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Atypical Presentation of Illness in the Elderly

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Atypical Presentation of Illness in the Elderly Saturday CME General Session Atypical Presentation of Illness in the Elderly Dale C. Moquist, MD Former Geriatric Coordinator Memorial Hermann Family Medicine Residency, Sugar Land Horseshoe Bay, Texas Educational Objectives By completing this educational activity, the participant should be better able to: 1. Discuss how the presentation of an acute illness is modified in older patients. 2. Identify what is taken as "normal" in the elderly can be a treatable or preventable illness. 3. Discuss what illnesses can be hidden in the elderly. Speaker Disclosure Dr. Moquist has disclosed that neither he nor members of his immediate family have a relevant financial relationship with an ineligible company. 11 Disclosure Atypical Presentation of Illness in the Elderly Dr. Moquist has disclosed that neither he nor members of his immediate family have a relevant financial relationship with any ineligible companies in the past 24 months. What is Going on With Grandma? Dale C. Moquist, MD C. Frank Webber Lectureship April 17, 2021 1 2 12 Goals By the end of this educational presentation, learners will be better Outline able to: 1. Discuss how the presentation of an acute illness is modified in Altered Physiology in the Elderly older patients. Altered Presentation in the Elderly 2. Identify what is taken as "normal" in the elderly can be a The Ms of Geriatric Care Altered Disease Presentations treatable or preventable illness. 3. Discuss what illnesses can be hidden in the elderly. 3 6 36 Changes in Body Composition with Age Altered Physiology in the Elderly • Bone mass, lean mass, water content Body Composition • Total body fat, commonly with intra-abdominal fat stores Thermal Variance • Cannot generalize well-standardized nutrient requirements of Nutrition Musculoskeletal young or middle-aged adults to older adults Endocrine Cardiovascular Pulmonary Renal 7 8 78 1 What is Normal in the Elderly? Nutrition Changes Gastric emptying delayed with fatty meals Compromised function not evident in resting state Decreased absorption of Vitamins A, D, K and Zinc Physiologic effects present when internal/external stressors Decreased Vitamin D production by skin Systems-wide dysregulation and loss of maintenance Decreased sense of smell Decreased response to thermal variance Altered flavor preferences Loss of fat and thinning of skin Decreased Iron, B12, and Calcium absorption Loss of sweat glands Decreased saliva production leads to oral infection Decreased blood flow to the skin Increase in achlorhydria Decreased muscle mass Atrophy of muscle layers leads to diverticula, decrease in transit time, and Fewer neurons to monitor temp constipation 9 10 910 Musculoskeletal Changes Endocrine Changes in Aging Joints become stiffer and less flexible Thyroxine does not change: Production declines and clearance decreases TSH shifts to higher levels in > 80 Decrease in bone density Triiodothyronine (T3) levels are unchanged until extreme old age Decrease tone and contractility Decrease in aldosterone and cortisol Movement slows and become limited Steady state of cortisol remains unchanged Decreased coordination and muscle weakness Increase in parathyroid, erythropoietin and norepinephrine Places overweight and obese at increased risk Decrease in testosterone Decrease in estrogen Decrease in growth hormone Negative feedback delayed after a stressor 11 12 11 12 Audience Polling Question #1 Prevalence of CVD Changes in the Heart Include Age Cohort Men Women 1. Increase in size and weight 20–39 years old 11.9% 10.0% 2. Increase in L ventricular wall thickness 40–59 years old 40.5% 35.5% 3. L atrium dilates 60–79 years old 69.1% 67.9% 4. L ventricular cavity size does not change ≥80 years old 84.7% 85.9% 5. None of the above 6. All of the above The prevalence of CVD increases progressively with age, exceeding 80% in both men and women >80 years old. 13 Slide 14 13 14 2 Principal Effects of Aging on the Principal Effects of Aging on the Cardiovascular System Cardiovascular System Age Effect Clinical Implication Age Effect Clinical Implication ↑ Arterial stiffness ↑ Afterload and systolic BP Impaired endothelium-dependent ↑ Demand ischemia and risk of coronary vasodilation artery disease and peripheral arterial ↓ ↑ Myocardial relaxation & Risk of diastolic heart failure and atrial disease compliance fibrillation ↓ Baroreceptor responsiveness ↑ Risk of orthostatic hypotension, falls, ↓ Impaired responsiveness to β- Maximum heart rate and cardiac and syncope adrenergic stimulation output; impaired thermoregulation ↓ Exercise response ↓ Exercise capacity and ↑ cardiac ↓ ↑ Sinus node function and Risk of sick sinus syndrome, (↓ maximal