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Dr. José Cáceres
is currently
Professor and Chief of the
Department of Radiology, HGU Vall
d’Hebron, Universidad Autónoma,
Barcelona, Spain. He studied at the
medical school of the University of
Seville before taking up a Residency
and then Fellowship at the
University of Cincinnati, Ohio, USA.
Prior to his current position,
Dr. Cáceres held the position of
Assistant Professor at the
University of Kentucky, USA.
Dr. Cáceres has a special interest in
Chest Radiology and congenital
malformations of the chest in adults.
He is a member of the Radiological
Society of North America, the
American Roentgen Ray Society, and
the European Society of Chest
Imaging (ESTI). Dr. Cáceres is a
former President of ESTI and is a
member of the Programme Planning
Committee of the European
Congress of Radiology. He is also a
reviewer for the European Journal of
Radiology, the American Journal of
Roentgenology and Radiology. |
Special considerations for the radiologist managing old and very old
patients
José Cáceres, MD
Department of Diagnostic Radiology
HGU Vall d’Hebron, Universidad Autónoma
Barcelona, Spain
Address for correspondence:
Dr José Cáceres
Professor and Chief, Department of Diagnostic Radiology
HGU Vall d’Hebron, Universidad Autónoma
Pg. De la Vall d’Hebron 119-129
08035 Barcelona, Spain
Tel: +34-93-274-6769 Fax: +34-93-274-6779
Email: jcaceres@vhebron.net
Abstract
Life expectancy in developed countries has almost
doubled in the past century. As a result, this ageing
population needs greater medical and supportive care, a
change which is affecting imaging departments. Elderly
patients create logistic problems due to their special
needs in transportation and poor mental status which
causes longer room occupancy.
Diagnostic imaging interpretation in the elderly is
affected by the difficulty in obtaining adequate clinical
information due to poor mental status and paucity of
symptoms. Radiographic patterns of disease are usually
masked in the elderly by alterations related to ageing.
As a result, it is common to use high-technology
examination techniques (e.g. CT and MRI). Although
they are expensive procedures, their use may save time
and expense by establishing accurate diagnoses and
avoiding intermediate, inconclusive examinations.
Introduction
Life expectancy in the Western world has increased
markedly over the past century. At the beginning of the
20th century, the life expectancy in males was around
46 years and only slightly higher in females. At the end
of the century, it had risen to 76 years in males and
82 years in females. Thus, during this short time, the life
expectancy of the population in developed countries
has almost doubled.
What is the current definition of elderly? Given the
good health of the general population, the current
retirement age (65 years) is not considered as old age.
Nowadays, it is suggested that old age begins at 75,
with the term ‘young old’ being applied to people
between 70 and 75 years of age; those over 85 years
of age are referred to as ‘oldest old’.
As a result of increasing wealth and better medical
attention, the population is getting older and, as such,
needs greater medical and supportive care.1 Hospital imaging departments are being influenced by this
change. Older patients create new problems and
challenges, which should be addressed by radiologists.
The imaging of the elderly affects imaging departments
in two ways: logistics and diagnosis.
Logistics
Elderly patients usually need transportation to and from
the imaging department, which increases the need for
auxiliary personnel. Once in the department, they often
have special needs (e.g. oxygen, nursing care) and they
should be placed in a separate room with an attending
nurse and facilities to give specialized care. Because of
their age, some of these patients will have hip or knee
prostheses, or pacemakers, which can result in imaging
artefacts or contraindicate a CT or MRI examination.
Another consequence of old age is slowness in getting
dressed and undressed, which means that patients will
need longer room time in comparison with younger
patients. In addition, many elderly patients have
difficulties in understanding instructions because of
diminished hearing or poor mental status. (About
18 million people in the world have dementia and this
number is expected to nearly double in the next
25 years.)
Diagnostic problems in imaging
In elderly patients, the diagnostic imaging process is
influenced in different ways:
- Insufficient clinical information: It is recognized that
clinical information is essential in the diagnostic
imaging process. Studies have shown that it may be ten
times more difficult to obtain useful clinical information
in elderly patients than in younger ones. This is probably
due to a combination of communication problems and
the paucity of symptoms in the elderly. They are more
likely than younger patients to present with vague
symptoms and have nonspecific findings on examination. Many of them have a diminished
sensorium,2 allowing pathology to advance prior to
symptom development. In addition, their pain is likely
to be less severe than expected for a particular disease.
 |
| Figure 1. Calcification in the annulus fibrosus of the mitral valve in a
79-year-old patient. |
- Definition of standards: A further problem for the
radiologist is the lack of standards establishing
normality in the elderly.3–6 For example, coronary
calcifications are given a different significance in a
middle-aged versus an elderly patient. It is very
important to define normal standards in this population
in order to separate real pathologies from findings that
are merely manifestations of old age (Figure 1).
- Changes in disease patterns: The characteristic patterns
of many disease processes change in the elderly and
may be masked by alterations related to ageing.7–8
For example, pneumonia appears as a segmental
air-space opacity in young patients, whereas in the
elderly it appears as a patchy infiltrate, due to the
accompanying emphysema (Figure 2). To better identify
the imaging features in this population, it is common to
use high-technology examination techniques, such as
CT and
 |
 |
| Figure 2. ‘Swiss-cheese’ pattern of pneumonia in an old patient. |
Figure 3. Diverticulitis in a 76-year-old patient with vague
abdominal symptoms. |
MRI.9-12 Although these are expensive procedures,
their use may save costs by establishing accurate
diagnoses and avoiding intermediate, inconclusive examinations. Computed tomography plays a very
important role in the evaluation of abdominal pain in
elderly patients, especially when the diagnosis in
unclear (Figure 3).
The emergence of multi-detector-row CT (MDCT)
promises great advances in this field. MDCT is a fast
and noninvasive technique and, among other
capabilities, allows virtual endoscopy of the hollow
viscera. For an elderly patient, it is probably more
appropriate to undergo virtual colonoscopy with this
technique than to have a barium enema.13, 14
With the current ageing of the population, it can be seen
that diagnostic imaging faces new problems which will
need to be addressed with new approaches, especially
in patients with diminished cognitive functions.
Key Learning
• Life expectancy in developed countries has almost doubled in the past century
• Elderly patients create logistic problems in imaging departments due to their special needs in transportation
and poor mental status
• Radiographic patterns of disease may be masked in the elderly by alterations related to ageing
• It is difficult to obtain adequate clinical information in the elderly due to poor mental status and paucity
of symptoms
• High-technology examinations (CT and MRI) may save time and expenses in the elderly, if used wisely |
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