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Achieving Your Dreams After 60

3 P's for Triumphant Aging, Passion, Perspective on Life, and Persistence

The media abounds with negative views about the impact of aging on physical, cognitive, and financial well-being. In fact, there are entire industries that have emerged to counteract the effects of aging — nutritional supplements, hormone treatments, surgical improvements, lotions, potions, and the like. They all seem to underscore Bette Davis’ famous quote, “Old age is no place for sissies.”

What if there were another point of view? What if aging brought about, not decline but our greatest accomplishments? What if we looked at aging as Dr.Christiane Northrup does? She tells us that “getting older is inevitable, but aging isn’t.”

Our book, #Senior Wonders: People Who Achieved Their Dreams After Age 60 profiles 23 individuals and two groups who not only survived into old age, but achieved their greatest successes. As we wrote our book, we looked for emerging themes. Were there any commonalities among these people? Although their accomplishments were in a variety of fields (arts, sciences, social causes, entertainment, etc.), several themes became apparent. We think of them as the 3 P’s:Passion, Perspective on Life, and Persistence.

Passion, by definition, is any compelling emotion or feeling. These individuals either had a strong belief in what they were doing, or in the case of those with an artistic bent, they couldn’t help creating, whether it was writing, painting, or acting.

Many of the seniors in our book faced daunting obstacles and accomplished their goals by sheer will and determination; they did not give up.

Perspective on life emerged as a theme when we noticed that several of our seniors commented that they couldn’t have achieved their success at an earlier age.  Having lived a long life enabled them to learn from failures and successes, establish a clear focus, and develop a unique perspective.

Our last P is Persistence. This theme became apparent when we observed that many of our seniors faced daunting obstacles and accomplished their goals by sheer will and determination; they did not give up.

Author Harry Bernstein and humanitarian Clara McBride Hale are two who exemplify these themes.

Bernstein was born in Stockport, England in 1910 and began his education as an architect. But when his teacher discouraged his career choice, he decided to pursue a writing career and moved to New York to accomplish his goal. Although he made a living as a writer, his wife, Ruby, had to work as a school secretary to subsidize the family income. He did have one novel published, but it wasn’t successful. Undaunted, Bernstein continued to write, penning more than 20 novels that were never published.

In 2007, at age 97, he wrote an autobiographical novel, The Invisible Wall, which received critical acclaim. The book poignantly described the “invisible wall” that separated the Jewish and Christian sections of his home town. At age 98, he published, The Dream, which told the story of his family’s move to America. Because these two books were so successful, he was awarded the Guggenheim Fellowship at age 98 to pursue his writing.

At 99, he published the third book in the series, The Golden Willow: The Story of a Lifetime of Love, about his marriage to Ruby and later years. His novels have been translated into several languages. Bernstein stated: “If I had not lived until I was 90, I would not have been able to write this book…It could not have been done, even when I was 10 years younger. I wasn’t ready. God knows what other potentials lurk in other people, if we could only keep them alive well into their 90s.”

When her husband died, Clara McBride Hale had to support herself and her three small children. Not wanting to leave her children unsupervised for extended periods of time, she opened a day care in her Harlem neighborhood. Many of the children in her care stayed overnight because their parents worked as domestics. She then decided to become a foster parent and raised 40 foster children, all of whom pursued a college education. At 64, after 28 years, she retired from the foster care system. Soon after, her daughter referred a drug-addicted mother and baby to Hale for help. Before long, she was caring for all this mother’s drug-addicted children.

As the word spread throughout New York City, more and more drug-addicted babies were left in Hale’s care. During the first year and a half, her family provided financial and other support to keep her mission going. Then, the Borough of Manhattan president, Percy Sutton, arranged public funding. Also, John Lennon left provisions for support of Hale House in his will.

In 1975, Hale House moved to 122nd Street where it remains today. After successfully reuniting hundreds of families, only 12 children had to be placed for adoption. At age 85, Clara McBride Hale was honored by President Ronald Reagan for her humanitarian work. She stated: “I’m not an American hero, I’m just someone who loves children.”

“Triumphant aging,” as exemplified by Bernstein and Hale, is a counter perspective to the pervasive negative beliefs about aging. Do you, your relatives or friends have untapped potentials or abandoned dreams? If so, consider what George Elliot said: “It’s never too late to be what you might have been.”

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Can Type O Blood Shield Us From Alzheimer’s?
People with O type blood have more grey matter in their brain, and may be more protected against conditions that cause cognitive decline, such as ‪#‎Alzheimer‬’s, than people with A, B, or AB blood types.
For a new study, researchers analyzed 189 Magnetic Resonance Imaging (MRI) scans from healthy volunteers and calculated the volumes of grey matter within the brain and the differences between blood types.
The findings, published in the Brain Research Bulletin, show that individuals with O blood have more grey matter in the posterior proportion of the cerebellum.
People with A, B, or AB blood have smaller grey matter volumes in temporal and limbic regions of the brain, including the left hippocampus, which is one of the earliest parts of the brain damaged by Alzheimer’s disease.
More Protection
Lower grey matter volume is normally seen in the brain as we age, but the differences are greater in people with blood types other than O, researchers say.
“The findings seem to indicate that people who have an O blood type are more protected against the diseases in which volumetric reduction is seen in temporal and mediotemporal regions of the brain like with Alzheimer’s disease for instance,” says research fellow Matteo DeMarco.
“However additional tests and further research are required as other biological mechanisms might be involved.”
“What we know today is that a significant difference in volumes exists, and our findings confirm established clinical observations,” adds Annalena Venneri, professor of neuroscience at the University of Sheffield.
“In all likelihood the biology of blood types influences the development of the nervous system. We now have to understand how and why this occurs.”
Source: University of Sheffield. Republished via underCreative Commons License 4.0.
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What You Can Do to Curb Elder Financial Abuse

Study shows what separates the victims from the vigilant

There’s no way to guarantee your aging parents won’t fall victim to #elder financial abuse, but there is one thing you can do to help cut the odds: Be sure they’re discussing their finances with someone they (and you) can trust.

That’s the upshot of the recent Allianz Life study, Safeguarding Our Seniors. When surveying 1,223 people who were 65 and older, Allianz found that only 8 percent of those who said they were victims of elder abuse also said they were “currently discussing their finances with another person.”

The Need to Talk About Money

And those who talk to “third-party resources” about their finances felt better equipped to identify and prevent elder financial abuse than those who don’t: 84 percent who regularly talk with friends and family about their finances and 82 percent who speak with hired money pros were confident about protecting themselves vs. 70 percent who do neither.

While 93 to 94 percent of survey respondents who talk about their finances with a hired professional or friends and family said they never sign documents they don’t completely understand, only 82 percent who handle their money alone said that.

Allianz Life President and CEO Walter White (yes, he has the same name as Breaking Bad’s fiend) told me he was somewhat surprised how few people 65+ are discussing their finances with anyone who could help them avoid becoming elder abuse victims — family members, friends or financial advisers. Only 24 percent are doing so regularly.

Allianz estimated that elder fraud victims have lost an average of $30,000 and more than 10 percent lost $100,000 or more.

“It’s one of the differences between Americans and Europeans,” said White. “In Europe, they won’t talk about their health but will talk about their finances. Here, it’s the opposite.”

One possible cause of elder abuse: #senior loneliness. “One reason older people are vulnerable is they don’t have as much social contact as younger people,” said White. So when someone reaches out in what seems like a friendly way, the recipient can subsequently let down his or her guard and let a con artist gain financial access.

Frank discussions about money are especially important as we age, White noted. “Our financial decision-making capabilities start to diminish,” he said. White discovered this firsthand. He told me his mother had been “meticulous with the family finances, almost to the point of it being too much — she kept every record.” But as his mother grew older, “her abilities started to diminish. Bills went unpaid and she couldn’t recall where all her investments were.”

Huge Potential for Abuse

And because an elderly person’s finances can be quite complex, this is an area with great potential for abuse, said White.

We’re not talking pennies, either. In an earlier study, Allianz estimated that elder fraud victims have lost an average of $30,000 and more than 10 percent lost $100,000 or more.

Kathleen Quinn, Executive Director of the National Adult Protective Services Association recently told a Senate Special Committee on Aging hearing that elder financial abuse is “rampant, largely invisible, expensive and lethal.” The 2010 Investor Protection Trust Elder Fraud Survey estimated that one in five Americans over 65 has been victimized by a financial fraud. MetLife has said that financial exploitation costs seniors at least $2.9 billion annually.

Sadly, as I recently learned during my interview with T.S. Laham, author of the new book, The Con Game: A Failure of Trust, sometimes family members are culprits, stealing from relatives. Quinn told the Senate that 90 percent of reported elder financial abuse cases involve a family member.

