Presentation of Disease in Older Adults Dr John S. Platt - - PowerPoint PPT Presentation

Presentation of Disease in Older Adults

Dr John S. Platt Consultant Physician in General Medicine and Medicine for the Elderly 28/2/13

The geriatrician’s role in care of

• lder people
• Unselected acute medical

admissions

• Ward rounds and

multidisciplinary meetings

• Outpatient clinics
• Stroke and TIA services
• Falls service
• Other specialist clinics eg

Parkinson’s disease, memory , incontinence

• Orthopaedic liaison
• Psychogeriatric liaison
• Referrals from other

departments

• Support of general

medical wards

• Day hospital
• Domiciliary visits
• Teaching and training
• Management

Leonardo da Vinci 1452-1519

Jeanne Calment 1875 -1997

Emma Freud re: father Clement

• Freud. Guardian 24/4/10
• He was 84 and hated being old. He was

many stone overweight, his legs hurt constantly, he was slow and lame, and things were going on in the waterworks area with which I refused to engage.

• For the last 10 years of his life he was

actively waiting for his death.

Physical Ageing

• Intrinsic age-related causes of cellular

damage

• Extrinsic causes of cellular damage over a

long period of time : diet, tobacco, alcohol , excess / inadequate exercise, sunlight

• Diseases : especially those of increased

prevalence in old age, often multiple

Effects of ageing on function

• Reduced functional capacity
• Reduced ability to cope with challenges
• Impaired homeostasis

Effects of ageing on physical function

• Impaired homeostasis:

hypothermia, dehydration

• Impaired kidney function:

drug toxicity

• Increased brain sensitivity

to drugs and alcohol

• Increased sway
• Impaired postural reflexes
• Reduced immunity
• Age related memory

impairment

• Reduced muscle strength

and bone mass

Effects of ageing

• Lean body ( fat free ) mass declines after 40yrs :

reduced skeletal muscle ‘sarcopaenia’

• Fat mass increases : 25% - 41% between 25 and

75yrs in women

• Vertebral bone loss begins at 3rd decade in women

accelerates after menopause, modified by diet, smoking, exercise and age of menopause

Succesful ageing -an 86 yr old lady

Effects of ageing on body temperature

• Failure to cope with extremes
• Reduced perception
• Reduced behavioural responses
• Lack of skin vasodilatation and sweating in

heat

• Lack of skin vasoconstriction and shivering

in cold

• Lack of response to pyrogens in infection

Frailty

• Vulnerability to health state change following

minor stressor events

• Sarcopaenia, anorexia, osteoporosis, fatigue, risk
• f falls, poor physical health
• Associated with adverse health outcomes

including increased disability, admission to long term care and increased mortality

• Interventions to limit progression have potential to

prevent disability and improve general health and well-being

Fried frailty model

• Weight loss : > 4.5kg or >=5%/yr
• Exhaustion : self reported
• Low energy expenditure : <383Kcal/wk

male, <270Kcal/wk female

• Slowness : standardised 15 foot walk times
• Weakness : grip strength
• 3 or more = frail : 8.5% women , 4% men

aged 64-74 ( n 638 )

Ageing and Disease

• The effects of disease far outweigh the effects of

ageing

• The aged are very heterogenous
• Many diseases are of very high prevalence in old

age and seldom seen in younger people

• Multiple pathology is common
• Older people may present with non-specific

symptoms , in atypical ways or at a late stage of the disease

Geriatric Giants

• Immobility
• Instability
• Incontinence
• Intellectual impairment
• … off legs, falls, incontinent, confused

Late presentation of disease

• Low expectations of health ‘it’s just my age’
• Fear of hospitalisation , investigations, operation
• Misinterpretation of significance of symptoms
• Depression and dementia
• Failure or ageism by health professionals
• Atypical features

Atypical presentation of disease

• No single disease dominates clinical picture
• No single major symptom
• One organ failure leads to another
• Reduced pain perception – ‘silent

presentations’

• As a social crisis

RAMPS

• Reduced reserve
• Atypical presentation of disease
• Multiple pathology
• Polypharmacy
• Social isolation

