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Concept Paper Atypical Presentation of Illness in Older Adults

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An atypical presentation of an illness in an older adult can appear as a subtle, nonspecific, or unusual manifestation that is outside the normal range of signs and symptoms for a specific illness. Nursing care of an older adult requires a through assessment of acute, chronic or complex illnesses. Illness in older adults is complicated by numerous medical problems and the physical changes of aging. Identification of an illness can be overlooked simply because symptoms might be reported vaguely. Multiple overlapping factors such as environmental, sociologic, physiologic and psychologic aspects need to be considered in the nursing assessment. It’s essential that nurses recognize atypical presentations of illness in older adults early to help improve patient care. Early detection can reduce the risk of missed diagnoses, death and/or prolonged hospitalization, and reduce rates of co-morbidity from treatable geriatric syndromes (GrayMiceli, 2007). Aging causes physiologic changes to the body. These normal age related changes could be similar to changes seen in the presence of pathological conditions. This causes a problem when normal changes mask early signs of an acute illness. Changes to the musculoskeletal system can affect a patient’s ability to function. Reduced bone mineral density leads to osteoporosis and an increased risk for fall-related fractures (Ebersole, Hess, Touhy, & Jett 2012, p. 48-49). Age related changes to the cardiovascular system are myocardial and blood vessel stiffening, decreased beta-adrenoceptor responsiveness, impaired autonomic reflex control of the heart rate, left ventricular hypertrophy, and fibrosis (Ebersole et al., 2012, p. 49). The older heart might not be able to compensate for physical conditions that impose added cardiac demand, such as infection, anemia, cardiac arrhythmias, surgery, diarrhea, hypoglycemia, malnutrition, or circulatory overload (Ebersole et al., 2012, p. 49). Only subtle age related changes occur in the

Concept Paper respiratory system. Changes to the lungs, thoracic cage, respiratory muscles, and respiratory centers develop as a person ages. Specific changes due to age include loss of elastic recoil, stiffening of the chest wall, inefficiency in gas exchange, and increased resistance to air flow (Ebersole et al., 2012, p. 50). A respiratory deficit can become problematic or life threatening when a patient has a sudden demand for increased oxygen or is exposed to noxious or infectious agents (Ebersole et al., 2012, p. 50). The renal system goes through both anatomical and functional age related changes. Urine is less concentrated, bladder holding capacity decreases,

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and the size and function of the kidneys decrease. Changes causing urinary incontinence increase in frequency but should not be considered a normal part of aging (Ebersole et al., 2012, p. 52). Changes that affect the digestive system can negatively affect comfort, function, and quality of life (Ebersole et al., 2012, p. 53). Teeth become vulnerable to caries and tooth loss, taste buds decline, the mouth becomes dry, food passing through the esophagus becomes sluggish, gastric motility and mucus decrease, stomach pH increases, absorption in the small intestine decreases due to decreased blood flow, and peristalsis slows in the large intestine (Ebersole et al., 2012). How the central nervous system ages is not well understood. The number of neurons in the central nervous system, brain weight, and size of the frontal lobe all decrease with age (Ebersole et al., 2012, p. 54). Mild memory impairments and difficulties with balance may be seen as normal age-related changes. Decreases in immune functioning, changes in lymphocyte function and relative lymphocyte populations all occur with aging (Ebersole et al., 2012, p. 59). This can lead to a greater risk for infection or a delayed response of an infection. The ability to develop adequate immunity after an infection or immunization decreases with age. Some of these physiological age related changes set the stage for increased susceptibility to both illness and to

Concept Paper the way in which a disease presents itself. Unfortunately, many of these changes are unavoidable. There are risk factors that place older adults in jeopardy for atypical presentations of

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illness. Risk factors can include being over age 85, taking multiple medications, having multiple co-morbidities, and a cognitive or functional impairment (Kresevic, 2012). A patient with decreased cognitive, perceptual, or expressive capacity might be unable to articulate their symptoms clearly. Advanced age will cause the body to respond differently to illness because of the physical changes of aging and cumulative effects of multiple medical conditions (Kresevic, 2012). Nonspecific symptoms and classic signs and symptoms that may represent a specific illness can include acute confusion, self-neglect, falling, incontinence, apathy, anorexia, dyspena, fatigue, lack of pain, or reduced mobility. Changes in behavior or function in an older adult are often indicative of an approaching illness (Kresevic, 2012). It is important to take reports of subtle changes from patients, family and care providers seriously. Any reports of mild confusion, a change in the ability to perform activities of daily living, and decreased appetite should be investigated further. To identify an atypical presentation of an illness, assessment will portray a vague presentation of illness, altered presentation of illness and/or under-reporting of illness. A vague, non-specific presentation of illness can be described as the “Giants of Geriatrics.” The Giants of Geriatrics: immobility, instability, incontinence and intellectual impairment (confusiondelirium), are the usual ways in which a disease presents itself in aging patients (Peg GrayVickery, 2010). Illness symptoms in older adults can present a confusing picture of altered presentation. Classic presentation of illnesses in a middle aged adult population will not always

