndromes common in older persons including sleep problems, incontinence, pain, dizziness, falls, depressive symptoms, fatigue, anorexia, and weight loss. Difficulty, degree of dependence, and change in ability in both self-care or basic activities of daily living (ADL—eating, dressing, grooming, bathing, walking, and transferring) and instrumental activities of daily living (IADL—taking medication, handling finances, using transportation, preparing meals, housekeeping, communicating outside the home, and shopping) are also integral components of the history in older persons. These functional activities often are the primary outcomes targeted in the treatment of older patients.
Assessment of mood, affect, and cognition
The clinical history of older persons should also include assessments of cognitive function, affect, and mood (depressive symptoms). These topics are discussed in detail in Chapters 62 and 63. Briefly, mood and affect can be screened for easily with tools such as the two-question depressive screen (In the past month, have you been sad, blue, or down in the dumps? Have you lost interest in most things or been unable to enjoy them?). More formal, systematic assessments should be undertaken if there is any question of depression. Cognitive status can be screened for with short tests such as the Mini-Cog. The Mini-Cog combines the three-item recall and the clock-drawing test (CDT). In a community-based study, the best performing scoring algorithm for the Mini-Cog was when the participant was judged to have dementia if either the three-item recall score was 0 or 1 to 2 and a CDT score was rated between 1 (mild) and 3 (severe). This scoring had a sensitivity of 99%, a specificity of 93%, a positive test likelihood ratio of 14.1, and a negative test likelihood ratio of 0.01. This scoring algorithm had a better sensitivity than other more commonly used cognitive tests. The Mini-Cog has several advantages, which makes it a useful screening tool. It takes less than 5 minutes to complete, is unaffected by language or education, and can be scored by untrained raters with minimal loss of accuracy. Knowing the cognitive status of an older adult also has important implications in decision making.
The physical examination in older persons differs from younger persons as well. The purpose of the physical examination in younger persons is primarily to diagnose specific diseases. The physical examination in older persons, however, also serves to identify treatable impairments such as muscle weakness, gait instability, or sensory impairments, and to directly observe the performance of key functional tasks.
While the technique of physical examination in an older person is often the same as in younger persons, direct observation and functional testing play particularly important roles in older persons. Observing the older patient as they walk down the hall, get on and off the examination table or sit up to the edge of the bed are valuable and time-efficient ways to ascertain relevant information concerning muscle strength, joint range of motion, and gait stability as well as difficulty with daily functional tasks. Similarly, buttoning and unbuttoning a shirt or blouse, taking shoes on and off, and writing a sentence are simple tests of fine-motor coordination, manual dexterity, and motor planning. Reading a prescription bottle or a magazine provides information on visual acuity. Observing a patient’s ability to follow multiple-step commands such as during finger-to-nose testing provides valuable information on cognitive and neurologic functioning. Recent weight loss can be judged from clothing that is too large, especially at the collar and waist.
Selecting components of the physical examination to perform
While the content of the physical examination will be much the same for older, as for younger patients, given time constraints, high-yield, relevant, but less traditional, examination items should take precedence. The functional tests described earlier are examples of high-yield items that should be part of the standard examination. For example, during day 5 of a hospitalization, it is likely more important to see if your patient can sit up or stand than to listen to the heart sounds. Other high-yield examination elements might include postural blood pressure, inspection of ear canal for cerumen, visual acuity, and foot examination.
Evaluation: Diagnostic Testing
Diagnostic testing poses additional challenges among older adults. The value of a diagnostic test is best determined by considering whether the test is accurate, the target disorder is dangerous if left undiagnosed, the test has acceptable risks, and effective treatment exists. All of these criteria are relevant as older patients often have multiple health conditions and limited life expectancy changing both the accuracy and value of diagnostic testing. Also, because older adults vary in the emphasis they place on outcomes other than mortality, even a good diagnostic test may not be appropriate for an individual patient.
Deciding whether a diagnostic test is important requires consideration of its ability to change the probability of disease prior to test completion (called the pretest probability of the target disorder) to a probability of the disease after test completion (called the posttest probability). As for the physical examination, the coexistence of diseases and age-related changes may affect the sensitivity, specificity, predictive value, and interpretability of laboratory, imaging, and other ancillary tests. Consequently, most tests have lower value among older adults. In addition, age-referenced normal values and ranges have been developed for some, albeit, not most laboratory tests.
In older persons, there are additional issues to consider including the ability of the patient to complete the test and whether the test does more good than harm. A patient with significant gait impairment, for example, is not going to be able to complete an exercise stress test. And, it may not be appropriate to consider a particular diagnostic test in someone with multiple comorbidities and poor quality of life if the purpose of that testing does not align with the patient’s goals. For example, a diagnosis of dyslipidemia is not clinically relevant in someone with advanced cancer.
