Definitions of older adults can vary, but usually, they are described as people with a chronological age of 65 years or older.10,11 Several studies have found increasing age to be a significant predictor of missed diagnoses. For example, one 2018 chart review study examining patients with hepatocellular carcinoma (HCC) found the strongest predictor of missed diagnosis of cirrhosis (a leading risk factor for HCC) to be age, which was associated with larger tumor sizes at HCC diagnosis and implied worse prognosis.12 Similarly, increasing age has been found to be associated with poorer diagnostic accuracy of heart failure, with older patients being less likely to receive echocardiograms.5,13
Several studies have also suggested a correlation between older age and missed diagnoses of respiratory conditions, including tuberculosis14-16 and asthma17,18; cancers19,20; mental health conditions such as depression21-23; and diabetes-related complications.24 A 2016 systematic review of the incidence and potential causes of diagnostic errors in older adults looked at seven prevalent diseases:
- Dementia.
- Chronic obstructive pulmonary disease.
- Heart failure.
- Parkinson’s disease.
- Stroke/transient ischemic attack.
- Acute myocardial infarction.
- Diabetes.
Researchers found that increasing age was often associated with lower diagnostic accuracy and resulted in both overdiagnosis and underdiagnosis of these common conditions.5
Older adults are a highly heterogeneous group who experience very different trajectories of age-related changes ages across the life course. These changes reflect cumulative disadvantages that occur throughout an individual’s life, requiring consideration of physiologic age in the diagnostic process.25-28 The unique characteristics and risk factors of individual patients are important for diagnosticians and care teams to consider throughout the diagnostic process and in making decisions to support older adults’ health.
In the following subsections, we present several challenges in approaching diagnostic safety that are unique to older adults. We divide these into patient, clinician, and structural factors (Figure 1).
Figure 1. Patient, clinician, and structural factors contributing to diagnostic errors in older adults
Patient factors
Atypical presentations. Older adults have more atypical presentations of medical conditions compared with their younger adult counterparts, and clinicians face many challenges in assessing and treating older patients for common diseases and conditions. For example, diagnosis of sepsis in older adults can be especially challenging and sepsis is often underdiagnosed, as older adults with sepsis often present with atypical, nonspecific symptoms.29-31 The most common example is the presence of altered mental status, but other examples of symptoms of infection in older adults include lethargy, tachypnea, loss of appetite, dehydration, weakness, dizziness, falls, and incontinence.29-31
Similarly, a 2023 scoping review aimed at identifying the atypical presentation of symptoms of COVID-19 in older adults identified 58 atypical symptoms that were reported in the literature. Geriatric syndromes (e.g., delirium, falls, reduced/loss of appetite or anorexia, or functional impairment) were the most prevalent atypical presentation.32
Differences in diagnoses of certain mental health conditions, such as borderline personality disorder (BPD), have also been noted between younger and older patients. In older patients with BPD, studies have found that symptoms shift to more depression, emptiness, and somatic complaints,33 with self-harm taking nonconventional forms such as nonadherence to medical regimes or misuse of medication.34
In a retrospective review of older adult patient cases in an emergency department (ED) of a tertiary care hospital in Thailand, researchers found that the prevalence of an atypical presentation was 28.6 percent of 633 older adult patients. Independent risk factors associated with atypical presentations were complicated urinary tract infection (UTI) and a history of dementia, with the absence of a fever with a disease known to cause fever as the most common atypical presentation.35
Several individual case reports describe atypical presentations of patients, challenges in diagnoses, and “hard-to-diagnose” conditions in the scientific literature. Table 1 provides examples of case reports in the medical literature that were published in the last 10 years and describe diagnostic errors of common conditions and health concerns in patients over age 50, with implications for the older adult population.
