At Atypical Presentation of Di Disease i in t the O Older Ad - - PDF document

8/17/20 1

At Atypical Presentation of Di Disease i in t the O Older Ad Adult

James Lin, DO, MS (Med Ed) President of the LECOM Institute for Successful Aging

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Le Learn rning O Object ctives

By the end of this lecture, the attendee will be able to:

• Recognize ageism in healthcare
• Identify characteristics of aging
• Understand age-related physiologic changes in the older adult
• Recognize the atypical presentation of disease in the older adult
• Recall atypical presentations of specific diseases

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Ag Ageism in Healthcare

Ageism: Process of systematic stereotyping and discriminating people because they are old

• Lack of training of geriatric professionals
• Older adults are less likely to receive preventative

healthcare

• Older adults are less likely to be tested for diseases
• Older adults are more likely to receive inappropriate or

incomplete treatments

• Aging seen as a disease state
• Failure to pursue uncomfortable subjects
• Exclusion from clinical trials

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Health Health Lit iter erac acy

Your naicisyhp has dednemmocer that you have a ypocsonoloc. A ypocsonoloc is a test for noloc recnac. It sevlovni inserting a elbixelf gniweiv epocs into your mutcer. You must drink a noloc noitaraperp diuqil the night before the noitanimaxe to clean out your noloc.

70% of 85+ year olds have low health literacy 43% of 65+ year olds have high school or less education

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Hi History y Taki king

• 75% of diagnosis can be made by history alone
• Incomplete history = missed diagnosis
• In 77% of interviews, patient problems are not fully elicited
• In 70% of interviews, physicians interrupt patient after 18 sec

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Ch Chief Comp Complaint

It depends on who you ask:

• Patient: “No complaints, I feel fine”
• Daughter: “Difficulty getting around the house, I am afraid she may fall”
• Physician: “Blood pressure should be better controlled”

4M’s – “What matters?”

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Ch Characteri ristics of

• f Ag

Aging

• AGING is the progressive decline and deterioration of

functional properties at the cellular, tissue, and organ level that lead to a loss of homeostasis, decreased ability to adapt to internal or external stimuli, and increased vulnerability to disease and mortality

• It is NOT a disease
• Does not cause symptoms
• Occurs at different rates
• Among individuals
• Within individuals – organs age at different rates
• Increases susceptibility & vulnerability to disease
• Mortality increases exponentially

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Pr Presentat ation of Disease

Less than 50% of older adults present with classic symptoms due to four general causes 1. Age-related physiologic changes 2. Age-related loss of physiologic reserve 3. Under-reporting of symptoms 4. Interactions of chronic conditions with acute illnesses

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At Atypical Pr Presentat ation of Disease

• Differences in the way diseases behave when occurring in older persons
• Differences in the way older persons behave when afflicted with disease
• Additive effects of aging restrict capacity to maintain homeostasis
• Blunting or absence of typical/classic symptoms and signs
• Causes delays in diagnosis, treatment and may contribute to mortality and

morbidity

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At Atypical Pr Presentat ation of Disease

• Defined as symptoms occurring outside of the

normal rubric of traditional signs and symptoms, which may signify an impending acute illness

• Risk factors:
• Over age 85
• Multiple comorbidities
• Multiple medications
• Cognitive or functional impairment

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Ag Aging Bo Body: Br Brain

• Brain peaks in size at age 25
• Area of cerebral ventricles relative to total brain area increases three to four

times

• ↓ number of nerve cells in brain
• ↓ cerebral blood flow by 20%
• IQ is highest between ages 18 - 25
• Creativity peaks in the 30s, then declines

“The effective, moving, vitalizing work of the world is done between the ages of 25-40”

• Sir William Osler

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Ag Aging Bo Body: Br Brain

Intellect

• Maintained until at least age 80
• Slowing in central processing → tasks take longer

Verbal skills

• Vocabulary 3x as large at age 45 as it is at age 20
• Maintained until age 70
• Gradually ↓ in vocabulary, ↑ semantic errors

Mentation

• Mild difficulty learning and forgetfulness in non-critical areas
• Recall of important memories not effected

