Atypical Presentations of Illness in the Elderly

Question 1

Goals of Tx in the elderly

Answer 1

When asked to prioritize health outcomes, most elderly patients will prioritize as follows:
	1- increased survival
	2- comfort
	3- cognitive function
	4- physical function

Question 2

Presentation of Illness

Answer 2

3 Factors that often affect the clinical presentation in the elderly:
1- over reporting or under reporting of symptoms and impairments
2- changes in the patterns of presentation of individual illnesses
3- an altered spectrum of health conditions

Question 3

Age related changes which may affect disease presentation

Answer 3

Presence of chronic and multiple organ system disease
Impaired homeostatic mechanisms
Decrease in general physiologic reserve
Altered pain perception
multiple medications

Question 4

Functional Status

Answer 4

Difficulty, degree of dependence and change in ability in both self-care or basic ADLs and instrumental ADLs.
These are important to ascertain as a change or decline in one’s functional status may indicate the onset of a new illness or worsening of an existing illness.

Question 5

Mental Status

Answer 5

Cognitive function (Mini-Cog, MMSE)
Affect/Mood
Social support
Economic/Environmental factors

Question 6

PE

Answer 6

Goals:
Identify treatable impairments

Functional evaluation:
Reading a prescription bottle (visual acuity)
Buttoning/unbuttoning shirt (fine motor)
Observe clothing (nutritional status)
Observe gait/getting on-off exam table (muscle strength/joint ROM)
Observe multi-step commands (cognition/neurological function)

Question 7

Pneumonia

Answer 7

Acute inflammation of lungs caused by infection.

Most common = bacterial (Streptococcus pneumoniae); occurs more frequently and with more serious consequences in the elderly

the most common fatal hospital-acquired infection

Question 8

Pneumonia Comparison of Ages

Answer 8

Young adult patients: Fever (80% to 90% of cases), Cough, Dyspnea, Chest discomfort

Typical:
Onset can be sudden with: Shaking/chills, High fever, Productive cough, Acute pleurisy, Lung infiltrates

Atypical:
Confusion or general deterioration
Cough/fever may be absent
Temperature lower

5-20% of the elderly, onset may be insidious.

It is not uncommon for an elderly patient to be afebrile even when septic.

Question 9

Pneumonia: PE

Answer 9

Signs of pulmonary consolidation often absent in the elderly.

*Dullness to percussion over areas of pulmonary consolidation and increased respiratory rate (> 26/min) are usually reliable clues

Question 10

Pneumonia Summary

Answer 10

the elderly patient with pneumonia is:
More likely to be bacteremic.
More likely to develop complications such as empyema or meningitis.
More likely to die as a result of the pneumonia.

Question 11

UTIs

Answer 11

Increases with age
2:1 female to male ratio
Asymptomatic bacteriuria is common, especially in women (30%)

Question 12

Common Pathogens of UTIs

Answer 12

E. coli = 70% elderly female, outpatients
40% with indwelling catheters, complicated infections or nosocomial infections
Klebsiella sp – 2Mc

Question 13

UTI s/sxs in elderly

Answer 13

urinary frequency
urge incontinence
dysuria is less common

urosepsis frequently manifests as confusion or altered mental status in the absence of systemic signs of infection such as fever or chills.

Question 14

Cardiac Disease

Answer 14

leading cause of death in the elderly

Due to atypical presentations, cardiovascular disease is often misdiagnosed in elderly patients.

Question 15

Myocardial Ischemia

Answer 15

The classic anterior chest pain of angina pectoris is frequently absent

• back of the shoulders (mistaken for osteoarthritis) or in the epigastric area (mistaken for PUD or hiatal hernia).
• *dyspnea is a more common presentation of cardiac ischemia than is angina pectoris.

Question 16

MI

Answer 16

Symptoms and Signs:
19-66% = chest pain
20-59% = dyspnea
15-33% = neurological symptoms (falling, vertigo)
0-19% = GI symptoms (n/v, heartburn, epigastric distress)
Other symptoms/signs = palpitations, increased claudication, PE, restlessness, sweating, sudden cardiac death, confusion, syncope or near syncope.

