Why tiredness and feeling unwell in an older adult matters
Vague tiredness in an older person has a long list of causes, physical and psychological, and they often come together. A structured history and a sensible first set of tests find most of the treatable ones; consider depression, but only after looking for physical illness.
What to ask in the history
- When it started and how it has changed
- Weight loss, appetite, fever, sweats
- Mood, sleep, interest, memory
- Breathlessness, chest pain
- Bowel changes, bleeding
- Urinary symptoms
- Pain
- New or changed medicines
- Alcohol
- Who he lives with, any recent loss, what he can still do
Red flags
- Weight loss
- Bleeding from the bowel or in the urine
- New confusion
- Low mood with thoughts of self-harm
- Fever
- Falls
What to examine
- Pallor, jaundice, lymph nodes, hydration, weight
- Heart, lungs, abdomen, rectal examination
- Thyroid
- Neurological examination and a cognitive screen
- A mood screen
First investigations
- Full blood count, ESR and CRP
- Kidney function, sodium and calcium
- Glucose, liver function, thyroid function
- Vitamin B12, folate, ferritin
- Urine test
- Chest X-ray
- Further tests as the findings direct
Differential diagnosis of tiredness and feeling unwell in an older adult
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Blood and metabolic
- Anaemia
- High calcium
- Low sodium
- Thyroid disease
- Diabetes
- Kidney failure
Cancer
- Bowel
- Lung
- Prostate
- Myeloma
- Lymphoma
Infection
- Tuberculosis
- Endocarditis
- Urinary infection
Mind
- Depression
- Early dementia
Medicines
- Side effects
- Too many medicines together
Common mistakes
- Calling it depression before looking for physical illness.
- Forgetting to check the calcium.
- Not reviewing his medicines.