Gerontology, Palliative Care & Prevention · Topic 6 of 14

Normal Aging & Atypical Presentation in Older Adults

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Geriatrics · aging and atypical illness

Normal Aging & Atypical Presentation in Older Adults

Disease, not normal aging, is the main cause of functional loss, and it hides in older adults: silent MI, serious infection without fever, delirium as the first sign.

01 · The silent missAbout 20% of acute MIs are silent

02 · Fever counts atLong-term care: single oral > 100 °F (37.8 °C)

03 · May be the first signNew confusion: search for acute illness

The rule

Disorders, not normal aging, are the main cause of functional loss

Organ function peaks near age 30, then declines gradually

Decline usually spares daily activities but matters under stress

Evaluate any new functional decline

Infection without the usual signs

Typical fever is absent in more than half of long-term care residents with serious infection

Altered mental status may be the only early sign of pneumonia or UTI search for illness

Decline in daily functioning may be the only early sign of pneumonia or UTI

Frail older adults: focal findings such as localized pain may be less prominent

Febrile older adult: more likely serious bacterial illness than a younger adult

See UTI, Pyelonephritis & Urosepsis.

Fever criteria (IDSA long-term care)

Lower thresholds, from the long-term care guideline

Single oral temperature over 100 °F (37.8 °C)

Repeated oral readings over 99 °F (37.2 °C)

Rise over 2 °F (1.1 °C) above baseline

These thresholds come from the IDSA guideline for long-term care residents; reviews apply them to frail older adults generally.

Normal aging: heart and lungs

Heart

Lower intrinsic and maximal heart rate

Blunted baroreflex

Slower diastolic relaxation and AV conduction

Higher peripheral resistance

More susceptible: syncope, atrial fibrillation, diastolic dysfunction, hypertension

Lungs

Lower vital capacity, FEV₁ and lung elasticity

Higher residual volume

Worse V/Q matching

Higher risk: death from pneumonia, respiratory failure with pulmonary disease

Normal aging: kidneys and body composition

Normal creatinine can hide low GFR

Kidneys

GFR falls about 8 mL/min/1.73 m² per decade after 40

Serum creatinine often stays normal

Renal mass, blood flow and tubular function fall

Free-water excretion is impaired

Body composition

Lean mass and total body water fall

Body fat percentage rises until about age 60

Usually raises drug levels and dehydration risk

Dosing rules: see Polypharmacy & the Beers Criteria

What the NP does

Confusionnew in an older adult

Search for acute illness

Feverfebrile older adult

Order urinalysis, urine culture, chest radiograph and blood cultures

Admit if bacteremia is suspected or vital signs are abnormal

Bacteriuriawith delirium

No local urinary symptoms or systemic signs: assess for other causes and observe carefully

IDSA recommends this rather than antibiotics

Urgeincontinence

Antimuscarinic Mirabegron

Start with bladder training, then add a drug

Use strong anticholinergics judiciously

Overflowincontinence

Relieve the obstruction; intermittent catheterization for an underactive detrusor

Other systems: neuro, endocrine, immune, GI, sensory

Neurologic aging: fewer dopamine receptorsStiffer muscles, impaired balance, reduced arm swing; reduced beta-adrenergic responsiveness; exaggerated responses to anticholinergic drugs

Endocrine aging: insulin resistanceReduced vitamin D absorption and activation; higher ADH secretion in response to osmolar stimuli, raising susceptibility to water intoxication

T-cell and B-cell function fall with ageRaises susceptibility to infection and lowers antibody response to immunization

Slower GI transit promotes constipationHepatic mass, hepatic blood flow and CYP450 activity fall, changing drug levels

Sensory aging: high-frequency hearing loss, presbyopia, cataractsReduced smell and taste with lower appetite

Transient incontinence: DIAPPERS

Reverse transient causes first

DIAPPERS

DeliriumInfectionAtrophic urethritis or vaginitisPharmaceuticalsPsychiatric disordersExcess urine outputRestricted mobilityStool impaction

Established incontinence: four types

Urge: moderate-to-large leak right after an irrepressible need to void

Stress: low-to-moderate leak with coughing, sneezing, bending or lifting

Stress: from outlet incompetence, second most common type in women

Stress can follow radical prostatectomy in men

Overflow: small-volume, often constant dribbling from an overfull bladder

Functional: cognitive or physical impairment or environmental barriers

Functional examples: dementia, stroke, a distant toilet

Functional: the urinary tract itself may be normal

Incontinence workup

Order in all incontinence: urinalysis, culture, BUN, creatinine, post-void residual

Post-void residual under 50 mL is normal

Post-void residual under 100 mL is usually acceptable over age 65

Post-void residual over 100 mL may suggest detrusor underactivity or outlet obstruction

The 200 mL figure on the Back Pain Red Flags sheet is a cauda equina adjunct, not this general threshold.

Urge or overflow incontinence?

	Urge	Overflow
Leakage	Moderate to large, right after urgency	Small, often constant dribbling
Mechanism	Detrusor overactivity	Outlet obstruction or detrusor underactivity
Who	Most common type in older adults	Second most common type in men
Treatment	Bladder training, then antimuscarinic or mirabegron	Relieve obstruction or intermittent catheterization

Pearl

In an older adult, no fever and no chest pain do not mean no disease.