Polypharmacy

Increased use of drugs with common and serious side effects eg warfarin

Delirium

• Acute confusional state
• Acute decline in attention and cognition
• Common in admissions and post operative
• Associated with increased mortality
• Hyper and hypo active forms
• May not be recognised

Confusion assessment method

• 1. Acute onset and fluctuating course
• 2. Inattention
• 3. Disorganised thinking – rambling or irrelevant

conversation, unclear or illogical flow of ideas, unpredictable switching of subjects

• 4. Altered level of consciousness : vigilant (

hyperalert) , lethargic,( drowsy, easily roused ) , stupor ( difficult to rouse ) , coma ( unrousable)

• 1+2+at least one from 3 or 4 suggests delirium

Dementia

• Clinical syndrome
• Cluster of symptoms/signs characterised by

memory difficulties, disturbance in language, psychological and psychiatric changes and impairments of daily life

• Chronic
• Global
• Progressive
• Usually irreversible

Neurological diseases of high prevalence in old age

• Stroke and transient ischaemic attack ( TIA)
• Parkinson’s disease
• The dementias :Alzheimer’s disease ,

vascular dementia, Lewy body dementia

Approximate prevalence of dementia

• Doubling 5 yearly > 60
• 1% 60
• 2% 65
• 4% 70
• 8% 75
• 16% 80
• 32% 85

Types of Dementia

• Alzheimer’s disease 50%
• Vascular dementia 25%
• Mixed AD-VaD 25%
• Lewy body dementia 15%
• Fronto-temporal, Parkinson’s disease

dementia etc 5%

Assessment of dementia

• History from patient
• Corroborative history from

partner/family/carer : cognitive and behavioural

• General examination
• Cognitive tests : Abbreviated mental test

score, Mimi-mental state examination, clock drawing test, ACE-R, MOCA etc

Treatable causes of dementia syndrome

• Is it delirium ? Infection, metabolic, alcohol

withdrawal, drugs etc

• Cerebral space occupying lesion : tumour or

chronic subdural haematoma

• Depression
• Hypothyroidism
• B12 or folate deficiency
• Normal pressure hydrocephalus
• Chronic alcohol abuse

Dementia screen

• FBC, ESR
• U/E, LFT,Calcium
• TFT
• Serum B12
• Red cell folate
• Chest radiograph
• ECG
• Urinalysis
• CT brain - +/- MRI brain

Cardiovascular disease of high prevalence in old age

• Ischaemic heart disease – angina,

myocardial infarction, heart failure- at post mortem 72% men,54% women > 70yrs had > 75% stenosis of >=1 coronary artery

• Atrial fibrillation : 5% 60-70yrs ,14% 71-

90yrs

• Hypertension – 50% 65-74yrs
• Valvular heart disease

Respiratory diseases of high prevalence in old age

• Chronic Obstructive Pulmonary Disease
• > 30% over 65s in one study : 2/3 on no

treatment

• Carcinoma of bronchus
• Pneumonias

Endocrine diseases of high prevalence in old age

• Diabetes mellitus 1.7% 20-44yrs

US white 8.2% 45-54yrs 12.5% 55-64yrs 17.9% 65-74yrs Worldwide 2000 20.1% > 65

• UK prevalence in adults 7.4%
• UK older adults: white 9% > 65 , S.Asian 27.8% 60-79
• Classified as Type 1 or Type 2 ( over 90%)
• Thyroid disease : hypothyroidism : tired, forgetful, weight

gain, dry skin, feel the cold :up to 5 % in older men, 15 % in women

Diseases more common in South Asian Elders

• Diabetes mellitus : 6 x more common than the

general population

• Diabetes increases risk of stroke x 2-4
• Ischaemic heart disease is also more common and

is increased in diabetic patients

• Tuberculosis affecting the lungs or other organs

more common and may present atypically

• Osteomalacia : bone disease due to inadequate

vitamin D synthesis in the skin

Complications of diabetes mellitus

• Eyes : retinopathy, blindness
• Kidneys : diabetic nephropathy - leading cause of

end stage disease needing dialysis

• Nervous system : stroke, peripheral neuropathy ,

autonomic neuropathy

• Cardiovascular system : ischaemic heart disease ,

peripheral vascular disease, amputation

• Infections
• Acute illness with diabetic coma : ketoacidosis,

hyperosmolar, lactic acidosis, hypoglycaemia

Musculo-skeletal system

• Osteoarthritis 17% m , 30% f > 60, lifetime risk of

knee OA by 85yrs of 45%

• 140,000 knee and hip replacements / yr in E&W:

