The traditional approach of "defining a chief complaint" is not appropriate to the chiropractic assessment of older people. It's more important that the chiropractor focus on the functional assessment of the older patient. Questions relative to the chiropractic visit might include a review of symptoms and systems, functional history such as abilities in activities of daily living, and whether current community services are being provided.
The family history, while vital in younger people to assess future risk of familial illness, has different significance in older patients. Medication history is crucial in assessing an older patient. Adverse effects from medication remain one of the most common, truly reversible causes of apparent dementia, and can even cause other common impairments. This is particularly true with medications that control pain yet create sedation. We also may see such things as instability and falling. The prescriber should be notified of the chiropractor's assessment of these findings and their impact on the patient's safety.
Items often overlooked in the review of systems when evaluating older patients include general assessment related to falling, balance, sleep and locomotion problems such as stiffness and pain. When conducting the physical examination of the older person, having the right office set-up is a key element. I always think safety, safety, safety. The examining table should be in the lowered position so the patient can get onto it with little assistance. It should be close to the floor in case of unmonitored falls. When in the supine position, a soft rolled pillow should be available for their neck so they can recline at 30 to 45 degrees. The cervical spine of the older person often lacks normal extension and has assumed an attitude of flexion. A medical provider friend of mine once attributed this to "a drooping-head syndrome."
There also must be enough space to observe the patient's ability to walk, balance and turn. Many chiropractors achieve this by observing the patient walk from the reception area. Others have installed small grip rails in their hallways in case of sudden loss in balance. If the patient must disrobe, a stance bar often is quite accommodating.
There are normal gait changes in older people of which the chiropractor should be cognizant. In elderly women, the waddling gait and narrow walking and standing base is completely normal. In elderly men, we often observe a small-stepped gait or wide walking and standing base. Techniques for obtaining an older patient's assessment are numerous, yet it's the plans for health maintenance upon which a chiropractor focuses their treatment goals in the management of the elderly patient.
"Ms. L's" daughter, a nurse, called her chiropractor because she is concerned that her mother, who "hates doctors," has had no health checkup in more than two years. The daughter has observed that her mother is having increasing problems with walking and mentions that she has been sleeping in her recliner with a heating pad across her bottom. Her mother is 78 years old and resides alone, with no apparent health problems, particularly any related to cardiovascular or respiratory disorders. The daughter wanted to bring her in for a chiropractic checkup, but was concerned she would not be open about her problems when she attended the chiropractic visit.
Ms. L arrived for her appointment. Her assessment included some information about her home and social environment. Certain aspects of the assessment were stressed during the interview, such as nutrition, cooking ability, the safety of the environment and the actual level of patient function on a daily basis. Early during the assessment, it was discovered that this patient had required three hours of self care in order to dress and prepare herself for the visit to the chiropractor. Ms. L confided in the chiropractic provider that it hurt her tail bone when she sat on the toilet.
History of falling or accidents and questions on living alone were assessed. It was discovered that this elderly patient had been married for 50 years and was a widow of two years. She revealed she was very hesitant to discuss her loneliness with her daughter or her current status of inactivity for fear of being a burden to her children.
Much of the physical examination was conducted supine with table legs extended and the headrest in a cocked-up position with a pillow under the patient's shoulders and neck to bring her up to 30 degrees. Direct examination of range of motion of the joints and assessment of musculoskeletal stability, mobility and strength was charted. Prior to this, a gait and balance assessment was conducted by asking the patient to ambulate across the room, get in the chair and get back up again to observe any loss in balance or coordination difficulty.
This patient demonstrated the challenge of a willing but at-risk individual for falls and malnourishment. It was determined that she microwaved most of her food and was short on daily protein requirements. She had some sacroiliac, ischial tuberosity osteoarthrosis and degenerative lumbar scoliosis that contributed to her walking disorder. This was revealed upon plain-film radiography review.
She never consented to coming to the office for a regular treatment plan. Nevertheless, appointments were scheduled that required her to become socially involved with her neighbors (who initially drove her to my office for appointments). This got her out of her house and improved her physical mobility. She was placed on a daily amount of protein per day (once a urinalysis confirmed the absence of proteinuria or albuminuria, the presence of which may be the single most important indication of renal disease), and advised that without sufficient daily amounts of required protein, the body cannot replace any old and worn-out tissue, and healing responses often are delayed.
It could be reasoned that overall, Ms. L was in much better shape physically than she even thought and that this contributed to her relatively good chiropractic rehabilitation from this incident. Not a month went by without "her regular chiropractic adjustments to keep her out of a wheelchair," as she described them to her friends and family. She lived for 12 more years in her home before a short stay in a retirement center, where she passed away quietly one morning.
Click here for previous articles by Nancy Martin-Molina, DC, QME, MBA, CCSP.