Insidious Illness in Active Seniors: Decoding Atypical Presentations
Carlos E. Jiménez, MD; Joseph Caravalho, Jr, MD; Inku Hwang, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 8 - AUGUST 97
In Brief: Older athletes and active seniors may have serious medical problems without commonly recognized signs and symptoms. The cases of an older tennis player, a golfer, and a deep-sea sport fisherman illustrate unusual presentations of coronary artery disease, bacterial pneumonia, and peptic ulcer disease in senior patients. Alertness for the effects of coexisting illnesses, chronic use of medicines, reduced physiologic and immunologic reserves, altered pain perception, and symptom denial can facilitate prompt treatment of active senior patients.
Though common diseases such as coronary artery disease, bacterial pneumonia, and peptic ulcer disease cause significant morbidity and mortality, they can be overlooked in older people, especially those who are active and athletic. Even "textbook" atypical presentations, common among the elderly, are based on data from a more sedentary elderly population and are often altered in active elders. By understanding the varied presentations and complex nature of disease processes among older individuals, primary care physicians can manage these patients' illnesses more effectively.
Case 1: Coronary Artery Disease
A 67-year-old retiree with no abnormal medical history played competitive tennis almost daily. During one match, he suffered a brief syncopal episode on the court. He was emergently transported to the nearest acute care center. His workup included a complete history and physical evaluation, blood chemistry, electrocardiogram (ECG), and brain computed tomography, none of which yielded abnormal findings. The patient recovered completely with intravenous hydration, and he was discharged with the presumptive diagnosis of dehydration. That evening he was found dead at home. The autopsy revealed a massive myocardial infarction with extensive coronary artery disease as the cause of death.
Silent symptoms. Several studies (1,2) have shown that atypical or silent symptoms of an acute myocardial infarction occur very frequently in the elderly. Classic angina pectoris involves some substernal chest pain, although multiple variations, grouped together as "atypical chest pain," may also be seen. Atypical presentations become more common with age because of diminished adrenergic responsiveness. Acute myocardial infarction presents silently or painlessly in 38% to 81% of people older than 70 years (3). Older patients, including active seniors, are more likely to present with dyspnea, syncope, delirium, or stroke, and less likely to have anginal chest pain. Other atypical symptoms include abdominal pain, lethargy, and arthralgias involving the shoulders, elbows, back, and neck.
Silent myocardial infarction is later confirmed by ECG, echocardiogram, radionuclide myocardial perfusion studies, or by the diagnosis of myocardial infarction complications, such as congestive heart failure (CHF), pulmonary edema, dysrhythmias, and valvular disease.
What to watch for. Because so many older men and women have atherosclerotic coronary artery disease, a previously healthy active older patient who presents with sudden unexplained behavioral changes, acute signs of cerebral insufficiency, new onset of abdominal or upper-extremity pain, or dyspnea should be evaluated for myocardial infarction. True syncope is often a warning sign for serious pathology and should not be ignored, even in the senior athlete.
Case 2: Bacterial Pneumonia
A 72-year-old avid golfer presented to an acute care clinic with a 2-week history of progressive, generalized weakness and anorexia. He reported no cough, fever, chills, or abdominal symptoms. His physical examination was within normal limits, and his laboratory studies were remarkable only for a leukocyte count of 9,900/mm3 with 84% segmented neutrophils. He was sent home with the diagnosis of "viral syndrome." The patient returned the following day with paroxysmal dyspnea and left pleuritic chest pain. A chest radiograph revealed a left lower lobe infiltrate and small ipsilateral effusion. While the patient was hospitalized, bacterial pneumonia and empyema were confirmed.
Few classic signs and symptoms. The elderly often present few clinical manifestations of pneumonia. Some of the classic physical signs, including bronchial breath sounds and increased tactile fremitus, may be lacking in older patients. Approximately 20% to 50% of older patients who have community-acquired pneumonia are afebrile on admission to the hospital (4,5). Other symptoms such as cough, sputum production, dyspnea, pleurisy, chills, and rigors are also inconstant clinical features (6).
The onset of bacterial pneumonia in an older individual may be insidious with nonspecific signs, such as confusion, falls, lethargy, and anorexia. The nonspecificity may lead the clinician to consider other diagnoses, such as cerebrovascular disease or CHF. Alternatively, pneumonia may present dramatically with septic shock or adult respiratory distress syndrome and overwhelm the previously healthy older adult in a day or two (7). On occasion, pneumonia may exacerbate coexistent diseases, making the initial diagnosis very difficult.
Chest x-rays are often unremarkable, without the typical lobar consolidation and air bronchograms. Although it is not as much a concern in the active older population, physicians should also bear in mind that illnesses like chronic obstructive pulmonary disease and CHF limit the sensitivity and specificity of the chest x-ray.
