How disease presents in the elderly, pitfalls in the consultation process and diagnosis of cancer in the aged

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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)
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How disease presents in the elderly

• Disease presents atypically

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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

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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.

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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.

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2. Atypical presentation contd

• 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.

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2. Atypical presentation contd

• 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.

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2. Atypical presentation contd

• 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.

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2. Atypical presentation contd

• 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.

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2. Atypical presentation contd

• 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

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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.

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3. Late presentation of illness contd

• The doctor may perhaps also share his patients
  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.

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3. Late presentation of illness contd

• 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.

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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.

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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.

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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 patients problems are
  continually evaluated to see whether goals are
  being reached.

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Conclusion
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Old man
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Another old man
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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.

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Pitfalls in the Consultation Process contd

• 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

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Pitfalls in the Consultation Process contd

• Diagnostic Pitfalls

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
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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.

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The skin contd

• 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.

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1.2 The muscles

• Atrophy
• Ptosis of eyelids, may suggest myastenia gravis

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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.

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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 persons blood flow to the brain is
  reduced in heart failure, myocardial infarction
  and cardiac arrhythmia and they present with
  delirium.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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The endocrines

• Hypothyroidism may mimic ageing.
• Diabetes mellitus with ?glucose tolerance

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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.

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Evaluation of the Elderly Person and
Communication Skills

• Eye contact. Sit near to patient.
• Treat the elderly with respect.
• Speak the elderly patients language if possible.
• Do not address the elderly lady as Granny
  without permission, especially if she is not your
  grandmother!!

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Evaluation of the Elderly Person and
Communication Skills contd

• 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.

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Evaluation of the Elderly Person and
Communication Skills contd

• 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.

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Evaluation of the Elderly Person and
Communication Skills contd

• 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.

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Evaluation of the Elderly Person and
Communication Skills contd

• High risk Elderly
• Age over 80 years
• Living alone
• Depression, bereavement
• Intellectual impairment
• Previous falls
• Incontinence

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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.

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Diagnosis of cancer in the aged contd

• Priority must be given to the interests of the
  patient. Often a less aggressive approach is to
  the elderly patients 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.

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Presentation of cancer in the aged

• Widespread metastases
• Hormonal syndromes
• Hypercalcaemia
• Hypoglycaemia
• Hypertrophic pulmonary osteoarthropathy
• Skin lesions
• Abnormal vascular syndromes

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1. Widespread metastases

• Bone
• pain or pathological fractures
• Liver
• pain and enlargement with or without jaundice
• Lung
• malignant effusion
• Brain
• confusion

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2. Hormonal syndromes

• ACTH bronchus and pancreas carcinoma
• Antidiuretic hormone (ADH) bronchus carcinoma
• Gonadotrophin bronchus carcinoma

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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

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4. Hypoglycaemia

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

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5. Hypertrophic pulmonary osteoarthropathy

• Caused by bronchus carcinoma.
• The joints are painful and may mimic rheumatoid
  arthritis
• Finger clubbing may also be present

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6. Skin lesions

• May be an early sign of malignancy e.g.
  acanthosis nigricans which consists of dark
  velvet-like lesions and are often associated with
  gastric carcinoma.

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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.

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Common cancers in the aged

• In 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.

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Common cancers in the aged contd

• Colorectal cancer
• Rectal 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
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Common cancers in the aged contd

• Lung cancer
• It 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 patients
  condition would allow it. In non-small cell
  bronchus carcinoma the median survival rate for
  non-resectable lesions is four months.

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Common cancers in the aged contd

• Breast cancer
• In 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).

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Common cancers in the aged contd

• Ovarian cancer
• It 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

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Common cancers in the aged contd

• Pancreas carcinoma
• It 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 pancreas
• By the time of diagnosis of pancreas carcinoma it
  is often too late.

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Common cancers in the aged contd

• Uterus - endometrial carcinoma
• In 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 patients condition.
  Hormonal therapy with progestogens may
  effectively control elderly patients with
  endometrial carcinoma.

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Common cancers in the aged contd

• Oesophagus carcinoma
• Dysphagia 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.

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Oesophagus Carcinoma
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Common cancers in the aged contd

• Gastric carcinoma
• It 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.

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Common cancers in the aged contd

• Prostate carcinoma
• More than 50 of men 60 ? histological foci of
  adenocarcinoma
• Only 1/3 clinically diagnosed
• Starts with symptoms of obstruction or infection
• Confirmed by digital rectal examination or PSA
• Prostate specific antigen ? false and
• However, high PSA (40) ? high risk

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Common cancers in the aged contd

• Transurethral 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.

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Common cancers in the aged contd

• Prostate cancer is staged by the Gleason scale
  (1-10), 1 indicating well differentiated and 10
  indicating poorly differentiated.

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Concluding remarks

• The difficulty of geriatric care is compounded
  by
• Atypical disease presentation
• Doctor-patient relationship is crucial
• 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

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• Thank you