What You Should Do

That’s why White recommends bringing in more than one trusted family member, as well as a money pro such as an financial adviser, accountant or an attorney.

One adult child could, for instance, take responsibility each month for reviewing a parent’s checkbook and credit card statements. Another could meet quarterly with the parent and his or her financial adviser and annually with the tax preparer.

A Problem That Will Only Grow

And it’s good to see, as Financial Planning’s Miriam Rozen just wrote, that more states are passing laws to protect their elderly residents and that the Securities and Exchange Commission’s first Office of the Investor Advocate is making elder abuse a priority.

“Everyone realizes that elder abuse is a problem that will only grow, due to demographics and technology that didn’t exist in the past,” said White.

Financial services firms and their advisers play an important role in curbing and spotting elder abuse, as the First Clearing Correspondent Services white paper, A Wake-Up Call for Financial Advisors: Creating Value for Elder Clients just laid out.

Said White: “I think we can do more.”

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Americans are living longer than ever before, and soon older adults will outnumber the young. Today, family #caregivers are providing 90 percent of parent care, in addition to balancing work and family, a job most cannot afford to do.

Who will take care of those who can no longer care for themselves? How will the nation adapt to ensure that adequate care can be provided for both the caregivers and for those being cared for?

CARING FOR MOM & DAD (premiering May 2015 on PBS, check local listings), seeks to answer these questions as it explores the emotional, health and financial challenges that many caregivers face every day, and offers solutions and tips to help others embarking on this new future.

In CARING FOR MOM & DAD, viewers meet families experiencing the challenges and joys of #caregiving. These are intimate portraits of struggling caregivers like Breanna Olson, a millennial who was forced to choose between a promising political career and moving back home to care for her parents, and Alicia Zepeda-Cervantes, a daughter thrust, almost overnight, into caregiving, who now must learn how to provide medical services that would traditionally be taken on by a nurse.


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Architect: Age-friendly design should be stylish, colorful, fun 

Growing old is "hard work" but it can be fun, insists Berkeley architect Susanne Stadler.

Stadler is co-founder of At Home with Growing Older, a group that includes social workers, psychologists and designers interested in promoting home-like settings, rather than institutional ones, as a "major contributor to healthy #aging."

She addressed a March 21 housing conference at Mitchell Park Community Center, which drew nearly 200 local residents to discuss the housing concerns of #seniors. A large majority of those attending the conference, which was sponsored by Avenidas and the City of #Palo Alto, said they do not plan to move and want to stay in their homes for the rest of their lives.

Age-friendly design goes well beyond ramps and traditional grab bars to include beautiful, "human-centered" design for all generations, playfulness and integration into the larger community, Stadler said, showing photos that included senior housing attached to a Swiss sports complex and a bathroom conceived as a "living room," with places to sit down and colorful, sporty-looking grips to provide support.

"If we can get past our denial and avoidance — not look at aging as a weakness but as a fact of life — then we can talk about what we need and ask for help when we need it," she said. "Home is the base for our well-being, and it should support the physical and emotional changes that age brings."

Stadler's own views about aging shifted dramatically when she moved from her native Austria to Berkeley to attend graduate school 30 years ago.

"In Austria I was used to adults being old in a certain way," she said. "It seemed that age dictated a certain dress code and code of behavior — certain 'dos and don'ts' — dignified, demanding respect from others.

"In Berkeley, things were different. People of all ages and abilities were out and about, and you couldn't judge people's status in society by their clothes. It was more colorful, bolder and definitely more fun. I was hooked, and I've been here ever since."

Still, Americans can learn from Europe's greater experience with aging societies and its track record on integrating seniors into centers of community life, she said.

In Salzburg, Austria, for example, Stadler said her mother's Mirabel Senior Residence is attached to "one of the city's most popular cafes (Fingerhut, or "Thimble"), which is buzzing all day long.

"The senior residents have a private entry into the cafe. In that way the cafe, if desired, becomes part of their larger living space."

In Basel, the 15-year-old St. Jakob Park soccer stadium — Switzerland's largest sports arena — incorporates a retirement home with more than 100 apartments, a gym and a shopping mall.

Stadler advises seniors to be proactive in making sure their homes work for them. Older people often adapt to annoyances rather than make even small changes that could improve their daily lives, she said.

"Most of us adapt to inconveniences for many, many years, but then there comes a time for everybody — an illness, a broken bone, knee surgery, hip replacement — when suddenly we notice that something is off in our environment.

"Take a fresh look at your house now and say, 'Is my bed really in the right room? Why does it have to be in the room where it's been for the past 30 years? Where else would I like to wake up?'"

She displayed a photo of a bathroom that uses colorful grips designed for climbing walls, rather than traditional grab bars, for support.

"We can learn from the tools and gadgets of extreme sports — aging is like an extreme sport," she said. "But instead of being about impairment, it can be about stretching yourself, being playful. We do need the same supports, but also the same imagination that has gone into these tools."

Stairs aren't always bad but can be great exercise tools, she said.

"Consider building in the incentive for daily exercise in your home — putting an exercise bar on the wall or a soft floor in the hallway so, as you walk by, you can do your daily exercise," she said.

Age-friendly design doesn't have to be something new, she said. Sometimes it's already there, such as in a Frank Lloyd Wright-designed interior with a wall of wide-spaced open shelving, displaying a series of large paintings.

"All of us have too much, and people don't have a chance to display what they have," she said. "These displays can be changed quite easily."

Becoming an "activist" for human-centered design means discovering your home's potential to adapt to you and expecting practical, creative and elegant solutions, she said.

In a separate presentation, Coldwell Banker Realtor Nancy Goldcamp said nearly 85 percent of seniors say they want to stay in their current house for the rest of their lives and that, statistically, 70 percent of them will remain in the home where they lived at their 65th birthday.

Clients over the decades have told her that, after fixing up their homes to put them on the market, they regret they did not make the improvements earlier so they could have enjoyed them, Goldcamp said.

She showed a series of "before and after" photos of minor improvements that made homes more livable, including adding stairs from a deck to a lawn, refreshing an unused balcony and adding walls to create a separate unit for a graduate student or a caregiver.

Transition specialist Cindy Hofen of Managing Moves & More, Mountain View, implored conference-goers to begin de-cluttering and "right-sizing" their possessions now, even though they do not intend to move.

"Close your eyes and think of your home as a clutter-free zone," she said. "Creating space creates opportunity.

"Keep only things that speak to your heart and disperse the rest. If it doesn't bring you joy, it doesn't belong in your house."

Contributing Writer Chris Kenrick can be emailed at Palo Alto Weekly

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Challenges of aging in San Mateo County

#Aging is a challenge but we have many advantages here in San Mateo County. Number one is the weather. It’s neither too hot nor too cold. We don’t have to worry about winter snow storms and slipping on ice. It is expensive to live here but most would agree if you can afford it, it’s the best place to be. But even though we live in one of the best places on Earth, growing old is a challenge and not for the faint of heart. If you are lucky enough to live a long life, one of the prices you pay is losing your network of friends or worse, a spouse. After you quit a busy life of work or raising children you also may lose a large network of people you see every day. Retired seniors often struggle to fill a void. The sudden lack of a connection they once enjoyed with colleagues, not to mention the experience of accomplishment, can come as an unpleasant shock. Retirement can be very lonely if you are not smart. And loneliness is not healthy.

In fact, according to a Palo Alto Medical Foundation study, seniors who are lonely have a 45 percent increased mortality rate of six years compared to seniors who are not. They also have twice the rate of falling or losing strength.

You can be lonely even if you still have a spouse at home, especially if you become the caregiver; you can be lonely even if you live in a senior facility. And, of course, if you live alone and do not have family and friends close by, you can become very isolated.

Still, most people prefer to live at home if they are able to do so. At some point, seniors who live at home will require help. And the older one gets, probably the need for help will increase.

In 2002, a group of seniors in Beacon Hill, Massachusetts decided to pool their talents and their needs and form a village. It was one of the first senior villages in the country. Now the movement is well past 100 throughout the country and there are several villages in the Bay Area. The original goal of Beacon Hill was to help seniors stay in their homes.

Now the new goal of Beacon Hill is to get seniors out of the house and into the community — to have purposeful engagement. For nothing is better for one’s health — better than many pills — than to have a purpose. Taking classes. Working out at the gym. Walking with friends. Playing bridge or bingo. Helping someone else through volunteer work. Tutoring students at school. Volunteering at church or at a nonprofit like Samaritan House. Or volunteering as part of a senior village.

The village concept is simple. Neighbors helping neighbors. But in an organized way. It’s usually started by a few people in a neighborhood, it’s a grassroots effort started by local citizens, communities of seniors helping other seniors, doing what they can to help fellow members remain in their own homes as long as possible. Driving, meal preparation, social events, etc. — whatever it takes to create the social support and satisfaction on the part of both those volunteering and those receiving help.

