Geriatric Clinico-Social Case in Community Medicine

The case information can be collected under the following broad headings as already discussed in the blog and lecture on ‘Format for CSC in Community Medicine’:
1. Identification and family data
2. Clinical history, general, and systemic examination of the index case
3. Family health and Housing Environment
4. Clinico-social diagnosis
5. Effect of the illness on the family
6. Management suggested (curative, preventive, and promotive)
Points no. 1 and 3 i.e. ‘Identification and family data’ and ‘Family health and Housing Environment’ have already been Explained in the following blogs and lectures:
• ‘Format for CSC’ and
‘Format for CSC’ Blog: http://www.ihatepsm.com/blog/format-clinico-social-case-taking-community...
‘Format for CSC’ Lecture: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation...
‘Format for CSC’ Lecture in HINDI: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation...
• ‘Family Health Study – definitions and explanations’
Hence, here we will discuss the remaining 4 headings i.e. History & examination, Clinico- social diagnosis, effect on the family and management of the individual geriatric case.

Health Problems of the elderly:
1. Problems due to ageing process:
a. Senile cataract
b. Glaucoma
c. Nerve deafness, presbycusis
d. Osteoporosis affecting mobility
e. Emphysema
f. Failure of special senses
g. Changes in mental outlook etc.
2. Chronic diseases whose prevalence is high among the elderly:
a. Atherosclerosis leading to hypertension and MI
b. Cancer – incidence rapidly rises after the age of 40 yr. carcinoma prostate is common after the age of 65
c. Accidents leading to fractures of fragile bones, fracture neck of femur is very common among the geriatric population
d. Diabetes Mellitus
3. Loco-motor system disorders:
a. Osteoarthritis
b. Rheumatoid arthritis
c. Fibrositis
d. Myositis
e. Neuritis
f. Spondylitis of spine etc.
4. Respiratory illnesses:
a. Chronic bronchitis
b. Asthma
c. Emphysema
5. Genitourinary system:
a. BPH: dysuria, nocturia, frequency and urgency of micturition etc.
6. Psychological Problems:
a. Mental changes: Impaired memory, rigid outlook and dislike of change, reduced income leading to fall in standard of living,
b. Sexual adjustment: leading to irritability, jealousy and despondency
c. Emotional disorders: due to social maladjustment resulting in inner withdrawal, depression and even suicide.

Remember:
• They may have multiple disorders.
• Early detection of problems and early intervention can avert further deterioration and improves quality of life, often needing relatively minor, inexpensive interventions e.g. Lifestyle changes.
• The management has to take into account the social handicap (eg, isolation) and lack of resources
• The history and physical examination should screen elderly patients for disorders that occur commonly in the elderly.
• There is a need to identify the caregivers and the support system.

Geriatric Clinic Social Case Taking: as per WHO Age-friendly Primary Health Care (AF PHC) toolkit, should include:
• Assess health/illness by conducting a complete history including mental status and social support
• Perform a comprehensive functional assessment
• Perform a comprehensive physical exam considering the changes associated with ageing.
• Assess the relationship between acute illness and known chronic illness in older persons.
• Assess the strengths and weaknesses of the care giving system of the elderly

