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Traditional education of clinicians hinges on typical presentations of common illnesses. The teaching of these classic presentations influences clinicians’ “illness scripts,” or preformed outlines on how a patient should present with a particular disease. Yet, what is often left out from medical training is the frequent occurrence of atypical presentations of illness in older adults. These presentations are termed atypical because they lack the usual signs and symptoms characterizing a particular condition or diagnosis. In older adults, so-called “atypical” presentations are actually quite common and can range from one-fifth to one-half of all presentations. For example, a change in behavior or functional ability is often the only sign of a new, potentially serious illness. Failure to recognize atypical presentations may lead to worse outcomes, missed diagnoses, and missed opportunities for treatment of common conditions in older patients. As in other illnesses, some of the reasons for delayed recognition may also be caused by social factors, such as lack of caregiver, lack of transportation, the fear of being hospitalized, and the risk of losing independence.
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The lack of specificity of some atypical presentations, however, can also lead to unnecessary workups, treatments, and hospitalizations. For example, always treating the feared possibility of a bacterial infection in the setting of nonspecific symptoms can prompt improper use of antibiotics that can cause harm to the patient and create drug resistance in the long run. Awareness of atypical presentations of common diseases is fundamental to high-quality care of older adults and also offers a unique opportunity to introduce key geriatric principles to trainees at all levels. Furthermore, identifying atypical presentations of common diseases in the older adult is a recommended minimum geriatrics competency for medical students, internal medicine residents, family medicine residents, surgery residents, and geriatric medicine fellows.
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DEFINING ATYPICAL PRESENTATIONS
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One definition of an atypical presentation of illness in an older person is: when an older adult presents with a disease state that is missing some of the traditional core features of the illness usually seen in younger patients. Atypical presentations usually include one of three features: (1) vague presentation of illness, (2) altered presentation of illness, or (3) nonpresentation of illness (ie, underreporting).
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IDENTIFYING PATIENTS AT RISK
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The prevalence of atypical presentation of illness in older adults increases with age. With the aging of the world’s population, atypical presentations of illness will represent an increasingly large proportion of illness presentations. The most common risk factors include:
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Increasing age (especially age 85 years or older)
Multiple medical conditions (“multimorbidity”)
Multiple medications (or “polypharmacy”)
Cognitive impairment
Residing in a care institution or functional dependence
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Understanding which patients may be more at risk of atypical disease presentation will guide clinicians to more astutely pick up subtle signs of illness. Rather than approaching a patient visit in the traditional way of ...