Clinical Geriatrics

Whenever I evaluate an older person I think of them clinically in three ways. First, I consider what findings relate to normal aging. Whether it is their wrinkling of the skin or their decrease in lung tidal volume, I try to determine whether there is anything out of the ordinary that may either represent an acceleration of the otherwise normal aging process or a disease, perhaps early in its course.

I then consider whether any of the presenting signs and symptoms relate to an age-prevalent illness. Diseases that may not occur commonly during an earlier period of life now need to be considered more seriously. Diseases such as polymyalgia rheumatica, Alzheimer’s disease, and T3 toxicosis, among many others, come more to mind when considering specific issues that have an impact on an older person’s well-being. Signs and symptoms may be due to more than one problem, and thus the principle of “economy of diagnosis,” or trying to find one unifying explanation for the cause of the patient’s problem, is less realistic when evaluating an older population.

Lastly, I consider the nonspecific or atypical nature in which many diseases present during later life. Shortness of breath may be the only warning of a heart attack in an older person (chest pain may not even be present); a change in mental status may be the only early finding in a urinary tract infection. Waiting for classic medical presentations will only delay the time to diagnosis and, unfortunately, increase both morbidity and mortality.

The “art” of caring for an older person—and may I also add “challenge”—is what continues to fascinate me daily. The practice of medicine is currently not easy, and I frequently hear medical students saying they are afraid to pursue a career as an internist out of fear that there is just “too much to know.” Despite my reassuring them to the contrary, deep down inside I know that the challenge in the future will be even greater than it is today as our population continues to age.

This issue of Clinical Geriatrics features a case report on a problem that is often misdiagnosed in the older person: Lyme disease. It discusses the subtle clinical clues that may help make this diagnosis in the older patient. I have long understood that this illness can be a great masquerader at any age, but particularly during later life. In fact, I have had Lyme disease twice in the past while living in what I eventually learned was an “epicenter” for Lyme disease, West chester County, NY. While other diagnoses must clearly be kept in the differential, diagnosing this problem in the older person is often more difficult, as symptoms are often nonspecific and resemble many findings associated with other illnesses. The classic bullet rash is often absent, as was the case in one of my presentations, and findings are often confused with arthritis, stroke, arrhythmia, and viral illness.

I hope that you share my enthusiasm for caring for older persons and the challenge and excitement that it involves. While the challenges are great, so are the rewards! I hope you will enjoy reading this issue as I have, and, as always, we welcome your com ments and suggestions.

Dr. Gambert is Chairman, Department of Medicine, and Physician-in-Chief, Sinai Hospital of Baltimore, and Professor of Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.