Older People - Patterns of Illness, Physiological Changes and Multiple Pathology
Distinguishing the accumulation of age related disease (morbidity) from true ageing is difficult. An important aspect of management of older adults is to recognise and understand how body systems are interlinked. Awareness of pathological and normal age-related physiological changes will assist your assessments and help you decide on best management of older people.
Firstly, the reader is forbidden to approach this section with a feeling of impending doom. Secondly, remember that not everyone experiences all mentioned issues, and those with disabling conditions have often accommodated to the changes without too much of an impact on their lifestyle.
In earlier life, the signs and symptoms of illness might be explained by a single diagnosis. In older people, the number of active or inactive pathological processes might compromise both the precise diagnosis as a basis of treatment, and include or be impacted on by a further disability. Hence awareness of different pathological processes and of normal age-related physiological changes will assist your assessment and management of older people.
‘True ageing should be universal and observed in all older members of a species. It should be intrinsic, that is, attributable to basic mechanisms innate to the organism and not exclusively due to modifiable environmental effects. It should be progressive in that it is seen as a gradual process of accumulated damage and decline.’ (Gershon and Gershon, 2000)
This decade-old statement still holds true. Before you read on either discuss these issues with colleagues, or revisit earlier sections of the Resource Booklet to ensure you understand ageing theories.
As we live longer, degenerative problems are becoming pre-eminent in older age and much of health care practice falls within the category of ‘longer-term / chronic' conditions. In many of these conditions, by the time they manifest themselves a successful cure is elusive. Distinguishing the accumulation of age related disease (morbidity) from true ageing is difficult. Izaks and Westendorp theorise a relationship between age and disease, placing them on either side of a continuum and finding little to distinguish between them.
Certain commonly seen conditions are liable to be disregarded by the individual, relatives or by the doctor as they develop slowly. For example, gradual onset of alterations in voice, in facial appearance, cold sensitivity, lethargy and slowing may be easily attributable to the ageing process that myxoedema (decreased activity of the thyroid gland) can be overlooked. Postural changes, stiffness and restricted activity often considered a part of ageing may cause the rigidity and bradykinesia of Parkinson’s to be missed. Investigations are often provoked due to comments from a visitor, especially one who has not seen the person for a long time and to whom the changes are noticeable. It is useful to identify underlying mechanisms that lead to true age related changes, as opposed to age related disease.
Altered responses to illness
Illnesses often present differently in old age than in youth. Regulation of body temperature is unstable or less responsive, so pyrexia may not be as marked as would be expected even in severe infections such as pneumonia, appendicitis or pyelonephritis. The converse, a lack of awareness of cold, or of the capacity to react normally to it, may lead to hypothermia.
Delirium is characterised by an acute, fluctuating change in mental status with inattention and altered levels of consciousness. Categories include hyperactive delirium, characterised by agitation and visual hallucinations, as opposed to hypoactive delirium characterised by lethargy and withdrawal. Precipitating factors including immobility, malnutrition, intercurrent illness, dehydration and, stress of admission to hospital or other unfamiliar settings.
Pain is common in older people. However as people age, they complain less of pain. The reason may be a decrease in the body's sensitivity to pain or a more stoical attitude toward pain. Some older people mistakenly think that pain is an unavoidable part of aging and thus minimise it or do not report it. Even in conditions that cause intense pain in earlier life (e.g. angina or fractures), there may be so little discomfort, or pain is referred in such a bizarre way, that diagnosis is delayed – sometimes with fatal consequences. Pain is often not correctly recognised and treated in people with dementia, and use of a scale such as the Abbey pain scale may help to recognise when a person is in pain.
Response to drugs also alters with age (see section on Medication).
Recovery from illness is often slower, owing to inter-current infections or to the debilitating nature of the condition. Conversely, some old people may make remarkable and quite unexpected recoveries from severe mental or physical impairment.