97% due to OA

• Osteoporosis and resultant fracture – vertebral,

proximal femur, pelvis

• Rheumatoid arthritis
• Polymyalgia rheumatica
• Paget’s disease of bone

J.G.Ballard 1930-2009. ‘Miracles of Life’. 2008

• In 2006, after a year of pain and discomfort

that I put down to arthritis, a specialist confirmed that I was suffering from advanced prostate cancer that had spread to my spine and ribs. Curiously, the only part

• f my anatomy that did not seem affected

was my prostate, a common feature of the disease.

Symptoms suggesting possible malignant disease

• Unexplained weight loss and poor appetite
• Coughing blood, passing blood in urine,

vaginal bleeding in old age, unexplained passage of blood in the motion

• Difficulty swallowing solids – sticking of

food ( dysphagia )

• Change of bowel habit
• Pain not easily explained by arthritis

Malignancy

• Lung cancer = Carcinoma of bronchus
• Colo-rectal carcinoma
• Breast carcinoma
• Carcinoma of prostate
• Carcinoma of bladder
• Haematological malignancies – multiple

myeloma, leukaemias, lymphomas

Anaemia a cause of tiredness, breathlessness

• Iron deficiency : dietary or blood loss
• Vitamin B12 deficiency
• Folic acid deficiency
• Anaemia of chronic disease – eg in chronic kidney

disease

• Diseases of the blood and bone marrow eg

myelodysplasia - a type of bone marrow failure causing anaemia

Visual loss

• Cataract
• Glaucoma
• Age-related macular degeneration
• Diabetic complications - retinopathy

Mustn’t grumble

• I’m going downhill in a decent fashion
• Much obliged
• Thank you for your time
• Shoot me , I’m better off out of it
• Bearing up
• It’s just my age
• Don’t get old !

The common sense approach when talking to the very old

• Deal with hearing and visual loss
• Avoidance of jargon
• Include their past and their interests
• Physical contact can be helpful
• Respect and forms of address
• Breaking down problems into lists
• Corroborative history later
• Always something that can be helped

James Parkinson 1755-1824

Parkinson’s disease -‘the lights change

before I’ve crossed the road’

• Progressive disorder, bradykinesia ( slowness of

initiating voluntary movement, progressive reduction in speed and amplitude of movement and difficulty switching from one motor programme to the next )+ at least one of: Muscular rigidity Coarse 4-6 Hz resting tremor Impaired righting reflexes

• Exclusions include recent neuroleptic drugs,

stepwise progression/ and-or multiple strokes, severe Alzheimer’s disease

Parkinson’s disease – ‘it’s just my age ’

• Tremor minimal in late onset – absent in 15%
• Consider if unexplained falls, fatigue, slowing

down, difficulty with dexterity, depression

• Micrographia
• Depression or dementia > 30%
• Constipation,drooling, freezing, dysphagia,

dystonoia, postural hypotension, nausea,cramps, fluctuations, incontinence

• Prevalence : 150 / 100,000

Stroke

• A clinical syndrome characterised by

rapidly developing clinical symptoms and/or signs of focal and at times global ( deep coma or subarachnoid haemorrhage ) loss of cerebral function lasting > 24 hours

• r leading to death with no apparent cause
• ther than that of vascular origin.

Ischaemia

• A reduction of blood supply to part of the

body

Infarct

• A small localised area of dead tissue caused

by an inadequate blood supply

Transient ischaemic attack

• A clinical syndrome characterised by acute

loss of cerebral or monocular function with symptoms lasting < 24 hours and which is thought to be due to inadequate cerebral or

• cular blood supply as a result of low blood

flow, arterial thrombosis or embolism associated with disease of the arteries, heart

• r blood.

