Unusual Presentations of Illness

Certain disorders manifest differently in elderly patients than in younger patients.

Hyperthyroidism may not produce the classic signs (eg, eye signs, enlarged thyroid gland). Symptoms and signs may be subtle and may include tachycardia, weight loss, fatigue, weakness, palpitations, tremor, atrial fibrillation, and heart failure. Patients may appear apathetic rather than hyperkinetic.

Hypothyroidism may be subtle in elderly patients. The most common symptoms are nonspecific (eg, fatigue, weakness, falling). Anorexia, weight loss, and arthralgias may occur. Cold intolerance, weight gain, depression, paresthesias, hair loss, and muscle cramps are less common than among younger adults; cognitive dysfunction is more common. The most specific sign, prolonged relaxation time after muscular contraction, may not be detectable in elderly patients because of decreased amplitude or absent reflexes.

Hyperparathyroidism may produce nonspecific symptoms: fatigue, cognitive dysfunction, emotional instability, anorexia, constipation, and hypertension. The characteristic symptoms are often absent.

Sarcoidosis in the elderly most commonly causes nonspecific symptoms (eg, weight loss, anorexia, weakness, fatigue) but may also cause shortness of breath, blurred vision, myopathy, and adenopathy.

Bacteremia may not cause fever; however, most elderly patients have at least a low-grade fever. Nonspecific manifestations (eg, general malaise, anorexia, night sweats, unexplained change in mental status) may also occur.

UTIs may be present in afebrile elderly patients. These patients may not report dysuria, frequency, or urgency but may experience dizziness, confusion, anorexia, fatigue, or weakness.

Meningitis may cause fever and a change in mental status without symptoms of meningeal irritation (eg, headache, nuchal rigidity).

Pneumonia may be indicated by malaise, anorexia, or confusion. Tachycardia and tachypnea are common, but fever may be absent. Coughing may be mild and without copious, purulent sputum, especially in dehydrated patients.

TB may manifest differently in elderly patients with coexisting disorders. Symptoms may be nonspecific (eg, fever, weakness, confusion, anorexia). Pulmonary TB may manifest with fewer respiratory symptoms (eg, cough, excessive sputum production, hemoptysis) than in younger patients.

Appendicitis pain tends to begin in the right lower quadrant rather than periumbilically, as it does in younger adults. Also, the eventual location of pain may be diffuse in the abdomen rather than localized to the right lower quadrant. However, tenderness in this quadrant is a significant early sign.

Biliary disorders may result in nonspecific mental and physical deterioration (eg, malaise, confusion, loss of mobility) without jaundice, fever, or abdominal pain. Abnormal liver function test results may be the only indication of a biliary disorder.

Acute bowel infarction may be indicated by acute confusion. Abdominal pain and tenderness may be absent.

Peptic ulcer disease may not produce classic ulcer symptoms; pain may be absent, nonspecific, or masked by NSAIDs. Dyspepsia (usually epigastric discomfort with bloating, nausea, or early satiety) is more common among elderly than among younger patients. GI bleeding may be painless. Slow, unrecognized blood loss may occur, resulting in severe anemia.

MI may manifest as diaphoresis, dyspnea, epigastric distress, syncope, weakness, vomiting, or confusion rather than as chest pain. Elderly patients with acute MI tend to delay longer than younger patients in seeking medical assistance after the onset of chest pain or other presenting symptoms of MI.

Heart failure may cause confusion, agitation, anorexia, weakness, insomnia, fatigue, weight loss, or lethargy; patients may not report dyspnea. Orthopnea may cause nocturnal agitation in patients with dementia and heart failure. Peripheral edema is less specific as a sign of heart failure in elderly than in younger patients. In bedridden patients, edema may occur in the sacral area rather than in the lower extremities.

This topic was last updated June 2006.