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Ag Age-As Associated Me Memor mory I Imp mpairme rment

• Normal age-related forgetfulness
• Unrelated to any pathologic process
• Primary features are:

1) Reduced multitasking performance 2) Reduced processing speed 3) Delay in retrieval of information

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Br Brain Function

• n on
• n EEG
• Normal brain function produces chaotic electroencephalographic (EEG)

fluctuations with changes related to the state of consciousness

• EEG frequencies of aging subjects show a loss of low-voltage fast waves and an

increase in slow waves with diffuse slow periodicity

• EEG latency, amplitude, and range of EEG frequencies elicited in response to light,

sound, and hyperventilation decline with age

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Men Mental Hea Health

Mental disorders are not a part of normal aging

18-54 yrs 55+ yrs Any anxiety disorder 16.4% 11.4% Any mood disorder 7.1% 4.4% Cognitive impairment 1.2% 6.6% Any mental disorder 21.0% 19.8% 15

At Atypical Presentation of Dep Depres ession

Compared to younger adults, older patients:

• Less “mood symptoms”
• More somatic symptoms - pain, weight loss, insomnia
• More irritability or anxiety
• Decreased functional status
• Social isolation, poor grooming/self-neglectful behaviors

Complicated by:

• Co-existing medical problems
• Cognitive deficits
• Multiple medications

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Ag Aging Bo Body: Pe Peripheral Nervous System

• ↓ number of spinal motor neurons
• Nerve conduction slows
• Decreased fine motor control
• ↓ vibratory sensation
• ↓ thermal sensitivity (warm-cool)
• Impaired proprioception
• Impaired two-point discrimination

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Aging Body: Vi Vision

• Difficulty focusing on near objects
• Decrease ability to judge distances
• Decrease ability to discriminate between colors
• Decrease dark adaptation
• Decrease ability to adapt to glare
• Lens becomes less transparent, yellows
• More rigid iris, ↓ pupil diameter
• Optic nerve, retina become less efficient
• Ciliary muscle atrophies

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Pr Presbyopia

• Age-related vision change in which increased distance is needed to focus near
• bjects
• Due to decreased lens elasticity and atrophy of the ciliary muscle
• Begins very slowly beginning sometime during the fourth decade of life

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Ag Aging Bo Body: Hearing

• By 30, ability to hear higher frequency begins ¯
• Each decade, the hearing loss gets 2½ x worse
• 50% decline is clinically important
• Difficulty discriminating source of sound

Cochlea

Loss of hair cells Stiffening of basilar membrane Neuronal loss

EAC

Thickened tympanic membrane Cerumen drier and thicker

Ossicles Joints degenerate

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Pr Presbycusis

Hearing loss ascribed to aging effects

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Ag Aging Bo Body: Ta Taste & Smell

• Atrophy of and ↓ number of taste buds
• Beginning in early 20s, ability to detect salty or sweet things decreases
• ↓ Thirst drive
• Olfactory impairment in 25% of 65+, 63% in 80+

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Ag Aging Bo Body: GI System

Age-Associated Change Possible Outcome ↓ stomach acid production Atrophic gastritis Impaired acid clearance GERD Slowing of gastric emptying, reduced antral stretch ↑ meal-induced satiety Impaired response to gastric mucosal injury Increased risk of gastric & duodenal ulcers ↓ liver size by 25% by age 70, ↓ blood flow by 10%/decade Impaired clearance of drugs ↓ effective colonic contraction Constipation ↓ tensile strength of smooth muscle in colonic wall Diverticulosis ↓ absorption Vitamin B12, iron, calcium deficiency

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At Atypical Presentation of GI GI Dis iseas ase

• Gastrointestinal ulcer or reflux disease
• Older adults report pain is subtle, atypical or absent compared to sharp,

localized pain

• Acute appendicitis
• Older adults report diffuse abdominal pain, confusion, urinary urgency,

absence of fever compared to right lower quadrant pain, fever

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Ag Aging Bo Body: Pu Pulmonary Syste tem

