Physical Domain
The physical domain includes many issues that come to the forefront with aging, often, in part, related to medical conditions that are more common with age. Aspects of the physical domain that healthcare providers should pay special attention to include mobility, falls, sensory functioning (vision/hearing), pain and bladder functioning. Impairment in any of these areas can significantly hinder functional independence.
Mobility
Mobility assessment provides an important window into the accuracy of patients' self-report of independent functioning and an understanding of potential threats to independence, such as falls and fall-related injury (see the 'Falls' section below). A key part of the mobility assessment involves asking both the patient and caregiver about falls within the past year. If the patient suffered a fall or has difficulty with walking or balance, relevant history, risk-factor assessment and physical examination should be undertaken.[9] The following physical examination maneuvers can be helpful with mobility assessment and screening.
Mobility Screening. The timed 'Up and Go' test is simple to perform, takes little time, and is sensitive and specific for detecting patients at risk for falls.[10] To perform the timed Up and Go test, the patient should sit in a hard-backed arm chair, fold his/her arms across their chest (to prevent the patient from using them to help with rising), arise from the chair without using their arms, walk 3 m, turn, walk back to the chair and return to the seated position. A patient with normal mobility should be able to accomplish this task in approximately 20 s or less.[11] Even when performed qualitatively instead of timed, the Up and Go test provides important information about gait, balance, endurance and lower extremity strength.
Mobility Assessment. The short physical performance battery (SPPB) is a more comprehensive assessment of physical function than the timed Up and Go test. The SPPB consists of three tasks to assess balance, strength and walking. The downside of the SPPB is that a stopwatch is required to score the instrument. The information gained with the SPPB can be used to identify individuals at risk of ADL or mobility impairment, and 1- and 4-year mortality.[12,13]
Falls
Falls are very common in the older population, with nearly 40% of individuals over the age of 65 years falling each year, and more than half of falls occurring in the home.[14] Approximately 10% of falls are injurious and, alarmingly, falls account for 87% of injuries and 95% of hip fractures in the elderly.[14] Approximately half of the individuals who sustain a hip fracture are not able to return to independent living, and up to 20% die within a year of the fracture.[14] Falls are often a result of problems with not only mobility, but also other functional areas, such as medications, visual impairment, cognitive impairment, pain, alcohol use or home safety issues.
Fall Screening. All patients should be asked whether they have fallen in the past year or have difficulty with walking or balance. If a fall is reported, patients should be asked about the frequency and circumstances of the fall(s). Older patients who report falls or difficulty with walking or balance should undergo multifactorial falls risk assessment and interventions.[9]
Falls Assessment. A multifactorial falls assessment should include assessing medications to withdraw/minimize psychoactive or other contributing medications; offering a tailored exercise program to improve balance, gait and strength training; evaluating and managing postural hypotension; evaluating and managing problems with feet or footwear; modifying the home environment to maximize safety; expediting cataract surgery, paricularly in older women in whom it is indicated; avoiding multifocal lenses while walking, paricularly on stairs; considering cardiac pacing in those with cardioinhibitory carotid sinus hypersensitivity with unexplained recurrent falls; and providing vitamin D supplements to those with suspected or proven vitamin D deficiency.[9]
Vision
One in three adults over the age of 65 years has some form of vision-reducing eye disease.[15] Cataracts, macular degeneration, glaucoma and diabetic retinopathy all become more prevalent with increasing age. However, many patients do not report symptoms of visual loss, assuming it is a normal part of aging, or that nothing can be done about it. Healthcare providers can minimize elderly patients' visual loss by screening for age-related eye disease. Intact vision is important to maintain functional independence; for instance, visual acuity is vital to driving and important to properly managing medications and finances. Furthermore, patients with visual disability are more likely to suffer from depression[16] and cognitive impairment.[17,18] Given the frequency of vision-reducing eye diseases in the aging population, many of which are irreversible if left untreated, it may be prudent to encourage even asymptomatic patients to have annual eye examinations by optometrists or ophthalmologists to screen for these conditions.
Vision Screening. It is important to initially screen for vision problems by asking patients if they wear glasses, and whether they have visual problems that interfere with their daily activities. For instance, providers may consider asking patients the following questions:
Do you have trouble recognizing faces?
Do you have problems reading a book or the newspaper?
Do you have problems watching television?
Does your eyesight interfere with any other activities?
A positive response should prompt further assessment of vision.
