Transcript How disease presents in the elderly: pitfalls in the consultation process

OPD
Dr E.N Britz (MBChB, MPraxMed)
How disease presents in the elderly
 Disease presents atypically
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Introduction
 Five common patterns of disease presentation:
1. Multiple pathology
2. Atypical presentation of illness
3. Late presentation
4. Silent presentation
5. Weakness, dependency and the pseudo-
silent presentation of illness
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1. Multiple pathology
 A study has found that people 65-74 years suffered
from 4.6 chronic conditions and those over 75 years,
from 5.8. According to the traditional medical model
there is a singular diagnosis for a range of abnormal
findings. This certainly does not apply to the aged!
 There are often several problems that must be
addressed at the same time.
 Optimal treatment of the elderly person usually
requires treating much more than the organ system
usually associated with the disease.
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2. Atypical presentation of illness
 A patient often has multiple complaints but no single
main complaint, or a main complaint that cannot be
linked to any serious identifiable illness. Due to the
diminished functional reserve in many systems and
the poor adaptation to illness as well as additional
pathology, an illness in one system (e.g. pneumonia)
will cause decompensation in another system e.g.:
 Pneumonia causes cardiac failure and delirium.
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2. Atypical presentation cont’d
 Drug induced Parkinsonism in the aged reflects the
loss of up to 50% of the neurons in the substantia
nigra of the basal ganglia.
 Drugs with a primary action outside the brain may
have neurological side effects, e.g. digoxin toxicity in
the aged may present as delirium.
 Dyspnoea will only appear in cardiac failure as a late
sign in cases of stroke or arthritis because of restricted
activity.
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2. Atypical presentation cont’d
 Symptoms will depend on which organ system is the
“weakest link”.
 Because the “weakest link” is so often the brain, the
lower urinary tract, or the cardiovascular or
musculoskeletal system, a limited number of
presenting symptoms predominate – acute confusion,
depression, falling, incontinence and syncope – no
matter what the underlying disease.
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2. Atypical presentation cont’d
 The organ system usually associated with a particular
symptom is less likely to be the source of that
symptom in older individuals than in younger ones:
 Acute confusion in older patients is less likely due to a
new brain lesion, incontinence to a bladder disorder or
syncope to heart disease.
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2. Atypical presentation cont’d
 There are impaired compensatory mechanisms in the
aged and disease can present earlier.
 Heart failure can be precipitated by mild
hyperthyroidism or mild hypertension.
 Delirium by mild hyperparathyroidism.
 Urinary retention by mild prostatic enlargement.
 Nonketotic hyperglycemic-hyperosmolar coma
(NKHHC) by mild glucose intolerance.
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2. Atypical presentation cont’d
 Low dose drugs can cause serious side-effects, e.g.
diuretics causing urinary incontinence and drugs such as
diphenhydramine causing delirium.
 A number of authors emphasized that certain patterns of
illness presentation are specific to the aged. They are
called The Giants of Geriatric Medicine: (ISAAC)
 Immobility
 Instability (falls)
 Incontinence
 Intellectual impairment
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3. Late presentation of illness
 Aged people:
 Liable to complain too late
 Illnesses of heart, lungs and CNS are commonly
mentioned
 Locomotor conditions, bladder dysfunction, depression
and confusion are not as commonly reported
 Keep in mind that there are those aged who enjoy a
good quality of life (60-75%). They are therefore
unknown to their GPs.
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3. Late presentation of illness cont’d
 The doctor may perhaps also share his patient’s
opinion that certain treatable conditions be attributed
to biological ageing.
 In the aged patient, the language of depression focuses
on somatic complaints, e.g. intestinal and bladder
malfunctioning, mobility problems and painful joints.
 Other problem areas are the description of pain,
attacks of fainting and loss of consciousness.
 Age is a normal physiological state.
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3. Late presentation of illness cont’d
 Age is a normal physiological state and is not the cause
of disease. Remember that 80% of people over 80 years
function well independently in the community.
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4. Silent presentation of illness
 All illnesses, no matter what age the patient,
commence with an asymptomatic period, e.g.
painless myocardial infarction, painless peritonitis,
painless peptic ulcers, painless perforation of
abdominal viscera, infection without fever, etc.