• Airway size ↓
• Mucociliary clearance slows & is less effective
• Chest wall stiffens, diaphragm weakens by 25%
• Costochondral cartilage becomes calcified & intercostal muscle

contraction accounts for less chest expansion so that by age 65, inspiration depends on abdominal muscles

• Enlargement of alveolar ducts results in a decreased surface area for

gas exchange

• Decreased responses to hypoxemia, hypercapnia, and mechanical

loading

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Ag Aging Bo Body: Pu Pulmonary Syste tem

• ↓ Elastic recoil of the lung, ↑ Residual volume
• Forced vital capacity ↓ by 0.15-0.3liters per decade
• Forced expiratory volume in 1 second ↓ by 0.2-0.3liters per decade
• Aerobic capacity decreases 1% per year between ages 20 and 60 = 40%
• Ventilation/perfusion mismatch changes arterial pO2

age appropriate pO2 = 100 - (age/3)

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At Atypical Presentation of PE

Compared to younger adults, older patients:

• More likely to present with syncope (24% vs 3%)
• More likely to be hypoxic and cyanotic
• Less likely to have pleuritic chest pain and hemoptysis

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Ag Aging Bo Body: Ca Cardiovascular r System

Age-Associated Change

↓ Beta- adrenergic receptor response ↑ vascular intimal thickness ↓ arterial compliance ↑ heart muscle thickness ↑ left atrial size, sinus node dysfunction

Possible Outcome

Impaired cardiac output Atherosclerosis Systolic hypertension, Stroke Congestive heart failure Dysrhythmias

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Agi Aging g Bo Body: y: Cardiovascu cular System

Compared to younger adults, older patients:

• Impaired inotropic & chronotropic maximal responses to catecholamine

stimulation & to sympathetic nervous system stimulation (stress response)

• Maximum heart rate declines with age

= 220 - age (in men) 190 - (0.8 x age) (in women)

• In order to preserve cardiac output following stress or exertion, stroke

volume is increased in response to reduced maximum heart rate

• Recovery after exertion is markedly prolonged

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At Atypical Pr Presentation of ACS

Classic signs observed with an MI Atypical presentation of MI Substernal chest pain Radiating pain to neck, jaw or arm Mild or absent pain Diaphoresis Acute confusion Dyspnea Mild or absent dyspnea Electrocardiogram evidence of infarction No electrocardiogram evidence or Non-Q wave infarction or silent 30

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Ag Aging Bo Body: Renal System

• Size and weight of kidneys decreases by 25%
• Total blood flow to the kidney decreases by 10% per decade after the age of 40
• Kidneys gradually become less efficient
• Decreased maximum urine osmolality
• Decreased renin-angiotensin-aldosterone responsiveness
• Impaired atrial natriuretic peptide responsiveness
• Fluid and electrolyte abnormalities, dehydration
• ↓ Vitamin D activation
• Bladder elasticity and capacity declines
• Enlargement of prostate gland
• Weakened urethral sphincter

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Creatinine Clearance

Creatinine clearance decreases roughly 7.5- 10mL/minute per decade 32

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Ag Aging Bo Body: Endo Endocrine ne System

• Thyroid gland atrophy
• Ovarian failure
• ↓ Insulin secretion → Impaired glucose tolerance
• ↓ Growth hormone, DHEA, testosterone, estrogen
• ↑ Parathyroid hormone, ANP, norepinephrine, baseline cortisol, erythropoietin

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At Atypical Pr Presentation of Hyperthyroidism

• Rapid heart rate
• Restlessness
• Fine tremor
• Increased bowel frequency
• Increased perspiration
• Opthalmopathy
• Classic presentation
• Atypical presentation
• Cardiac arrhythmias
• Lethargy, fatigue
• Coarse tremor
• Weight loss
• Proximal muscle wasting
• Congestive heart failure

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Bod Body Comp Compos

• sition
• n
• ↓ total body water = ↓ capacity to balance electrolytes &

↑ risk of dehydration

• ↓ muscle mass = serum creatinine inaccurate reflection of

renal function

• ↑ fat = greater reservoir for deposition of lipid soluble

drugs

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Maximal height in 30-40s with loss of 5cm until age 75