Establishing whether a test does more good than harm would theoretically require randomizing patients to a diagnostic strategy that includes the test under investigation or to one in which the test is not available and following patients in both groups forward in time to determine the frequency of patient-important outcomes. While such trials are rare, there are a few of them. Consider for example a recent Cochrane review of studies that evaluated the impact of screening for prostate cancer. Five randomized trials including more than 341,342 patients found no statistically significant difference in prostate cancer mortality between men randomized to prostate cancer screening and controls (risk ratio [RR]: 1.00, 95% confidence interval [CI]: 0.86–1.17). However, neither study assessed the effect of prostate cancer screening on all-cause mortality, nor did they explore other important outcomes such as quality of life or anxiety.
In deciding whether to perform a laboratory, imaging, or other ancillary test, the clinician should consider the issues outlined in Table 9-1 and the principles described in this chapter. This decision process is illustrated for the example of noninvasive imaging for carotid stenosis. Consider for example, an 80-year-old patient who presents with a transient ischemic attack. A carotid Doppler ultrasound is ordered and reveals greater than 70% stenosis of the carotid artery on the affected side. Magnetic resonance angiography (MRA) is ordered and the patient’s family wants to discuss whether to proceed with the test. Before the MRA is done, several issues should be considered in addition to ensuring that surgery is available and effective in your setting. Would the patient consider carotid endarterectomy? If the answer is no, further diagnostic testing is not warranted. Are there significant comorbidities or contraindications to the surgery? For example, if a patient has advanced dementia and poor functional status, the benefits of surgery would be questionable both because of their competing morbidities limiting the time through which they might benefit and the greater difficulty they might have in participating in the perioperative care and rehabilitation. If surgery might be contemplated, then it is appropriate to determine whether there are accurate and reliable tests for diagnosing carotid stenosis available in your setting.
TABLE 9-1ISSUES TO CONSIDER IN DECIDING WHETHER TO PERFORM A DIAGNOSTIC TEST AND HOW TO INTERPRET RESULTS |Favorite Table|Download (.pdf) TABLE 9-1 ISSUES TO CONSIDER IN DECIDING WHETHER TO PERFORM A DIAGNOSTIC TEST AND HOW TO INTERPRET RESULTS
How will the results be used?
Definition and interpretation of normal (see Table 10-2)
Is the test accurate in the patient for whom it is being considered?
Can the test distinguish persons with and without the targeted condition?
Do the potential consequences of the test justify its cost and inconvenience?
Can the test be performed and interpreted in a competent fashion?
A recent systematic review of the accuracy of noninvasive imaging tests compared with intra-arterial angiography for significant carotid stenosis in symptomatic patients can help with the last question noted above. Forty-one studies including 2541 patients were included in this review. The accuracy of the four imaging techniques for diagnosing significant carotid stenosis is provided in Table 9-2. For diagnosing 70% to 99% stenosis, the specificity was lowest for MRA and Doppler ultrasonography. Thus, MRA may result in inappropriate surgery in up to one in seven patients. This systematic review suggests that noninvasive testing cannot appropriately be used to recommend carotid endarterectomy. Patients should be made aware that they will likely require intra-arterial angiography, which does carry a small but real risk of complications. Unless the clinician considers patient outcome goals and risk preferences as well as the accuracy of the diagnostic tests, some patients will have surgery who do not need or desire it and some medically treated patients will have preventable strokes.
TABLE 9-2ACCURACY OF NONINVASIVE IMAGING TECHNIQUES FOR DIAGNOSING 70% TO 99% CAROTID STENOSIS COMPARED WITH INTRA-ARTERIAL ANGIOGRAPHY |Favorite Table|Download (.pdf) TABLE 9-2 ACCURACY OF NONINVASIVE IMAGING TECHNIQUES FOR DIAGNOSING 70% TO 99% CAROTID STENOSIS COMPARED WITH INTRA-ARTERIAL ANGIOGRAPHY
|IMAGING TECHNIQUE ||SENSITIVITY (95% CI) ||SPECIFICITY (95% CI) ||+LR ||−LR |
|CEMRA ||95% (88–97) ||93% (89–96) ||13 ||0.06 |
|DUS ||89% (85–92) ||84% (77–89) ||5.6 ||0.13 |
|MRA ||88% (82–92) ||84% (76–97) ||5.5 ||0.14 |
|CTA ||77% (68–84) ||95% (91–97) ||15 ||0.24 |