OPD Dr E.N Britz (MBChB, MPraxMed)

1. How disease presents in the elderly, pitfalls in the consultation process and diagnosis of cancer in the aged OPD Dr E.N Britz (MBChB, MPraxMed)

2. How disease presents in the elderly • Disease presents atypically

3. Introduction • Five common patterns of disease presentation: • Multiple pathology • Atypical presentation of illness • Late presentation • Silent presentation • Weakness, dependency and the pseudo-silent presentation of illness

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. Conclusion

18. Old man

19. Another old man

20. 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.

21. 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

22. Pitfalls in the Consultation Process cont’d Diagnostic Pitfalls

23. 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.

24. 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.

25. 1.2 The muscles : • Atrophy • Ptosis of eyelids, may suggest myastenia gravis

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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 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.

33. 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.

34. 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”

35. 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.

37. The endocrines • Hypothyroidism may mimic ageing. • Diabetes mellitus – with ↓glucose tolerance

38. 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.

39. 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!!

40. 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.

41. 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.

42. 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.

43. 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

44. 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.

45. 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.

46. Presentation of cancer in the aged • Widespread metastases • Hormonal syndromes • Hypercalcaemia • Hypoglycaemia • Hypertrophic pulmonary osteoarthropathy • Skin lesions • Abnormal vascular syndromes

47. 1. Widespread metastases • Bone: • pain or pathological fractures • Liver: • pain and enlargement with or without jaundice • Lung: • malignant effusion • Brain • confusion

48. 2. Hormonal syndromes • ACTH: bronchus and pancreas carcinoma • Antidiuretic hormone (ADH): bronchus carcinoma • Gonadotrophin: bronchus carcinoma

49. 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”

50. 4. Hypoglycaemia • It is caused by pancreas island cell or liver cell tumors, secreting insulin or insulin-like growth factor.