Visual Assessment. While numerous vision questionnaires are available, the standard of care is the Snellen Chart. While relatively low tech, the Snellen Chart remains a very good assessment of visual function. The patient should stand 4.5 m from the chart and read the letters with each eye independently and then both eyes. An impairment of 20/50 or worse, or a difference of one line or more between eyes should prompt referral to an eye care specialist.[19]
Hearing
Like vision loss, hearing loss can significantly impact functional abilities as well as participation in social activities. Patients with hearing loss are at higher risk for accelerated cognitive decline/impairment,[20] and of being misclassified regarding the severity of their cognitive impairment.[21] Hearing loss is often not evident during a standard office visit in a quiet office with one-on-one conversation. Thus, healthcare providers must screen patients for hearing loss. Furthermore, it is prudent for healthcare providers to examine patients' ear canals to rule out cerumen impaction as a reversible cause of hearing difficulty.
Hearing Screening. Elderly individuals should be asked if they feel they have a hearing impairment. A 'yes' response has a positive likelihood ratio of 2.5 (95% CI: 1.7–3.6) for hearing impairment,[22] and these patients should be referred for formal audiometric testing.
Hearing Assessment. Patients who reply 'no' to the verbal screen should be further screened with a whispered-voice test, and those who fail this screening maneuver should be referred for formal audiometric testing.[22] The whispered-voice test has a positive likelihood ratio of 6.1 (95% CI: 4.5–8.4).[22] To perform the whispered-voice test, the examiner stands 2 feet behind the patient and gently whispers three random numbers or letters, while occluding and rubbing the patient's contralateral external auditory canal; the rubbing provides sufficient masking to the contralateral ear. If patients are not able to repeat back all three numbers after two tries, they have failed the screening test.
Persistent Pain
Persistent pain in the older patient is prevalent and often hard to treat. In fact, approximately 25–50% of community-dwelling elders have pain that interferes with their ability to function normally.[23] Persistent pain can impact sleep, mood, cognition and functional status, and may lead to the use of additional medications. Despite this, persistent pain is often overlooked in the assessment of function. Furthermore, the presence of multiple medical comorbidities makes the evaluation and treatment of pain more difficult.
Persistent Pain Screening. The most important screening question is to ask the older patient about the presence of pain. The intensity of the pain should also be assessed using scales, such as numeric rating, verbal descriptor, facial pain and visual analog scales.[24,25] Pain intensity scales can be administered by staff with limited training. It can be helpful to have several scales available, given that patients demonstrate a wide variability in comprehension and preference for different scale formats. Some older patients, such as nonverbal patients with severe dementia, may be unable to verbally express their pain. For these patients, there are other scales that may be used to assess pain. We recommend initially evaluating for behavioral indicators of pain, such as vocalizations, grimacing, bracing or restlessness.[26]
Persistent Pain Assessment. A positive screen for pain should prompt the healthcare provider to proceed with further assessment, including patient history, physical examination and medication review. The history should be obtained from the patient or caregiver, and should focus on how the pain interferes with the patient's ability to function in their environment and quality of life. Other historical items would identify the location, timing, severity, and aggravating and alleviating factors. Given the availability of over-the-counter products, the provider should ask about previous treatments that have been tried and the success of the treatments at reducing pain and improving function. A physical exam that is thorough, however, also guided by the information obtained during the history, should be conducted. Finally, psychosocial factors that may contribute to pain should be explored, such as psychological well-being, ability to cope, interpersonal processes and pain-related disability.[25]
Urinary Incontinence
Urinary incontinence is a common condition occurring in 15% of community-dwelling older individuals and 50% of nursing home residents.[27,28] Despite the availability of potential treatments, many patients are unwilling to openly discuss with providers unless prompted.[29] The in-office urodynamic assessment of urinary incontinence is beyond the scope of the busy primary care provider. However, the majority of screening, assessment and treatment of incontinence does not require urodynamic assessment. Patients may feel embarrassed about incontinence or feel that nothing can be done to improve their condition, therefore the clinician must create a nonjudgmental and empathetic atmosphere.
Urinary Incontinence Screening. There are numerous screening questionnaires for urinary incontinence to assess for overactive bladder/detrusor instability, but few are validated. The 3 Incontinence Questions is a validated screening tool that can reliably and effectively distinguish between stress and urge incontinence.[30] In both men and women, the initial discussion is an important starting point.
Urinary Incontinence Assessment. After a positive screening for incontinence, a more detailed history of incontinence should be obtained, including timing of symptoms, frequency, amount and associated medical conditions. Focused assessment should target potential treatable causes, including benign prostatic hypertrophy (postvoid residual volume), urinary tract infection (urinalysis), hyperglycemia (urinalysis), fecal impaction (rectal examination) or drug-induced urinary incontinence (e.g., diuretics, alcohol and caffeine). Both portable ultrasonic bladder scanners and urinalysis dipsticks are affordable, reliable, and can provide important information needed to assess and treat incontinence. Additionally, the efficacy of medications to treat incontinence, notably urinary anticholinergics, can also be useful in the diagnosis of urge and stress incontinence.
Aging Health. 2013;9(6):579-591. © 2013 Future Medicine Ltd.