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5. Weakness, dependency and the
pseudo silent presentation of illness
 A person may become incontinent with an urinary
tract infection. This leads to collapse of the social
network and a social crisis develops. Almost
everything in the aged is urgent. If an aged person is
ill on Monday, he will be worse by Tuesday and by the
end of the week he may be bedridden, dehydrated,
confused and incontinent.
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Conclusion
 The classic disease oriented model is of lesser
relevance in geriatric medicine, but the problem
oriented model is essential and is practiced by
doctors in geriatrics. The patient’s problems are
continually evaluated to see whether goals are being
reached.
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Conclusion
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Old man
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Another old man
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Pitfalls in the Consultation
Process
Physiological ageing and diagnostic pitfalls:
 It is very satisfying to be a family physician of aged
patients. They have already lived a lifetime, experienced
many things and one can learn a lot from them.
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Pitfalls in the Consultation
Process cont’d
AIMS
 Add life to years not years to life
 Optimize fitness (diet, exercise, rehabilitation)
 Facilitate visits to dentist, optician, chiropodist, social
worker, occupational therapist and audiologist.
 Alleviate social problems : pension
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Pitfalls in the Consultation
Process cont’d
Diagnostic Pitfalls
1. Skin
2. Muscles
3. Bones
and
joints
7.
Urogenital
system
8.
9. Brain
Neurological
system
4. Cardiovascular 5. Respiratory
system
system
6.
GIT
10. Autonomic
decline
12.
Endo
crines
11. Blood
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1.1 The skin:
 Loss of elasticity –
dryness and thinness of
the skin and loss of
subcutaneous supportive
tissue make the diagnosis
of dehydration difficult.
 Wrinkles – caused by
collagen atrophy.
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The skin cont’d
 The blood vessels break and there are bruises present.
Senile purpura.
 Slow wound healing.
 Loss of subcutaneous fat, atrophy of the skin lead to
pressure sores, especially in bedridden patients.
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1.2 The muscles :
 Atrophy
 Ptosis of eyelids, may suggest myastenia gravis
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The bones and joints
 Degenerative changes in the joints, especially the
knee, ankle and foot joints lead to stiffness and
reduction in movement. Impaired corrective responses
necessary for balance lead to instability and falls.
 Thinning of vertebral cartilage and osteophyte
formation. (with loss of height.)
 Osteopenia(age-related) and pathological
osteoporosis.
 Loss of height – 1.5 cm every 20 years.
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The cardiovascular system
 Symptoms :
 Dyspnoea is common, not necessarily
due to cardiac failure.
 Many elderly people move so little that even if there is
heart failure present, breathlessness is not a complaint.
 They walk slowly, and thus do not easily get angina.
 The elderly person’s blood flow to the brain is reduced
in heart failure, myocardial infarction and cardiac
arrhythmia and they present with delirium.
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The cardiovascular system
 Signs :
 Difficulty to evaluate the heart size on CXR
 The liver may appear to be enlarged,
pushed downwards by the expanding lungs.
 Systolic ejection murmur due to aortic sclerosis, may be
misdiagnosed as aortic stenosis.
 Stasis oedema
 Absence of claudication in arteriosclerosis obliterans
 Kinking of the carotid artery in the neck with
accompanying pulsation mimics A. Carotis aneurysm.
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The respiratory system
 The shape of the chest may mimic emphysema : barrel
shaped, with decreased movement of the chest wall.
 Age-related decrease in lung function
 There is a decrease in the lungs’ defence mechanisms :
 ↓cough-reflex, ↓ciliary action of the mucus membranes
 ↓immunoglobulin production and ↓production of phagocytic
macrophages.
 Bronchopneumonia – may present with: deterioration in
general health, fatigue, delirium, mild
tachypnoea(24/min), no or little fever, coughing
sometimes.
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The digestive tract.
 Loss of appetite because of ↓smell and ↓taste
 Dry mouth – atrophy of the salivary glands
 Chewing problems – loss of teeth, and atrophy of the gums.
 Swallowing problems -neuromuscular incoordination.