Question 17

Myocardial Infarction

Answer 17

prevalence of “silent” myocardial infarction increases with age, with >25% of elderly patients demonstrating no symptoms
S/Sxs
Acute C.H.F.
Exacerbation of previously stable C.H.F.
Acute renal failure

Question 18

Peptic Ulcer Disease

Answer 18

excoriated segment of the GI mucosa, typically in the stomach (gastric) or first few centimeters of the duodenum (duodenal).

Question 19

PUD - atypical

Answer 19

fewer and less severe symptoms typical of PUD due to a decrease in sensation of visceral pain.
- Abdominal pain may be absent or of minimal severity even in those older patients who require hospitalization
Abdominal discomfort is absent in 50%. If abdominal pain is present, it is often nondescript, poorly localized, not necessarily “burning”, often not relieved by eating and may have misleading patterns of radiation.
- Melena (stool darkened by oxidized blood) is the most common clinical presentation of duodenal ulcer.
- 2MC: dyspepsia and tenderness on abdominal exam.

Also: Confusion, Abdominal distention, Anorexia and weight loss

Complications occur in approximately 50%
bleeding (mortality rate of elderly with bleeding ulcer = 29-60%)
Perforation
Gastric outlet obstruction (due to inflammation/edema/scarring)
penetration

Question 20

Constipation

Answer 20

Constipation is the most common GI complaint in the elderly, with up to 60% of outpatients reporting use of laxatives.

Symptoms: abdominal discomfort, loss of appetite and nausea

Question 21

Fecal Impaction

Answer 21

low fiber diets
low fluid intake
decreased motor activity of smooth muscles of the bowel
decreased sensory function of the rectum/anus
Medications
Decreased physical activity and ambulation

It can be life threatening.
Intestinal obstruction
Colonic ulceration
Overflow incontinence
Paradoxical diarrhea
Urinary retention/infections
Straining: hemorrhoids, syncope, TIAs, cardiac ischemia, anal fissures, rectal prolapse

Question 22

Fecal Impaction Typical Sxs

Answer 22

anorexia
nausea and vomiting
Paradoxical diarrhea/incontinence of stool
Abdominal pain may be present or absent
Urinary retention, frequency and overflow incontinence

Question 23

Hypothyroidism

Answer 23

more common in the elderly
TSH rises without a change in serum T4
most frequently due to autoimmune thyroiditis (Hashimoto’s).

Question 24

Common Causes of Hypothyroidism

Answer 24

Most common:
Hashimoto’s thyroiditis
Previous irradiation
Surgical removal of thyroid gland
Idiopathic hypothyroidism

Others:
Pituitary/hypothalamic d/o causing TSH deficiency
Iodine-induced hypothyroidism
Use of lithium or other antithyroid drugs

Question 25

S/sxs of Hypothyroidism

Answer 25

Fatigue
Weakness
Cold intolerance
Dry, course skin 
Constipation
Lethargy
Depression

Question 26

Hypothyroidism - atypical

Answer 26

Failure to thrive
Confusion
Anorexia
Weight loss
Falling
Incontinence
Decreased mobility
Constipation
Muscle weakness/aches
CHF
Anemia
Depression
Dementia
Myxedema Coma
Recent onset edema
Carpal tunnel syndrome (uni or bilateral?)

Question 27

Screening Hypothyroidism in elderly

Answer 27

TSH
Screening every 5 years for all men 65 and older
Screening every 5 years for all women 35 and older
More frequent screenings should be performed for those with risk factors for thyroid disease

Question 28

Hyperthyroidism in elderly

Answer 28

Most common cause in younger adults: Grave’s disease
Most common cause(s) in elderly:
Multinodular and uninodular toxic goiter
Iodine induced hyperthyroidism
Excessive consumption of T4 or T3.

