Disease Presentations in the Older Adult

Question 1

What is homeostenosis?

Answer 1

Question 2

Why are non-specific complaints important?

Most frequent symptoms in A+E inc ?
This group has ? yet often ?

Ageist language is harmful- E.g. ? suggests ? but has ?
These patients need ?

Answer 2

Most frequent symptoms in A+E inc fatigue, weakness, and reduced mobility. This group has 3x increased risk of in-hospital death yet often low triage priority.

Ageist language is harmful- E.g. ‘acopia’ – suggests nothing medically wrong but has morbidity + mortality as high as 22%
These patients need doctors who will think carefully about what the underlying cause(s) of symptoms are!

( “Acopia” refers to a condition where a person is deemed unable to cope with their living situation, often due to functional decline or social issues.)

Question 3

Atypical presentation – the geriatric giants
Immobility
Instability (basically falls)
Intellectual impairment
Incontinence
Iatrogenic

Describe imobility- the causes and consequences

Answer 3

‘Can’t get up’, ‘can’t walk’, ‘generally weak’, ‘off legs’. Causes:
Acute or chronic illness
Medication side effects
Pain
Delirium or dementia
Sarcopenia (accelerated loss of muscle mass and function)
Mood
Lack of mobility aid

Serious consequences if badly managed – pressure ulcers, dependence, death

Question 4

what are the causes of delirium and how is it different to dementia?

Answer 4

Question 5

Atypical presentation – the geriatric giants
Immobility
Instability
Intellectual impairment (delerium or dementia)
Incontinence
Iatrogenic

Describe Incontinence- what are the 4 consequences of incontinence?

Answer 5

Not a normal part of ageing. Types:
Urge – sudden/intense desire to pass urine
stress – urine leaks when bladder under pressure
Overflow – with urine retention
Functional – can’t get to toilet/commode

Consequences
Damage to skin
Infection
Embarrassment
social isolation

Question 6

What are the reversible causes of incontinence?

Answer 6

Question 7

What happens to the immune system with age?

Answer 7

Some activities increase:memory T cells, autoantibodies
Some activities decrease:

• Ab and IL production in response to foreign Ags
• helper T cells ability to proliferate
• macrophage clearance of Ags
• complement pathway during acute infection

Overall immune system becomes less efficient and less appropriate - immune dysfunction rather than a wearing out

Question 8

What are the consequences of the changes to the ageing immune system?

Increased ? with infection
Impaired ? predisposes to ?
Altered ? –> increased ?
Reduced ? –> increased susceptibility to ?
Response to ? may be less good
? surveillance–> ? incidence
Reduced ? –> ? may ? w age

Answer 8

Increased morbidity and mortality with infection
Impaired cellular immunity predisposes to reactivation of certain disease e.g., shingles, TB
Altered Ab production –> increased fatality from pneumonia, flu, hospital acquired infection
Reduced lymphokines –> increased susceptibility to parasites
Response to vaccination may be less good
Falling immune surveillance–> higher cancer incidence
Reduced IgE hypersensitivity –> allergies may improve w age

Question 9

How does temperature regulation change with age?

• Impaired ? (reduced SNS activity)
• Reduced ? – less ?
• Reduced ? (sarcopenia)
• Fewer cells in ?, reduced ?
• ? –e.g. ?
• ? - eg
• Cognitive ?, Social ?–> ?

All of these factors increase the risk of ?

Answer 9

• Impaired vasodilation + vasoconstriction (reduced SNS activity)
• Reduced subcutaneous fat – less insulation
• Reduced shivering (sarcopenia)
• Fewer cells in hypothalamus, reduced sensitivity to feedback
• Chronic diseases –e.g. hypothyroid, malnutrition
• Meds - Beta-blockers, neuroleptics, sedatives
• Cognitive impairment, Social isolation–> hard to put on jumper, turn heating on etc

All of these factors increase the risk of hypothermia in elderly

Question 10

making a diagnosis can be difficult becuase symptoms can present differently in the elderly. give examples of this

Answer 10

• Hypoglycaemia – more likely to have confusion, slurred speech, visual disturbance (related to low brain glucose) than classical sweating, palpitations, tremor
• PE – less likely to have pleuritic chest pain or hemoptysis, more likely to have syncope
• TB – less often have fever, sweating or haemoptysis
• Covid– fever, cough and breathlessness can be absent. Instead, may be delirium, falls, malaise, functional decline, dizziness, headache, diarrhoea, nausea/vomiting, abdo pain

Question 11

Why else is making a diagnosis difficult in the elderly

Answer 11

Comorbidities= misleading, hard to distinguish pathology from ‘normal ageing’ or frailty. Symptoms can be multifactorial

Also, obs can be misleading- tachycardia may be absent in physiological stress due to reduced ability to respond to beta adrenergic stimulation. B blockers can mask tachycardia
May not have fever with infection; i.system produces fewer cytokines, leukotrienes and other inflammatory markers.

Hypotension may not develop as quickly in response to hypovolaemia or sepsis bc peripheral vasculature= less elastic