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Traditional education of health care clinicians hinges on typical presentations of common illnesses. 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, “atypical” presentations are actually quite common. 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.
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In medical education, teaching about atypical presentations of medical illness in the older patient offers a unique opportunity to introduce key geriatric principles to trainees at all levels of training. Furthermore, atypical medical presentations in the older adult are now an Accreditation for Graduate Medical Education (ACGME) Geriatrics competency, underscoring the importance of integrating this concept into medical education for all learners.
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Defining Atypical Presentations
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The definition of an atypical presentation of illness 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 3 features: (a) vague presentation of illness, (b) altered presentation of illness, or (c) 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 or functional impairment
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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, the clinician may also need to expand beyond the “typical” evaluation of illness and incorporate questions or exam findings that correlate with an atypical presentation (Table 7–1). For example, recognition of an atypical presentation of illness requires a clinician to pay more attention to small changes in cognition compared to baseline. In the case of a patient with dementia, this can be difficult to determine as some older adults with dementia still experience minor daily variations in cognition. Gathering this baseline level of information requires patience, time, and having reliable caregivers and family member informants. Many times, in order to arrive at an accurate history of present illness, the clinician will have to undertake a systematic investigative approach.
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