The idea is to coordinate a web of volunteer support, information and a connection to resources.

There is usually a fee to become a member of one of these senior villages. In Foster City, which has 65 members, it’s an all-volunteer and no-paid-staff venture so far. The dues are $1 a day or $365 a year; for two people $475 a year. Sequoia Village for residents of Redwood City, San Carlos and Belmont is just getting started. Fees will be between $30-$80 a month. In the MidPeninsula ( San Mateo, Hillsborough, Burlingame) and on the Coast, villages are in the planning stages. Here are the contact numbers: Foster City Village, 378-8541; Sequoia, 260-4569; Coastside, 728-9494; MidPeninsula, 434-2455.

Still, organizing a village is difficult, say those who try. It can easily take two to three years before a new aging-in-place community can roll out services. Still, it’s a movement which has caught on across the country, in California, in the Bay Area and in San Mateo County.

Sue Lempert is the former mayor of San Mateo. Her column runs every Monday. She can be reached at

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Silicon Valley looks to ‘disrupt’ elder care 

As Apple and IBM use technology to check on the #elderly in Japan, they join a growing segment of Silicon Valley taking interest in elder care.

Though it’s not as “sexy” as the latest app, the space has generated some buzz after the Apple APPL, +19.38% announcement and the $20 million funding of senior care startup Honor by big names such as Andreessen Horowitz and YELP CEO Jeremy Stoppelman.

The move makes sense as the baby boomer generation ages and as the elderly and disabled services industry is estimated to bring in $43 billion in revenue in 2015.

Malay Gandhi, managing director of Rock Health, a digital health focused firm that invested in Honor, said he receives “tons” of pitches from startups in that space.

AngelList, a startup and investing platform, shows 211 startups related to #elder care, with an average valuation of $4.5 million.

The startups listed include Lively, an emergency response watch for seniors, True Link, which offers a Visa card for seniors that can be tailored to restrict fraud, and CareLinx, a caregiver marketplace.

As the population ages, Max Wolff, chief economist at Manhattan Venture Partners, said he sees current technology trends meeting elder health care.

“The Internet of Things and wearable are going to radically transform health care,” Wolff said.

Other startups don’t say they’re specifically aimed at seniors, but the founders were inspired by issues with their aging parents. Google Inc.’s ex-commerce chief founded Vida--a platform that gives patients access to the health care community, sends medication reminders and allows family and caregivers to track the progress--after witnessing her father’s struggle with illness.

In fact, the target customer for these startups often isn’t the senior, who may have a fixed income, but their children, caregivers or insurance companies.

“I think you have to find the right entry points,” Gandhi said.

Still, even as big names in Silicon Valley enter the space, elder care isn’t the most popular topic in the Valley, Gandhi said. That just means there’s more room for disruption.

“If people aren’t paying attention, they’re probably doing something wrong,” he said.

Source: Marketwatch, Caitlin Huston

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Diagnosis of the Elderly Patient

Evaluation of the #elderly usually differs from a standard medical evaluation. For elderly patients, especially those who are very old or frail, history-taking and physical examination may have to be done at different times, and physical examination may require 2 sessions because patients become fatigued.

The elderly also have different, often more complicated health care problems, such as multiple disorders, which may require use of many drugs (sometimes called polypharmacy) and thus greater likelihood of a high-risk drug being prescribed ( Potentially Inappropriate Drugs in the Elderly (Based on the American Geriatrics Society 2012 Beers Criteria Update)). #Diagnosis may be complicated, resulting in delays or missed diagnoses, and sometimes drugs are used inappropriately. Early detection of problems results in early intervention, which can prevent deterioration and improve quality of life often through relatively minor, inexpensive interventions (eg, lifestyle changes). Thus, some elderly patients, particularly the frail or chronically ill, are best evaluated using a comprehensive geriatric assessment (see Comprehensive geriatric assessment), which includes evaluation of function and quality of life, often by an interdisciplinary team. 

Multiple disorders

On average, elderly patients have 6 diagnosable disorders, and the primary care physician is often unaware of some of them. A disorder in one organ system can weaken another system, exacerbating the deterioration of both and leading to disability, dependence, and, without intervention, death. Multiple disorders complicate diagnosis and treatment, and effects of the disorders are magnified by social disadvantage (eg, isolation) and poverty (as patients outlive their resources and supportive peers) and by functional and financial problems.

Clinicians should also pay particular attention to certain common geriatric symptoms (eg, delirium, dizziness, syncope, falling, mobility problems, weight or appetite loss, urinary incontinence) because they may result from disorders of multiple organ systems.

If patients have multiple disorders, treatments (eg, bed rest, surgery, drugs) must be well-integrated; treating one disorder without treating associated disorders may accelerate decline. Also, careful monitoring is needed to avoid iatrogenic consequences. With complete bed rest, elderly patients can lose 5 to 6% of muscle mass and strength each day (causing sarcopenia), and effects of bed rest alone can ultimately result in death.

Missed or delayed diagnosis

Disorders that are common among the elderly are frequently missed, or the diagnosis is delayed. Clinicians should use the history, physical examination, and simple laboratory tests to actively screen elderly patients for disorders that occur only or commonly in the elderly ( Disorders Common Among the Elderly); when diagnosed early, these disorders can often be more easily treated. Early diagnosis frequently depends on the clinician’s familiarity with the patient’s behavior and history, including mental status. Commonly, the first signs of a physical disorder are mental or emotional. If clinicians are unaware of this possibility and attribute these signs to dementia, diagnosis and treatment can be delayed.


Prescription and OTC drug use should be reviewed frequently, particularly for drug interactions and use of drugs considered inappropriate for the elderly (see Drug Categories of Concern in the Elderly). When multiple drugs are used, computer-based management is more efficient.

Caregiver problems

Occasionally, problems of elderly patients are related to neglect or abuse by their caregiver (see Elder Abuse). Clinicians should consider the possibility of patient abuse and drug abuse by the caregiver if circumstances and findings suggest it. Certain injury patterns are particularly suggestive, including

Frequent bruising, especially in difficult-to-reach areas (eg, middle of the back)
Grip bruises of the upper arms
Bruises of the genitals
Peculiar burns
Unexplained fearfulness of a caregiver in the patient

Often, more time is needed to interview and evaluate elderly patients, partly because they may have characteristics that interfere with the evaluation. The following should be considered:

Sensory deficits: Dentures, eyeglasses, or hearing aids, if normally worn, should be worn to facilitate communication during the interview. Adequate lighting and elimination of visual or auditory distraction also helps.

Underreporting of symptoms: Elderly patients may not report symptoms that they consider part of normal aging (eg, dyspnea, hearing or vision deficits, memory problems, incontinence, gait disturbance, constipation, dizziness, falls). However, no symptom should be attributed to normal aging unless a thorough evaluation is done and other possible causes have been eliminated.

Unusual manifestations of a disorder: In the elderly, typical manifestations of a disorder may be absent (see Unusual Presentations of Illness in the Elderly). Instead, the elderly may present with general symptoms (eg, fatigue, confusion, weight loss).

Functional decline as the only manifestation: Disorders may manifest solely as functional decline. In such cases, standard questions may not apply. For example, when asked about joint symptoms, patients with severe arthritis may not report pain, swelling, or stiffness, but if asked about changes in activities, they may report that they no longer take walks or no longer volunteer at the hospital. Questions about duration of functional decline (eg, “How long have you been unable to do your own shopping?”) can elicit useful information. Identifying people when they have just started to have difficulty doing basic activities of daily living (ADLs) or instrumental ADLs (IADLs) may provide more opportunities for interventions to restore function or to prevent further decline and thus maintain independence.

Difficulty recalling: Patients may not accurately remember past illnesses, hospitalizations, operations, and drug use; clinicians may have to obtain these data elsewhere (eg, from family members, a home health aide, or medical records).

Fear: The elderly may be reluctant to report symptoms because they fear hospitalization, which they may associate with dying.

Age-related disorders and problems: Depression (common among the elderly), the cumulative losses of old age, and discomfort due to a disorder may make the elderly less apt to provide health-related information to clinicians. Patients with impaired cognition may have difficulty describing problems, impeding the physician’s evaluation.


A clinician’s knowledge of an elderly patient’s everyday concerns, social circumstances, mental function, emotional state, and sense of well-being helps orient and guide the interview. Asking patients to describe a typical day elicits information about their quality of life and mental and physical function. This approach is especially useful during the first meeting. Patients should be given time to speak about things of personal importance. Clinicians should also ask whether patients have specific concerns, such as fear of falling. The resulting rapport can help the clinician communicate better with patients and their family members.