Table 1. Examples of case reports with diagnostic errors of common health concerns in older adults
| Authors | Title | Description/Summary |
|---|---|---|
| Barrett and Hoover (2023)36 | Differential screen and treatment of vestibular dysfunction in an elderly patient: a case report | A 72-year-old male presented to his physical therapist 23 days after falling off a ladder, resulting in a mild traumatic brain injury. He was initially diagnosed with a labyrinthine concussion due to ongoing symptoms of “falling backwards,” poor gait, and diminished mobility. A physical therapy examination later revealed atypical benign paroxysmal positional vertigo, highlighting the importance of thorough medical screening and differential diagnosis for all conditions, regardless of referral source. |
| Cosme, et al. (2023)37 | Newly diagnosed Type 1 diabetes in an elderly patient | A 71-year-old patient presented to the ED with polyuria, polydipsia, and tiredness. She was identified with hyperglycemia and high blood and urine ketone bodies. Further laboratory workup showed she was positive for anti-GAD and anti-ICA antibodies and her HbA1c was 14.1 percent. Because the patient’s symptoms were associated with metabolic ketoacidosis in the presence of high titers of more than one positive type 1 diabetes (T1D)-related antibody, a diagnosis of T1D was achieved. Recognition of adult-onset T1D is important, as a prompt diagnosis can avoid misdiagnosis of type 2 diabetes. GAD=glutamic acid decarboxylase; ICA=islet cell antibodies;HbA1c=hemoglobin A1c |
| Guibentif, et al. (2016)38 | Acute appendicitis in elderly adults: a difficult diagnosis | Appendicitis may present with unspecific symptoms of infection in older adult patients. Patient A (83 years old) had underlying cognitive impairment and acutely altered mental status, with delayed abdominal complaint; Patient B (87 years old) had acute appendicitis with initial nonspecific signs of infection: fever and leukocytosis. Patient B developed an acute abdomen, delaying diagnosis by 8 days. Older adults typically have more comorbidities and greater frailty, where appendicitis may present with nonspecific symptoms of infection. |
| Lamjoun, et al. (2023)39 | Normal pressure hydrocephalus and mania symptoms: case report | A 54-year-old male presented with psychiatric symptoms suggestive of a manic episode but left the hospital against medical advice before needed tests could be performed. In the patient’s second admission, symptoms worsened and included urinary incontinence and gait disorder. MRI showed a quadric ventricular hydrocephalus and the patient was diagnosed with idiopathic cerebral hydrocephalus, requiring neurosurgery. This case exemplifies the importance of considering organic causes of psychiatric symptoms in older people. |
| Hoyt and Jordan (2023)40 | The diagnostic challenge of an older adult with epigastric pain in the emergency department | Epigastric pain is a common complaint in patients presenting to the ED. A 70-year-old man described a sudden-onset pain that began while he was sitting comfortably in a chair smoking a cigar, nausea and vomiting, and nonbloody nonbilious stomach contents. He was hemodynamically stable. A stat outpatient CT was to be scheduled for the following day but was not performed until 6 days later, revealing a gangrenous gallbladder and requiring urgent operative intervention. |
Comorbid conditions and multiple chronic conditions. Currently, it is estimated that four out of five older adults have MCCs, which generally refers to patients with two or more chronic physical or behavioral health conditions concurrently.41-43 Age-related changes in physiology can include decreased organ function reserve and an increased prevalence of common comorbid conditions, including hypertension, cardiovascular disease, presbyopia, and hearing loss.44
The National Council on Aging reports that 94.9 percent of adults age 60 or older have a chronic condition (with 78.7% having two or more) and describes the 10 common chronic conditions for adults over age 65, including:
- Hypertension (60%).
- High cholesterol (51%).
- Obesity (42%).
- Arthritis (35%).
- Ischemic/coronary heart disease (29%).
- Diabetes (27%).
- Chronic kidney disease (25%).
- Heart failure (15%).
- Depression (16%).
- Alzheimer’s disease and dementia (12%).45
These and other comorbid conditions can affect the presentation of new diseases and obscure the clinical picture and ability to reach a timely, accurate diagnosis.
Individual patients may additionally differ in their interpretation of signs and symptoms as normal aging or part of their MCCs, potentially choosing not to report certain symptoms to their clinical provider, adding further complication to diagnostic decision making.46-48 Further, decreased sensation, cognitive decline, and functional limitations associated with the aging process can hinder an older adult’s ability to interpret and accurately report symptoms. Clinicians need to adopt a comprehensive and multidimensional approach to diagnosis, incorporating patient-centered care principles49 with their clinical judgment and evidence-based guidelines to navigate the complexities of aging and optimize diagnostic accuracy in older adults.
Communication barriers. Older adults may face communication barriers due to hearing loss, vision impairment, language barriers, or cognitive impairments, which can hinder the gathering of accurate medical history and symptom reporting. Older adults with cognitive impairments are particularly vulnerable throughout the diagnostic process, as they may have difficulty interpreting and articulating key symptoms essential for diagnosis during the clinical encounter and be written off as “poor historians” of their care.48,50
Several studies have found that hearing loss is directly associated with longer delays in seeing the doctor51 and several unmet healthcare needs.52 Hearing is the basic substrate for oral communication throughout a clinical encounter. Thus, older adults are vulnerable to poor communication throughout all phases of the diagnostic continuum and in all care settings, especially in health environments with loud background noise and rapidly paced clinician speech.53,54
In one study, researchers interviewed 59 older adults with hearing loss about the contexts of mishearing within a clinical setting. Patients reported occasions when problems of mishearing were focused on illness-related information and communication breakdowns where patients would miss what was being said by physicians and nurses entirely (e.g., communication of a diagnosis).54 Despite the prevalence of hearing loss among older populations, few studies consider hearing loss in patient-provider communication55 and to our knowledge, the relationship between hearing loss and diagnostic errors has not yet explicitly been explored.