heart rate, maximal complications (ischemia, heart failure, conduction velocity in the atrioventricular block, left anterior cardiac output, VO2 max, coronary shock, arrhythmias, death) with illness atrioventricular node and fascicular block, and bundle branch blood flow, peripheral vasodilation) infranodal conduction system block 15 16 Clinical Effects of CV Changes Cardiac Procedures in Adults > 65 • In healthy older adults, age-related changes have modest clinically relevant effects on cardiac hemodynamics and performance at rest 71% of CVD hospitalizations Resting heart rate, ejection fraction, stroke volume, and cardiac output are >50% of percutaneous and surgical coronary procedures well preserved even at very advanced age 60% of defibrillator implantations • Ability to respond to increased demands associated with exercise or 71% of arterial endarterectomies illness (either cardiac or noncardiac) declines progressively with advancing age 82% of permanent pacemakers Peak aerobic capacity declines inexorably with age 17 Slide 18 17 18 Audience Polling Question #2 Age-Related Pulmonary changes include all of the following Pulmonary Changes except: • Reduced airway size 1. Decreased elastic recoil • Shallow alveolar sacs • Reduced chest wall compliance 2. Surface of the lung decreases • Intercostal muscle atrophy 3. Residual volume decreases • Reduction in diaphragmatic strength by 25% 4. Vital capacity decreases • Decline of Forced Vital Capacity (FVC) 5. Forced vital capacity decreases • PaO2 decreases with age: 110-(0.4 X age) 19 20 19 20 3 Difficulties in Recognizing Urinary Changes Respiratory Symptoms Kidney size and weight decreases • A common misperception is that older people tend to GFR declines overestimate or exaggerate respiratory symptoms – the opposite Concentrating ability declines is more often true Impaired electrolyte homeostasis • Older people often have more than one cause of their problems Serum creatinine overestimates kidney function Dyspnea, cough, and wheezing may overlap Decrease in renal blood flow The causes may include a combination of diseases such as Decrease in ability to resorb glucose asthma or emphysema, obstructive sleep apnea, heart failure, Decrease in renal clearance of drugs and toxins and GERD 21 22 21 22 Lower Urinary Tract Changes Bladder contractility decreases Altered Presentation in the Elderly Uninhibited bladder contractions increase Diurnal urine output occurs later in day Different 95th Percentile Sphincteric striated muscle attenuates Why Altered Presentation Post void residual increases Lots of Icebergs Bladder capacity decreases Rule of Fourths Vaginal mucosal atrophy is prevalent Disease Presentation Prostate hypertrophy in men 23 25 23 25 Why Altered Acute Presentation? Altered central processing Direct effect of the brain by the illness Patients' negativity: No chief complaint Tolerate symptoms limiting activities Fear of illness and treatment Hospitalization Institutionalization Denial of symptoms Ignorance of significance of bodily changes Peripheral sensitivity Reduced sensation and awareness Unrecognized depression 26 27 26 27 4 More on Altered Presentation Decrease in functional reserve Reduced stamina and fatigue Increase of physiologic diversity: What is normal Environment and function Immobility Multiple morbidities Iatrogenesis Icebergs are common 28 29 28 29 Rule of Fourths Disease Presentation ¼ Due to Disease: Medical Treatment Abrupt change in functional status ¼ Due to Disuse: Activity Regimen Falls occurring as prodrome to developing illness Brain is especially vulnerable organ ¼ Due to Misuse: Prevent & Preserve Limited reserve of several organ systems: Certain illnesses present in ¼ Due to Physiologic Aging: Adapt & Compensate an organ system remote from those primarily affected Cardiovascular symptoms are often symptoms of other illnesses Sloane P.; Chapter 1 Principles of Primary Care of Older Adults; Primary Care Geriatrics. Elsevier 2014. 30 31 30 31 Mind/Mentation The Ms of Geriatric Care Maintaining mental activity Abrupt change in cognitive function = Delirium Dementia may be underlying chronic condition Mind/Mentation D rugs Micturition Eelectrolytes L ack of Drugs Mobility I nfections Medications R educed Sensory Multi-Complexity I ntracranial U rinary Retention Matters Most M yocardial 32 33 32 33 5 Micturition Problem = Incontinence Instability Leads to Mobility Problem Warning signs of underlying disease Falls can start the escalating loss of independence Delirium Fear of fracture Infection Especially hip fracture A trophic Vaginitis P harmaceuticals Inability to take care of oneself P sychologic –Think Depression ADLs E ndocrine IADLs Restricted Mobility Underlying disease S tool Impaction 34 35 34 35 Another Mobility Problem: Immobility Medications
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