ILLNESS PRESENTATION IN THE ELDERLY

1
ILLNESS PRESENTATION IN THE ELDERLY

• Y. Beloosesky, A. Weiss
• Department of Geriatrics
• Rabin Medical Center, Beilinson Hospital

2
ILLNESS PRESENTATION IN THE ELDERLY

• Underreporting of illness.
• Changes in distribution and altered medical
  models of illness.
• Non specific presentation of diseases.
• Atypical presentation of diseases.

3
UNDERREPORTING OF ILLNESS

• 1. The prevalent attitude of Ageism,
• (Agedisability/morbidity) reduces demand for
  health care.
• 2. The perception of unresponsive system of care,
  
• disinterested personnel or lack of facilities
  for elderly.
• 3. Depression reduces the desire for
  improvement,
• Dementia diminishes the capacity to
  accurately describe symptoms.
• 4. Denial fear of economic, social and
  functional consequences.
• 
  Hazzard,
  Princ. of Geriat. Med. and Geront.

4
ILLNESS PRESENTATION IN THE ELDERLY

• Underreporting of illness.
• Changes in distribution and altered medical
  models of illness.
• Non specific presentation of diseases.
• Atypical presentation of diseases.

5
ILLNESS PRESENTATION IN THE ELDERLY

• Underreporting of illness.
• Changes in distribution and altered medical
  models of illness.
• Non specific presentation of diseases.
• Atypical presentation of diseases.

6
NON SPECIFIC PRESENTATION OF ILLNESS

• A functional and/or cognitive impairment,
  secondary to a disease occurring in a remote
  system from the affected organ.
• The Giants of Geriatrics
• Immobility
• Instability
• Incontinence
• Intellectual impairment
• 
  (confusion-delirium)
• 
  
• 
  Isaac
  B. Health Care of the Elderly

7
NON SPECIFIC PRESENTATION OF ILLNESS

• Dizziness
• Eating/Drinking difficulties
• Weight loss
• Failure to thrive
• General deterioration

8
ILLNESS PRESENTATION IN THE ELDERLY

• Underreporting of illness.
• Changes in distribution and altered medical
  models of illness.
• Non specific presentation of diseases.
• Atypical presentation of diseases.

9
ATYPICAL PRESENTATION IN COMMON DISEASES

• Infections
• Cardiac diseases
• Endocrine diseases
• Acute abdominal and peptic disease
• Depression

10
EXAMPLES OF ATYPICAL PRESENTATION OF INFECTIOUS
DISEASES

• Pneumonia
• U.T.I
• Meningitis
• Bacteremia
• Tuberculosis

11
Fever General Definition

• Among healthy individuals age 18 40 years
• An A.M. temperature of gt 37.20C , or a P.M.
  temperature of gt 37.70C

Harrisons principles of internal medicine
12
INFECTIOUS DISEASE

• Altered febrile response in the elderly.
• 10-30 of elderly patients with serious
  infections
• are a-febrile.
• A new definition of fever for elderly is
  proposed
• 1. Persistent elevation of body temp. of at
  least 1.2c
• over normal values (regardless of the
  technique).
• 2. Oral or rectal temp. of 37.2c and 37.5c
  
• respectively, on repeated measurements.
• Norman DC, Yoshikawa
  TT, Inf. Dis. Clin. North Am. 1996

13
EXAMPLES OF ATYPICAL PRESENTATION OF INFECTIOUS
DISEASES

• Pneumonia
• U.T.I
• Meningitis
• Bacteremia
• Tuberculosis

14
Pneumonia in the general population

• Productive cough of purulent sputum
• The temperature may rise to 38.939.4C
• In a few a single episode of shaking chills
  followed by sustained fever and a cough
  productive of blood-tinged sputum

15
Pneumonia in the elderly

• The onset of disease may be insidious
• Minimal cough, no sputum production,
• no fever
• May appear tired or confused

16
Pneumonia in the elderly cont.

• Nausea and vomiting or diarrhea - up to 20 of
  cases
• Symptoms of a new cardiac arrhythmia, myocardial
  ischemia, or an actual infarction (10 of
  patients)
• May precipitate cardiogenic or noncardiogenic
  pulmonary edema

17
PNEUMONIA - ATYPICAL PRESENTATION

• Mean age 78, home 69,nursing home 19,
• Dependent in ADL 65.
• Cough, Fever and Dyspnea in 56,
• No Leucocytosis in 31.
• No fever in 39
• Patients in advanced age, premorbid functional
• impairment, cognitive impairment on admission,
  are most likely to have atypical
  presentation of pneumonia.
• 
  Harper C, Newton P,
  J. Am.
  
