Introduction

At the turn of the twentieth century, there were 65 000 people in the UK aged 85 or older. By 2050, it is projected there will be more than three million. Old age is still associated with frailty, disability and loss of independence. The positive aspects of ageing, such as sagacity, maturity and experience, are too often neglected. One hopes that these commonly held negative beliefs about growing old will gradually disappear, as the period between the average age of onset of disability in the old and the average age of death narrows and the elderly enjoy healthier lives.

Age is traditionally defined in terms of chronological age. Older people are considered in three distinct chronological groups: the young old (65-74), the old (75-84) and the very old (85+). However, older people are a very heterogeneous group and each old person should be respected as an individual and not merely classed according to their chronological age. Frailty, disability and dependency are not synonymous with getting old. The accumulation of disability resulting from chronic disease and environmental insults must be separated from the process of merely getting older, i.e. senescence. People age at different rates, and it is the interplay of environmental, genetic and acquired pathological processes that determines an individual’s biological age. Functional age takes into account the combination of a person’s biological and chronological ages and, although difficult to define, this concept circumvents the negative implications of grouping individuals together because of arbitrary socioeconomic or statutory definitions, such as ‘pensioner’. With an increasingly healthy and longer-lived population, these concepts will require redefinition according to functional ability.

Presentation of disease in older people

Two major factors influence the recognition of disease processes in older people:

The acceptance of ill health and disease as ‘ageing’, with its resultant disabilities, means that many older people expect to be frail, rarely complain and often seek help late. Coming to terms with some disability or change is necessary at all ages, and acceptance is part of survival. However, the tacit acceptance of inevitable deterioration – for example in vision, hearing, teeth and feet – may lead to treatable conditions being ignored and result in loss of independence. Table 6.1 illustrates what may be regarded as normal ageing and what is pathological.

Table 6.1 Normal ageing and changes in body systems

System	Normal ageing	Pathophysiological changes common in older age
Cardiovascular	Slight increase in heart size Normal stroke volume and left ventricular ejection fraction Exertional oxygen consumption declines 7.5-10% per decade; thus exercise tolerance is reduced

Respiratory Alimentary Hepatobiliary Renal Genitourinary Nervous system, including higher senses Endocrine Musculoskeletal Dermatological Haematological and immune system

FEV₁, forced expiratory volume in 1 second; FSH, follicle stimulating hormone; FVC, forced vital capacity; GI, gastrointestinal; GFR, glomerular filtration rate; LH, luteinizing hormone; PEFR, peak expiratory flow rate.

The range of presentation of disease in old age is an essential element for the student and practitioner to comprehend. The term ‘geriatric giants’ (Box 6.1) refers to a set of symptoms and signs that occur in old age which may have as their cause many different disease processes. In normal day-to-day circumstances, ageing organs are able to maintain normal metabolic function. However, when major stressors are experienced, as in acute illness, functional capacity is exceeded and rapid clinical deterioration may occur. In the elderly patient, multiorgan failure may develop rapidly in the context of illness, especially infections. Another important concept is that of multiple comorbidities, which may be causally linked, although more typically they are not. Iatrogenic illness, most commonly due to polypharmacy, often exacerbates disability in the older person.

Recognition of the social presentation of disease is of major importance in older patients. The ‘social admission’ to hospital and the subsequent failure to cope with this upheaval, often termed ‘acopia’ (a made-up word), usually indicates a poor level of information gathering in the process of history taking, examination and investigation. The likelihood of the disease process leading to social decompensation, for example relatives leaving a person in the emergency department or the breakdown of the older person’s level of physical and mental function during hospitalization or illness at home, can usually be predicted and hence often prevented, thereby avoiding secondary disability.

Proper diagnosis and management in older people requires the identification and treatment of amenable clinical problems, and recognition of the special needs and the specific clinical presentations of older people. Thus, social aspects of care may be as important as the disease process itself. Understanding this encourages a patient-centred multidisciplinary team approach. Caring for older people requires clinical acumen and much skill. Geriatricians not only recognize diseases and their presentations in older people, but perhaps equally importantly act as their patients’ advocate in all areas of healthcare.

History

Taking a good history is always essential but requires particular sensitivity in the elderly. Respect for autonomy should always be afforded, just as for the young. ‘Don’t talk about patients, talk with them’, especially when dealing with carers. Negotiate how much information the patient would like to share with carers when giving investigation results or trying to obtain corroborative information. Avoid being judgemental and paternalistic. The grey-haired are not necessarily disabled or confused! Even severely physically disabled people, no matter what their age, may have the brightest minds.

There are several universal practical points in the way the history is approached which are particularly important when taking a history from an older patient (Box 6.2). The first contact is extremely important (Box 6.3). Eye contact, a greeting, an outstretched hand (expecting a returned handshake), your name and the purpose of the meeting are all that are required to begin with. These relatively simple gestures can provide a wealth of information in the first few minutes. Depressed and very anxious patients may avoid eye contact. The handshake is often revealing. Some patients with dementia may not respond, not recognizing the meaning of the social gesture. Frightened older patients may continue to clutch one’s hand. Giving your name and purpose puts people at ease and can also be used later to assess short-term memory. Ask the person ‘What is your name?’ Be alert for hearing impairment. The reply will indicate how a person wishes to be addressed; alternatively, the patient may be specifically asked this.

The environment should be changed to suit the individual patient, particularly if he is in a wheelchair, has multiple carers or is deaf. Ensure the patient puts on any spectacles or hearing aid. If he is hearing impaired, try to sit in a well-lit area to aid lip reading. Hearing impairment is such a common problem that any setting where older people are seen regularly should have a communication aid available. Talking at the bedside in a busy environment is accepted practice, but be sure the patient is really at ease, especially if any delicate or personal issues need to be discussed. Drawing the bed curtains offers some privacy and dignity to the patient but does not ensure privacy.

The cadence of the history may be slower than with younger people. Try to avoid interrupting the patient. There may be multiple medical and social issues, and it is important to let patients tell the story in their own way, as they will often prioritize issues. Learning to interrupt politely and redirect the conversation is a necessary but difficult skill to learn. Only when the patient has given consent should you attempt to corroborate information with relatives or carers.