Functional decline and health-related social needs. Recent research from the Centers for Disease Control and Prevention suggests that about 10 percent of adults over age 50 lack reliable transportation to meet their needs.56 Lack of access to public transport can harm older people, especially those with frailty and functional impairments.57 It is also a social determinant of health for this population, as it leads to reduced access to healthcare services, appointments, and social services.58
MCCs, comorbidities, frailty, and cognitive impairment can affect older adults’ ability to navigate healthcare facilities and keep necessary clinical appointments for diagnostic procedures or follow through with diagnostic testing. Older adults, even if functionally independent, may need a companion to help them with transportation, mobility, and visits to a healthcare facility. Clinical visits may therefore require the attendance of a “companion” (e.g., family member or unpaid caregiver) who may need to schedule time away from work to accompany the older adult to the appointment.
Socially isolated older adults (i.e., those who may not have an involved family member or friend) may find the use of healthcare services and diagnostic testing excessively burdensome. One study examined characteristics associated with dementia underdiagnosis in a nationally representative cohort of Medicare beneficiaries. Researchers found that older adult patients who attended doctor visits alone were more likely to be undiagnosed and unaware of a dementia diagnosis.59 For certain stigmatized health concerns, such as mental illness, older adults may be less likely to follow through on referrals and care due to negative attitudes within society toward older adults and negative attitudes toward mental illness (i.e., “double stigmatization”).60,61
Polypharmacy and prescribing cascades. Adverse drug events from medication can often mimic acute medical conditions in older adults, thus contributing to diagnostic errors and a “prescribing cascade,” where a second, potentially unnecessary drug is prescribed to treat the adverse drug event. For example, a class of antihypertensive medicines can cause leg swelling, which can often be misdiagnosed as heart failure in older adults, thus leading to the prescription of a diuretic medication.62
In addition, incorrect medication reconciliation due to care fragmentation contributes to diagnostic errors. In the United States, electronic health records (EHRs) are not connected with community pharmacy records. Thus, patients have to accurately report all of their medications and doses to clinicians, or clinicians have to communicate and coordinate with patients’ community pharmacies to compile an accurate medication list.
Older adults who take multiple medications and seek care from two or more healthcare systems are vulnerable to errors. In volume-based healthcare systems where primary care clinician appointments are time crunched and clinical pharmacists are generally not part of the primary care clinical team, inaccurate medication lists are common in these patients’ EHRs, thereby contributing to diagnostic errors.63,64
For example, a clinician newly involved in the care of an older adult with cognitive impairment who does not have access to records from other clinicians and community pharmacies may not know that the patient recently ran out of levothyroxine for hypothyroidism, which resulted in worsening visual hallucinations. This clinician may erroneously diagnose a mental illness and prescribe an antipsychotic medication. Furthermore, older adults often see multiple providers using different EHRs that lack interoperability, making timely medication reconciliation challenging.
Clinician factors
Ageism/age bias. Ageism is “the stereotyping, prejudice, and discrimination against people on the basis of their age”65 and can operate without conscious awareness and without intended malice.66,67 Ageism can be structural, interpersonal, or internalized and may impact a clinician’s ability to provide an accurate and timely diagnosis.68
Typical ageist stereotypes may include beliefs about the frailty, senility, and dependence of older adult patients. These stereotypes can have several effects throughout the diagnostic continuum, including:
- Undertriage and underrecognition of geriatric syndromes.
- Assumptions of frailty, dependence, and impairment as a norm.
- Dismissive language and behavior around concerns.
- Not addressing “what matters most” to older adults.69
Several studies suggest that these biases are likely to influence diagnosis, particularly around mental health.70 For example, the implicit notion that older people may naturally be expected to be depressed because of their age may lead to lower levels of screening for depression.23
Cognitive load factors. As clinicians face the challenge of diagnosing and managing complex clinical conditions during time-crunched appointment slots, thorough physical exams may get replaced by expensive diagnostic tests. Clinical judgment may be replaced by quick-to-use algorithm-based diagnostic tools. A thorough chart review can become burdensome or infeasible. In addition, older adults often present to their clinician with atypical presentation of an acute condition or exacerbation of chronic disease.
The cognitive factors that result in diagnostic errors in ambulatory care settings are particularly salient among older adults and include:
- Impaired judgment, vigilance, or memory.
- Lack of knowledge.