• Changes in

posture

• Age-related disc

compression

• Increased hip and

knee flexion

↑

Bod Body Comp Compos

• sition
• n

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Ag Aging Bo Body: Musculoskeletal System

• Strength and coordination peak at 19
• Body is the most flexible until age 20
• ↓ Type II (fast twitch) fibers
• ↓ Tone and contractility
• Lean body mass decreases steadily after physical maturity
• Reduces to 2/3 its value in young adults
• Body weight increases with age because stored fat and body water increase in

excess of the loss of lean body mass

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Ag Aging Bo Body: Muscles

Sarcopenia = Age-related loss of muscle & function

• Muscle mass decreases in relation to body weight by 15% per decade

between ages 50-60, and 30% thereafter

• Strength of grip decreases 60% from age 30 to age 80
• Lower-extremity strength is lost at a relatively faster rate than upper-

extremity strength

• Activity does play an important mitigating role but aging muscles can

tend towards increased rigidity and loss of tone even with regular exercise

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Ag Aging Bo Body: Joints

↓ thickness of cartilage Collagen becomes stiffer & disordered Unable to handle mechanical stress

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At Atypical Pr Presentation of Gout

Compared to younger adults, older patients:

• More likely to have polyarticular attacks
• More likely to involve upper extremities
• More likely to have sub-acute to chronic, indolent course
• Increased incidence of tophi
• Tophi appear earlier in the disease

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Agi Aging g Bo Body: y: Der Derma matologi gical System em

Age-Associated Change Possible Outcomes

Slower cell replacement

• Dryness/Rough surface
• Delayed healing

↓ Sweating

• Tendency to hyperthermia

↓ Elasticity

• Lax skin/wrinkles

↓ Immunologic & inflammatory responsiveness

• Injuries and infections
• Impaired wound healing

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Agi Aging g Bo Body: y: Hema Hematologi gical System em

• % of marrow space occupied by hematopoietic tissue declines
• ↓ stem cells in marrow
• Slowed erythropoiesis
• ↓ incorporation of iron into RBC
• Average values of hemoglobin and hematocrit ↓ slightly

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• Immune response to infection declines with age due to T cell:
• Decrease number
• Decreased responsiveness
• Decreased production & response to IL-2
• Decreased activity of helper and cytotoxic T cells
• Decreased humoral antibody-mediated response
• Lower peak temperature with infection
• Decreased heat production per kg body weight
• Reduced muscle activity
• Less efficient shivering

Older adults are the largest group of “immuno- compromised” patients

Aging Body: y: Im Immunological System em

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Fe Fever

• Aged normal temperature runs one degree below normal youngers:
• oral = 35.8-36.8°C (96.4-98.2°F)
• Alternative definition of fever in the elderly (sensitivity of 82.5% and specificity of

89.9%):

• Persistent elevation of body temperature of 1.1-1.3°C (2°F) or greater

from the patient’s baseline

• Oral temperature of ≥ 37.2°C (99°F) on repeated measurements

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Ri Risk Factor

• rs for
• r Infection
• n
• Impairment of the normal physiologic reserves
• Living environments allow for the development of infection, foster transmission
• f infectious agents, contribute to the rise of antibiotic-resistant bacteria
• Invasive devices, (indwelling urinary catheters, intravenous catheters, feeding

tubes, and tracheostomies), provide portal of bacteria entry

• Malnutrition is associated with limited immune response and impaired wound

healing

• Immune Senescence

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At Atypical Presentation of Infect ction

Compared to younger adults, older patients:

• May have fewer symptoms, might present with nonspecific consequences of

infection that on the surface appear unrelated

• Classical manifestation of infection (fever, leukocytosis, tachycardia) may be

absent or blunted in 20-30%

• 20%-45% of elderly with bacteremia have a normal WBC count
• 60-70% of all deaths due to sepsis occur in the elderly partially due to delay in

diagnosis

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At Atypical Pr Present ntation of Infection

• Fatigue
• Anorexia
• Incontinence (urinary or fecal)
• Mental status change
• Falls
• Loss of functional capacity
• Malaise