History:
Unless the mental status seems compromised, the elderly should be interviewed alone to facilitate the discussion of personal matters.
You may need to speak with a relative/caregiver, for their viewpoint on the functional and mental status.
1. Identification and family data: as explained in the blog/lecture on “Format for CSC”
2. Presenting complaints, if any and history of present illness
• Sometimes there may not be ANY presenting complaints as the elderly consider them as a part of normal aging e.g. dyspnoea, hearing or vision deficits, incontinence, constipation, dizziness, falls etc.
• No symptom should be attributed to normal aging unless a thorough evaluation is done and other possible causes have been eliminated.
• Sometimes disorders may manifest merely as functional deterioration. For example, when asked about joint symptoms, patients with even severe arthritis may not report pain, swelling, or stiffness, but if asked about changes in activities, they may, for example, report that they no longer go out for walking
• Questions should be asked specifically to check for the disorders frequently affecting the elderly, which he/she may have forgotten to mention. The list mentioned at the outset may be of help in ruling out common disorders of the elderly. E.g.
o Dysuria, nocturia, frequency and urgency of micturition etc.
o Hearing loss
o Breathlessness, orthopnoea
o Vision change, r/o cataract and glaucoma
o Polyuria, polydipsia, weight loss in spite of good hunger to r/o DM
o Symptoms to r/o cancers like haemoptysis, blood in urine, vaginal bleeding after menopause, seizures, blood in stool, etc.
o Peripheral neuropathies: abnormal sensation or loss of sensation in any limb
o Especially assess for the 4 ‘Geriatric Giant’ problems of the elderly (WHO)
 Memory loss
 Depression
 Urinary Incontinence
 Falls/immobility
A PG student can use the WHO AF PHC Tool 1: a 10-minute comprehensive screening
3. History of past illness: stroke, MI, cancers, fall & injury, depression, TB etc.
4. Known case of any illness: HT, DM, hypo/hyper thyroid, peripheral neuropathy etc.
a. Duration of the illness:
b. Treatment taken and from where:
c. Treatment compliance:
5. Personal History:
a. Bladder: history of stress incontinence, history suggestive of any degree of uterine prolapse, burning micturition etc.
b. Bowel: regular/ irregular, any change in bowel habits, blood in stool etc.
c. Smoking
d. Alcohol
e. Exercise
6. Dietary History: Calculate the percent deficit/high intake of calories as compared to the RDA. Don’t forget to consider the reduction in the calorie requirement according to the age.
Any other problem in eating e.g. inability to chew leading to decreased intake etc.
7. Menstrual history (female):
a. Age at menarche
b. Regularity of the cycles
c. Age at menopause
d. Menopausal symptoms
8. Obstetric history (female):
a. Number of children
b. Mode and place of delivery of each child
c. Was regular ANC taken in all pregnancies?
9. Contraception use (especially the cause of uncommon observation e.g. unusually large age gap between births)

11. Functional Status:
a. History to assess mental status and the ability to function independently
b. A PG student is expected to fill out a standardized ADL and IADL scales, calculate the score and classify the functional status as: Independent/Needs assistance/Dependent
c. Any circumstance (e.g., recent loss of a loved one, a change in residence or living situation, loss of independence) which may contribute to depression.
12. Social History:
a. Interpersonal relationship with other members of the family
b. Economically dependent/independent
c. Do family members take care of him/her during illness
d. Is he/she socially active
e. Are they aware of any social service schemes for elderly?
f. Are they availing any social service schemes for elderly?
The student is expected to know about the services and schemes for the elderly in the area.

