Geriatric Medicine/Overview of Geriatric Syndromes

Chapter 4: Overview of Geriatric SyndromesEdit

Objectives:

  1. Define the term geriatric syndrome.
  2. Describe unique features of common health conditions affecting older adults.
  3. Develop a method for diagnosing and treating geriatric syndromes using non-pharmacologic and pharmacologic methods.
  4. Understand the atypical presentation of illnesses in geriatric patients.

Geriatric SyndromesEdit

A geriatric syndrome describes health conditions associated with certain signs and symptoms that predominantly affect older adults. The term is loosely and ill-defined because geriatric syndromes do not fit into discrete disease categories.

Examples of geriatric syndromes include (and will be the subject of forthcoming chapters):

  1. Elder abuse - Chapter 1
  2. Polypharmacy - Chapter 2
  3. Dementia - Chapter 5
  4. Delirium - Chapter 6
  5. Depression - Chapter 7
  6. Urinary incontinence - Chapter 8
  7. Skin breakdown and pressure ulcers - Chapter 9
  8. Ambulatory dysfunction and falls - Chapter 10
  9. Orthostatic hypotension and syncope - Chapter 10
  10. Osteoporosis - Chapter 10


The above list is certainly not exhaustive. In addition to geriatric syndromes, geriatric patients also are simultaneously experiencing later stages of chronic diseases. Each of these geriatric syndromes will be the subject of subsequent chapters; polypharmacy was previously covered in Chapter 2.

Multiple underlying factors as well as multiple organ systems contribute to the findings in geriatric syndromes. Often, the chief complaint of the patient does not accurately reflect the reason why the patient is being evaluated by a physician. The normal senescence of the immune system will also play a role, particularly with infectious processes and response of the geriatric patient is often quite different from that of adults between the ages of 18-65.

Example: Delirium
An 80-year-old female presents to her primary care physician for evaluation of acute confusion with her son. Her son notes that she was in her usual state of health two days ago when he last spoke with her. However, this morning, when he called his mother on the phone, she kept saying that she had to catch a bus to go work, despite the fact that she has not worked in 15 years. She has had no sick contacts. She does complain of pain and pressure “down below” that started one day ago. She notes that she is urinating much more frequently than usual and describes an urge to go immediately. She denies any coughing or neck stiffness. Her son is unable to provide additional history as the patient lives alone. She has had no recent medication changes. Her past medical history is notable for hypertension without any cardiac or renal manifestations and diabetes mellitus type 2 which is very well controlled. She has no previous surgeries. She does not smoke or drink. Her home medications include amlodipine and metformin. She has no drug allergies. Her vital signs show the following: BP 130/86, HR 104, RR 18, T 99.6 F, sat 96% in room air. What is the etiology of her symptoms?


Delirium is responsible for her acute confusion in the example above. Delirium always occurs secondary to another process. Particularly in elderly patients, it is the result of toxic metabolic encephalopathy, a dysfunction of the brain that occurs as a result of infection. In this case, the likely infection is a urinary tract infection (UTI). It is able to be diagnosed empirically on the presence of urinary frequency and urgency. Also, her temperature is slightly elevated but not febrile (above 100.4 F) because of the normal age-related senescence of the immune system. Treatment with antibiotics is warranted while awaiting the results of urinalysis with culture and sensitivity (U/A C&S). Delirium affects both the genitourinary system and the nervous system. As a result of the infection, the patient is confused. Delirium will be discussed in detail in Chapter 6. By contrast, in a younger individual, distinct physical symptoms, such as a fever, urinary frequency, urinary urgency, dysuria, hematuria, and suprapubic pressure, will be immediately apparent and able to be identified. In an older adult, these symptoms may or may not be present; however, increased confusion, agitation, or withdrawal may instead be the presenting symptoms.