The following article provides some perspective into different aspects of frailty and co-morbidity, some exploring the functional impact of these issues.
Cigolle C et al (2009). Comparing Models of Frailty: The Health and Retirement Study. J Am Geriatr Soc; 57; 830–839
Fries J (1980). Aging, natural death and the compression of morbidity. New Eng J of Med; 303; 130 - 135
Guralnik J, Ferruci L, Balfour J, Volpato S, di Iorio a (2001). Progressive versus catastrophic loss of the ability to walk: Implications for the prevention of mobility loss. Journal of the American Geriatric Society; 49; 1463 - 70
Patrick L, Knoefel F, Gaskowski P, Rexroth D (2001). Medical Comorbidity and rehabilitation efficiency in geriatric inpatients. Journal of the American Geriatric Society; 49; 1471 – 1477
Pain in older people: Reflections and experiences from an older person’s perspective. Help the Aged publication accessed online at: http://www.britishpainsociety.org/book_pain_in_older_age_ID7826.pdf
The Further Reading box below lists conditions often seen in the older population. It is not exhaustive, and as you gain more experience, your knowledge about the conditions will increase. Relevant information and facts about these conditions can be found in textbooks that specialise in the clinical areas listed. Alongside some conditions or categories are dedicated UK websites of the organisations that support their cause. Remember there will be differences in prevalence and presentation depending on the country you are from.
The NHS Choices website has a section on conditions and treatments – Health A – Z. The site describes some common conditions with tabs that links to real patient stories as well as symptoms, causes, diagnosis, treatments etc http://www.nhs.uk/Conditions/Pages/hub.aspx
Health Talk Online (Dipex) is a charity that uses a website to share information about patient experiences across all sorts of health care areas. You can see stories related to diagnosis, activity etc by clicking on the A - Z conditions tab. http://www.healthtalkonline.org/
Orthopaedic conditions – see the National Osteoporosis Society www.nos.org.uk and the Arthritis Research Council www.arc.org.uk websites for information on conditions such as osteoporosis and osteomalacia, fractures – especially femoral and humeral necks, Colles and vertebral fracture, Paget’s disease, Osteoarthritis and Rheumatoid arthritis
Neurological conditions include Cerebro-vascular disease - see The Stroke Association site at http://www.stroke.org.uk/index.html; Parkinson’s disease - see Parkinson's UK site http://www.parkinsons.org.uk/default.aspx in particular in the 'Professional's section; Neuropathies and other such neurological conditions can be accessed through the National Institute for Neurological Disorders and Stroke site at http://www.ninds.nih.gov/index.htm
General medical conditions - search health data-bases or look on e-medicine sites such as http://www.emedicinehealth.com/diabetes/article_em.htm. Diabetes, Falls, Diverticulitis and Irritable Bowel Syndrome, Carcinomas, Incontinence, Urinary tract infections, Hernia – especially hiatus, Renal failure
Cardiorespiratory conditions - information through the British Heart Foundation at http://www.bhf.org.uk/ and lung conditions at the British Lung Foundation at http://www.lunguk.org/ . Include ischaemic heart disease, congestive cardiac failure, pneumonias and chronic obstructive pulmonary diseases
Psychological conditions. If the mental health problem is related to a long-term physical condition e.g. stroke, rheumatoid arthritis, you may find information in a source about the medical condition. If the issue is purely of a mental health origin, look up a specific mental health resources e.g. Depression; Dementia at Alzheimer's at http://alzheimers.org.uk/ , Lewy body disease at http://www.lewybody.org/, and dementia UK at http://www.dementiauk.org/
- Izaks G and Westendorp R (2003). Ill or just old? Towards a conceptual framework of the relation between ageing and disease. BMC Geriatrics, 3(7). www.biomedcentral.com/1471-2318/3/7
- Elie M, Cole MG, Primeau FJ, Bellavance F (1998). Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med; 13(3): 204–212