General PHYSICAL EXAMINATION
1. General appearance:
2. Vitals:
a. Respiratory rate: A normal respiratory rate in elderly patients ranges from 16 to 25 breaths/min. A rate of > 25 breaths/min may be the first sign of a lower respiratory tract infection, heart failure etc.
b. Pulse: pulse rate, rhythm and character, posterior tibial and dorsalis pedis pulses should also be felt.
c. BP
All elderly patients should also be assessed for orthostatic hypotension because it is common.
• BP is first measured with patients in the supine position,
• Then after they have been standing for 3 to 5 min.
• If systolic BP falls by ≥ 20 mm Hg after patients stand, or any symptoms of hypotension are detected, orthostatic hypotension is diagnosed.
Caution is required when testing hypovolemic patients.
d. Temperature
3. Anthropometry:
a. Height (in cms)
b. Weight (in Kgs)
c. BMI
d. Waist circumference
4. Skin: Ecchymoses may be seen as they readily appear, because the dermis thins with aging; most often seen on the forearm
Normal age related findings are:
• Longitudinal ridges on the nails and
• Absence of the crescent-shaped lunula
Look for any sign of a neoplasm
5. Pallor, icterus, cyanosis, clubbing, LNE and edema
• Pedal edema, if present it may be more likely due to venous insufficiency. STILL congestive heart failure (CHF) is common and should be ruled out.
6. EYES:
a. Conjunctiva
b. Cataract
c. Pseudoptosis (decreased size of the palpebral aperture)
d. Entropion (inversion of lower eyelid margins)/ Ectropion (eversion of lower eyelid margins)
e. Arcus senilis (a white ring at the limbus)
f. Pupils symmetrical and reactive
g. Testing visual acuity: both near and distant vision in field conditions e.g. finger counting at 6 and 3 meters and reading or any near work
h. Glaucoma
i. Extra-ocular movements (may be affected due to a previous/current stroke)
j. Ideally Ophthalmoscopy should be done to check for cataracts, optic nerve or macular degeneration, and evidence of glaucoma, hypertension, or diabetes
2. Ears:
a. Any abnormality of the pinna
b. External auditory canal is examined for cerumen and tympanic membrane abnormality to determine possible reversible causes of hearing loss and disequilibrium (e.g. cerumen impaction, serous otitis media, ruptured tympanic membrane).
c. Evaluate auditory acuity (hearing):
• Keeping the face out of the patient’s view, whisper 3 to 6 random words 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 are more likely to report difficulty in understanding speech than in hearing sounds.
3. Mouth:
a. Missing teeth, artificial denture
b. The mouth is examined for signs of cancer (e.g. leukoplakia, erythroplakia, ulceration, mass)
Systemic Examination
All systems should be examined as per the standard protocol. However, some additional points are to be especially observed for, in an elderly:
1. Cardio Vascular System:
• Unexplained and asymptomatic sinus bradycardia in apparently healthy elderly people may not be clinically important. An irregularly irregular rhythm suggests atrial fibrillation
• Systolic murmurs are frequently present and most are due to benign aortic sclerosis
• All diastolic murmurs need evaluation

2. Respiratory System: In men and women, the breasts should be examined for irregularities and nodules. Look if the nipples are retracted. Observe the skin over the breast for any abnormal appearance like ‘peau d’orange’
• Some rales may be age related findings and may not indicate pneumonia or pulmonary edema. Hence look for other symptoms or signs to rule out these disorders
• Localized ronchi may point towards an obstruction in the bronchi (e.g. carcinoma).

3. Central nervous system:
Cranial Nerves examination: Following observations may be associated with normal aging:
• Upward and downward eye movement can be slightly limited.
• When tracking the finger of the examiner, the eye movements may seem jerky.
• Bell phenomenon (reflex upward movement of the eyes during closure) may be absent.
• Sense of smell may diminish with age YET an asymmetric loss is always abnormal
Muscle tone:
• Increased muscle tone, assessed by flexing and extending the elbow and knee, is a normal finding in elderly people;
o However, jerky movements during examination and cogwheel rigidity are abnormal
• Presence of ‘Intention tremor’ and some resting tremors are benign conditions.
o Unilateral tremors may indicate stroke.
o A resting tremor with a "pill-rolling" character is worrisome
o Extrapyramidal signs (muscle rigidity, tremor) may indicate Parkinson's disease or may be the adverse effects of drugs like neuroleptic medication

Muscle strength:
• Muscles may appear weak in the elderly especially among those who don’t do regular resistance training
o If weakness is symmetric, does not worry the elderly, and has not affected his/her functional level, it may not indicate any neurologic disease
• Deep tendon reflexes and vibratory sense may be decreased normally due to aging
• Coordination difficulty may indicate cerebrovascular disease