  
  Geriat. Soc. 1989

18
EXAMPLES OF ATYPICAL PRESENTATION OF INFECTIOUS
DISEASES

• Pneumonia
• U.T.I
• Meningitis
• Bacteremia
• Tuberculosis

19
U.T.I in the general population

• Cystitis dysuria, frequency, urgency,
• suprapubic pain
• Symptoms of acute pyelonephritis develop rapidly
  over a few hours or a day fever, shaking chills,
  nausea, vomiting, abdominal pain, diarrhea
  sympts of cystitis
• Tachycardia, generalized muscle tenderness
• Physical exam. marked tenderness on deep
  pressure in costovertebral angle/s or on deep
  abdominal palpation

20
Clinical Presentations of Symptomatic UTI in
Elderly Populations
21
U.T.I - ATYPICAL PRESENTATION

• Worsening or new onset of incontinence.
• Increased urgency or frequency may not be
  present.
• There may be mild leucocyturia (pyuria) and no
  nitrates.
• Multiples organisms on culture may be real, not
  contamination.
• Asymptomatic bacteriuria in 20-50 of women, and
  in 20 of men over 80 years (usually no need to
  treat).

22
EXAMPLES OF ATYPICAL PRESENTATION OF INFECTIOUS
DISEASES

• Pneumonia
• U.T.I
• Meningitis
• Bacteremia
• Tuberculosis

23
MENINGITIS - classical symptoms

• nausea and vomiting
• headache
• neck stiffness
• lethargy
• confusion

24
MENINGITIS in the elderly

• Confusion
• Headache
• Nausea vomiting
• Seizures and photophobia
• Nuchal rigidity is less sensitive and
• specific sign as it is in younger patients

Choi C, Clin. Geriat. Med. 1992 Rasmussen
HH et al., Age Ageing 1992
25
EXAMPLES OF ATYPICAL PRESENTATION OF INFECTIOUS
DISEASES

• Pneumonia
• U.T.I
• Meningitis
• Bacteremia
• Tuberculosis

26
EXAMPLES OF ATYPICAL PRESENTATION OF INFECTIOUS
DISEASES

• Pneumonia
• U.T.I
• Meningitis
• Bacteremia
• Tuberculosis

27
TUBERCULOSIS

• Classic symptoms
• Cough
• Fever
• Hemoptysis
• Nocturnal sweats
• Weight loss
• Chest X-Ray abnormalities in the upper lobes

28
TUBERCULOSIS in the elderly

• Insidious onset
• Fever often absent, hemoptysis less common
• Anorexia
• chronic fatigue
• low-grade fever
• functional and cognitive decline
• Chest X-Ray abnormalities - more in the mid and
  lower zones, more milliary shadowing
• More extra-pulmonary tuberculosis

Davies PD, Drug Ageing 1996
29
ATYPICAL PRESENTATION IN COMMON DISEASES

• Infections
• Cardiac diseases
• Endocrine diseases
• Acute abdominal and peptic disease
• Depression

30
MYOCARDIAL INFARCTION - ATYPICAL PRESENTATION

• The chest pain is the most frequent symptom up to
  age 85.
• The chest pain is vaguely described, poorly
  localized, can be isolated to the throat,
  shoulder or abdomen.
• High incidence of congestive heart failure.
• Association with confusion, syncope, stroke.
• High incidence of unrecognized or silent MI
  (50).
• 
  
  
  
  
  
  Emmet KR,
  Geriatrics 1998
• 
  Tresch DD, J. Am. Geriat.
  
  
  Soc. 1998

31
MYOCARDIAL INFARCTION - ATYPICAL PRESENTATION

• Comparison of elderly 75 with younger 65.
• Elderly patients had less typical chest pain,
  higher incidence of CHF and evolved a greater
  proportion of non-Q-wave MI.
• Comparison of elderly 70 with younger 69.
• Elderly patients significantly delayed more than
  6 hours seeking medical assistance, had less ST
  elevation, Q waves and more CHF.
• 
  Paul SD et al., Am.
  Heart J. 1996
• 
  Tresch DD et al., Arch. Int. Med.
  