Other atypical presentations of illness in geriatric patients include:

  • absence of fever or leukocytosis with infection such as influenza, pneumonia, or a urinary tract infection; sepsis can occur and be associated with falls, delirium, urinary incontinence, and decreased oral intake
  • back pain as a sign of secondary metastatic cancer
  • absence of chest pain with myocardial infarction; may see fatigue and gastroesophageal reflux (“heartburn”) symptoms
  • absence of paroxysmal nocturnal dyspnea or cough with pulmonary edema or acute exacerbation of congestive heart failure; will often see an insidious change in function
  • absence of sadness with major depressive disorder; associated with vague complaints and apathy or hyperactivity


Documentation of a Geriatric Patient EncounterEdit

Chapter 3 discussed the components of a History and Physical, and the additions made for a Comprehensive Geriatric Assessment. As such, it should be apparent that as much as geriatric disease processes require a unique approach, so does encounter documentation of a geriatric patient. It is helpful to think of a patient encounter as a blueprint for writing documentation. A physician should be able to ask at least ten questions based on the chief complaint. The physical exam should be structured around the chief complaint.

For the subjective portion, the mnemonic OPQRST (onset, provocation/palliation, quality, radiation, severity, and time course) is a good start for the History of Present Illness but does not always cover all relevant issues. Always inquire about recent changes in medication.

A geriatric-specific review of systems should include, in addition to fevers, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, constipation, headache, etc.:

  • Ambulatory dysfunction and falls
  • Visual impairment – blurry, double, or decreased
  • Hearing impairment
  • Insomnia
  • Uncontrolled pain
  • Cognitive impairment
  • Depression
  • Anxiety
  • Dizziness


For the objective portion, always include the vital signs. Examine, at a minimum, the heart, lungs, and abdomen. For specific chief complaints, tailor the physical exam to the chief complaint.

System-specific physical examinations include the following:

Genitourinary system:

  • Assessment of suprapubic pressure
  • Assessment of costovertebral angle tenderness


Nervous (central and peripheral) system:

  • Cranial nerves: assess each level vs. gross function
  • Muscle strength of upper and lower extremities
  • Deep tendon reflexes of upper and lower extremity of biceps, brachialis, triceps, patellar, Achilles reflexes
  • Coordination:
    • Finger-to-nose
    • Heel-to-shin
    • Tandem walking (i.e. heel-to-toe)
  • Timed get up and go test
  • Cognitive testing: MOCA (or part of it, i.e. digit span)


Neurological evaluation involves:

  • muscle strength testing
  • sensation testing
  • deep tendon reflex testing


Muscle Strength Testing:
Muscle strength testing involves testing muscle groups for weakness or asymmetry of strength. Strength is graded on a scale from 0 to 5:

Score Interpretation
0/5 No contraction
1/5 Palpable or visible contraction
2/5 Active movement, full range of motion, no gravity
3/5 Active movement, full range of motion, against gravity
4/5 Active movement, full range of motion, against gravity and normal resistance
5/5 Exert sufficient resistance considered normal if no inhibiting factors are present
Table 4.1 - Muscle strength testing score and interpretation


Muscle strength testing is performed bilaterally for the upper and lower extremities. If weakness if present, both sides should be compared. Causes of asymmetric muscle strength are multifactorial but not limited to a cerebrovascular accident (a stroke) or other neurologic pathology.

Muscle strength testing of the upper extremity is done by assessing spinal levels C5-T1 through the following motions against resistance with the patient seated:

Spinal level Motions
C5 Elbow flexion
C6 Wrist extension
C7 Wrist flexion
C8 Curling of the fingers
T1 Finger abduction/adduction
Table 4.2 - Muscle strength testing of the upper extremity


Muscle strength testing of the lower extremity is done by assessing spinal levels L2-S1 through the following motions against resistance with the patient seated:

Spinal level Motions
L2 Hip flexion (knee to the ceiling)
L3 Knee extension (knee kick forward)
L4 Knee flexion (knee pulled backward from extension)
L5 Great toe extension (great toe toward the ceiling)
S1 Plantarflexion ("pushing on the gas pedal")
Table 4.3 - Muscle strength testing of the lower extremity


