OPDDr E.N Britz (MBChB, MPraxMed)

How disease presents in the elderlyDisease presents atypically

2

IntroductionFive common patterns of disease

presentation:

1. Multiple pathology2. Atypical presentation of illness3. Late presentation4. Silent presentation5. Weakness, dependency and the

pseudo-silent presentation of illness3

1. Multiple pathologyA 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.

4

2. Atypical presentation of illnessA 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.

5

2. Atypical presentation cont’dDrug 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.

6

2. Atypical presentation cont’dSymptoms 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.

7

2. Atypical presentation cont’dThe 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.

8

2. Atypical presentation cont’dThere 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.9

2. Atypical presentation cont’dLow 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)ImmobilityInstability (falls)IncontinenceIntellectual impairment

10

3. Late presentation of illnessAged people:

Liable to complain too lateIllnesses of heart, lungs and CNS are

commonly mentionedLocomotor 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.

11

3. Late presentation of illness cont’dThe 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.12

3. Late presentation of illness cont’dAge 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.

13

4. Silent presentation of illnessAll 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.

14

5. Weakness, dependency and the pseudo silent presentation of illnessA 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.

15

ConclusionThe 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.

16

Conclusion

17

Old man

18

Another old man

19

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.

20

Pitfalls in the Consultation Process cont’dAIMSAdd life to years not years to lifeOptimize fitness (diet, exercise, rehabilitation)Facilitate visits to dentist, optician, chiropodist,

social worker, occupational therapist and audiologist.

Alleviate social problems : pension

21

Pitfalls in the Consultation Process cont’dDiagnostic Pitfalls

1. Skin 2. Muscles

3. Bones and joints

4. Cardiovascular system

5. Respiratory system

6. GIT

7. Urogenital system

8. Neurological system

9. Brain 10. Autonomic decline

11. Blood 12. Endocrines

22

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.

23

The skin cont’dThe 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.

24

1.2 The muscles : AtrophyPtosis of eyelids, may suggest myastenia

gravis

25

The bones and jointsDegenerative 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.

26

The cardiovascular systemSymptoms :

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.

27

The cardiovascular systemSigns :

Difficulty to evaluate the heart size on CXRThe 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 oedemaAbsence of claudication in arteriosclerosis obliteransKinking of the carotid artery in the neck with

accompanying pulsation mimics A. Carotis aneurysm.

28

The respiratory systemThe 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.

29

The digestive tract.Loss of appetite because of ↓smell and ↓tasteDry mouth – atrophy of the salivary glandsChewing 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 IHDDiscomfort after big meals : atrophy of the mucosa,

↓motility, ↓gastric juices.Constipation : atrophy of colon, ↑connective tissue,

↓peristalsis.Fecal incontinence : ↓external anal sphincter reflex.

30

Urogenital systemAtrophy 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.

31

The neurological systemAbsence of the ankle reflex and vibration sense

may be normal. The ↓proprioreceptive sensation , slowing of

corrective reflexes caused by conduction delay in semi-circular 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.32

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.

33

Autonomic declineThere 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”

34

The bloodPatient is pale because of reduction in

melanophore (pigment cells containing melanin) activity.

Increased ESRImmune system dysfunction with an increase

in autoimmune diseases, cancer and infection.

Increased platelet adhesiveness, ↑fibrinogen, leading to thrombosis e.g. CVI, MI, PE, DVT.

35

36

The endocrinesHypothyroidism may mimic ageing.Diabetes mellitus – with ↓glucose tolerance

37

ConclusionNow 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. 38

Evaluation of the Elderly Person and Communication SkillsEye 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!!

39

Evaluation of the Elderly Person and Communication Skills cont’dSpend 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.

40

Evaluation of the Elderly Person and Communication Skills cont’dObservation 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.

41

Evaluation of the Elderly Person and Communication Skills cont’dSpeak 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.

42

Evaluation of the Elderly Person and Communication Skills cont’dHigh risk Elderly

Age over 80 yearsLiving alone Depression, bereavementIntellectual impairmentPrevious fallsIncontinence

43

Diagnosis of cancer in the agedMalignancy 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.

44

Diagnosis of cancer in the aged cont’dPriority 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.

45

Presentation of cancer in the aged1. Widespread metastases2. Hormonal syndromes3. Hypercalcaemia4. Hypoglycaemia5. Hypertrophic pulmonary osteoarthropathy6. Skin lesions7. Abnormal vascular syndromes

46

1. Widespread metastasesBone:

pain or pathological fracturesLiver:

pain and enlargement with or without jaundiceLung:

malignant effusionBrain

confusion

47

2. Hormonal syndromesACTH: bronchus and pancreas carcinomaAntidiuretic hormone (ADH): bronchus

carcinomaGonadotrophin: bronchus carcinoma

48

3. HypercalcaemiaIt 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”

49

4. HypoglycaemiaIt is caused by pancreas island cell or liver

cell tumors, secreting insulin or insulin-like growth factor.

50

5. Hypertrophic pulmonary osteoarthropathyCaused by bronchus carcinoma.The joints are painful and may mimic

rheumatoid arthritisFinger clubbing may also be present

51

6. Skin lesionsMay be an early sign of malignancy e.g.

acanthosis nigricans which consists of dark velvet-like lesions and are often associated with gastric carcinoma.

52

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.

53

Common cancers in the agedIn 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.

54

Common cancers in the aged cont’dColorectal cancerRectal 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 or gastritis

Constipation, false diarrhoea or total intestinal obstruction

55

Common cancers in the aged cont’dLung cancerIt 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 non-resectable lesions is four months.

56

Common cancers in the aged cont’dBreast cancerIn 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).

57

Common cancers in the aged cont’dOvarian cancerIt 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

58

Common cancers in the aged cont’dPancreas carcinomaIt 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 pancreasBy the time of diagnosis of pancreas

carcinoma it is often too late.

59

Common cancers in the aged cont’dUterus - endometrial carcinomaIn 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.

60

Common cancers in the aged cont’dOesophagus carcinomaDysphagia 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.

61

Oesophagus Carcinoma

62

Common cancers in the aged cont’dGastric carcinomaIt 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.

63

Common cancers in the aged cont’dProstate carcinomaMore than 50% of men 60+ → histological foci

of adenocarcinomaOnly 1/3 clinically diagnosedStarts with symptoms of obstruction or infectionConfirmed by digital rectal examination or PSAProstate specific antigen → false + and –However, high PSA (40+) → high risk

64

Common cancers in the aged cont’dTransurethral 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.

65

Common cancers in the aged cont’dProstate cancer is staged by the Gleason

scale (1-10), 1 indicating well differentiated and 10 indicating poorly differentiated.

66

Concluding remarksThe difficulty of geriatric care is compounded

by:1. Atypical disease presentation2. Doctor-patient relationship is crucial3. 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

67

Thank you

68