 Diaphragmatic hernia : may be asymptomatic, may be a
cause of GORD, may mimic IHD
 Discomfort after big meals : atrophy of the mucosa,
↓motility, ↓gastric juices.
 Constipation : atrophy of colon, ↑connective tissue,
↓peristalsis.
 Fecal incontinence : ↓external anal sphincter reflex.
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Urogenital system
 Atrophy of the kidney parenchyma, ↓blood supply renders
the elderly more susceptible to renal failure:
 Intrinsic renal pathology e.g. tubular necrosis and renal
infections.
 Extrarenal causes of renal failure :
 ↓ extracellular fluid volume e.g. dehydration caused by
diarrhoea and vomiting, low fluid intake, especially during
warm weather – due to loss of thirst sensation, any
infection, polyuria associated with uncontrolled DM.
 ↓ circulating blood volume through blood loss and shock,
caused by myocardial infarction, gram-negative
septicaemia, heart failure, etc.
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The neurological system
 Absence of the ankle reflex and vibration sense
may be normal.
 The ↓proprioreceptive sensation , slowing of
corrective reflexes caused by conduction delay in semicircular canals, vestibular apparatus and cerebellum and
increased reaction time lead to instability and falls.
(proprioreceptors are sensory nerve endings)
 The stooped posture and wide-based shuffling gait often
found, lead to instability and falls.
 Poor vision and deafness may lead to paranoia.
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The brain (DIMTOP)
 The normal loss of brain cells and decreased blood supply
to the brain lead to acute delirium resulting from
conditions outside the brain such as cardiac failure,
myocardial infarction, arrhythmia, dehydration, loss of
blood, bronchopneumonia and UTI (DIMTOP)
 TIAs can thus also be caused by diseases outside the brain.
 Pseudo-dementia: Temporary impaired intellectual
function may result from depression.
 Often when an elderly person is transferred to a hospital,
he/she becomes confused. Solution – let the elderly person
bring his/her own bedspread and pillow along.
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Autonomic decline
 There is deterioration in thermoregulatory
mechanisms. There may be a reduced fever reaction
after serious infections.
 With ageing the baroreceptor-sensitivity is reduced
so that the postural blood pressure regulatory
mechanism declines and the elderly patient falls easily.
“Postural hypotension”
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The blood
 Patient is pale because of reduction in melanophore
(pigment cells containing melanin) activity.
 Increased ESR
 Immune system dysfunction with an increase in
autoimmune diseases, cancer and infection.
 Increased platelet adhesiveness, ↑fibrinogen, leading
to thrombosis e.g. CVI, MI, PE, DVT.
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The endocrines
 Hypothyroidism may mimic ageing.
 Diabetes mellitus – with ↓glucose tolerance
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Conclusion
 Now you know about all the diagnostic pitfalls. What is the





solution?
The S.O.A.P. method.
S – Subjective: The patient, the family member/ nurse.
Notebook to save time!
O – Objective: Help the patient with mobility if necessary.
A – Assessment: Write down the diagnosis and hand to the
patient.
P – Plan: Explain about the treatment. Write in large letters
the names of the medicines.
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Evaluation of the Elderly Person and
Communication Skills
 Eye contact. Sit near to patient.
 Treat the elderly with respect.
 Speak the elderly patient’s language if possible.
 Do not address the elderly lady as “Granny” without
permission, especially if she is not your grandmother!!
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Evaluation of the Elderly Person and
Communication Skills cont’d
 Spend adequate time during the consultation,
especially during the first one.
 Do not appear to be in a hurry.
 The doctor-patient relationship is the key to the
treatment of the elderly patient.
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Evaluation of the Elderly Person and
Communication Skills cont’d
 Observation can save a lot of time. Greet the
patient in the waiting room. Look at the emotional
reaction, the handgrip, the ease or difficulty of getting
out of the chair, the walking gait and the ability to sit
in the examining room chair. This observation process
takes no extra time.
 Be very patient.
 The medical history is often long and sometimes
irrelevant.
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Evaluation of the Elderly Person and
Communication Skills cont’d
 Speak to the family and caregivers.
