I found him unconscious.
I was called to see this 78-year-old man. He was diagnosed with dementia, but it did not hinder his daily activities prior. He was still able to walk, talk and even eat on his own. That day, his family found him unresponsive and unconscious. They called me, frantic and anxious.
I went to see him. Like what his family claimed, he was not arousable.
I checked his blood pressure and oxygen levels – which were all within normal range.
Could he have suffered a stroke or heart attack? His electrocardiogram (ECG) result was fine.
His neurological examination was also normal.
What could it be? I thought to myself.
I probed the family members further. Did he have constipation?
‘Ya, he has had constipation for many years already.’
When did he last pass stools?
‘For almost 1 week already, doctor.’
One week!
I quickly put in an IV drip, gave him stool softeners and an enema to evacuate his bowel.
He managed to pass stools and regained consciousness 6 hours later.
What we initially thought was a stroke was in actual fact, an issue related to constipation.
I have had many experiences like this.
Geriatric patients have an unusual presentation of common diseases.
Take a fever or cold for example. A younger person is bound to have a fever, cough and runny nose. If they have a lung infection, also known as pneumonia, they will likely present with classic signs of cough, breathlessness, fever, rigours and chills. However, elderly people seldom present with fever. Instead, they become weak, lethargic, all the while refusing to eat and move.
Caregivers may misinterpret it as them being stubborn when in actual fact, they are sick.
From my clinical experience as a doctor, I have come to realise that it is very difficult to detect and diagnose the underlying issue in the early stages of the disease. That is why many of the elderly receive treatment late.
What we assume is a normal process of ageing, stubbornness or being uncooperative could have something sinister lying underneath.
Is it a Normal Process of Aging or… Not?
It can be hard to determine if an elderly person is healthy or not.
Is poor appetite due to a physiological decrease in appetite, or is it a red flag for dementia?
Is his/her constipation due to a normal process of ageing caused by weak pelvic floor muscles and immobility or is there obstruction of the small intestines?
The main message is this: Abnormal signs and symptoms are actually more common in elderly people for various reasons.
A change in mood and behaviour may not simply be them being ‘difficult’ or ‘obstinate’, but a possible underlying illness.
As caretakers and family members, it is important for us to be able to pick up subtle signs of sickness and bring them up to their doctors.
Who is at Risk?
It can be harder to distinguish between those who
- Are of older age
Especially those above the age of 85.
- Have various medical conditions
This is extremely common amongst the elderly, as the number of comorbidities we develop tends to increase as we age.
- Take different types of medications
Polypharmacy can cause a lot of side effects, which may also mask symptoms of acute diseases.
- Already have an impaired cognitive function
They may not be able to communicate any form of discomfort or pain, which can make spotting symptoms a challenge.
So then, what symptoms do we ought to look out for?
Fret not!
As caretakers and/or family members, we are the most familiar with the individual’s day-to-day moods and behaviour. We are the ones who are the most in tune with their daily habitual patterns, when they wake up, how often they eat, their personalities, their likes and dislikes.
Thus, we are able to pinpoint and identify anything that does not seem right.
Here are some questions that ought to spark our concerns:
- Has there been any recent mood changes?
Are they perhaps more subdued, and not so talkative? Are they confused or agitated?
- Have there been any changes to their medication since this started?
This helps us identify if it is a side effect of a medication, or something else.
- Is this the first time that this has happened?
If yes, were there any potential triggers- a fall, a recent sick member in the family?
- When was the last time he/she was sick? What were his/her symptoms like?
Subtle patterns of how they exhibit illnesses can help us identify the illness at an early stage and treat them.
Abnormal Presentations
Infection
When we fall sick, hallmark features include fever and muscle aches. Did you know? One-third of elderly adults do not present with fever when they have infections!
A study done in Thailand found that 34.4% of people above 65 years old who presented at the emergency department did not have a fever.
Pneumonia (Lung infection)
Typical symptoms would include cough, breathlessness and fever.
In the elderly, they may simply appear tired, lethargic and confused.
Urinary tract infection (UTI)
A young adult would typically present with painful urination, increased urge to urinate, fever and chills.
An elderly adult may not have any of those symptoms! Instead, they actually appear confused, wet themselves (incontinence), and have a low appetite.
Other abnormal presentations we ought to watch out for are sudden falls, changes in mental state, and refusing to drink or eat.
