Makindo Medical Notes

👵🧓 Older adults frequently present with complex, overlapping medical conditions. Ageing is associated with reduced physiological reserve, multimorbidity, polypharmacy, and atypical disease presentation. As a result, illness often manifests as falls, delirium, immobility, incontinence, or functional decline rather than classic textbook symptoms.

Why Disease Looks Different in the Elderly

• 🔻 Reduced homeostatic reserve → minor insults lead to major deterioration.
• 🧠 Altered pain perception, cognition, and communication.
• 💊 Polypharmacy increases adverse drug events and interactions.
• 🧓 Frailty amplifies vulnerability to acute illness.
• 🏠 Social factors (isolation, carer strain) strongly influence outcomes.

Cardiovascular Conditions

Hypertension

• Driven by arterial stiffening and reduced baroreceptor sensitivity.
• Often asymptomatic yet a major contributor to stroke, heart failure, and vascular dementia.
• Over-aggressive treatment risks postural hypotension, syncope, and falls.
• Targets should be individualised based on frailty and life expectancy.

Ischaemic Heart Disease

• Frequently presents atypically: dyspnoea, fatigue, nausea, delirium.
• Silent myocardial infarction is more common.
• Decision-making around angiography and revascularisation must balance benefit vs burden.

Heart Failure

• HFpEF predominates due to ventricular stiffness and long-standing hypertension.
• Presents with breathlessness, oedema, recurrent admissions, or functional decline.
• Renal dysfunction, hypotension, and frailty often limit guideline-directed therapy.

Atrial Fibrillation

• Prevalence rises sharply with age.
• High embolic stroke risk — anticoagulation usually outweighs fall risk.
• May present with falls, heart failure, or delirium rather than palpitations.

Neurological Conditions

Stroke and TIA

• Incidence and severity increase markedly with age.
• Often complicated by dysphagia, aspiration pneumonia, delirium, and immobility.
• Secondary prevention must consider bleeding risk, cognition, and adherence.

Dementia

• Includes Alzheimer’s disease, vascular dementia, Lewy body dementia, and mixed pathology.
• Progressive decline in memory, executive function, judgement, and daily functioning.
• Vascular risk factors play a major role even in “Alzheimer’s” dementia.
• Behavioural and psychological symptoms (agitation, hallucinations, wandering) often trigger hospital admission.
• Patients are highly vulnerable to delirium, infection, and medication side effects.
• Capacity assessment, safeguarding, and advance care planning are central to management.
• Carer burden and social support often determine outcomes more than cognition alone.

Delirium

• Acute, fluctuating disturbance of attention and awareness.
• Common precipitants: infection, dehydration, pain, constipation, urinary retention, drugs.
• Always represents serious underlying pathology in older adults.
• Strong predictor of mortality, institutionalisation, and future dementia.

Parkinson’s Disease

• Neurodegenerative disorder characterised by bradykinesia, rigidity, tremor, and postural instability.
• Non-motor symptoms (constipation, depression, autonomic dysfunction, hallucinations) often dominate.
• Falls and freezing of gait are major causes of morbidity.
• Medication timing is critical — missed doses can cause severe deterioration.
• Dopaminergic therapy may worsen hallucinations and postural hypotension.
• Advanced disease is associated with dementia, dysphagia, aspiration, and frailty.

Respiratory Conditions

Chronic Obstructive Pulmonary Disease (COPD)

• Cumulative smoking exposure and impaired mucociliary clearance.
• Exacerbations may present with confusion, falls, or reduced mobility.
• Oxygen therapy requires caution due to CO₂ retention risk.

Pneumonia

• Often presents atypically with delirium, anorexia, or immobility.
• Aspiration risk increased by dysphagia and poor cough reflex.
• Mortality is significantly higher than in younger adults.

Endocrine and Metabolic Conditions

Type 2 Diabetes Mellitus

• Insulin resistance and declining beta-cell reserve.
• Hypoglycaemia carries high risk of falls, cognitive impairment, and death.
• Glycaemic targets should prioritise safety over tight control.

Hypothyroidism

• Symptoms overlap with ageing: fatigue, cognitive slowing, weight gain.
• Over-replacement risks atrial fibrillation and osteoporosis.

Osteoporosis

• Often silent until fragility fracture.
• Hip fractures carry high 1-year mortality and loss of independence.
• Vitamin D deficiency and falls risk are key contributors.

Musculoskeletal Conditions

Osteoarthritis

• Degenerative joint disease causing pain, stiffness, and reduced mobility.
• Leads to deconditioning, social isolation, and falls.
• Imaging severity often poorly correlates with symptoms.

Sarcopenia

• Age-related loss of muscle mass and strength.
• Driven by inactivity, inflammation, and malnutrition.
• Central to frailty and poor recovery after illness.

Renal and Urological Conditions

Chronic Kidney Disease

• Physiological decline in GFR with age.
• Marked impact on drug clearance and toxicity.
• AKI often triggered by dehydration or infection.

Benign Prostatic Hyperplasia

• Causes lower urinary tract symptoms, retention, and UTIs.
• Anticholinergic drugs worsen cognition and delirium.

Urinary Incontinence

• Multifactorial: mobility, cognition, bladder dysfunction, medications.
• Strongly associated with falls, depression, and care home admission.

Gastrointestinal and Nutrition

Constipation

• Very common due to immobility, dehydration, and medications.
• Can precipitate delirium, urinary retention, and bowel obstruction.

Malnutrition

• Caused by poor intake, chronic disease, dysphagia, and social isolation.
• Leads to sarcopenia, infection risk, and delayed recovery.
• Unintentional weight loss is always a red flag.

Mental Health

Depression

• Often underdiagnosed and presents atypically.
• May manifest as apathy, weight loss, or somatic complaints.
• Treating depression improves functional outcomes.

Geriatric Syndromes (Cross-Cutting)

• 🚶 Falls: usually multifactorial (vision, balance, drugs, environment).
• 🧓 Frailty: reduced resilience to stressors; predicts poor outcomes.
• 💊 Polypharmacy: increases delirium, falls, and hospitalisation.
• 🛏️ Pressure ulcers: marker of immobility and poor overall health.

Key Take-Home Principles

• Think in syndromes, not single diagnoses.
• Expect atypical presentations.
• Function, cognition, and goals of care matter as much as pathology.
• Small insults can cause disproportionate decline.
• Comprehensive Geriatric Assessment is central to good care.