Van Halen helps physician rethink older patients’ physical exam

Kevin B. O'Reilly
Editor
AMA Wire
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During its touring heyday, the rock band Van Halen looked for brown M&M’s in the dressing room as a clue that venue officials might have missed something bigger in preparing for the group’s electricity-draining, pyrotechnic-laden concert performances. Similarly, there are small details in the presentation of older patients with multiple conditions that should alert physicians to deeper problems lurking beneath the surface, says geriatrician Andrea Wershof Schwartz, MD, MPH.

While Van Halen hit the top of the Billboard charts in 1984 with the song, “Jump,” the group has gained another claim to fame in the ensuing years. In its touring contract, the band insisted that a bowl of M&M’s be placed in its dressing room. But, they added in writing, “Warning: absolutely no brown ones.” The reason for this, lead singer David Lee Roth later explained, was to give the band a quick way determine whether the venue had carefully followed the band’s more critical instructions regarding electric power demands, stage construction and more. If they couldn’t pick out a few candy-shelled chocolates, what else could have been missed?

For Dr. Schwartz, an instructor in medicine at Harvard Medical School, the M&M’s story has become a routine part of a grand-rounds talk for residents on what she dubs “rock star geriatrics.” There are three things related to seniors’ movement—a world apart from Roth’s trademark split-legged stage jumps—that all physicians should watch for: how they walk, how well they put on and take off their socks, and what their feet look like.

“When you are treating an older adult with multiple medical problems, the patient—and even the doctor—can feel overwhelmed if you go problem by problem, potentially missing the forest for the trees,” Dr. Schwartz told AMA Wire®. “These particular things are part of the physical exam that I hadn’t prioritized prior to geriatrics training. Since incorporating them into my physical exam, I find they are an efficient way to get valuable information about the patient’s overall functional status and then to tailor their overall medical care to impact the things they care the most about.”

Might as well walk (walk!)

The first thing Dr. Schwartz looks out for is how her patients walk as they enter the room. She noted in a recent JAMA Internal Medicine essay that gait speed is a strong predictor of mortality and a slow walk can prompt physicians to ponder a patient’s arthritic knees and hips, muscle strength, pain control, balance, vitamin supplementation, fall risk, cardiovascular status and other elements of care. Other questions might come to mind, such as whether the patient has grab bars installed in the shower at home or is taking medications that can increase fall risk.

The second small yet telling detail comes in the form of the “sock-on, sock-off” test. This is “a task that requires balance, vision, dexterity, joint flexibility and muscle strength,” noted Dr. Schwartz, who also works in the geriatrics and palliative care division of the VA Boston Healthcare System and the New England VA’s Geriatrics Research Education and Clinical Center. Even patients who seem to be doing well from the knees up can reveal deeper troubles if they struggle to pull up their socks. They may need at-home support from an occupational therapist or a sock-donning tool. Failing this test can show that patients are in danger of no longer being able to live independently.

After the walk and the socks comes the feet.

“I have been surprised many times in my career thus far by the disconnect between how a patient is dressed and how their feet may look,” Dr. Schwartz wrote. “Even if they have no difficulty taking off their socks and shoes, the dexterity required to cut one’s own toenails may prove more challenging.”

If patients cannot clip their toenails and lack family or friends to ask for help, that can offer another warning signal about their need for greater support.

“Long toenails, in and of themselves, we know how to treat that and we involve podiatry when necessary,” Dr. Schwartz said. “But the deeper question is how a person is managing on their own if they can’t take off their socks or reach their toenails. How is this person best able to maintain their independence and accomplish their care goals?”

More broadly, these three warning signs can give physicians a bigger picture of how their patients are doing as a whole. “Keeping in mind a person’s functional status helps us know whether a plan of care is realistic, has the best risk-benefit ratio, matches what the patient is hoping for, or will help that patient have the best quality of life,” Dr. Schwartz said. “Using functional status as a starting point, we can better tailor the medical care we deliver.”

The customized approach can encompass areas such as how aggressive to be about cancer screenings or senior diabetic patients’ A1c goals, or stronger encouragement of advance-care planning, she said.

“These three maneuvers should not be seen as extra things to add on to the clinical evaluation, but as quick tools that can be used to make an assessment of the kind of frailty a patient might be experiencing and that can then help the busy clinician see how to prioritize the medical care that is appropriate for the older adult,” she said.

If physicians take Dr. Schwartz’s advice to heart, it may not be so long before the core members of Van Halen—now in their 60s—benefit from an exam approach that keeps clinicians’ eyes peeled for those little things that say a lot.

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Jun 09, 2017
The Maryland State Medical Society offers physicians free training in use of the state PDMP and to identify and help patients with opioid-use disorders.