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Unusual Presentations of Illness in the Elderly

By Richard W. Besdine, MD, Professor of Medicine, Greer Professor of Geriatric Medicine, and Director, Division of Geriatrics and Palliative Medicine and of the Center for Gerontology and Healthcare Research, Warren Alpert Medical School of Brown University

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In the elderly, many common conditions can exist without their characteristic features. Instead, the elderly may have 1 nonspecific geriatric syndromes (eg, delirium, dizziness, syncope, falling, weight loss, incontinence). These syndromes result from multiple disorders and impairments; nonetheless, patients may improve when only some of the precipitating factors are corrected. An even better strategy is to identify risk factors for these syndromes and correct as many as possible, thus reducing the likelihood of the syndrome’s developing at all.

Although virtually any illness or drug intoxication can cause geriatric syndromes, the following disorders are especially likely to trigger one or more of them, sometimes instead of causing the typical symptoms and signs.

Acute bowel infarction may be indicated by acute confusion. Abdominal pain and tenderness may be minimal or absent.

Appendicitis pain tends to begin in the right lower quadrant rather than periumbilically. Eventually, pain may be diffuse in the abdomen rather than localized to the right lower quadrant. However, tenderness in this quadrant is a significant early sign.

Bacteremia causes a low-grade (at least) fever in most elderly patients, although fever may be absent. The source of bacteremia may be difficult to identify. Elderly patients may have nonspecific manifestations (eg, general malaise, anorexia, night sweats, unexplained change in mental status).

Biliary disorders may result in nonspecific mental and physical deterioration (eg, malaise, confusion, loss of mobility) without jaundice, fever, or abdominal pain. Abnormal liver function test results may be the only indication.

Heart failure may cause confusion, agitation, anorexia, weakness, insomnia, fatigue, weight loss, or lethargy; patients may not report dyspnea. Orthopnea may cause nocturnal agitation in patients who also have dementia. Peripheral edema is less specific as a sign of heart failure in elderly than in younger patients. In bedbound patients, edema may occur in the sacral area rather than in the lower extremities.

Hyperparathyroidism may cause nonspecific symptoms: fatigue, cognitive dysfunction, emotional instability, anorexia, constipation, and hypertension. Characteristic symptoms are often absent.

Hyperthyroidism may not cause the characteristic signs (eg, eye signs, enlarged thyroid gland). Instead, symptoms and signs may be subtle and may include tachycardia, weight loss, fatigue, weakness, palpitations, tremor, atrial fibrillation, and heart failure. Patients may appear apathetic rather than hyperkinetic.

Hypothyroidism may manifest subtly in elderly patients. The most common symptoms are nonspecific (eg, fatigue, weakness, falling). Anorexia, weight loss, and arthralgias may occur. Cold intolerance, weight gain, depression, paresthesias, hair loss, and muscle cramps are less common than among younger patients; cognitive dysfunction is more common. The most specific sign—delayed tendon reflex relaxation—may not be detectable in elderly patients because of decreased amplitude or absent reflexes.

Meningitis may cause fever and a change in mental status without symptoms of meningeal irritation (eg, headache, nuchal rigidity).

MI may manifest as diaphoresis, dyspnea, epigastric discomfort, syncope, weakness, vomiting, or confusion rather than as chest pain. After the onset of chest pain or other presenting symptoms of MI, elderly patients tend to delay longer than younger patients in seeking medical assistance.

Peptic ulcer disease may not cause characteristic ulcer symptoms; pain may be absent or nonspecific. Dyspepsia (usually epigastric discomfort with bloating, nausea, or early satiety) is more common among elderly than among younger patients. Elderly patients have more frequent, more severe GI bleeding, which may be painless. Slow, unrecognized blood loss may occur, resulting in severe anemia.

Pneumonia may be indicated by malaise, anorexia, or confusion. Tachycardia and tachypnea are common, but fever may be absent. Coughing may be mild and without copious, purulent sputum, especially in dehydrated patients.

TB may manifest differently in elderly patients with coexisting disorders. Symptoms may be nonspecific (eg, fever, weakness, confusion, anorexia). Pulmonary TB may manifest with fewer respiratory symptoms (eg, cough, excessive sputum production, hemoptysis) than in younger patients.

UTIs may be present in afebrile elderly patients. These patients may not report dysuria, frequency, or urgency but may experience dizziness, confusion, anorexia, fatigue, or weakness.

Other problems that manifest differently in the elderly include alcohol abuse, adverse drug effects, depression, pulmonary embolism, systemic infections, and unstable angina.