Reflexes:
• Diminished or absent tendon reflexes, if bilateral, may be due to aging process.
o Asymmetric tendon reflexes usually indicate a disorder
Sensations:
• Check for loss of sensations due to peripheral neuropathies (e.g. diabetic). Especially important if the case has history suggestive of diabetes.
• Vibratory sense may be decreased normally due to aging
Gait:
Normal age-related findings may include the following:
• Short and slow steps, possibly because of weak limb muscles, poor balance or fear of falling
• Slight changes in walking posture (e.g., greater pelvic rotation, may be due to a combination of increased abdominal fat, weak abdominal muscles, and tight hip flexors etc.)
4. Gastro intestinal system:
• Look for any type of hernia as the muscles are weak. Ventral, inguinal and femoral hernias, if present, should be checked for reducibility
• Age related emphysematous changes in lungs may cause the liver edge to be palpable below the costal margin without actual hepatomegaly. This must be assessed by percussion.
5. Genitourinary system:
Male: If facility present, examine for BHP..
Female: If facilities exist, do a bimanual pelvic examination. Postmenopausal estrogen reduction leads to atrophy of the vaginal and urethral mucosa; the vaginal mucosa appears dry and smooth (lacks rugae). The ovaries should not be palpable 10 yr after menopause; palpable ovaries suggest cancer.
Examine for any degree of prolapse of the urethra, vagina, cervix, and uterus. They are asked to cough to check for urine leakage and intermittent prolapse.
If not possible in the field, comment to the examiner that it was not possible for you to conduct this examination
6. Musculoskeletal system examination
Inspect for abnormal posture, as well as assess the joints for any swelling and normal movement. This screening may be conducted systematically using the acronym ‘GALS’, which stands for Gait, Arms, Legs and Spine
Gait
Ask the patient to walk a few steps, turn and walk back. Observe the patient’s gait for symmetry, smoothness and the ability to turn quickly.
Normal age-related findings have been already discussed before.
Arms
• Ask the patient to put their hands behind their head.
• Assess shoulder abduction and external rotation, and elbow flexion
• Examine the hands:
• Bony overgrowths at the distal interphalangeal joints; i.e. Heberden nodes or bony overgrowths at the proximal interphalangeal joints i.e. Bouchard nodes: both suggest Osteoarthritis (OA)
• Subluxation of the metacarpophalangeal joints with ulnar deviation of the fingers suggests Chronic Rheumatoid Arthritis (RA)
• Swan-neck deformity also suggests RA (Swan-neck deformity results due to hyperextension of the proximal interphalangeal joint with flexion of the distal interphalangeal joint))
• Boutonnière deformity also points towards RA ((hyperextension of the distal interphalangeal joint with flexion of the proximal interphalangeal joint)
• Ask the patient to squeeze your fingers. Assess grip strength.
• Gently squeeze across the metacarpophalangeal (MCP) joints to check for tenderness due to an inflammatory joint disease. Also look at the face too for any wincing due to pain.
Legs
• Ask the patient to lie on the couch, assess full flexion and extension of both knees, feeling for crepitus.
• With the hip and knee flexed to 90º, hold the knee and ankle and assess internal rotation of each hip in flexion (this is often the first movement affected by hip problems).
• Perform a patellar tap to check for a knee effusion.
• Inspect the feet for swelling, deformity, and callosities on the soles.
o 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.
o Toe deformities may be a result of years of using poorly fitting shoes or from RA, diabetes etc.
o Look for injuries and ulcers suggestive of neuropathy or DM
• Squeeze across the matatarsophalangeal (MTP) joints to check for tenderness suggesting inflammatory joint disease. Observe the face for expression of discomfort.
Spine
• With the patient standing, inspect the spine from behind for evidence of scoliosis, and from the side for abnormal lordosis or kyphosis.
• Ask the patient to tilt their head to each side, so as to bring the ear towards the shoulder. Assess the lateral flexion of the neck (this is sensitive in the detection of early neck problems)
• Ask the patient to touch their toes and simultaneously palpate the vertebrae for normal movement. The lumbar spine flexion can be assessed by positioning two or three fingers on the lumbar vertebrae. Your fingers should move apart during flexion and back together during extension
Family health and Housing Environment
As explained in detail in the blog and lecture on ‘Format for CSC taking in Community Medicine’
Clinico social diagnosis
Clinical Diagnosis: Provisional diagnosis along with other age related problems which may be present e.g. problems with vision, hearing, continence, gait, and balance

