Key Differences in Geriatric Assessment

When performing a head-to-toe assessment, there are some key differences that you can expect to notice in an older adult. 

Changes to vital signs:

• Temperature may be lower than normal. Additionally, older adults may not develop fever in all infections, so the absence of fever does not rule out an infectious process.
• Blood pressure is likely to be slightly elevated due to arteriosclerosis. Additionally, many geriatric patients have orthostatic hypotension, which is a decrease of 20 mmHg or more after moving from a supine to standing position.
• RR may be elevated up to 25 bpm without a pathophysiological process.
• Older adults often have slightly lower SpO2 levels. While a younger adult typically has a normal oxygen saturation level of 97 – 100%, an older adult without respiratory disease may have an SpO2 around 95%.

Body composition and musculoskeletal changes:

• Weight may be decreased due to lack of appetite, lack of ability to prepare foods, poor dentition, and lack of resources to obtain food.
• Height may decrease over time due to osteoporosis, kyphosis and reduction in space between vertebral disks.
• Reduction in joint mobility with decreased ROM.
• Body fat increases and lean muscle mass decreases.
• Bones decrease in density.
• Increased anterior-posterior diameter of the chest.

Changes to integumentary system:

• Skin will be thin and may tear easily (take care when removing tape, for example).
• Skin turgor will be reduced. To examine skin turgor, grasp skin at the back of the hand and release…it will not snap back as quickly as it would in a younger adult.
• Ecchymosis may be present and is often on the forearm. Even small traumas can cause bruising in older adults. Additionally, many adults take daily aspirin, which further increases risk for bruising.
• Areas of hyperpigmentation (age spots or “liver spots”) may be visible on areas that are exposed to the sun.
• Skin may be dry due to a decrease in oil production and itching may occur.
• Nails may become brittle and yellowed. Toenails may harden and thicken which can make ingrown toenails more common.
• Decreased sweat production leads to difficulty keeping the body cool. Hyperthermia can result in hot weather.
• The layer of subcutaneous fat thins, which affects the body’s ability to maintain body temperature and provides less padding against trauma. Medications absorbed in SubQ tissue may be affected.
• Elderly patients are at higher risk for pressure injury.
• Wound healing is slower in the elderly and can be exacerbated by chronic conditions such as diabetes.

Changes to sensory organs: 

• Sensitivity to touch, temperature and pain reduce with aging, putting the individual at risk for injury (this is more prevalent in the lower exremities than the upper).
• Pupils decrease in size and react more slowly to changes in light, making it difficult for many elderly individuals to see well at night.
• The eyes may be dryer due to decreased tear production. 
• Visual acuity declines, especially in near and peripheral vision.
• Color differentiation becomes more difficult making it harder to distinguish blue from green. Since warm colors are easier to see, so an elderly individual may benefit from using a red nightlight vs. an uncolored or blue-ish light.
• Though not a normal part of aging, cataracts are very common and are present in about 35% of individuals age 70 to 74, with the incident increasing with age.
• Hearing declines in both ears, especially the ability to hear high-frequency sounds such as whistles or children’s voices.
• Balance may be affected due to changes in the inner ear, making the individual more prone to falls.
• Taste buds decrease in number and size with aging.
• Decreased saliva production can lead to dry mouth and affect taste.
• Smell diminishes with age due to less mucus production and loss of nerve endings. 
• Decreased taste and smell both contribute to lower food intake, putting the individual at risk for nutrient deficiencies and weight loss.

Changes to neurological function: 

• The most common change is slower processing speed, though intelligence typically remains unchanged.
• Ability to recall recent memories may be reduced.
• Less robust reflexes, which can make the individual more prone to falls.
• Shorter sleep cycles with more frequent waking during the night and early waking.
• Depression may be more prevalent due to decreases in neurotransmitter function and the stresses of aging such as death of a spouse, loss of physical health, retirement, etc…

Changes to the respiratory system:

Changes to the respiratory system put the individual at higher risk for infection and respiratory compromise, though changes are typically only evident when under stress:

• Weaker muscles of respiration.
• Lung function decreases, including how quickly and forcefully they can exhale.
• Decreased cough strength.
• Decreased mucus production and ciliary dysfunction reduces the body’s ability to rid itself of pathogens.
• Changes to the thoracic cavity due to aging creates a smaller chest cavity.
• Reduction in surface area for gas exchange due to alveoli deterioration and reduction in elastic recoil.

Changes to the cardiovascular system:

• Increased stiffness in large arteries (arteriosclerosis) which leads to hypertension.
• Heart rate may be slower due to the decrease in pacemaker cells and the development of fibrous tissue and fat deposits in electrical pathways of the heart.
• Murmur is more likely due to stiffening and thickening of the heart valves.
• Baroreceptors become less sensitive, leading to orthostatic hypotension (always think “fall risks” when a patient has OH!).
• It may be more difficult to locate the apical impulse due to an increase in the anterior-posterior diameter of the chest.
• S4 may be audible in advanced age due to reduced ventricular compliance. If loud, this may be pathological and indicate left ventricular failure.
• Dorsalis pedis and posterior tibial pulses may be more difficult to palpate due to arteriosclerotic changes. This can also make the legs feel cooler than expected.
• Veins stretch with aging and valves become less functional, which leads to decreased venous return and more prevalence of varicose veins. 

Changes to gastrointestinal system:

• Loss of teeth leads to difficulty chewing, which may affect nutritional intake.
• Esophageal peristalsis decreases which can lead to difficulty swallowing or early satiety.
• Slower peristalsis can lead to constipation.
• Changes in the stomach lining put the elder individual at higher risk for peptic ulcer disease, especially when taking NSAIDs or aspirin regularly.
• Decreased elasticity of the stomach can cause early satiety leading to weight loss.

Changes to the genitourinary system:

• Urinary leakage or incontinence.
• Increased urinary frequency.
• Urinary retention and BPH.
• Increased risk for UTI.
• Decreased GFR and renal blood flow which makes the individual less resilient when faced with acute renal insufficiency.

Other important factors: 

• Many older adults take multiple medications, so be aware of polypharmacy. When possible, have the patient or family member bring in all the medications for a full reconciliation.
• Ability to perform ADLs may be reduced. A collection of functional assessment tools is available here.
• Fall Risk is increased in the elderly for multiple reasons including orthostatic hypotension, decreased muscle mass and reduced reflexes. The CDC has a wealth of information on their website.

Take this topic on the go by tuning in to episode 268 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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