 Ask patients to compile a list of problems(notebook)
 Ask about: Diet, Sleeping pattern, Constipation,
Urinary problems, History of falls, Medication,
Alcohol abuse, Teeth or dentures, Weight increase
or loss.
 Do a thorough physical examination.
 Evaluate the whole person.
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Evaluation of the Elderly Person and
Communication Skills cont’d
 High risk Elderly
 Age over 80 years
 Living alone
 Depression, bereavement
 Intellectual impairment
 Previous falls
 Incontinence
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Diagnosis of cancer in the aged
 Malignancy may present with non-specific symptoms
such as vague pain, weight loss or general weakness. A
comprehensive clinical examination and
biochemical and hematological examination will
provide more information. It is sometimes difficult to
decide how to act when a malignancy is suspected or
diagnosed.
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Diagnosis of cancer in the aged cont’d
 Priority must be given to the interests of the patient.
Often a less aggressive approach is to the elderly
patient’s advantage, even if the diagnosis is still
uncertain. Good communication between patient,
family and health-care workers is very important so
that they may as a team decide on joint action.
 Patients often present late because of fear of the
diagnosis of malignancy.
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Presentation of cancer in the aged
1.
2.
3.
4.
5.
6.
7.
Widespread metastases
Hormonal syndromes
Hypercalcaemia
Hypoglycaemia
Hypertrophic pulmonary osteoarthropathy
Skin lesions
Abnormal vascular syndromes
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1. Widespread metastases
 Bone:
 pain or pathological fractures
 Liver:
 pain and enlargement with or without jaundice
 Lung:
 malignant effusion
 Brain
 confusion
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2. Hormonal syndromes
 ACTH: bronchus and pancreas carcinoma
 Antidiuretic hormone (ADH): bronchus carcinoma
 Gonadotrophin: bronchus carcinoma
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3. Hypercalcaemia
 It is secondary to:
 Metastatic bone disease.
 Excessive parathormone production.
 Bronchus carcinoma.
 Kidney carcinoma.
 The symptoms and signs are nocturia, nausea,
vomiting, constipation, weakness or even coma.
“Moans, groans and stones”
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4. Hypoglycaemia
 It is caused by pancreas island cell or liver cell tumors,
secreting insulin or insulin-like growth factor.
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5. Hypertrophic pulmonary
osteoarthropathy
 Caused by bronchus carcinoma.
 The joints are painful and may mimic rheumatoid
arthritis
 Finger clubbing may also be present
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6. Skin lesions
 May be an early sign of malignancy e.g. acanthosis
nigricans which consists of dark velvet-like lesions and
are often associated with gastric carcinoma.
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7. Abnormal vascular syndromes
Abnormal vascular syndromes in the aged with
already impaired circulation indicates the presence of
an underlying cancer.
 Peripheral gangrene, secondary to the presence of
circulating cryoglobulins or cryofibrinogen may be
experienced even before the cancer is diagnosed.
 Chronic, disseminated intra-vascular coagulation
plus purpura or gangrene or a series of cerebrovascular
incidents may also be a sign of malignancy.
 Recurring thrombophlebitis may be the first sign of
pancreas carcinoma.
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Common cancers in the aged
 In aged men cancer occurs in the lungs, prostate,
colon and rectum and pancreas.
 In aged women cancer occurs in the breast, colon and
rectum, lungs, pancreas, ovaria and body of the uterus.
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Common cancers in the aged cont’d
Colorectal cancer
 Rectal carcinoma may present as rectal bleeding and
the patient may complain of tenesmus.
 Rectal bleeding should not only be ascribed to piles.
 Tumours in:
Ascending -
Transverse -
Descending colon
May present as iron
deficiency, weight
loss or a palpable
mass
May mimic gall colic Constipation, false
or gastritis
diarrhoea or total
intestinal
obstruction
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Common cancers in the aged cont’d
Lung cancer
 It may present as dyspnoea, chest pain, haemoptysis or
with symptoms of nerve infiltration. The diagnosis is
made on the X-ray appearance and confirmed by
sputum cytology, pleural effusion cytology or fine
needle aspiration (FNA) cytology.