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Fe Fever and Infection

• When fever is present, it is infectious in etiology approximately 90% of the time
• Temperature >37.8 °C (100 °F) in elderly is associated with markers of serious

illness over 75% of the time:

• Hospitalization for 4 or more days
• Need for surgery or an invasive procedure
• Positive blood cultures
• Administration of IV antibiotics for 3+ days
• Repeat ED visit within 72 hours
• Death within 1 month

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At Atypical Pr Present ntation of Pn Pneumonia

Classic Presentation Productive cough of purulent sputum Temperature elevation Pleurisy Rigors Atypical Presentation Insidious onset Fatigue, confusion Minimal cough, no sputum, no fever Nausea/vomiting/diarrhea New cardiac arrhythmia or ischemia

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At Atypical Pr Present ntation of Pn Pneumonia

Compared to younger adults, older patients:

• No Cough and Dyspnea in 44%
• No Leukocytosis in 31%
• No fever in 39%
• Nausea and vomiting or diarrhea in up to 20%
• New cardiac arrhythmia, myocardial ischemia, or an actual infarction in 10%

Most frequent missed diagnosis on autopsy

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At Atypical Pr Present ntation of TB

Compared to younger adults, older patients:

• More frequently present with non-respiratory symptoms
• Classic cough, night sweats, fever, hemoptysis are less common
• Middle or lower lobe infiltrate more likely than classic upper lobe infiltrate
• Bilateral involvement is more common
• PPD responses are less pronounced

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At Atypical Pr Present ntation of UTI

Compared to younger adults, older patients:

• Anatomic variations during the aging process:
• Changes in prostatic function in men
• Changes in vaginal flora associated with menopause in women
• Other risk factors for older adults:
• Higher rates of incontinence
• More frequent urologic instrumentation
• Higher rates of catheterization
• Comorbid diseases
• Medications that alter bladder function

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At Atypical Pr Present ntation of UTI

Classic Presentation Dysuria Frequency Urgency Suprapubic pain

Atypical Presentation

Functional decline Malaise/Weakness Anorexia Mental status change Incontinence

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At Atypical Pr Present ntation of UTI

Diagnosis in older adults:

• May be mild leukocyturia (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)

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At Atypical Pr Present ntation of Endocarditis

Compared to younger adults, older patients:

• Less likely to have classic findings:
• Splenomegaly
• Osler’s nodes
• Janeway lesions
• Conjunctival hemorrhages
• More likely to require transesophageal echo as transthoracic echo less likely to

detect vegetations

• TTE 75% sensitivity in younger patients
• TTE 45% sensitivity in older patients

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• n endocarditis prospective cohort study. Arch Intern Med 2008; 168:2095-103

Fried LP, et al. Diagnosis of illness presentation in the elderly. J Am Geriatr Soc 1991; 39:117-23 Harchelroad F. M D Acute Thermoregulatory Disorders, Clinics in Geriatric Medicine Vol. 9,No. 3 aug. 1993 Hersh,L et al, Clinical Mgt of UI in Women, American Family Physician, May 1, 2013, Vol 87,No 9,pp634-640 Pinquart M, et al, Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy & psychotherapy.Am J Psychiatry. 2006;163:1493-1501 Reuben DB, Yoshikawa TT, Besdine RW, Geriatric Review Syllabus Rosso,A et al Geriatric Syndromes and Incident Disability in Older Women J of Amer Geriatric Society, March 2013, Vol 61 No 3 371-379 Schaaf H, et al Tuberculosis at extremes of age. Respirol 2010: 15;747-63 Stenhagen,M,et al, Falls in Elderly People Aging Clin Experience Resp April 2013;25(1):59-67 Timmons S, et al. Pulmonary embolism: differences in presentation between older and younger patients. Age Ageing 2003;32:601-5 Unutzer,J et al, Late Life Depression, NEJM,2007;357: 2269-2276 Wheeler A, Bernard G. Treating patients with severe sepsis. NEJM 1999;340(3):207-214 WHO (2002) Active Aging: A Policy Framework. Geneva: World Health Organization

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