ABSTRACT
An assessment of an ill young person should lead to a unifying single diagnosis. While such an approach can also be true for older people, some sick old people differ in their presenting features from younger persons. What are these differences? A helpful mnemonic is ‘NAMES’:
• Non-specific presentation • Atypical or uncommon presentation • Multiple pathologies or diagnoses • Erroneous attribution of symptoms to old age • Single pathology/illness can lead to catastrophic
consequences
NON-SPECIFIC PRESENTATION
The first President of the British Geriatrics Society, Dr Trevor Howell, described five great problems
often encountered in aged patients. These ‘dragons’ usually carried a poor prognosis and made caring for older people arduous. They were:
• Confusion • Incontinence • Contractures of joints • Bedsores and other ulcers • Falls
Bernard Issacs continued the mythological theme by describing the ‘Giants of Geriatric Medicine’ (falls, immobility, confusion and incontinence) and recently geriatricians have tried to describe the pattern of presentation into an aidemémoire using the letter ‘I’ (incontinence, instability i.e. unsteadiness leading to falls, immobility, intellectual failure and iatrogenic illness). These may be the only presenting features of illness. With such non-specific presentation differential diagnosis is broad and the doctor has to use all available information from the history (which may have to be sought from a third party), carry out a full examination and appropriate investigations to find the cause of vague symptoms. A physician looking after an elderly patient not only requires medical knowledge but also observational, listening and deductive skills.
