Older People - Patterns of Illness,

Physiological Changes and Multiple

Pathology
Good Practice

Distinguishing the accumulation of age related disease (morbidity) from true

ageing is difficult. An important aspect of management of older adults is to
recognize 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.

Discussion Point

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 accumulate d
damage and decline. (Gershon and Gershon, 2000)

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 theories a relationship between age and disease, placing them on
either side of a continuum and finding little to distinguish between them.

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 characterized by an acute, fluctuating change in mental status

with inattention and altered levels of consciousness. Categories include
hyperactive delirium, characterized by agitation and visual hallucinations, as
opposed to hypoactive delirium characterized by lethargy and withdrawal.
Precipitating factors including immobility, malnutrition, inter current 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 minimize 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 recognized and treated in people with dementia,
and use of a scale such as the Abbey pain scale may help to recognize 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.
Comprehensive Geriatric Assessment

The geriatric assessment is a multidimensional, multidisciplinary diagnostic

instrument designed to collect data on the medical, psychosocial and functional

capabilities and limitations of elderly patients. Various geriatric practitioners use the

information generated to develop treatment and long-term follow-up plans, arrange

for primary care and rehabilitative services, organize and facilitate the intricate

process of case management, determine long-term care requirements and optimal

placement, and make the best use of health care resources.

The geriatric assessment differs from a standard medical evaluation in three general

ways: (1) it focuses on elderly individuals with complex problems, (2) it emphasizes

functional status and quality of life, and (3) it frequently takes advantage of an

interdisciplinary team of providers.

Performing a comprehensive assessment is an ambitious undertaking. Below is a list

of the areas geriatric providers may choose to assess:

Current symptoms and illnesses and their functional impact.

Current medications, their indications and effects.

Relevant past illnesses.

Recent and impending life changes.

Objective measure of overall personal and social functionality.

Current and future living environment and its appropriateness to function and

prognosis.

Family situation and availability.

Current caregiver network including its deficiencies and potential.

Objective measure of cognitive status.

 Objective assessment of mobility and balance.

Rehabilitative status and prognosis if ill or disabled.

Current emotional health and substance abuse.

Nutritional status and needs.

Disease risk factors, screening status, and health promotion activities.

Services required and received.