Deep Tendon Reflexes:
Deep tendon reflex testing involves placing the physician’s thumb on the belly of the muscle and striking it with a reflex hammer and observing the movement of the reflex being tested. Strength is graded on a scale from 0 to 4 (score may see listed as 2/4 or 2+, see below):

Score Interpretation
0/4 No response; absent
1/4 Diminished; hypoactive
2/4 Normal tone
3/4 Brisker than average; hyperactive
4/4 Very brisk; clonic; sustained
Table 4.4 - Deep tendon reflex testing score and interpretation


  • The biceps reflex (C5 nerve root) is elicited by the physician placing the thumb on the biceps tendon and striking the thumb with the reflex hammer and observing the arm movement. This is repeated and compared with the other arm.
  • The brachioradialis reflex (C6 nerve root) is observed by striking the brachioradialis tendon directly with the hammer when the patient's arm is resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex supination. Repeat and compare to the other arm.
  • The triceps reflex (C7 nerve root) is measured by striking the triceps tendon directly with the hammer while the physician is holding the patient's arm with the opposite hand. Repeat and compare to the other arm.
  • The patellar reflex (L4 nerve root) is performed by the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer. Repeat and compare to the other leg.
  • The ankle reflex (S1 nerve root) is elicited by the physician holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion.


Sensory Dermatomes:

Sensation testing is utilized to assess pain, light touch, and proprioception. A dermatome is an area of the skin that is supplied by a branch of a single spinal nerve root. Dermatomes may not correspond precisely to Figure 4.1, but the key sensory points are identified.

Figure 4.1 - Sensory dermatomes

Reference: Figure modified from: https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf


For the assessment section, list diagnoses that are supported by documentation in the subjective and objective section. (For standardized testing, it is recommended to list at least three relevant diagnoses. Do not include diagnoses listed as “rule out” in this list; rather, list what is supported by documentation as opposed to what is not.)

For the plan section, include non-pharmacologic treatments, medications (always try non-pharmacologic before pharmacologic), imaging with consideration of cost and need, labs with consideration of cost and need, and recommended follow up with primary care physician and/or specialists or other members of the interdisciplinary team.


Example Case and DocumentationEdit


Example: Urinary incontinence
Subjective:

CC: “I can’t stop going to the bathroom!”

HPI: Jane Doe is an 84-year-old female who presents to the office complaining of urinary incontinence. She states her problem began 2 weeks ago. She notes that she has to urinate every hour all day long and all night long. She denies any pain, bleeding, or burning with urination. She feels that she completely empties her bladder. She does not identify anything that makes the symptoms better or worse. She describes a feeling of "urgency". She has not wanted to leave her home because of fear of having to go to the bathroom and not finding one or making it in time. She has tried to cut back on her fluid and caffeine intake. She has not been placed on any new medications since her symptoms began. She has 5 children who were all vaginally delivered. She has not followed up with her ob/gyn since the birth of her last child. She has not had any accidents but has taken to wearing pads. She denies constipation.

REVIEW OF SYSTEMS: (only document what you ask)
General: Denies fevers, chills, night sweats, or fatigue.
Eyes: Denies blurry vision, double vision, eye pain, or discharge.
ENT: Denies tinnitus, earache, decreased hearing, or facial pain.
Lungs: Denies shortness of breath, cough, wheezing, or sputum production.
CV: Denies chest pain, palpitations, lightheadedness, or dyspnea on exertion.
GI: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation.
GU: Positive for urge incontinence, increased urinary frequency, and increased urinary urgency. Denies dysuria or hematuria.
MSK: Denies ambulatory dysfunction, falls, back pain, joint pain, muscle aches, or muscle cramps.
Skin: Denies rashes, itching, flushing, or bruising.
Psych: Denies anxiety, depression, anhedonia, insomnia, or cognitive impairment.
Neuro: Denies numbness, tingling, dizziness, headaches.
The remainder of review of systems is negative except as noted above in the HPI.