Functional Assessment: Independent/ needs assistance/ dependent.
A postgraduate student presenting the case in an examination may apply the ADL and IADL scale, calculate the scores and present the interpretation of the scores to the examiner.
Social Diagnosis:
• The problems detected in the physical, biological and psychosocial environment are listed here. These have been discussed in detail in the blog and lectures on ‘CSC format’
• In addition, the elderly person’s social network, support system, resources, safety and accessibility of the patient’s environment are to be mentioned. Safety threats at home should also find a mention. These factors influence the treatment approach.
• Social security:
a. Which schemes and facilities for the elderly are available in the area, is the elderly benefitting from them? Why not?
b. Which schemes are not functional in the area?
Advice and Suggested Management:
Comprehensive management comprises of
• Physical and mental health,
• Functional status,
• Social adaptability, and
• Environmental conditions.
Hence, the treatment plan includes measures for protecting the health and functional status and to maximize their quality of life of the elderly
Look for treatable conditions that could improve functional status and Refer to the appropriate facility for management of medical problems E.g.
• Treatment of arthritis to improve activities of daily life
• Muscle weakness can be improved with resistance training; especially for the legs. Also, it can improve mobility and reduce fall risk.
• Referral to an ophthalmologist should be considered when visual acuity is low or visual impairment is interfering with daily activities or evidence of glaucoma/cataract etc.
Note: undergraduate students are not authorized to render the above advice directly to the patient. They should only discuss the management with the examiner and their senior doctors, who will in turn deliver the advice and referrals.
Inform about social security schemes which may benefit the elderly
Suggest steps to improve function and safety at home and outdoors, which are feasible in the given circumstances.
The format can be completed within the 45 minutes given for the case in any exam. While presenting the case, only the relevant information may be given under the broad headings e.g. ‘Systemic examination findings were normal except reduced muscle power in all the limbs’,
The student must have knowledge of all the schemes and social security measures available for the benefit of the elderly in that area at that time.
Another lecture/blog deals with those available in India at present (2018)
Attention Students!! You must see the lecture and blog on ‘Format for Clinico Social Case Taking in Community Medicine’ as the details of ‘Family Health Study’ have been omitted in this lecture for avoiding repetition.
Otherwise you may MISS taking these EXTREMELY IMPORTANT assessment in a CSC.

References:
• Poornima Tiwari, Shashank Tiwari. Chapter 17: Format for Clinico-Social Case Taking. Mastering Practicals: Community Medicine. Lippincott Williams & Wilkins; Gurugram, Haryana, India
• Park’s Textbook of Preventive and Social Medicine; 24th edition, 2017; Bhanot Publishers, Jabalpur
• WHO, 2008. Age-friendly Primary Health Care Centres Toolkit
• Clinical assessment of the musculoskeletal system: a guide for medical students and healthcare professionals. Ed. 2011, editor; Andrew Hassell, 2011. Arthritis Research UK, Derbyshire
• GOI, 2011. OPERATIONAL GUIDELINES, National Programme for Health Care of the Elderly (NPHCE). Directorate General of Health Services, Ministry of Health & Family Welfare, New Delhi
• Details of Welfare Schemes for the Aged Persons: Press Information Bureau website, Government of India, Ministry of Social Justice & Empowerment, 19-March-2015 17:04 IST available at: http://pib.nic.in/newsite/PrintRelease.aspx?relid=117406 accessed on 31st July 2018
Practical Book Community Medicine
Format for CSC taking (blog): http://www.ihatepsm.com/blog/format-clinico-social-case-taking-community...
CSC taking: Geriatric case (blog): http://www.ihatepsm.com/blog/geriatric-clinico-social-case-community-med...
‘Format for CSC’ Lecture: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation...
‘Format for CSC’ Lecture in HINDI: http://www.ihatepsm.com/resource/format-clinico-social-case-presentation...
Lecture on the definitions and explanations of terms used in Family Health Study: http://www.ihatepsm.com/resource/terms-used-family-health-study-definiti...
Hindi lecture on the definitions and explanations of terms used in Family Health Study: http://www.ihatepsm.com/resource/terms-used-family-health-study-definiti...

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Geriatric Clinico-Social Case in Community Medicine