A mental status examination may be necessary early in the interview to determine the patient’s reliability; this examination should be conducted tactfully so that the patient does not become embarrassed, offended, or defensive. Routine screening for physical and psychologic disorders ( Screening Recommendations for Elderly Patients) should be done annually, beginning at age 70.

Often, verbal and nonverbal clues (eg, the way the story is told, tempo of speech, tone of voice, eye contact) can provide information, as for the following:

Depression: Elderly patients may omit or deny symptoms of anxiety or depression but betray them by a lowered voice, subdued enthusiasm, or even tears.

Physical and mental health: What patients say about sleep and appetite may be revealing.

Weight gain or loss: Clinicians should note any change in the fit of clothing or dentures.

Unless mental status is impaired, a patient should be interviewed alone to encourage the discussion of personal matters. Clinicians often also need to speak with a relative or caregiver, who often give a different perspective on function, mental status, and emotional state. These interviews may be done with the patient absent, present, or both.

The clinician should ask the patient’s permission before inviting a relative or caregiver to be present and should explain that such interviews are routine. If the caregiver is interviewed alone, the patient should be kept usefully occupied (eg, filling out a standardized assessment questionnaire, being interviewed by another member of the interdisciplinary team).

If indicated, clinicians should consider the possibility of drug abuse by the patient and patient abuse by the caregiver.

Medical history

When asking patients about their past medical history, a clinician should ask about disorders that used to be more common (eg, rheumatic fever, poliomyelitis) and about outdated treatments (eg, pneumothorax therapy for TB, mercury for syphilis). A history of immunizations (eg, tetanus, influenza, pneumococcus), adverse reactions to immunizations, and skin test results for TB is needed. If patients recall having surgery but do not remember the procedure or its purpose, surgical records should be obtained if possible.

Clinicians should ask questions designed to systematically review each body area or system and thus check for other disorders and common problems that patients may have forgotten to mention ( Clues to Disorders in Elderly Patients).

Drug history

The drug history should be recorded, and a copy should be given to patients or their caregiver. It should contain

Drugs used
Dosing schedule
Reason for prescribing the drugs
Precise nature of any drug allergies
All drugs used should be recorded: topical drugs (which may be absorbed systemically), OTC drugs (which can have serious consequences if overused and may interact with prescription drugs), dietary supplements, and medicinal herb preparations (because many can interact adversely with prescription and OTC drugs).

Patients or a family member should be asked to bring in all of the above drugs and supplements at the initial visit and periodically thereafter. Clinicians can make sure patients have the prescribed drugs, but possession of these drugs does not guarantee adherence. Counting the number of tablets in each vial during the first and subsequent visits may be necessary. If someone other than a patient administers the drugs, that person is interviewed.

Patients should be asked to demonstrate their ability to read labels (often printed in small type), open containers (especially the child-resistant type), and recognize drugs. Patients should be advised not to put their drugs into one container.

Alcohol, tobacco, and recreational drug use history

Patients who smoke should be counseled to stop and, if they continue, not to smoke in bed because the elderly are more likely to fall asleep while doing so.

Patients should be checked for signs of alcohol use disorders, which are underdiagnosed in the elderly. Such signs include confusion, anger, hostility, alcohol odor on the breath, impaired balance and gait, tremors, peripheral neuropathy, and nutritional deficiencies. Screening questionnaires (eg, AUDIT— Screening Recommendations for Elderly Patients and Levels of Screening for Alcohol Problems) and questions about quantity and frequency of alcohol consumption can help. The 4 CAGE questions are quick and straightforward; the clinician asks if the patient has ever felt

Need to C ut down drinking
A nnoyed by criticism about drinking
G uilty about drinking
Need for a morning E ye-opener
Two or more positive responses to the CAGE questions suggest the possibility of alcohol abuse. Questions about use of other recreational drugs or substances of abuse also are appropriate.

Nutrition history

Type, quantity, and frequency of food eaten are determined. Patients who eat ≤ 2 meals a day are at risk of undernutrition. Clinicians should ask about the following:

Any special diets (eg, low-salt, low-carbohydrate) or self-prescribed fad diets
Intake of dietary fiber and prescribed or OTC vitamins
Weight loss and change of fit in clothing
Amount of money patients have to spend on food
Accessibility of food stores and suitable kitchen facilities
Variety and freshness of foods

The ability to eat (eg, to chew and swallow) is evaluated. It may be impaired by xerostomia and/or dental problems, which are common among the elderly. Decreased taste or smell may reduce the pleasure of eating, so patients may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients who are worried about urinary incontinence may reduce their fluid intake; as a result, they may eat less food.

Mental health history

Mental health problems may not be detected easily in elderly patients. Symptoms that may indicate a mental health disorder in younger patients (eg, insomnia, changes in sleep patterns, constipation, cognitive dysfunction, anorexia, weight loss, fatigue, preoccupation with bodily functions, increased alcohol consumption) may have another cause in the elderly. Sadness, hopelessness, and crying episodes may indicate depression. Irritability may be the primary affective symptom of depression, or patients may present with cognitive dysfunction. Generalized anxiety is the most common mental disorder encountered in elderly patients and often is accompanied by depression.

Patients should be asked about delusions and hallucinations, past mental health care (including psychotherapy, institutionalization, and electroconvulsive therapy), use of psychoactive drugs, and recent changes in circumstances. Many circumstances (eg, recent loss of a loved one, hearing loss, a change in residence or living situation, loss of independence) may contribute to depression.

Patients’ spiritual and religious preferences, including their personal interpretation of aging, declining health, and death, should be clarified.

Functional status

Whether patients can function independently, need some help with basic activities of daily living (ADLs) or instrumental ADLs (IADLs), or need total assistance is determined, often as part of comprehensive geriatric assessment. Patients may be asked open-ended questions about their ability to do activities, or they may be asked to fill out a standardized assessment instrument with questions about specific ADLs and IADLs (eg, Katz ADL Scale [ Katz Activities of Daily Living Scale], Lawton IADL Scale [ Lawton Instrumental Activities of Daily Living Scale]).

Social history

Clinicians should identify patients’ living arrangements, particularly where and with whom they live (eg, alone in an isolated house, in a busy apartment building), accessibility of their residence (eg, up stairs or a hill), and what modes of transportation are available to them. Such factors affect the ability of the elderly to obtain food, health care, and other important resources. A home visit, although difficult to arrange, can provide critical information. For example, clinicians can gain insight about nutrition from the refrigerator’s contents and about multiple ADLs from the bathroom’s condition. The number of rooms, number and type of phones, presence of smoke and carbon monoxide detectors, and condition of plumbing and heating system are determined, as is the availability of elevators, stairs, and air conditioning. Home safety evaluations can identify home features that can lead to falls (eg, poor lighting, slippery bathtubs, unanchored rugs), and solutions can be suggested.

Having patients describe a typical day, including activities such as reading, television viewing, work, exercise, hobbies, and interactions with other people, provides valuable information.

Clinicians should ask about the following:

Frequency and nature of social contacts (eg, friends, senior citizens’ groups), family visits, and religious or spiritual participation
Driving and availability of other forms of transportation
Caregivers and support systems (eg, church, senior citizens’ groups, friends, neighbors) that are available to the patient
The ability of family members to help the patient (eg, their employment status, their health, traveling time to the patient’s home)
The patient’s attitude toward family members and their attitude toward the patient (including their level of interest in helping and willingness to help)
Marital status of patients is noted. Questions about sexual practices and satisfaction must be sensitive and tactful but thorough. The number and sex of sex partners are determined, and risk of sexually transmitted diseases (STDs) is evaluated. Many sexually active elderly people are not aware of the increasing incidence of STDs in the elderly and do not follow or even know about safe sex practices.

Patients should be asked about educational level, jobs held, known exposures to radioactivity or asbestos, and current and past hobbies. Economic difficulties due to retirement, a fixed income, or death of a spouse or partner are discussed. Financial or health problems may result in loss of a home, social status, or independence. Patients should be asked about past relationships with physicians; a long-time relationship with a physician may have been lost because the physician retired or died or because the patient relocated.

Patient wishes regarding measures for prolonging life must be documented. Patients are asked what provisions for surrogate decision making (advance directives—see Advance Directives) have been made in case they become incapacitated, and if none have been made, patients are encouraged to make them. Getting patients and their surrogates accustomed to discussing goals of care is important; then when circumstances require medical decisions and prior documentation is unavailable or not relevant to the circumstance (which is very common), appropriate decisions can be made.

