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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #27, #28


Learning Objectives

  • To describe the prevalence of common nonpain symptoms in older adults

  • To address the evaluation and management of fatigue and dyspnea

  • To review how multimorbidity influences symptom management

Key Clinical Points

  1. The presence of multiple co-occurring symptoms in older adults is common.

  2. Screening for common symptoms should be a routine component of a comprehensive geriatric assessment.

  3. Because the evidence base for symptom management in older adults is sparse, especially for those with multiple chronic conditions, a thoughtful approach that is informed by patient preferences is necessary to optimize benefit and minimize adverse effects.


Advances in medicine have led to our ability to stave off many acute life-threatening events and have contributed to the development of numerous co-occurring chronic conditions defined as multimorbidity. The experience of multiple conditions is often characterized by an array of symptoms associated with these conditions and/or their treatments. The presence of bothersome symptoms in older adults may contribute to illness burden in ways that may not be predictable on the basis of any one diagnosed disorder. However, these symptoms have a negative influence on older adults’ function and quality of life (QoL).

Many symptoms are addressed throughout this textbook: anorexia is covered in Chapter 34, sleep disorders in Chapter 49, dizziness in Chapter 50, pain in Chapter 56, depressed mood and anxiety in Chapters 71 and 73, and constipation in Chapter 95. The focus of this chapter is overall symptom assessment, evaluation and management of fatigue and shortness of breath, especially for those with advanced illness, and special considerations in the context of multimorbidity.

Multiple symptoms occur frequently in chronically ill older adults. Because many individual conditions, such as cancer, heart failure, and chronic obstructive pulmonary disease (COPD), are associated with high symptom burden, their accumulation contributes to a large and complex array of symptoms (Figure 57-1). Among older oncology patients, the average number of symptoms reported on the Memorial Symptom Assessment Scale (MSAS) was 10. In a population-based sample of older adults using a 10-item symptom tool, the average number of symptoms was 3.7 and one-third of the population had five or more. In this cohort, the most common nonpain symptoms were fatigue (48%), weakness (39%), constipation (36%), anxiety (36%), anhedonia or depression (37%), shortness of breath (35%), and poor appetite. In a study of 318 adults followed by a housecalls program, 43% reported severe burden from one or more symptoms. The symptoms with the highest severity ratings were depression, pain, loss of appetite, and shortness of breath. Few longitudinal studies of the general older adult population have assessed changes in the symptom experience over time. Among 754 older adults in their last year of life, ...

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