How to perform an abdominal exam on older patients

The technical aspects of abdominal exams for older patients are identical to a younger adult’s exam. However, some aspects of the exam may differ slightly, including how you position the patient for the exam, and their presenting signs and symptoms.

For many reasons, abdominal pain can be more difficult to diagnose in older patients. Older patients tend to present with subtle signs and symptoms. As well, vital sign abnormalities don’t occur as reliably as in younger patients. Older patients are also less likely to develop a fever.

Often, several comorbid medical conditions may be present in an older patient, which can exacerbate or mask an intraabdominal process. Medications for comorbid chronic diseases such as hypertension may mask tachycardia, and a blood pressure that is normal or is at the low end of the normal range may actually be a subtle sign of serious pathology in older patients. Because the change in blood pressure is minimal, it may not trigger a physician’s response and might be overlooked.

Older patients may also present later in the disease process due to cognitive impairment (from dementia or stroke), a fear of a loss of independence, a lack of transportation, or a lack of social support. As well, older patients may be placed at a lower acuity triage level in an emergency department due to their subtle presentation, which results in treatment delays for urgent conditions.

A patient’s history is very important in all populations, but especially in older patients because of its complexity. Unfortunately, many older patients are unable to give an adequate history due to underlying medical conditions such as dementia or prior stroke.

A good medical history can provide clues about the patient’s condition. Not having a detailed history can hinder a provider’s ability to make a diagnosis. When obtaining the patient’s medical history, use what is available. Gather history from caregivers, referring physicians, family members, and nursing facility staff. If none of these are available, review any available emergency room, nursing facility, and hospital records.

Make sure to document baseline measures as well as changes in cognitive, ambulatory, and functional status. Obtain an accurate list of their medications, and pay particular attention to anticoagulant, antiplatelet, immunosuppressant, opiate, nonsteroidal, and antihypertensive medications. This will aid in determining the causal or exacerbating factors. For example, anticoagulants may exacerbate a gastrointestinal bleed.

How to position an older patient in preparation for an abdominal exam

Positioning an older patient is a key component to maintaining their well-being and comfort during the exam. Use lots of pillows to support their neck, back, and knees, especially in patients who have kyphosis or severe arthritis.

Congestive heart failure and chronic obstructive pulmonary disease (COPD) can cause shortness of breath. So, older patients with these disorders may not be able to lay completely flat. Modify the angle of the bed to 45° to accommodate them.

In older patients who present with abdominal pain, several important diagnoses can be easily missed. Let’s take a look at a few examples and review the common reasons why these diagnoses are overlooked:

• Appendicitis
• Abdominal aortic aneurysms (AAA)
• Mesenteric ischemia
• Acute cholecystitis

Appendicitis

Appendicitis can be easily missed because older patients usually lack a fever and leukocytosis (e.g., elevated white blood count). They may also lack typical physical exam findings such as localized tenderness, rebound tenderness, and guarding.

The atypical presentation of appendicitis in older patients includes vague nausea, confusion, or anorexia. Often, these symptoms suggest other diagnoses such as gastroenteritis or a urinary tract infection (UTI) which can delay the diagnosis.

Abdominal aortic aneurysms (AAA)

An AAA can be missed in older patients who do not have a bruit or a pulsatile abdominal mass. Thus, it is important to remember the associated risk factors for an AAA which include male gender, smoking history, hypertension, and an age greater than 65 years.

Mesenteric ischemia

An older patient’s vague complaints in the absence of physical findings may increase the risk of a provider missing mesenteric ischemia. A high level of suspicion and understanding of the older population is required. These patients often have normal laboratory findings on presentation. Only after advanced imaging, such as computed tomography angiography of the abdomen and pelvis, is the ischemia diagnosed.

Acute cholecystitis

Acute cholecystitis may also be missed in older patients. They may present atypically with epigastric pain, no nausea or vomiting, and normal lab values. This presentation can lead to a missed diagnosis.

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