Eliciting the history calls for an astute clinician: patients may accidentally or intentionally underreport symptoms; the presentation of acute illnesses may differ from younger patients; common symptoms may mask a geriatric syndrome; or patients may have
cognitive impairment.
Underreporting
Older patients tend to give more positive ratings to their overall health than younger adults, even when affected by disease and disability. Some are reluctant to report their symptoms. Some are afraid or embarrassed; others try to avoid clinical expenses or the discomforts of diagnosis and treatment. Still others overlook their symptoms, thinking they are merely part of aging, or they may simply forget about them.
To minimize delayed diagnosis and treatment, ask direct questions, use the well-validated geriatric screening tools, and consult with family members and caregivers.
Atypical Presentations of Illness
Acute illnesses present differently in older adults. Older patients with infections are less likely to have fever. Older patients having a myocardial infarction are less likely to report chest pain; symptoms of atypical or no chest pain, shortness of breath, palpitations, syncope, and confusion are more common. Older patients with hyperthyroidism and hypothyroidism have fewer symptoms and signs. One third of older adults with hyperthyroidism present with fatigue, weight loss, and tachycardia in lieu of the classic features of heat intolerance, sweating, and hyperreflexia. Up to 35% present with atrial fibrillation. Hyperthyroidism increases the risk of osteoporosis, and, in affected women, the risk of hip and vertebral fractures increases threefold. In older adults, hypothyroidism is most commonly caused by autoimmune thyroiditis (Hashimoto thyroiditis); fatigue, weakness, constipation, dry skin, and cold intolerance are often attributed to other conditions, medication side effects, or aging.
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