Key Points

Unless corrected, sensory deficits, especially hearing deficits, may interfere with history-taking.
Many disorders in the elderly manifest only as functional decline.
As part of the drug history, the patient or a family member should be asked to bring in all the patient’s drugs, including OTC drugs, at the initial visit and periodically thereafter.
Health care practitioners must often interview caregivers to obtain the history of functionally dependent elderly patients.
Physical Examination

Observing patients and their movements (eg, walking into the examination room, sitting in or rising from a chair, getting on and off an examination table, taking off or putting on socks and shoes) can provide valuable information about their function. Their personal hygiene (eg, state of dress, cleanliness, smell) may provide information about mental status and the ability to care for themselves.

If patients become fatigued, the physical examination may need to be stopped and continued at another visit. Elderly patients may require additional time to undress and transfer to the examining table; they should not be rushed. The examining table should be adjusted to a height that patients can easily access; a footstool facilitates mounting. Frail patients must not be left alone on the table. Portions of the examination may be more comfortable if patients sit in a chair.

Clinicians should describe the general appearance of patients (eg, comfortable, restless, undernourished, inattentive, pale, dyspneic, cyanotic). If they are examined at bedside, use of protective padding or a protective mattress, bedside rails (partial or full), restraints, a urinary catheter, or an adult diaper should be noted.

Vital Signs

Weight should be recorded at each visit. During measurement, patients with balance problems may need to grasp grab bars placed near or on the scale. Height is recorded annually to check for height loss due to osteoporosis.

Temperature is recorded. Hypothermia can be missed if the thermometer cannot measure temperatures more than a few degrees lower than normal. Absence of fever does not exclude infection.

Pulses and BP are checked in both arms. Pulse is taken for 30 sec, and any irregularity is noted. Because many factors can alter BP, BP is measured several times after patients have rested > 5 min.

BP may be overestimated in elderly patients because their arteries are stiff. This rare condition, called pseudohypertension, should be suspected if dizziness develops after antihypertensives are begun or doses are increased to treat elevated systolic BP.

All elderly patients are checked for orthostatic hypotension because it is common. BP is measured with patients in the supine position, then after they have been standing for 3 to 5 min. If systolic BP falls ≥ 20 mm Hg after patients stand, orthostatic hypotension is diagnosed. Caution is required when testing hypovolemic patients.

A normal respiratory rate in elderly patients may be as high as 25 breaths/min. A rate of > 25 breaths/min may be the first sign of a lower respiratory tract infection, heart failure, or another disorder.


Initial observation includes color (normal rubor, pale, cyanotic). Examination includes a search for premalignant and malignant lesions, tissue ischemia, and pressure ulcers. In the elderly, the following should be considered:

Ecchymoses may occur readily when skin is traumatized, often on the forearm, because the dermis thins with aging.
Uneven tanning may be normal because melanocytes are progressively lost with aging.
Longitudinal ridges on the nails and absence of the crescent-shaped lunula are normal age-related findings.
Nail plate fractures may occur because with aging, the nail plate thins.
Black splinter hemorrhages in the middle or distal third of the fingernail are more likely to be due to trauma than to bacteremia.
A thickened, yellow toenail indicates onychomycosis, a fungal infection.
Toenail borders that curve in and down indicate ingrown toenail (onychocryptosis).
Whitish nails that scale easily, sometimes with a pitted surface, indicate psoriasis.
Unexplained bruises may indicate abuse.
Head and Neck


Normal age-related findings may include the following:

Eyebrows that drop below the superior orbital rim
Descent of the chin
Loss of the angle between the submandibular line and neck
Dry skin
Thick terminal hairs on the ears, nose, upper lip, and chin
The temporal arteries should be palpated for tenderness and thickening, which may indicate giant cell arteritis.

Progressive descent of the nasal tip is a normal age-related finding. It may cause the upper and lower lateral cartilage to separate, enlarging and lengthening the nose.

Normal age-related findings include the following:

Loss of orbital fat: It may cause gradual sinking of the eye backward into the orbit (enophthalmos). Thus, enophthalmos is not necessarily a sign of dehydration in the elderly. Enophthalmos is accompanied by deepening of the upper eyelid fold and slight obstruction of peripheral vision.
Pseudoptosis (decreased size of the palpebral aperture)
Entropion (inversion of lower eyelid margins)
Ectropion (eversion of lower eyelid margins)
Arcus senilis (a white ring at the limbus)
With aging, presbyopia develops; the lens becomes less elastic and less able to change shape when focusing on close objects.
The eye examination should focus on testing visual acuity (eg, using a Snellen chart). Visual fields can be tested at the bedside by confrontation—ie, patients are asked to stare at the examiner so that the examiner can determine differences between their and the examiner’s visual field. However, such testing has low sensitivity for most visual disorders. Tonometry is occasionally done in primary care; however, it is usually done by ophthalmologists or optometrists as part of routine eye examinations or by ophthalmologists when a patient is referred to them because glaucoma is clinically suspected.

Ophthalmoscopy is done to check for cataracts, optic nerve or macular degeneration, and evidence of glaucoma, hypertension, or diabetes. Findings may be unremarkable unless a disorder is present because the retina’s appearance usually does not change much with aging. In elderly patients, mild to moderate elevated intracranial pressure may not result in papilledema because cortical atrophy occurs with aging; papilledema is more likely when pressure is markedly increased. Areas of black pigment or hemorrhages in and around the macula indicate macular degeneration.

For all elderly patients, an eye examination by an ophthalmologist or optometrist is recommended every 1 to 2 yr because such an examination may be much more sensitive for certain common eye disorders (eg, glaucoma, cataracts, retinal disorders).


Tophi, a normal age-related finding, may be noted during inspection of the pinna. The external auditory canal is examined for cerumen, especially if a hearing problem is noted during the interview. If a patient wears a hearing aid, it is removed and examined. The ear mold and plastic tubing can become plugged with wax, or the battery may be dead, indicated by absence of a whistle (feedback) when the volume of the hearing aid is turned up.

To evaluate hearing, examiners, with their face out of the patient’s view, whisper 3 to 6 random words or letters into each of the patient’s ears. If a patient correctly repeats at least half of these words for each ear, hearing is considered functional for one-on-one conversations. Patients with presbycusis (age-related, gradual, bilateral, symmetric, and predominantly high-frequency hearing deficits) are more likely to report difficulty in understanding speech than in hearing sounds. Evaluation with a portable audioscope, if available, is also recommended because the testing sounds are standardized; thus, this evaluation can be useful when multiple providers are caring for a patient. Patients are asked whether hearing loss interferes with social, work, or family functioning, or they may be given the Hearing Handicap Inventory for the Elderly (HHIE), a self-assessment tool designed to determine the effects of hearing loss on the emotional and social adjustment of the elderly. If hearing loss interferes with functioning or if the HHIE score is positive, they are referred for formal audiologic testing.


The mouth is examined for bleeding or swollen gums, loose or broken teeth, fungal infections, and signs of cancer (eg, leukoplakia, erythroplakia, ulceration, mass). Findings may include

Darkened teeth: Due to extrinsic stains and less translucent enamel, which occur with aging
Fissures in the mouth and tongue and a tongue that sticks to the buccal mucosa: Due to xerostomia
Erythematous, edematous gingiva that bleeds easily: Usually indicating a gingival or periodontal disorder
Bad breath: Possibly indicating caries, periodontitis, another oral disorder, or sometimes a pulmonary disorder
The dorsal and ventral surfaces of the tongue are examined. Common age-related changes include varicose veins on the ventral surface, erythema migrans (geographic tongue), and atrophied papillae on the sides of the tongue. In edentulous patients, the tongue may enlarge to facilitate chewing; however, enlargement may also indicate amyloidosis or hypothyroidism. A smooth, painful tongue may indicate vitamin B 12 deficiency.

Dentures should be removed before the mouth is examined. Dentures increase risk of oral candidiasis and resorption of the alveolar ridges. Inflammation of the palatal mucosa and ulcers of the alveolar ridges may result from poorly fitting dentures.

The interior of the mouth is palpated. A swollen, firm, and tender parotid gland may indicate parotitis, particularly in dehydrated patients; pus may be expressed from Stensen duct when bacterial parotitis is present. The infecting organisms are often staphylococci.

Painful, inflamed, fissured lesions at the lip commissures (angular cheilitis) may be noted in edentulous patients who do not wear dentures; these lesions are usually accompanied by a fungal infection.

Temporomandibular joint

This joint should be evaluated for degeneration (osteoarthrosis), a common age-related change. The joint can degenerate as teeth are lost and compressive forces in the joint become excessive. Degeneration may be indicated by joint crepitus felt at the head of the condyle as patients lower and raise their jaw, by painful jaw movements, or by both.


The thyroid gland, which is located low in the neck of elderly people, often beneath the sternum, is examined for enlargement and nodules.

Carotid bruits due to transmitted heart murmurs can be differentiated from those due to carotid artery stenosis by moving the stethoscope up the neck: A transmitted heart murmur becomes softer; the bruit of carotid artery stenosis becomes louder. Bruits due to carotid artery stenosis suggest systemic atherosclerosis. Whether asymptomatic patients with carotid bruits require evaluation or treatment for cerebrovascular disease is unclear.

