With older adults (aged 65 and over) collectively being the largest and fastest-growing population, you’d think their medical care would be, at minimum, up to par with the rest of the generations—if not more exceptional.
Surprisingly, this is not always the case. Misdiagnosis is common in older adults, with the most comprehensive studies finding diagnostic error rates of greater than 10%.
Older adults often present with a constellation of factors unique to their stage in life, which can greatly contribute to diagnostic error—both overdiagnosis and underdiagnosis.
Advanced age often disqualifies older adults from clinical trials
One hindrance to the proper diagnosis of older adults is the existence of an evidence gap; medical professionals simply need more research on this population. However, advanced age is more often than not an exclusion criterion for clinical trials.
…medical professionals simply need more research on this population.
This causes a cascade of problems because many study designs rely on available knowledge about past data to combine with observational data to make predictions about future events. However, if past data on older adults is scarce, then using this data in present-day clinical trials may be misleading or harmful. This leads to an absence of reliable data about the probability of disease manifestations in older adults.
Symptoms in older adults present differently
If you’re 35 and you come down with pneumonia, you’re most likely going to show up at the emergency room with a fever. However, if you’re 77 with pneumonia, a fever is actually unlikely. In fact, you may not even be coughing. As a 77-year-old with pneumonia, there’s a greater than 50% chance the only symptom you’ll present with is confusion.
Heart attacks and older adults can be even more confounding to doctors. Some estimate that nearly 50% to 80% of older adults having a heart attack will not present with standard heart attack symptoms but will instead have only vague symptoms like confusion, restlessness or fatigue.
Communication challenges and a lack of history and family involvement
When patients have hearing impairments and cognitive impairments, it’s difficult for clinicians to gather an accurate and complete history. To make matters more difficult, these two diagnoses are often missed and thus not included in the patient’s record, so the clinician is unaware of them at the time of the intake.
When patients have hearing impairments and cognitive impairments, it’s difficult for clinicians to gather an accurate and complete history.
Add this confusion to a lack of appropriate family involvement, and the clinician is more likely to miss key aspects of the patient’s history, which may ultimately lead to misdiagnosis.
Presence of multiple chronic diseases
Geriatric medicine is complex. Older adults may have multiple chronic diseases, each of which requires its own specialist and a battery of medications. This makes for a muddle of medications, side effects, medications for side effects, symptoms and conditions for generalists and specialists to sort out and rifle through at each appointment.
To make matters more confusing, these clinicians may not always communicate with one another in the best ways. The current health care system makes it easy for a critical diagnosis to fall through the cracks or for a misdiagnosis to make its way into the patient’s chart. This is why older adults often benefit the most if they can see as few clinicians as possible.
Older adults often benefit the most if they can see as few clinicians as possible.
In addition, overmedicating older adults – known as polypharmacy – is all too common. And reliable medication reconciliation and safely reducing the number of medications an older adult is taking are both critical for older adults but may not be practiced appropriately unless there’s heavy family intervention.
Ageism in health care
Ageism is unfortunately still prevalent in health care settings and can lead to a clinician “closing the case” on a diagnostic exploration. Ageism is defined as “the process of systematic stereotyping or discrimination against people because they are old, just as racism and sexism accomplish with skin color and gender.”
Unfortunately, some clinical care and decision support systems are built upon these stereotypes, and an implicit sense of futility may overshadow some decisions made when treating older adults. In fact, a recent systematic review of ageism in health care found that ageism is a major contributor to adverse health outcomes in older adults.
Nearly 20% of Americans age 50 and older say they have experienced ageism in health care settings, which can result in inappropriate or inadequate care, according to a 2015 report. One study estimates the annual health cost of ageism in America, including over- and undertreatment of common medical conditions, totals $63 billion.
Caregivers can help ensure diagnostic excellence in older adults
As caregivers, you’re the first line of defense against ageism in health care, and the first line of offense when it comes to advocating for your loved one in the health care setting. Be aware of overtreatment (excessive testing and seemingly unnecessary procedures) as well as undertreatment, which can lead to misdiagnosis.
If your loved one has hearing impairment or cognitive impairment, speak up. Let the health care team know right away, and insist that it is documented in their chart. And if your loved one has multiple chronic illnesses, try to get a dedicated geriatrician on board to centralize their care. Also, consult with your local medical centers to see if they offer comprehensive medication review services. Streamlining your loved one’s medication list will go a long way in keeping them safe.
If your loved one has multiple chronic illnesses, try to get a dedicated geriatrician on board to centralize their care.
As a caregiver, you have a stressful role, but you can make a huge difference in the quality of care your loved one receives! So, carry on with your dedication and care. You make a difference.