  
  1996

32
C.H.F. CLASSIC SYMPTOMS

• The cardinal symptoms of HF are fatigue and
  shortness of breath
• Dyspnea during exertion less strenuous
  activity at rest
• Tricuspid Insuff. and Right vent. failure
• Orthopnea
• Paroxysmal Nocturnal Dyspnea (PND)
• Cheyne-Stokes Respiration
• Acute Pulmonary Edema

33
C. H. F - ATYPICAL PRESENTATION

• Exertional dyspnea may be absent.
• Symptoms of low cardiac output weakness,
  fatigue, confusion, falls, blackout fits,
  insomnia, non-productive cough.
• Loss of fat and muscle tissue, cardiac cachexia.
• Basilar rales may be caused by lung disease,
• leg edema can be the result of venous stasis
  and hypoalbuminemia.
• Elevation of J.V.P and S3 gallop are more
  specific.
• 
  King D,
  Postgrad. Med. J. 1996

34
ATYPICAL PRESENTATION IN COMMON DISEASES

• Infections
• Cardiac diseases
• Endocrine diseases
• Acute abdominal and peptic disease
• Depression

35
HYPERTHYROIDISM

• Tremor is more course, ocular signs are less
  frequent.
• Diarrhea is rare, more loose stools and
  constipation relief.
• Anorexia, less appetite, weight loss and proximal
  muscular weakness.
• Cardiovascular signs CHF, palpitation, atrial
  fibrillation, new onset of angina pectoris.
• Apathetic Thyrotoxicosis- the patient appears
  frail, wasted, unanimated.
• 
  Gambert
  SR, Escher JE, Geriatrics 1988

36
DIABETES - ATYPICAL PRESENTATION

• Polyuria, polyphagia and polydipsia are not
  necessary present.
• Severe dehydration, hyperosmolarity and even
  coma, can rapidly develop without prior warning.
• Polyuria can be confused with prostatic or
  urinary diseases.

37
DIABETES - ATYPICAL PRESENTATION cont

• Confusion, delirium, behavioral changes may be
  caused by hyper or hypoglycemia.
• Long term sequelae neuropathies affecting
  gastric empting, sensation, vasomotor instability
  and gait.
• 
  
• 
  Gambert SR, Clin. Geria Med. 1990

38
ATYPICAL PRESENTATION IN COMMON DISEASES

• Infections
• Cardiac diseases
• Endocrine diseases
• Acute abdominal and peptic disease
• Depression

39
ACUTE ABDOMEN IN THE ELDERLY

• The diagnosis may be difficult because of unique
  factors.
• Less abdominal inflammatory response
  less guarding/spasm, lower leucocytes
  count and lower and delayed temperature.

40
ACUTE ABDOMEN IN THE ELDERLY cont

• Different anatomical factors, eg. poor blood
  supply to a thinner appendix predisposing to
  perforation gangrene.
• Multiple abdominal diseases gallstones,
  diverticulosis, atherosclerosis
• Communication problems confusion, aphasia,
  dementia.
• 
  Phillips SL, Burns GP, Med.
  Clin. North Am. 1988

41
BILIARY TRACT DISEASE

• Biliary tract disease is the single most common
  cause of
• abdominal operations ( 1/3), in the elderly.
• Sometimes, the biliary colic is replaced by
  only vague abdominal complains.
• In gallbladder perforation (occurring primarily
  in elderly), only a 1/3 of pts have a history or
  prior symp. of gallstones.
• Common bile duct stones are found at the time of
  cholecystectomy in 10 of younger pts, but gt50
  of pts over age 70 years.
• 
  Hazzard, Princ.
  of Geriat.
  
  Med. and
  Geront.