Samuel Johnson’s stroke 1783

• I perceived that I had suffered a paralytick stroke

and that my speech was taken from me . I had no pain, and so little dejection in this dreadful state, that I wondered at my own apathy, and considered that perhaps death itself , when it should come , would excite less horrour than seems now to attend to it. In order to rouse the vocal organs , I took two drams. Wine has been celebrated for the production of eloquence…Though God had stopped my speech , he left me my hand…

Stroke types

• Blocked artery : infarction
• Why has the artery

blocked?

• Has the blockage started

in the artery wall or travelled from elsewhere ?

• Can we unblock ?
• What can we do to prevent

a recurrence ?

• Burst artery : haemorrhage
• Why has the artery burst ?
• Can we reduce the damage

?

• What can we do to prevent

a recurrence ?

Stroke types

• Occlusive

(infarct) 88% : arterial ( rarely venous ) blockage by clot within vessel Thrombotic : clot develops within vessel large vessel – eg middle cerebral artery infarct small vessel - lacunar infarct Embolic – clot travels from heart

• r carotid artery
• Haemorrhagic

12% : bleed from burst artery Primary intracerebral Subarachnoid

Stroke burden

• 174-216 / 100,000 /year affected in UK
• 110,000 strokes in England per year
• 11% of all deaths in England
• Third commonest cause of death in England after coronary

heart disease and cancers

• >50% stroke victims are > 75 ; 25 % are < 65
• Commonest cause of severe disability in UK
• Pre 2008 : 20-30 % die by 30 days – 30% by 3 months
• 300,000 stroke survivors with mod – severe disability in

community

• 20% of medical hospital beds

Bamford classification of stroke

• Total anterior circulation stroke TACS
• Partial anterior circulation stroke PACS
• Lacunar stroke LACS
• Posterior circulation stroke POCS

Total anterior circulation stroke

• Hemiparesis and hemisensory loss
• Homonymous hemianopia
• Cortical dysfunction – dysphasia, visuospatial or

perceptual

• Occlusion of anterior, middle or internal carotid

artery due to thrombosis or embolism from heart, aorta or carotid artery

• At 1 year : 60% dead, 35 % dependent, only 5 %

independent

Partial anterior circulation stroke

• 2 of the 3 clinical features of TACS or

cortical dysfunction alone

• Same causes as TACS
• At 1 year : 15 % dead, 30 % dependent, 55

% independent

Lacunar stroke

• Hemiparesis or hemisensory or hemisensory-

motor loss or ataxic hemiparesis with NO cortical dysfunction

• Differerent cause : small perforating artery

microatheroma or hypertensive small vessel disease-

• All other types 85 % infarct , 15 % haemorrhage –

LACS is 95 % infarct

• 1 year : 10 % dead, 30 % dependent, 60 %

independent

Posterior circulation stroke

• Brainstem symptoms and signs – diplopia,

vertigo, ataxia, bilateral limb problems, hemianopia, cortical blindness etc.

• Causes ; occlusion of vertebral, basilar or

posterior cerebral artery incl embolism from heart or vertebrobasilar artery

• 1 year : 20 % dead, 20 % dependent, 60 %

independent

Outcome at 1 yr by stroke subtype

60 60 55 5 Indep 20 30 30 35 Dep 20 10 15 60 Dead POCS LACS PACS TACS

Stroke management

• Confirm diagnosis and identify impairments
• Identify cause that needs specific treatment
• Decide on appropriate interventions
• Specific treatment : minimise impairment
• General : hydrate, nourish, prevent complications
• Co-ordinated rehab: minimise disability
• Adaptations : minimise handicap
• Secondary prevention: risk factors, drugs, surgery
• Support of and communication with patient/carers