The neck is checked for flexibility. Resistance to passive flexion, extension, and lateral rotation may indicate a cervical spine disorder. Resistance to flexion and extension can also occur in patients with meningitis, but unless meningitis is accompanied by a cervical spine disorder, the neck can be rotated passively from side to side without resistance.

Chest and Back

All areas of the lungs are examined by percussion and auscultation. Basilar rales may be heard in the lungs of healthy patients but should disappear after patients take a few deep breaths. The extent of respiratory excursions (movement of the diaphragm and ability to expand the chest) should be noted.

The back is examined for scoliosis and tenderness. Severe low back, hip, and leg pain with marked sacral tenderness may indicate spontaneous osteoporotic fractures of the sacrum, which can occur in elderly patients.


In men and women, the breasts should be examined annually for irregularities and nodules. For women, monthly self-examinations are also recommended, as is annual screening mammography, especially for women who have a family history of breast cancer. If nipples are retracted, pressure should be applied around the nipples; pressure everts the nipples when retraction is due to aging but not when it is due to an underlying lesion.


Heart size can usually be assessed by palpating the apex. However, displacement caused by kyphoscoliosis may make assessment difficult.

Auscultation should be done systematically. In elderly patients, a systolic murmur most commonly indicates

Aortic valve sclerosis: Typically, this murmur is not hemodynamically significant, although risk of stroke may be increased. It peaks early during systole and is rarely heard in the carotid arteries.

However, systolic murmurs may be due to other disorders, which should be identified:

Aortic valve stenosis: This murmur, in contrast to that of aortic valve sclerosis, typically peaks later during systole, is transmitted to the carotid arteries, and is loud (greater than grade 2); the 2nd heart sound is dampened, pulse pressure is narrow, and the carotid upstroke is slowed. However, in elderly patients, the murmur of aortic valve stenosis may be difficult to identify because it may be softer, a 2nd heart sound is rarely audible, and narrow pulse pressures are uncommon. Also, in many elderly patients with aortic valve stenosis, the carotid upstroke does not slow because vascular compliance is diminished.

Mitral regurgitation: This murmur is usually loudest at the apex and radiates to the axilla.

Hypertrophic obstructive cardiomyopathy: This murmur intensifies when patients do a Valsalva maneuver.

Fourth heart sounds are common among elderly people without evidence of a cardiovascular disorder and are commonly absent among elderly people with evidence of a cardiovascular disorder. Diastolic murmurs are abnormal in people of any age. Unexplained and asymptomatic sinus bradycardia in apparently healthy elderly people may not be clinically important.

If new neurologic or cardiovascular symptoms develop in patients with a pacemaker, evaluation for variable heart sounds, murmurs, and pulses and for hypotension and heart failure is required. These symptoms and signs may be due to loss of atrioventricular synchrony.

GI System

The abdomen is palpated to check for weak abdominal muscles, which are common among elderly people and which may result in hernias. Most abdominal aortic aneurysms are palpable as a pulsatile mass; however, only their lateral width can be assessed during physical examination. In some patients (particularly thin ones), a normal aorta is palpable, but the vessel and pulsations do not extend laterally. Screening ultrasonography of the aorta is recommended for all older men who have ever smoked. The liver and spleen are palpated for enlargement. Frequency and quality of bowel sounds are checked, and the suprapubic area is percussed for tenderness, discomfort, and evidence of urinary retention.

The anorectal area is examined externally for fissures, hemorrhoids, and other lesions. Sensation and the anal wink reflex are tested. A digital rectal examination (DRE) to detect a mass, stricture, tenderness, or fecal impaction is done in men and women. Fecal occult blood testing is also done.

Male GU System

The prostate gland is palpated for nodules, tenderness, and consistency. Estimating prostate size by DRE is inaccurate, and size does not correlate with urethral obstruction; however, DRE provides a qualitative evaluation.

Female Reproductive System

Regular pelvic examinations, with a Papanicolaou (Pap) test every 2 to 3 yr until age 65, are recommended. At age 65, testing can be stopped if results of the previous 2 consecutive tests were normal. If women ≥ 65 have not had regular Pap tests, they should have at least 2 negative tests, 1 yr apart, before testing is stopped. Once Pap testing has been stopped, it is restarted only if new symptoms or signs of a possible disorder develop. If women have had a hysterectomy, Pap tests are required only if cervical tissue remains.

For pelvic examination, patients who lack hip mobility may lie on their left side. Postmenopausal reduction of estrogen leads to atrophy of the vaginal and urethral mucosa; the vaginal mucosa appears dry and lacks rugal folds. The ovaries should not be palpable 10 yr after menopause; palpable ovaries suggest cancer. Patients should be examined for evidence of prolapse of the urethra, vagina, cervix, and uterus. They are asked to cough to check for urine leakage and intermittent prolapse.

Musculoskeletal System

Joints are examined for tenderness, swelling, subluxation, crepitus, warmth, redness, and other abnormalities, which may suggest a disorder:

Heberden nodes (bony overgrowths at the distal interphalangeal joints) or Bouchard nodes (bony overgrowths at the proximal interphalangeal joints): Osteoarthritis

Subluxation of the metacarpophalangeal joints with ulnar deviation of the fingers: Chronic RA

Swan-neck deformity (hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint) and boutonnière deformity (hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint): RA

These deformities may interfere with functioning or usual activities.

Active and passive range of joint motion should be determined. The presence of contractures should be noted. Variable resistance to passive manipulation of the extremities (gegenhalten) sometimes occurs with aging.


Diagnosis and treatment of foot problems, which become common with aging, help elderly people maintain their independence. Common age-related findings include hallux valgus, medial prominence of the 1st metatarsal head with lateral deviation and rotation of the big toe, and lateral deviation of the 5th metatarsal head. Hammer toe (hyperflexion of the proximal interphalangeal joint) and claw toe (hyperflexion of the proximal and distal interphalangeal toe joints) may interfere with functioning and daily activities. Toe deformities may result from years of wearing poorly fitting shoes or from RA, diabetes, or neurologic disorders (eg, Charcot-Marie-Tooth disease). Occasionally, foot problems indicate other systemic disorders (see Table: Foot Manifestations of Systemic Disorders).

Patients with foot problems should be referred to a podiatrist for regular evaluation and treatment.

Neurologic System

Neurologic examination for elderly patients is similar to that for any adult. However, nonneurologic disorders that are common among elderly people may complicate this examination. For example, visual and hearing deficits may impede evaluation of cranial nerves, and periarthritis (inflammation of tissues around a joint) in certain joints, especially shoulders and hips, may interfere with evaluation of motor function.

Signs detected during the examination must be considered in light of the patient’s age, history, and other findings. Symmetric findings unaccompanied by functional loss and other neurologic symptoms and signs may be noted in elderly patients. Clinicians must decide whether these findings justify a detailed evaluation to check for a neurologic lesion. Patients should be reevaluated periodically for functional changes, asymmetry, and new symptoms.

Cranial nerves

Evaluation may be complex.

Elderly people often have small pupils; their pupillary light reflex may be sluggish, and their pupillary mitotic response to near vision may be diminished. Upward gaze and, to a lesser extent, downward gaze are slightly limited. Eye movements, when tracking an examiner’s finger during evaluation of visual fields, may appear jerky and irregular. Bell phenomenon (reflex upward movement of the eyes during closure) is sometimes absent. These changes occur normally with aging.

In many elderly people, sense of smell is diminished because they have fewer olfactory neurons, have had numerous upper respiratory infections, or have chronic rhinitis. However, asymmetric loss (loss of smell in one nostril) is abnormal. Taste may be altered because the sense of smell is diminished or because patients take drugs that decrease salivation.

Visual and hearing deficits may result from abnormalities in the eyes and ears rather than in nerve pathways.

Motor function

Patients can be evaluated for tremor during handshaking and other simple activities. If tremor is detected, amplitude, rhythm, distribution, frequency, and time of occurrence (at rest, with action, or with intention) are noted.

Muscle strength

Elderly people, particularly those who do not do resistance training regularly, may appear weak during routine testing. For example, during the physical examination, the clinician may easily straighten a patient’s elbow despite the patient’s effort to sustain a contraction. If weakness is symmetric, does not bother the patient, and has not changed the patient’s function or activity level, it is likely to be clinically insignificant. Increased muscle tone, measured by flexing and extending the elbow or knee, is a normal finding in elderly people; however, jerky movements during examination and cogwheel rigidity are abnormal.

