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ILLNESS PRESENTATION IN THE ELDERLY

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ILLNESS PRESENTATION IN THE ELDERLY Y. Beloosesky, A. Weiss Department of Geriatrics Rabin Medical Center, Beilinson Hospital ILLNESS PRESENTATION IN THE ELDERLY ... – PowerPoint PPT presentation

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Title: 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
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