Laboratory testing can also be confusing because older patients with pneumonia often present with a normal or only slightly increased leukocyte count. As in our patient, one clue that suggests bacterial pneumonia is a significant left shift on the differential ("bandemia").
Preventing pneumonia. Prevention of community-acquired pneumonia in older adults is just as important as timely diagnosis and treatment. Smoking cessation improves the respiratory mucociliary function. Good oral hygiene and vaccination against Streptococcus pneumoniae and viral influenzae should be strongly encouraged.
Case 3: Peptic Ulcer Disease
A 66-year-old deep-sea sport fisherman developed new, unremitting substernal chest pressure while working in his boat. An ECG obtained within 2 hours of symptom onset was consistent with an acute inferior wall myocardial infarction. However, thrombolytic therapy was contraindicated because of a markedly depressed hematocrit that suggested possible gastrointestinal bleeding. Urgent two-vessel percutaneous transluminal coronary angioplasty performed on the day of admission was uneventful. After the patient was stabilized, an esophagoduodenoscopy to evaluate the patient's anemia revealed three duodenal ulcers.
Ulcers without epigastric pain. Atypical clinical presentations are common for older patients who have peptic ulcer disease (PUD). Classic burning epigastric pain is often absent and, when present, tends to be vague and poorly localized, with misleading radiation. Signs and symptoms, which may occur alone or together, include weight loss, anorexia, confusion, emesis, and melena.
Since the majority of PUD cases were previously documented in people between the third and fifth decades of life, PUD has not been regarded as a disease of the elderly. However, autopsy and clinical data (8) have shown that PUD's prevalence among older people is at least equal to its prevalence among younger patients. More important, these data revealed increased mortality and serious morbidity in the older group. Chronic nonsteroidal anti-inflammatory drug use, Helicobacter pylori infections, and tobacco use have contributed to such trends among the elderly (9).
What to Watch for in Active Seniors
Physicians will be seeing more and more patients like the ones in these three cases. Since the 1970s, many more Americans older than 65 years have been running, walking, biking, golfing, swimming, and playing tennis. The number is growing partly because people are living longer. In 1900, the average life expectancy in the United States was approximately 49.5 years, but today it is close to 80. During the next 20 to 30 years, the number of Americans 65 years and older is expected to swell to well over 65 million—from the current 12.5% to 22% of the total US population (10).
The growing number of older exercisers also reflects people's desire for physical fitness and a sense of well-being (10). The role of regular aerobic exercise in preventing and treating illnesses such as coronary artery disease, stroke, hypertension, and diabetes is well documented in the medical literature (11-14); older Americans are increasingly aware of these benefits and are more motivated to participate.
Physical issues. This growing number of older Americans will present distinct needs to healthcare professionals. Aging causes anatomic and physiologic changes that make people more prone to disease. In addition, the clinical presentations of illness in senior athletes can be unusual, subtle, or even nonexistent for several reasons (15):
Psychological considerations. Physicians should also recognize the psychological challenges of providing care to active seniors. Illness is often devastating for the older athlete who is used to a general sense of physical fitness and well-being. This may lead an individual to downplay or deny symptoms and to resist seeking medical attention, thus delaying diagnosis (10).
The physician, as well, may be biased by the patient's active lifestyle and may be less vigilant for serious underlying disease. For example, a physician may underemphasize coronary artery disease in a differential diagnosis if the patient gives a history of avid running. Although exercise can lower the risks of certain diseases, it cannot eliminate the aging process that affects both athletic and sedentary seniors (16).
Improving care. Finally, more research is needed. Medical decisions about older athletes may be skewed because there are few data on the pathophysiology of illnesses within the active elderly population. Most current knowledge is based on the more traditional, typically sedentary, older patient. Future studies may clarify what are now considered "atypical" clinical presentations among senior athletes.
Misunderstanding the clinical variability of illnesses among active and athletic seniors sometimes leads to delayed diagnosis and unabated disease progression, magnifying the risk of adverse disease and management outcomes (17). To prevent such outcomes and to work within the time and budget constraints of the current healthcare system, primary care physicians must be increasingly skilled in recognizing and treating illnesses in an older active population.
The assertions presented here are the private views of the authors and are not to be construed as official or as reflecting the views of the Army or Department of Defense.
Drs Jiménez, Caravalho, and Hwang are internists and nuclear medicine physicians at Walter Reed Army Medical Center in Washington, DC, and are assistant professors at the F. Edward Hebert School of Medicine, Uniformed Services University of Health Sciences in Bethesda, Maryland. They are members of the American College of Physicians. Address correspondence to Carlos E. Jiménez, MD, Nuclear Medicine Service, Dept of Radiology, Walter Reed Army Medical Center, Washington, DC 20307-5001.