Question 29

Common s/sxs of Hyperthyroid

Answer 29

Neurologic and psychiatric symptoms
Nervousness or alertness
Emotional lability (Anxiety, Irritability or even Psychosis)
Proximal Muscle Weakness
Insomnia
Adrenergic symptoms
Palpitations
Tremor
Frequent Bowel Movements, Diarrhea
Excessive Sweating
Heat intolerance
Miscellaneous
Weight loss despite increased appetite (hypermetabolism)
Oligomenorrhea or Amenorrhea

Question 30

Classic Tried for Hyperthyroid

Answer 30

Young: tachycardia, exopthalamous, goiter
Elderly: tachy, weight loss, fatigue (weakness/apathy)

Question 31

Apathetic Hyperthyroidism

Answer 31

Many of the common symptoms of hyperthyroidism in the elderly are similar to those generally associated with hypothyroidism such as depression, lethargy, congestive heart failure, constipation and muscle weakness.
Thyrotoxicosis is uncommon in the elderly.

Question 32

Hyperthyroidism Atypical S/Sxs

Answer 32

Ocular signs
Decreased appetite
Tachycardia in the elderly is defined as how many beats per minute?
Thyroid gland size = enlarged, normal size or impalpable?
Diarrhea or constipation = which is more common?
Nervousness/anxiety = more or less common than in younger patients?
Sweating = more or less common than in younger patients?
Observed tremor = more or less common than in younger patients?
Hyperactive reflexes with quick recoil = more or less common than in younger patients?

May present with cardiac signs/symptoms of heart failure and angina.
Because cardiac issues are very prevalent in the elderly population, the possibility of an underlying hyperthyroidism is likely to be missed or not even suspected.

Question 33

Hyperparathyoidism

Answer 33

produce excessive PTH resulting in disorders of bone metabolism.
The incidence of primary hyper-parathyroidism increases steadily with age

Question 34

Hyperparathyroidism - classic

Answer 34

Mnemonic (classic presentation is uncommon)
Stones
Bones
Abdominal groans
Psychic moans

Gastrointestinal complaints MC S/Sxs
n/v
Anorexia
Weight loss
Abdominal pain
Dyspepsia
constipation

Possible mental and emotional symptoms of hyperparathyroidism can include:
Depression
Anxiety
Decreased memory (esp recent memory)
Personality change
Delirium
Acute psychosis

Question 35

Delirium

Answer 35

clinical state characterized by an acute, fluctuating change in mental status, with inattention and altered levels of consciousness.
may develop over a short period of time and may fluctuate daily.

*does NOT present differently in the elderly patient compared to the young adult patient. Causes of acute confusion or delirium in the elderly are more varied and encompass a larger range of disorders including metabolic, neurologic and medication toxicity.

Question 36

Causes of Delirium in Elderly Pt

Answer 36

Medications (use of or withdrawal)
Electrolyte and physiologic abnormalities
Infection (esp urinary and resp infections)
Reduced sensory input 
Intracranial problems (stroke, bleeding, etc)
Myocardial problems (MI, CHF)
Pulmonary embolus
Sepsis (especially urosepsis)
Surgical abdomen/fecal impaction
Endocrine disorders
Dehydration
Hypoxemia

Question 37

S/sxs of Delirium (from Merck)

Answer 37

Sudden onset
Precise time of onset
Usually reversible
Short duration (days to weeks)
Fluctuations (over minutes to hours)
Abnormal levels of consciousness
drug use/withdrawal or acute illness
Almost always worse at night
Inattention
Variable disorientation
Typically slow, incoherent and inappropriate language
Impaired but variable recall

Question 38

Dx and Tx

Answer 38

CAM (Confusion Assessment Method):
Acute change in mental status
Symptoms that fluctuate over minutes or hours
Inattention
Altered level of consciousness
Disorganized thinking
Treat the underlying disorders, removal of contributing factors, behavioral control, avoidance of iatrogenic complications, support of the patient and family