Atypical Presentations of Illness in the Elderly Flashcards
Goals of Tx in the elderly
When asked to prioritize health outcomes, most elderly patients will prioritize as follows: 1- increased survival 2- comfort 3- cognitive function 4- physical function
Presentation of Illness
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
Age related changes which may affect disease presentation
Presence of chronic and multiple organ system disease Impaired homeostatic mechanisms Decrease in general physiologic reserve Altered pain perception multiple medications
Functional Status
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.
Mental Status
Cognitive function (Mini-Cog, MMSE)
Affect/Mood
Social support
Economic/Environmental factors
PE
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)
Pneumonia
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
Pneumonia Comparison of Ages
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.
Pneumonia: PE
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
Pneumonia Summary
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.
UTIs
Increases with age
2:1 female to male ratio
Asymptomatic bacteriuria is common, especially in women (30%)
Common Pathogens of UTIs
E. coli = 70% elderly female, outpatients
40% with indwelling catheters, complicated infections or nosocomial infections
Klebsiella sp – 2Mc
UTI s/sxs in elderly
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.
Cardiac Disease
leading cause of death in the elderly
Due to atypical presentations, cardiovascular disease is often misdiagnosed in elderly patients.
Myocardial Ischemia
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.
MI
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.
Myocardial Infarction
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
Peptic Ulcer Disease
excoriated segment of the GI mucosa, typically in the stomach (gastric) or first few centimeters of the duodenum (duodenal).
PUD - atypical
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
Constipation
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
Fecal Impaction
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
Fecal Impaction Typical Sxs
anorexia
nausea and vomiting
Paradoxical diarrhea/incontinence of stool
Abdominal pain may be present or absent
Urinary retention, frequency and overflow incontinence
Hypothyroidism
more common in the elderly
TSH rises without a change in serum T4
most frequently due to autoimmune thyroiditis (Hashimoto’s).
Common Causes of Hypothyroidism
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
S/sxs of Hypothyroidism
Fatigue Weakness Cold intolerance Dry, course skin Constipation Lethargy Depression
Hypothyroidism - atypical
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?)
Screening Hypothyroidism in elderly
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
Hyperthyroidism in elderly
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.
Common s/sxs of Hyperthyroid
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
Classic Tried for Hyperthyroid
Young: tachycardia, exopthalamous, goiter
Elderly: tachy, weight loss, fatigue (weakness/apathy)
Apathetic Hyperthyroidism
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.
Hyperthyroidism Atypical S/Sxs
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.
Hyperparathyoidism
produce excessive PTH resulting in disorders of bone metabolism.
The incidence of primary hyper-parathyroidism increases steadily with age
Hyperparathyroidism - classic
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
Delirium
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.
Causes of Delirium in Elderly Pt
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
S/sxs of Delirium (from Merck)
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
Dx and Tx
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