Sarcopenia (a decrease in muscle mass) is a common age-related finding. It is insignificant unless accompanied by a decline or change in function (eg, patients can no longer rise from a chair without using chair arms). Sarcopenia affects the hand muscles (eg, interosseous and thenar muscles) in particular. Weak extensor muscles of the wrist, fingers, and thumb are common among patients who use wheelchairs because compression of the upper arm against the armrest injures the radial nerve. Arm function can be tested by having patients pick up an eating utensil or touch the back of their head with both hands.


Motor reaction time and motor coordination are tested. Reaction time often increases with age, partly because conduction of signals along peripheral nerves slows. Coordination decreases because of changes in central mechanisms, but this decrease is usually subtle and does not impair function.

Gait and posture

All components of gait should be assessed; they include initiation of walking; step length, height, symmetry, continuity, and cadence (rhythm); velocity (speed of walking); stride width; and walking posture. Sensation, musculoskeletal and motor control, and attention, which are necessary for independent, coordinated walking, must also be considered.

Normal age-related findings may include the following:

Shorter steps, possibly because calf muscles are weak or because balance is poor
Reduced gait velocity in patients > 70 because steps are shorter
Increased time in double stance (when both feet are on the ground), which may be due to impaired balance or fear of falling
Reduced motion in some joints (eg, ankle plantar flexion just before the back foot lifts off, pelvic motion in the frontal and transverse planes)
Slight changes in walking posture (eg, greater downward pelvic rotation, possibly due to a combination of increased abdominal fat, abdominal muscle weakness, and tight hip flexor muscles; a slightly greater turn-out of the toes, possibly due to loss of hip internal rotation or to an attempt to increase lateral stability)
In people with a gait velocity of < 1 m/sec, mortality risk is significantly increased.

Aging has little effect on walking cadence or posture; typically, the elderly walk upright unless a disorder is present ( Some Causes of Gait Dysfunction).

Overall postural control is evaluated using Romberg test (patients stand with feet together and eyes closed). Safety is paramount, and a clinician doing the Romberg test must be in position to prevent the patient from falling. With aging, postural control is often impaired, and postural sway (movement in the anteroposterior plane when patients remain stationary and upright) may increase.


The deep tendon reflexes are checked. Aging usually has little effect on them. However, eliciting the Achilles tendon reflex may require special techniques (eg, testing while patients kneel with their feet over the edge of a bed and with their hands clasped). A diminished or absent reflex, present in nearly half of elderly patients, may be normal. It occurs because tendon elasticity decreases and nerve conduction in the tendon’s long reflex arc slows. Asymmetric Achilles tendon reflexes usually indicate a disorder (eg, sciatica).

Cortical release reflexes (known as pathologic reflexes), which include snout, sucking, and palmomental reflexes, commonly occur in elderly patients without detectable brain disorders (eg, dementia). Babinski reflex (extensor plantar response) in elderly patients is abnormal; it indicates an upper motor neuron lesion, often cervical spondylosis with partial cord compression.


Evaluation of sensation includes touch (using a skin prick test), cortical sensory function, temperature sense, proprioception (joint position sense), and vibration sense testing. Aging has limited effects on sensation. Many elderly patients report numbness, especially in the feet. It may result from a decrease in size of fibers in the peripheral nerves, particularly the large fibers. Nonetheless, patients with numbness should be checked for peripheral neuropathies. In many patients, no cause of numbness can be identified.

Many elderly people lose vibratory sensation below the knees. It is lost because small vessels in the posterior column of the spinal cord change. However, proprioception, which is thought to use a similar pathway, is unaffected.

Mental status

A mental status examination is important (see also Examination of Mental Status). Patients who are disturbed by such a test should be reassured that it is routine. The examiner must make sure that patients can hear; hearing deficits that prevent patients from hearing and understanding questions may be mistaken for cognitive dysfunction. Evaluating the mental status of patients who have a speech or language disorder (eg, mutism, dysarthria, speech apraxia, aphasia) can be difficult.

Orientation may be normal in many patients with dementia or other cognitive disorders. Thus, evaluation may require questions that identify abnormalities in consciousness, judgment, calculations, speech, language, praxis, executive function, or memory, as well as orientation. Abnormalities in these areas cannot be attributed solely to age, and if abnormalities are noted, further evaluation, including a formal test of mental status (see Mental status), is needed.

With aging, information processing and memory retrieval slow but are essentially unimpaired. With extra time and encouragement, patients do such tasks satisfactorily (unless a neurologic abnormality is present).

Nutritional Status

Aging changes the interpretation of many measurements that reflect nutritional status in younger people. For example, aging can alter height. Weight changes can reflect alterations in nutrition, fluid balance, or both. The proportion of lean body mass and body fat content changes. Despite these age-related changes, body mass index (BMI) is still useful in elderly patients, although it underestimates obesity. Waist circumference and waist-to-hip ratio have been used instead. Risks due to obesity are increased if the waist circumference is > 102 cm (> 40 in) in men and > 88 cm (> 35 in) in women or if the waist-to-hip ratio is > 0.9 in men and > 0.85 in women.

If abnormalities in the nutrition history (eg, weight loss, suspected deficiencies in essential nutrients) or BMI are identified, thorough nutritional evaluation, including laboratory measurements, is indicated.

Key Points

Valuable information about a patient’s function can be gained by observing the patient.
Physical examination should include all systems, particularly mental status, and may require 2 sessions.

Comprehensive geriatric assessment

Comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of elderly people.

The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors as well as physical and mental health ( A Geriatric Assessment Instrument). Ideally, a regular examination of elderly patients incorporates many aspects of the comprehensive geriatric assessment, making the 2 approaches very similar. Assessment results are coupled with sustained individually tailored interventions (eg, rehabilitation, education, counseling, supportive services).

The cost of geriatric assessment limits its use. Thus, this assessment may be used mainly in high-risk elderly patients, such as the frail or chronically ill (eg, identified via mailed health questionnaires or interviews in the home or meeting places). Family members may also request a referral for geriatric assessment.

Assessment can have the following benefits:

Improved care and clinical outcomes
Greater diagnostic accuracy
Improved functional and mental status
Reduced mortality
Decreased use of nursing homes and acute care hospitals
Greater satisfaction with care
If elderly patients are relatively healthy, a standard medical evaluation may be appropriate.

Comprehensive geriatric assessment is most successful when done by a geriatric interdisciplinary team (typically, a geriatrician, nurse, social worker, and pharmacist). Usually, assessments are done in an outpatient setting. However, patients with physical or mental impairments and chronically ill patients may require inpatient assessment.

Assessment Domains

The principal domains assessed are

Functional ability: Ability to do activities of daily living (ADLs) and instrumental ADLs (IADLs) are assessed. ADLs include eating, dressing, bathing, transferring between the bed and a chair, using the toilet, and controlling bladder and bowel. IADLs enable people to live independently and include preparing meals, doing housework, taking drugs, going on errands, managing finances, and using a telephone.

Physical health: History and physical examination should include problems common among the elderly (eg, problems with vision, hearing, continence, gait, and balance).

Cognition and mental health: Several validated screening tests for cognitive dysfunction (eg, mental status examination—see Examination of Mental Status) and for depression (eg, Geriatric Depression Scale [ Geriatric Depression Scale (Short Form)], Hamilton Depression Scale) can be used.

Socioenvironmental situation: The patient’s social interaction network, available social support resources, and special needs and the safety and convenience of the patient’s environment are determined, often by a nurse or social worker. Such factors influence the treatment approach used. A checklist can be used to assess home safety.

Standardized instruments make evaluation of these domains more reliable and efficient ( A Geriatric Assessment Instrument). They also facilitate communication of clinical information among health care practitioners and monitoring of changes in the patient’s condition over time.

Source: Mayo Clinic

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Declining teens — the hidden story in #aging of America

The proportion of teens is at its smallest point in American history, with greater decline coming. And that poses some interesting demographic challenges, according to Philip Bump, who writes of the shift on The Fix blog in the Washington Post.

“Teen death” is how a colleague responded when he showed her the numbers.

Writes Bump, “That’s a bit strong, but the point is an interesting one: By 2050, teens (does that need a hashtag?) will make up a small percentage of the population. But then I looked at the long-term trend and discovered something alarming: There are currently fewer #teens as a percentage of all Americans than at any point on record. And it will keep dropping.”

The percentage of Americans who are teens is in decline because an increasing portion of Americans are older and the overall population keeps growing.

Bump does note “teen pockets” in the West, “thanks to high birthrates among# Mormons and #Hispanics.”

The teen years are challenging from many vantage points, from hormones to education to simply finding a job and launching into adulthood.

“American teenagers are now the most stressed-out age group in the U.S., according to the American Psychological Association’s 2013 Stress In America survey. While adults rate their stress at a 5.1 on a 10-point scale, teens rate their stress levels at 5.8,” wrote Huffington Post’s Carolyn Gregoire in 2014. The school year was cited as one of the most stressful periods, the survey found.