42
ACUTE APPENDICITIS

• 96 patients 60 years (39 70 years)
• Only 20 presented classically with nausea or
  vomiting, fever (38.6c), right lower quadrant
  pain, elevated or shifted WBC.
• Only 61, 33, 47 had right lower quadrant pain,
  nausea or vomiting and fever 37.6c
  respectively.
• 72 of patients had perforated appendicitis, 30
  abscess formation.
• 
  
  Horattas MC et al. Am. J. Surg. 1990

43
ACUTE PANCREATITIS

• In the elderly - gallstones etiology is the most
  common.
• As in the young, abdominal pain is the major
  symptom.
• In 5-10 of cases, pain is absent.
• Pain may be vague, physical exam unremarkable.
• Non specific signs tachycardia, hypotension,
  tachypnea, confusion.
• 
  
  Gullo L, J. Clin. Gastroenter. 1994

44
ACUTE DIVERTICULITIS

• In the elderly, diverticulitis may occur in an
  aggressive form Phlegmonous inflammation,
  Fistula to adjacent organs or skin, Obstruction
  of the colon.
• Many episodes subside, the patient has left lower
  quadrant pain, tenderness, moderate abdominal
  distension and moderate temperature elevation.
• 
  Phillips SL,
  Burns GP, Med. Clin. North Am. 1988

45
PEPTIC ULCERS classical symptoms

• Epigastric pain described as a burning or gnawing
  discomfort, an ill-defined, aching sensation or
  as hunger pain
• The typical pain pattern in DU occurs 90 min to 3
  h after a meal and is frequently relieved by
  antacids or food
• Pain that awakes the patient from sleep (between
  midnight and 3 A.M.) is the most discriminating
  symptom
• In GU pain may be precipitated by food

46
PEPTIC ULCERS in the ELDERLY

• Elderly patients have significantly higher
• risk to develop peptic ulcers and
  complications
• from NSAIDs.
• Pain is absent in one third of the cases.
• Pain, when present, can be vague
• and poorly localized.
• Presenting symptoms may be systemic
• and related to blood loss and anemia (i.e.
  falls, syncope).
• 
  
  Borum ML, Clin. Geriat.
  
  
  Med. 1999

47
PEPTIC ULCERS

• Comparison of elderly 65 with younger
  64
• In the elderly DU was significantly less common
  (42 vs 66), typical epigastric pain was more
  rare (35 vs 91), bleeding - more common (59 vs
  14), atypical location - more common and larger
  ulcer size.
• HP was present more often in patients 64.
  Elderly patients who did not use NSAIDs, 35
  were HP negative.
• 
  
  Kemppainem H et al. Gerontology 1997

48
ATYPICAL PRESENTATION IN COMMON DISEASES

• Infections
• Cardiac diseases
• Endocrine diseases
• Acute abdominal and peptic disease
• Depression

49
Depression classical symptoms

• Five (or more) of the following symptoms have
  been present during the same 2-week period and
  represent a change from previous functioning at
  least one of the symptoms is either (1) depressed
  mood or (2) loss of interest or pleasure.
• Depressed mood most of the day, nearly every day
  (e.g., feels sad or empty)
• Markedly diminished interest or pleasure in all,
  or almost all, activities most of the day, nearly
  every day
• Significant weight loss when not dieting or
  weight gain (e.g., a change of gt5 of body weight
  in a month), or decrease or increase in appetite
  nearly every day
• Insomnia or hypersomnia nearly every day

Harrisons principles of internal medicine
50
Depression classical symptoms cont

• Psychomotor agitation or retardation nearly every
  day
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or
  inappropriate guilt (which may be delusional)
  nearly every day
• Diminished ability to think or concentrate, or
  indecisiveness, nearly every day
• Recurrent thoughts of death (not just fear of
  dying), recurrent suicidal ideation without a
  specific plan, or a suicide attempt or a specific
  plan for committing suicide

51
DEPRESSION IN ELDERLY

• Elderly patients have less dysphoria (sadness),
  more vegetative symptoms (sleep, appetite
  disturbances, somatic complaints).
• Cognitive dysfunction apathy, diminished
  concentration.
• Social withdrawal, isolation, dependency.
• Pseudo-dementia confusion, demented like.
• Association with anxiety, irritability.
• 
  Reynolds CF,
  Geriatrics 1996
• 
  
  
  
  
  
  
  

52
CONCLUSIONS

• The medical approach to the older, especially
  frail person, is different from that of the
  younger, requiring better understanding and
  knowledge of their illness.
• There is a high prevalence of nonspecific and
  atypical illness presentation in the elderly.

53
CONCLUSIONS

• Even though enormous progress has been
• made in medical technology, the physician
• must be attentive and vigilant to the illness
• presentation in the elderly and should play a
• pivotal role in avoiding delay in diagnosing
• and improving patient outcome.

54
THANK YOU