Interesting fact:
Older adults have a lower basal temperature due to reduced muscle mass and reduced thermogenesis after eating! A temperature of >37.3℃ (which is otherwise normal in a young adult) may suggest infection.
Heart disease
Heart attack
Typical symptoms would be crushing chest pain, breathlessness, nausea and vomiting. The pain may radiate to our left arm and neck.
However, older adults may only experience dizziness, tiredness, palpitations, fainting spells, and even confusion.
They may not even complain of chest pain! In fact, only 40% of adults above the age of 80 years old have chest pain during a heart attack!
Heart failure
Typical presentations would include leg swelling (peripheral edema), tiredness and breathlessness.
However, changes may appear gradually and subtly in older adults. These include loss of appetite, reduced mobility and confusion.
Abdomen Issues
What tummy disorders are there?
Cholecystitis (inflammation of the gallbladder), bowel obstruction, diverticulitis (where small pouches of the intestines become infected or inflamed), and cancer. These are some of the many.
Typically, a person would present with abdominal pain, nausea, vomiting, sweating and fast heart rate.
However, symptoms may be vague in the elderly – no tummy pain (a ‘silent’ presentation), slight discomfort, constipation, loss of appetite, or change in mobility.
The core issue with abdominal issues is that symptoms exhibited by the elderly are vague.
Hence, they are only discovered at late stages, which in turn, results in high mortality rates.
Furthermore, the elderly may not be willing to voice out their discomfort as they do not want to be a burden or fear losing independence.
Cognitive Impairment
Dementia and depression are sadly still underdiagnosed among older adults.
1 in 4 people above the age of 80 suffer from dementia.
Dementia
Cognitive changes are subtle. It may start off with reduced function, and difficulty in understanding or perception of surroundings.
An elderly person may become delirious, which is often triggered by infection, dehydration, and organ failure.
In Alzheimer’s disease, their memory and language will be affected.
Depression
A typical presentation would be low mood, sadness, disturbed sleep and loss of appetite.
However, in the elderly, they might actually have a lack of sadness. In fact, they may appear agitated or have vague tummy symptoms like discomfort, and constipation.
It often goes undiagnosed, as we often chalk it up to a physiological process of ageing (empty nest syndrome), or due to the side effects of medication.
Thyroid issues
Hyperthyroidism
This is a condition where there is an increased production of thyroid hormones in the body.
This disease can cause palpitations, fast heart rate, insomnia and weight loss.
However, an elderly may paradoxically feel tired, lethargic and confused.
Hypothyroidism
This condition is the opposite of hyperthyroidism.
Typical symptoms include sluggishness, lethargy, weight gain and feeling cold all the time. However, in older adults, it may present as the opposite! They may actually feel confused and become easily agitated.
Something is ‘Off’
It can be hard to pick up the subtle signs. It is easy for us to blame ourselves and beat ourselves up for not detecting certain diseases sooner, or for chalking them up to being ‘difficult’. However, we need to understand that the elderly person does not present with typical symptoms like younger adults. Knowledge is power.
As caretakers and family members, we know our elderly people best. We are familiar with their behaviours, their likes and dislikes, and their comorbidities. We are able to tell when something just doesn’t seem ‘right’.
Health is wealth, let us continue to be vigilant in loving and caring for our family members.
References
- D. Melady, A. Perry. Ten best practices for the older patient in the Emergency Department. Clin Geriatr Med, 34 (3) (2018), pp. 313-326
- P. Limpawattana, P. Phungoen, T.Mitsungnern, et al. Atypical presentations of older adults at the emergency department and associated factors. Arch Gerontol Geriatr, 62 (2016), pp. 97-102
- Cassandra Vonnes, Rosalie El-Rady, When You Hear Hoof Beats, Look for the Zebras: Atypical Presentation of Illness in the Older Adult, The Journal for Nurse Practitioners, Volume 17, Issue 4, 2021, Pages 458-461, ISSN 1555-4155, https://doi.org/10.1016/j.nurpra.2020.10.017.
- Case Studies: Atypical Presentation of Severe Illness in Older Adults https://www.clinicaladvisor.com/home/meeting-coverage/gapna-2022/atypical-presentation-falls-dizziness-older-adults/
- LANDEFELD C. Atypical Presentations of Illness in Older Adults. In: Current diagnosis and treatment: Geriatrics. New york: Mcgraw-hill; 2014. p. 30–3.
