At Atypical Presentation of Di Disease i in t the O Older Ad - PDF document

8/17/20 At Atypical Presentation of Di Disease i in t the O Older Ad Adult James Lin, DO, MS (Med Ed) President of the LECOM Institute for Successful Aging 1 Le Learn rning O Object ctives By the end of this lecture, the attendee will be able to: • Recognize ageism in healthcare • Identify characteristics of aging • Understand age-related physiologic changes in the older adult • Recognize the atypical presentation of disease in the older adult • Recall atypical presentations of specific diseases 2 1

8/17/20 Ag Ageism in Healthcare Ageism: Process of systematic stereotyping and discriminating people because they are old • Lack of training of geriatric professionals • Older adults are less likely to receive preventative healthcare • Older adults are less likely to be tested for diseases • Older adults are more likely to receive inappropriate or incomplete treatments • Aging seen as a disease state • Failure to pursue uncomfortable subjects • Exclusion from clinical trials 3 Health Health Lit iter erac acy Your naicisyhp has dednemmocer that you have a ypocsonoloc. A ypocsonoloc is a test for noloc recnac. It sevlovni inserting a elbixelf gniweiv epocs into your mutcer. You must drink a noloc noitaraperp diuqil the night before the noitanimaxe to clean out your noloc. 70% of 85+ year olds have low health literacy 43% of 65+ year olds have high school or less education 4 2

8/17/20 Hi History y Taki king • 75% of diagnosis can be made by history alone • Incomplete history = missed diagnosis • In 77% of interviews, patient problems are not fully elicited • In 70% of interviews, physicians interrupt patient after 18 sec 5 Ch Chief Comp Complaint It depends on who you ask: • Patient: “No complaints, I feel fine” • Daughter: “Difficulty getting around the house, I am afraid she may fall” • Physician: “Blood pressure should be better controlled” 4M’s – “What matters?” 6 3

8/17/20 Ch Characteri ristics of of Ag Aging • AGING is the progressive decline and deterioration of functional properties at the cellular, tissue, and organ level that lead to a loss of homeostasis, decreased ability to adapt to internal or external stimuli, and increased vulnerability to disease and mortality • It is NOT a disease • Does not cause symptoms • Occurs at different rates • Among individuals • Within individuals – organs age at different rates • Increases susceptibility & vulnerability to disease • Mortality increases exponentially 7 Pr Presentat ation of Disease Less than 50% of older adults present with classic symptoms due to four general causes 1. Age-related physiologic changes 2. Age-related loss of physiologic reserve 3. Under-reporting of symptoms 4. Interactions of chronic conditions with acute illnesses 8 4

8/17/20 At Atypical Pr Presentat ation of Disease • Differences in the way diseases behave when occurring in older persons • Differences in the way older persons behave when afflicted with disease • Additive effects of aging restrict capacity to maintain homeostasis • Blunting or absence of typical/classic symptoms and signs • Causes delays in diagnosis, treatment and may contribute to mortality and morbidity 9 Atypical At Pr Presentat ation of Disease • Defined as symptoms occurring outside of the normal rubric of traditional signs and symptoms, which may signify an impending acute illness • Risk factors: • Over age 85 • Multiple comorbidities • Multiple medications • Cognitive or functional impairment 10 5

8/17/20 Ag Aging Bo Body: Br Brain • Brain peaks in size at age 25 • Area of cerebral ventricles relative to total brain area increases three to four times • ↓ number of nerve cells in brain • ↓ cerebral blood flow by 20% • IQ is highest between ages 18 - 25 • Creativity peaks in the 30s, then declines “The effective, moving, vitalizing work of the world is done between the ages of 25-40” - Sir William Osler 11 Ag Aging Bo Body: Br Brain Intellect • Maintained until at least age 80 • Slowing in central processing → tasks take longer Verbal skills • V ocabulary 3x as large at age 45 as it is at age 20 • Maintained until age 70 • Gradually ↓ in vocabulary, ↑ semantic errors Mentation • Mild difficulty learning and forgetfulness in non-critical areas • R ecall of important memories not effected 12 6

8/17/20 Ag Age-As Associated Me Memor mory I Imp mpairme rment • Normal age-related forgetfulness • Unrelated to any pathologic process • Primary features are: 1) Reduced multitasking performance 2) Reduced processing speed 3) Delay in retrieval of information 13 Br Brain Function on on on EEG • Normal brain function produces chaotic electroencephalographic (EEG) fluctuations with changes related to the state of consciousness • EEG frequencies of aging subjects show a loss of low-voltage fast waves and an increase in slow waves with diffuse slow periodicity • EEG latency, amplitude, and range of EEG frequencies elicited in response to light, sound, and hyperventilation decline with age 14 7