Concept Paper compare to that of older adults. Pneumonia, urinary tract infections, myocardial infarctions and pain are examples of these. Typical signs of pneumonia in older adults will not present with leukocytosis and fever. Instead, older adults will develop a decreased appetite, fatigue, a new cardiac arrhythmia or nausea and vomiting (Peg Gray-Vickery, 2010). Urinary tract infections will not show the usual symptoms of dysuria, frequency, urgency, fever or pain. An older adult will have worsening or a new onset of incontinence, no reports of urgency or frequency, or multiple organisms on a urine culture (Peg Gray-Vickery, 2010). In the case of a myocardial infarction, older adults will report fatigue, nausea, shortness of breath, or a decline in functional status (Peg Gray-Vickery, 2010). Pain is also not typically presented by verbal reports in older adults. Often a change in behavior or function, anxiety, or agitation is the early indicator of escalating pain (Peg Gray-Vickery, 2010). Under reporting of an illness by older adults can

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significantly impact their quality of life. Many symptoms or hidden illness in older adults such as depression, incontinence, musculoskeletal stiffness, falling, alcoholism, osteoporosis, hearing loss, dementia, dental problems, poor nutrition, sexual dysfunction and osteoarthritis are regarded as a “normal” part of aging to families and patients (Peg Gray-Vickery, 2010). They are reluctant to complain or report these symptoms. The nurses have an important role in determining whether or not a presentation of illness is typical or atypical. The nurse must be able to identify normative changes in aging and differentiate them from pathological processes. He or she must also be able to develop interventions to correct adverse effects associated with aging and assist with developing programs to promote successful aging. It is important for the nurse to educate patients, family, and staff members on normal and abnormal age-related changes. The nurse should continue to reassess and monitor elderly patients in their care.

Concept Paper Different strategies are used to help nurses identify atypical presentations of illness. Detection can be accomplished by a thorough nursing assessment. The nursing assessment should be comprehensive and not problem-focused. Data needs to be critically analyzed to determine whether or not an atypical presentation may exist (Gray-Miceli, 2007). Nursing interventions may include taking frequent vital signs, measuring daily intake, output, and daily weights or observing for pain, function and behavior (Gray-Miceli, 2007). Nurses should also monitor for confusion, delirium, incontinence or function decline. This can be accomplished by

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comparing presenting signs and symptoms with the patient’s normal baseline. Family might also be able to provide medical history as to what is normal and abnormal for the patient. Several legal and ethical issues are frequently encountered in the work of gerontological nursing. Elderly patients with atypical presentations of illness make these issues more difficult and unable to be quickly solved. Many ethical dilemmas arise because of inadequate patientclinician communication (Mueller, Hook, & Fleming, 2004). Communicating effectively is a nurse’s duty and an important feature that may prevent ethical or legal dilemmas. One dilemma that may present itself in a patient experiencing atypical symptoms, mistaken for an age-related condition, is the process of informed consent. For example, an elderly patient with impaired cognition due to an undiagnosed acute condition might be treated as if they can understand and evaluate alternative treatments when they truly cannot. Nurses should review the patient’s symptoms, their preferences, and advocate for older adults to protect their rights. The nursing approach to older adults is different from that of a younger person. While assessing an older adult patient, nurses need to remember that familiar warning signs and symptoms of disease may be absent. It can be hard to differentiate age-related changes from true disease pathology. Most older adults have multiple chronic conditions and will not report

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symptoms they believe to be normal. It’s important to never interpret confusion as a normal sign of aging. Older patients are more likely to develop cognitive problems when experiencing acute or chronic illnesses. Timely recognition and treatment of illness will lessen mortality and morbidity and promote optimal quality of life for older adults. Critical thinking will help guide nurses to an appropriate nursing intervention when an atypical presentation is suspected. The high prevalence of nonspecific and atypical presentations of illness in the elderly requires nurses to have a better understanding and knowledge of this growing population.

Concept Paper References Ebersole, P., Hess, P., Touhy, T. A., Jett, K., & Luggen, A.A. (2012). Towards Healthy Aging: Human needs & nursing response (8 th ed.). St. Louis, MO: Mosby.

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Gray-Miceli, D. (2007). Modification of assessment and atypical presentation in older adults with complex illness. Retrieved from http://hartfordign.org/uploads/File/gnec_state_of_papers/gnec_atypical_presentations.pdf

Kresevic, D. (2012). Function: nursing standard of practice protocol: assessment of physical function evidence-based content. Retrieved from consultgerirn.org/topics/function/want_to_know_more

Mueller, P.S., Hook, C., & Flemming, K. (2004). Ethical issues in geriatrics: a guide for

clinicians. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15065621

Peg Gray-Vickery. (2010). Assessing Older Adults. Retrieved from http://www.nursingcenter.com/pdf.asp?aid=976058