“It is alarming that the teen stress experience is so similar to that of adults. It is even more concerning that they seem to underestimate the potential impact that stress has on their physical and mental health,” Norman B. Anderson, CEO and executive vice president of the APA, said in a statement that accompanied release of the annual survey. “In order to break this cycle of stress and unhealthy behaviors as a nation, we need to provide teens with better support and health education at school and home, at the community level and in their interactions with health care professionals.”

When Pew Research Center looked at teens, it focused primarily on facts regarding technology, noting that 95 percent are online, that most have a cellphone though not necessarily a smartphone, that they’re virtually all involved with some form of social networking on the Internet.

Job reports paint a different picture of the teen years. According to a ChildTrends teen and young adult employment report, job numbers have bounced up and down a bit since 2000, but the trend overall has been down.

Finding jobs is a challenge for teens, particularly since the start of the recession in 2007, which saw a lot of older Americans competing for jobs that had traditionally been held by teens. 2010 marked an absolute low point, the Deseret News reported, but the numbers are still bouncing around.

According to ChildTrends, in “October 2013, 47 percent of all youth ages 16-24 were employed either full- or part-time. Youth enrolled in high school had an employment rate of 17 percent, while the rate for those in college, either full- or part-time, was 45 percent.”

It said that 35 percent of the group, which ranges from high school through mid-20s, were not employed at all.

As for who teens are, reports that 96.5 percent of American teenagers have “performed a random act of kindness,” most alone and without fanfare. More than half volunteer during the holidays and donate both time and money.

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The News From The #Aging In America Conference 

I’ve recently returned from the American Society on Aging’s mammoth Aging in America 2015 conference in Chicago where 3,000 attendees learned about key issues affecting people 50+.

I’ve already written about one promising program to curb elder abuse that I heard about at the conference, the #Elder Financial Safety Center in Dallas, Texas. Over the coming weeks, my Next Avenue colleague, Health Editor Emily Gurnon, and I will write more about what we learned. But today I want to blog about some tidbits I picked up relating to my two beats: Work & Purpose and Money & Security, plus experts’ views on The Politics of Aging. 

Work & Purpose

A frequent theme at the sessions about work was voiced by Gregory Merrill, President and CEO of the National Older Worker Career Center: “Older workers are an untapped national resource.” But, Merrill added, “our challenge is to help employers understand that and be sure older workers continue to apply for jobs.” Highlights from the work sessions:

Why finding work is hard for the unemployed after 50: Speaking at one of the conference’s national forums called “Employing Older Workers Makes Good Business Sense,” Lori Trawinski, of the AARP Public Policy Institute and Project Director of AARP’s Future of Work@50+ Initiative, said: “It’s much more difficult for older, unemployed workers to get rehired. They’re more likely to have worked at one employer for a long time. Many haven’t done resumés or interviews in years and are not familiar with online job-search tools. And many are hurting emotionally.”

And, as I wrote in my blog about the new AARP survey of people 45 to 70 who’ve been unemployed in the past five years, many who have been hired are now earning less than they did before (though their working conditions are often better, too).

Next Avenue blogger Kerry Hannon, who moderated a panel about boomer jobs and entrepreneurship after 50 at the related conference, the What’s Next Boomer Business Summit, said: “It’s really, really hard to find work over 50.”

How to improve your prospects for getting hired: Also speaking at the older workers’ forum, Barbara Hoenig, a consultant on mature workers and workforce development with CVS Health, urged job applicants to put more time and effort into their cover letters and resumés.

“Your cover letter is your calling card and it’s what we work with at first,” said Hoenig. She also was dismayed that the resumés she generally sees “are the same no matter where the applicant is applying.” Hoenig advised: “Put information in to create a unique resumé for the particular job.”

What boomer workers are like: Ken Dychtwald, president and CEO of the boomer research and consulting firm AgeWave, said at the forum that boomer workers have a few unique traits.

“They have an unwillingness to trust authorities; they’re rule breakers; they believe power comes from the self, not from the group; they’re unbelievably motivated and they’re drama queens and kings,” he said. “They complain about everything. Watch what starts to happen in the coming decades when they start to hurt.”

Boomer workers also often have serious eldercare issues to contend with, Dychtwald said. “The average boomer lost more work to eldercare than to childcare last year, yet we have not embraced parentcare as a work-related benefit,” he noted.

Employers that “get” the advantages of older workers: Dychtwald said that when Google — which he says gets 3 million unsolicited job applications a year — needed to appoint a Director of Engineering in 2012, it chose scientist/inventor/futurist Ray Kurzweil, who’s now 66.

IBM, Dychtwald added, is “doing wonderful things” mentoring employees, includingreverse mentoring (where a younger worker mentors an older one). Hallmark Cards offers sabbaticals and gap years, “which makes total sense for our long lives,” said Dychtwald. The consulting firm Booz Allen Hamilton is big on rehiring former employees (its program is called Comeback Kids).

And “CVS is doing wonderful things putting older people in customer-facing positions because many of their clients are older,” said Dychtwald.

Why job-searching is especially tough for older, low-income people:Executives from Generations on Line, which simplifies the Internet for seniors, spoke about a workshop they launched in Baltimore, Md., to teach older, low-income residents how to apply for jobs online.

VJ Pappas, the group’s Chief Operating Officer, found that the students who enrolled generally weren’t very familiar with using the Internet to look for work. Employers often don’t make it easy for them. “The job application for Home Depot required 38 clicks, Walmart required 49 clicks and CVS required 50 clicks. They’re tough to get through,” said Pappas. As a result, some of the students gave up.

Generations on Line hopes to roll out its workshop nationwide.

Money & Security

A few sessions dealt with strengthening your finances and with making communities more age-friendly. Highlights:

How women can avoid running out of money: Cindy Hounsell, President of theWomen’s Institute for a Secure Retirement (WISER), encouraged women to “go online every year and get your Social Security estimate at the Social Security website; learn how to invest; consider working longer or doing part-time work and consider annuities that offer guaranteed income for life.” Added Hounsell: “I’m a big fan of annuities, but it’s the buying of them that’s really hard.”

Sandra Timmermann, a business and aging strategist formerly with the now-defunct MetLife Mature Market Institute, also favored annuities as a potential source of retirement income for women. “They can really be very good,” she said. Timmermann also recommended giving reverse mortgages (income payouts based on your home equity) a second look, since a regulatory crackdown has improved them. “The product is changing to make it more of a holistic plan,” she said.

Coming soon: a new way to check out a community for livability. Debra Whitman, AARP’s Executive Vice President for Policy Strategy and International Affairs, said that in late April, AARP will unveil its Livability Index. This free online tool will be packed with data in seven categories (from transportation to health) to let you see how well your neighborhood and community scores according to AARP’s livability standards and will allow you to get similar scores for places around the country.

It could be a useful resource to help you choose where to live or retire and might be a way to pressure your local officials to make your community more age-friendly. As Whitman said: “Communities must take big steps to meet the needs of their aging populations. It’s time for communities to wake up and take action.”

The Politics of Aging

The “Politics of Aging” panel featured three liberals (memo to American Society on Aging: Next year, include a conservative for balance). Highlights:

Larry Polivka, Director of the Claude Pepper Center at Florida State University, said: “The Republican advantage of 50+ and 60+ white voters has become enormous. That’s very different from the way older voters voted 10 years ago, which was Democratic and had been for 30 years.”

His explanation: “Democrats have ceased to make the issues of retirement security, Social Security, Medicare and Medicaid high visible priorities for the last few election cycles…This election trend will continue unless Democrats make an effort to prioritize these programs.” Polivka exhorted: “Can you tell me what the Democrats’ message has been on retirement security for the last 10 years or on Social Security or Medicare? There is no message!”

Obama, Polivka said, “never made Social Security a clear priority. In fact, it has been necessary to convince him not to make cuts to the program.”

Richard Browdie, CEO of the Benjamin Rose Institute on Aging, said: “We Democrats make things so complicated, using paragraphs to explain what others do in sentences. We are more complete and accurate and honest intellectually, but way less effective.” Speaking about Republicans, Browdie said: “You have to admire their elegance in their ability to reframe the debate.”

Bob Blancato, President of Metz, Blancato & Associates (a consulting, government affairs and advocacy firm) and contributor to Next Avenue, forecasted a possible reversal among older voters in 2016. “Without Obama, we may see more older voters coming back to the Democratic party,” he said.

After next year’s Aging in America conference, I’ll let you know if the pundits see things any differently.

Richard Eisenberg is the senior Web editor of the Money & Security and Work & Purpose channels of Next Avenue and Assistant Managing Editor for the site and a contributor to Forbes. Follow him on Twitter @richeis315.

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