PAST MEDICAL HISTORY: Hypertension

PAST SURGICAL HISTORY: Denied

FAMILY HISTORY: Both parents passed from colon cancer complications

SOCIAL HISTORY: No former or current alcohol, tobacco, or drug use. Retired secretary.

MEDICATIONS: amlodipine 5 mg 1 tab daily

ALLERGIES: NKDA (no known drug allergies)


Objective: (only document what is examined)

PHYSICAL EXAM:
VS: 130/80, 76, 18, 99.8 F, 97% RA
GENERAL: AAO x 3, NAD, MMM
CARDIO: +S1S2 regular rate and rhythm no murmurs/rubs/gallops; no lower extremity edema
RESP: CTA B/L no rales/wheezing/rhonchi/accessory muscle use
ABDOMEN: soft, non-tender, non-distended +BS in all quadrants no rebounds/guarding
GENITOURINARY: (+) suprapubic tenderness; elicits "urge" (-) CVA tenderness

Labs/Imaging: none to review

MOCA: not performed
PHQ-2/9: not performed

Assessment: Support with documentation in subjective/objective!
1. Urge incontinence
2. Stress incontinence
3. Urinary tract infection (low grade fever noted in vitals)
4. Bladder prolapse
(Note: may say mixed urge and stress incontinence too)

Plan: Always consider necessity! How will what you order change management?
1. Medications: none at this time; consider oxybutynin if symptoms worse but be mindful of anticholinergic effects
2. Imaging: none at this time
3. Labs: U/A C&S (CBC necessary? Debatable. Does it change your management? How?)
4. Non-pharmacologic: Kegel exercises, scheduled toileting, decrease fluid intake
5. Follow up: 2 weeks; follow up with ob/gyn as discussed for pelvic/rectal exam<


Review QuestionsEdit

1. Which of the following correctly characterizes a geriatric syndrome?

A. A set of signs and symptoms that do not fit into discrete disease categories.
B. A set of signs and symptoms associated with longer life expectancy.
C. A set of signs and symptoms that is not associated with increased transitions in care settings due to hospitalization and sub-acute rehabilitation stays.
D. A set of signs and symptoms that only affect mentation changes.
E. A set of signs and symptoms that occur with decreasing frequency with increasing age.

2. An 83-year-old female presents to the emergency department complaining of chest pain. She describes a sensation of “heartburn” in her epigastric and substernal regions. She states her symptoms began approximately one hour prior to presentation. Her past medical history is notable for hypertension and hyperlipidemia for which she is prescribed lisinopril and rosuvastatin. She denies radiation of her pain anywhere. She has never had symptoms like this before. She denies a previous diagnosis of gastroesophageal reflux. Her vital signs are unremarkable. Her physical exam is unremarkable. An EKG done at the time of presentation was unremarkable. Cardiac enzymes are pending. Which of the following therapies is appropriate to start and why?

A. Omeprazole due to gastroesophageal reflux disease
B. Morphine, oxygen, nitroglycerin, aspirin, metoprolol tartrate, and lisinopril due to cardiac ischemia
C. Levofloxacin due to aspiration pneumonia
D. Physical therapy due to physical deconditioning
E. Albuterol nebulizer treatment and furosemide due to chronic systolic heart failure and pulmonary edema

Answers to Review QuestionsEdit

  1. A - A geriatric syndrome describes health conditions associated with certain signs and symptoms that predominantly affect older adults. The term is loosely and ill-defined because geriatric syndromes do not fit into discrete disease categories.
  2. B - Myocardial infarction has an atypical presentation particularly in geriatric females. Symptoms of reflux and chest pain should be treated as a myocardial infarction until proven otherwise. Appropriate treatment for myocardial infarction begins with morphine for pain, oxygen, nitroglycerin to maintain coronary artery patency, aspirin, metoprolol tartrate, and lisinopril.