 Pulmonary resection is done if the patient’s condition
would allow it. In non-small cell bronchus
carcinoma the median survival rate for nonresectable lesions is four months.
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Common cancers in the aged cont’d
Breast cancer
 In postmenopausal women the firm painless lump is
caused by cancer in 80% of cases. It may also present
as a nipple discharge, nipple retraction, skin edema or
inflammation.
 Breast cancer spreads to regional lymph nodes,
bone, pleurae, liver and lungs. Local treatment may
be effective. Tumor growth is usually slower in the
aged and responds to hormone therapy (tamoxifen).
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Common cancers in the aged cont’d
Ovarian cancer
 It may present as abdominal pain, discomfort or
abdominal enlargement, abnormal vaginal
bleeding or a mass found incidentally during a
routine vaginal examination. All such masses in the
aged must be considered malignant until proven
otherwise.
 The diagnosis is based on tissue biopsy or ascites fluid
cytology. Further management depends on the staging
of the carcinoma
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Common cancers in the aged cont’d
Pancreas carcinoma
 It presents as epigastric pain which spreads to the back
and is relieved somewhat by leaning forward. It may
also present as jaundice, steatorrhea, digestive tract
bleeding, weight loss or depression, as well as
hyperglycemia and glucosuria.
 80% head of pancreas, 20% tail of pancreas
 By the time of diagnosis of pancreas carcinoma it is
often too late.
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Common cancers in the aged cont’d
Uterus - endometrial carcinoma
 In 90% of cases abnormal vaginal bleeding occurs. All
postmenopausal women, more than one year
postmenopausal, with vaginal bleeding are considered
to suffer from endometrial cancer, unless proven
otherwise.
 The diagnosis is made by differential dilatation and
curettage (DDandC). Treatment depends on the tumor
staging and the patient’s condition. Hormonal therapy
with progestogens may effectively control elderly
patients with endometrial carcinoma.
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Common cancers in the aged cont’d
Oesophagus carcinoma
 Dysphagia of recent onset is often the first sign of
oesophageal carcinoma. By the time that the diagnosis
is made, the tumor has spread to the oesophagus wall
so that surgical resection is no longer possible.
 Achalasia is a motor disturbance which presents as
dysphagia for fluid and solid foods. An underlying
malignant condition must be looked for, such as
adenocarcinoma of the stomach fundus or metastatic
tumors in the gastro-oesophageal region.
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Oesophagus Carcinoma
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Common cancers in the aged cont’d
Gastric carcinoma
 It may present with non-specific symptoms such as
anorexia, weight loss or anemia, or gastric outlet
obstruction. Patients at risk are those who have had
previous gastric surgery, atrophic gastritis or
pernicious anaemia.
 Changes in bowel habits, especially the onset of
diarrhoea, may be the first symptom of gastric
carcinoma.
 The diagnosis is usually made on gastroscopy and
confirmed by cytology and biopsy.
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Common cancers in the aged cont’d
Prostate carcinoma
 More than 50% of men 60+ → histological foci of
adenocarcinoma
 Only 1/3 clinically diagnosed
 Starts with symptoms of obstruction or infection
 Confirmed by digital rectal examination or PSA
 Prostate specific antigen → false + and –
 However, high PSA (40+) → high risk
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Common cancers in the aged cont’d
 Transurethral prostatectomy (TURP) is used for
localized prostate carcinoma. It spreads in a third of
men over 70 years but is not the cause of death.
Radical prostatectomy is done in men under 70 years.
 About 5% of patients have symptoms of metastases to
the spinal column, pelvis or femur, which may be
diagnosed radiologically or by bone scans. If there are
metastases, androgen ablation is done by medication
or orchidectomy.
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Common cancers in the aged cont’d
 Prostate cancer is staged by the Gleason scale (1-10), 1
indicating well differentiated and 10 indicating poorly
differentiated.
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Concluding remarks
 The difficulty of geriatric care is compounded by:
1. Atypical disease presentation
2. Doctor-patient relationship is crucial
3. A diversity of diseases as well as cancer are associated
with old age
We have to distinguish between normal ageing and
disease in the aged
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Thank you
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