PHILADELPHIA – People in their 80s are much more varied in their physical condition than people in their 20s, Dr. Moira Fordyce said at a conference sponsored by the American Society on Aging.
As a result, a physician must carefully assess each elderly patient to determine their status and the body systems that need particular attention.
Of course, aging itself is not an illness, and aging alone does not cause illness. But aging does bring a loss of resilience to most people, and makes the possibility of illness more likely. In addition, normal aging changes coupled with the potential for having multiple problems, taking multiple medications, and having delayed diagnoses means that many disorders have an atypical presentation in the elderly, said Dr. Fordyce, a geriatrician in Belmont, Calif.
Atypical presentations are common in the elderly for disorders that include cardiovascular diseases, infections, constipation, confusion and other central nervous system disorders, diabetes and other metabolic disorders, endocrine disorders such as thyroid disease, and injuries, such as head injuries.
Symptoms and signs of disease are sometimes unreliable, such as pain, temperature, and white blood cell counts. Other types of symptoms require careful investigation, including bowel symptoms such as new-onset constipation or other changes in bowel habits, shortness of breath at rest, bleeding, and a low hemoglobin level.
Other disorders that require assessment include agitation, ankle swelling, confusion, depression, pain, stiffness, and difficulty swallowing.
The interval between physical examinations also needs tailoring to specific patient needs. In robust, older adults, a physical examination every year is not needed, although many patients like an annual connection with their doctor. Time spent with a patient is more important than screening tests, said Dr. Fordyce, who is also a clinical professor of medicine at Stanford (Calif.) University.
Screening tests must be used judiciously, with realistic expectations about the likelihood of disorder in an asymptomatic patient and the potential value of the test's results. Screening tests are limited by the risk for false-positive results, a risk that becomes substantial if enough tests are done. If 20 screening tests are performed on a patient, there is a 64% risk that at least one will be a false positive that identifies an abnormality that really doesn't exist.
Laboratory tests also are more difficult to interpret in elderly patients, in part because the variability of normal values increases with age. But lab tests can add valuable information when they're ordered to rule out or confirm a diagnosis that is suspected based on the history and physical. They also are useful for tracking changes in elderly patients, and to monitor responses to therapy.
Multifactorial clinical syndromes are a special problem for the elderly. Falls, for example, can have several intrinsic or extrinsic causes. Elderly patients who have had more than one fall in the prior year should be carefully evaluated to find the reason.
Other multifactorial syndromes include urinary incontinence, which is not a normal consequence of aging. Incontinence is a symptom, not a disease, and while it is often neglected, all types can be helped, and some sorts even cured. Incontinence can have local causes, such as a tumor, stone, or weak pelvic floor muscles; a general cause such as dementia or stroke; causes of transient incontinence include drugs, retention, infection, and polyuria.
Confusion is more common as a presenting feature of illness than fever or pain in the elderly. It can result from medical causes, medications, mobility issues, delirium, dementia, and depression. “Find and treat the treatable [confusion] as soon as possible, and manage the irreversible,” Dr. Fordyce advised.
Cognitive impairment and dementia are, of course, common syndromes affecting the elderly. About 80% of everyone older than 70 has some age-related change in their memory. But cognitive impairment and dementias involve memory loss that is worse than expected for age. About 40% of people with cognitive impairment progress to dementia within 3 years.
Dr. Fordyce recommended testing elderly patients with the 30-question, Mini-Mental Status Examination. Asking the patient to draw the face of a clock and fill in the numbers is also a sensitive test, she said. Other effective screening tools are asking the patient to name in 2 minutes as many flowers or other items in a list as they can. A patient who says they're worried about their memory usually does not have Alzheimer's disease. If a caregiver says that the patient has memory problems, Alzheimer's is much more likely, she said.