8/17/20 Men Mental Hea Health Mental disorders are not a part of normal aging 18-54 yrs 55+ yrs Any anxiety disorder 16.4% 11.4% Any mood disorder 7.1% 4.4% Cognitive impairment 1.2% 6.6% Any mental disorder 21.0% 19.8% 15 Atypical Presentation of At Dep Depres ession Compared to younger adults, older patients: Less “mood symptoms” • More somatic symptoms - pain, weight loss, insomnia • More irritability or anxiety • Decreased functional status • Social isolation, poor grooming/self-neglectful behaviors • Complicated by: Co-existing medical problems • Cognitive deficits • Multiple medications • 16 8

8/17/20 Ag Aging Bo Body: Pe Peripheral Nervous System • ↓ number of spinal motor neurons • Nerve conduction slows • Decreased fine motor control • ↓ vibratory sensation • ↓ thermal sensitivity (warm-cool) • Impaired proprioception • Impaired two-point discrimination 17 Aging Body: Vi Vision • Lens becomes less transparent, yellows • More rigid iris, ↓ pupil diameter • Optic nerve, retina become less efficient • Ciliary muscle atrophies • Difficulty focusing on near objects • Decrease ability to judge distances • Decrease ability to discriminate between colors • Decrease dark adaptation • Decrease ability to adapt to glare 18 9

8/17/20 Pr Presbyopia • Age-related vision change in which increased distance is needed to focus near objects • Due to decreased lens elasticity and atrophy of the ciliary muscle • Begins very slowly beginning sometime during the fourth decade of life 19 Ag Aging Bo Body: Hearing • By 30, ability to hear higher frequency begins ¯ • Each decade, the hearing loss gets 2½ x worse • 50% decline is clinically important Cochlea EAC Loss of hair cells Ossicles Stiffening of basilar Thickened tympanic membrane membrane Joints Cerumen drier and Neuronal loss degenerate thicker • Difficulty discriminating source of sound 20 10

8/17/20 Pr Presbycusis Hearing loss ascribed to aging effects 21 Ag Aging Bo Body: Ta Taste & Smell • Atrophy of and ↓ number of taste buds • Beginning in early 20s, ability to detect salty or sweet things decreases • ↓ Thirst drive • Olfactory impairment in 25% of 65+, 63% in 80+ 22 11

8/17/20 Ag Aging Bo Body: GI System Age-Associated Change Possible Outcome ↓ stomach acid production Atrophic gastritis Impaired acid clearance GERD Slowing of gastric emptying, reduced ↑ meal-induced satiety antral stretch Impaired response to gastric Increased risk of gastric & duodenal mucosal injury ulcers ↓ liver size by 25% by age 70, ↓ Impaired clearance of drugs blood flow by 10%/decade ↓ effective colonic contraction Constipation ↓ tensile strength of smooth muscle Diverticulosis in colonic wall Vitamin B12, iron, calcium ↓ absorption deficiency 23 Atypical Presentation of At GI Dis GI iseas ase • Gastrointestinal ulcer or reflux disease • Older adults report pain is subtle, atypical or absent compared to sharp, localized pain • Acute appendicitis • Older adults report diffuse abdominal pain, confusion, urinary urgency, absence of fever compared to right lower quadrant pain, fever 24 12

8/17/20 Ag Aging Bo Body: Pu Pulmonary Syste tem • Airway size ↓ • Mucociliary clearance slows & is less effective • Chest wall stiffens, diaphragm weakens by 25% • Costochondral cartilage becomes calcified & intercostal muscle contraction accounts for less chest expansion so that by age 65, inspiration depends on abdominal muscles • Enlargement of alveolar ducts results in a decreased surface area for gas exchange • Decreased responses to hypoxemia, hypercapnia, and mechanical loading 25 Ag Aging Bo Body: Pu Pulmonary Syste tem • ↓ Elastic recoil of the lung, ↑ Residual volume • Forced vital capacity ↓ by 0.15-0.3liters per decade • Forced expiratory volume in 1 second ↓ by 0.2-0.3liters per decade • Aerobic capacity decreases 1% per year between ages 20 and 60 = 40% • Ventilation/perfusion mismatch changes arterial pO2 age appropriate pO2 = 100 - (age/3) 26 13