Stroke: complications

• Dysphagia: aspiration

pneumonia malnutrition,

• Dehydration
• Spasticity,contractures

pressure sores

• Shoulder pain, oedema of

affected limb

• Post stroke epilepsy
• Deep vein thrombosis,

pulmonary embolism

• Central post stroke pain
• Falls and fractures
• Incontinence
• Constipation
• Personality / behaviour

change

• Loss of self -esteem,

bereavement, depression, anxiety, emotionalism

Incidence of post stroke complications: BMJ 16 April 2011

• Dysphagia : up to 50%: most of these regain swalow by

second week

• Delirium : 13-48% : assessment difficult : may be due to

infection

• Hospital acquired infection ( pneumonia / urinary ): 30%
• Depression : a third ? Questionable screening / diagnosis
• Falls : increased risk hip /femur fracture x 2
• Urinary incontinence : 40-60% falling to 15% at 1 yr

Disorders of visuo-spatial function

• Hemi-inattention: inability to respond appropriately to

environmental stimuli on one side

• Sensory extinction: fails to register stimulus on one side

when both sides simultaneously stimulated

• Visual agnosia : difficulty recognising people or objects
• Allaesthesia : attributes sensory stimulation to opposite

side

• Anosognosia: denial of impairment esp. weakness
• Non-belonging : denies ownership of a limb or insists it’s

another’s

Other parietal lobe disorders

• Apraxia: difficulty executing tasks ( eg dressing ,

constructional ) despite apparently adequate limb movement, visual or sensory loss or neglect

• Astereognosis: failure to recognise objects placed

in affected hand despite preserved sensation

• Agraphaesthesia: can’t identify a number drawn
• n affected hand despite preserved sensation

National Stroke Audit 2010 : 11,353 patients

• 91% Trusts have stroke unit ( 2008 )
• 52% have acute stroke unit “
• 78% have neurovascular clinic “
• Mean age stroke 73 m, 79 f
• 9 % die by 7 days, 17% by 30 days
• 18% diabetic
• 57% hypertension
• 27% atrial fibrillation
• 18% ischaemic heart disease

National Stroke Audit 2010

• Mood assessed in 84 %
• Cognition assessed in 84%
• 36% of 288 sites had a clinical psychologist (

2008 )

• 88% admitted to a stroke unit during stay
• 2/3 spent more than 90% their stay on a stroke unit
• 5% thrombolysed
• 13% pneumonia , 6% urinary infection 28% plan

to promote urinary incontinence

Key audit indicators

• SU for > 90% stay
• Screen for safe swallow < 24 hrs
• Brain scan < 24 hrs
• Aspirin < 48hrs
• Physio < 72 hrs, OT < 4 days, SLT< 72 hrs
• Weighed
• Mood assessed
• Initially admitted to SU , ITU,CCU
• Rehab goals agreed by team < 5d
• Discussion about diagnosis with patient recorded

Recent developments in acute stroke

• Thrombolysis ( alteplase ) given within 3 hours of

symptoms to selected patients reduces death and dependency – increased public awareness, urgent assesssment and rapid access to scanning : risk of haemorrhage and death

• Early access to TIA clinics with urgent doppler

scanning of carotid arteries and surgical intervention ( carotid endarterectomy ) if > 70 % stenosis of symptomatic side

Jean-Dominique Bauby’s stroke 1996

• I have known gentler awakenings. When I came to the

hospital ophthalmologist was leaning over me and sewing my right eyelid shut with a needle and thread, just as if he were darning a sock . Irrational terror swept over me . What if this man got carried away and sewed up my left eye as well , my only link with the outside world, the only window to my cell, the one tiny opening of my cocoon…in the tones of a prosecutor demanding a maximum sentence for a repeat offender , he barked out : Six months !..this man who spent his days peering into people’s pupils was apparently unable to interpret a simple look.

Rembrandt van Rijn 1607-1669

Further reading

• National Clinical Guidelines for Stroke. Royal College of Physicians

June 2008

• www.rcplondon.ac.uk
• National Stroke Strategy DoH Dec 2007
• Stroke: a practical guide to management. Warlow et al Blackwell

Science 2001

• Oxford Textbook of Geriatric Medicine: Evans and Williams OUP
• The Frailty Syndrome Clegg & Young JRC Physicians Vol 11. 1 . 72-

75 Feb 2011

• Post Acute Care and secondary prevention after ischaemic stroke BMJ

2011;342861-867

• Brocklehurst’s Textbook of Geriatric Medicine
• The Diving Bell and the Butterfly J-D Bauby Harper Perennial 2004