- Faulty data gathering and synthesis.71
- Improper communication (e.g., inadequate handoffs, failure to establish clear lines of responsibility).72
Without appropriate time and system support for a thorough assessment, the initial clinical response can be to attribute the condition to the patient’s age or to find a less likely but convenient label based on a false alert or superficial explanation of the patient’s symptoms. This response can result in a missed diagnosis. For example, acute delirium is often missed on inpatient services,73 and acute or subacute functional decline is frequently labeled as failure to thrive, resulting in worse outcomes for aging patients.74
Several studies show that older adults are frequently misdiagnosed with UTIs75-77 and pneumonia.78,79 Such misdiagnoses raise major concerns about the unnecessary prescription of antibiotics in this population and the impact of inappropriate antibiotic therapy, such as increased risk of drug interactions, negative health outcomes, and mortality.
Overdiagnosis and screening dilemmas. Overdiagnosis is also considered an undesirable diagnostic event80 and is a common and significant problem within older adult populations. Overdiagnosis occurs when a test finds an abnormality that is technically a “true positive” but would have never caused actual illness, even if undiscovered and untreated.81 Overdiagnosis can be a result of overtesting, where a diagnostic test or screening is performed despite the lack of clear benefits or where benefits are outweighed by harm.82
Screening without considering the patient’s holistic needs can reduce time available for more relevant and helpful discussions for older adult patients (e.g., reducing polypharmacy, healthy behavior counseling). It can also result in a diagnostic and treatment cascade for something that otherwise would not have caused symptoms during the patient’s lifetime.83,84 Cancer screening, for example, is commonly considered a standard practice in preventive medical care but it requires clinicians to consider patient preferences and weigh potential harms of screening and followup diagnostic tests (e.g., the “diagnostic cascade”) with the possibility of benefit.83,85-87
Concerns of over-screening and its implications for overpayments have been raised. For example, among Medicare Advantage managed care enrollees, risk-score gaming aims to identify as many diagnostic codes as possible to improve profits. Some screening is for conditions in which asymptomatic screening is generally not recommended by the U.S. Preventive Services Task Force and expert societies.88
Systemic and Organizational Factors
Diagnostic testing. Many of the common reference values for laboratory diagnostic tests are determined in young and healthy adults between the ages of 20 and 40. Validation of reference values for older adults can be challenging because the high underlying burden of illness among older adults makes it difficult to distinguish between age-related changes in physiology and pathologic changes.89 For example, current pyuria cutoffs have been found to promote inappropriate UTI diagnosis in older women90 and hematological reference intervals for frequently used laboratory tests in older adult populations are still under debate.89,91,92
In the past 5 years, considerable efforts have taken place to evaluate and improve the diagnostic accuracy of screening tools specific to older adults and various geriatric conditions. For example, efforts to evaluate the diagnostic accuracy of tests for cognitive status or decline,93,94 geriatric depression,95-97 frailty,98,99 and undiagnosed hypothyroidism100 are abundant in the scientific literature.
Clinical and methodological heterogeneity between studies can make it challenging to recommend one diagnostic test for use as a screening instrument over others. However, systematic reviews and meta-analyses can provide the highest possible grades of evidence and identify the most promising tools for improving diagnosis in specific settings and environments.87
Fragmented care. Older adults are more likely to have MCCs and use multiple medications. They may experience “polydoctoring,” where patients see multiple healthcare providers and are at risk of fragmented care through a lack of coordination and effective communication between their multiple providers.101
Care fragmentation can result in excess testing and procedures102,103 and suboptimal quality and outcomes in the older adult population.104,105 Multiple healthcare providers may prescribe medications independently and without full awareness of the patient’s complete medical regimen, with the potential for drug-drug interactions that can mask or mimic symptoms of other conditions.
Older veteran populations who seek care at both the Department of Veterans Affairs (VA) and community health systems, for example, are especially likely to have overlapping medications from the same drug classes dispensed by the VA and community pharmacies.106,107 Evidence supports the relationship between highly fragmented care and a higher risk of hospitalization for these patients.108
Other systemic factors include a primarily fee-for-service payment model that incentivizes volume over quality of patient encounters and reimbursement rules that favor procedural specialties over cognitive specialties. Thus, clinicians providing primary care services to older adults lack clinical support staff (e.g., registered nurses, clinical pharmacists, social workers, nutritionists) and face institutional pressure to maintain unrealistically large patient panel sizes. This scenario places older adults with MCCs at higher risk for diagnostic errors.
Insufficient workforce and geriatrics training. It is essential that all health professionals be familiar with common diagnostic challenges in caring for older patients, have basic competencies in the care of older adults, and contribute their perspectives through shared and collaborative care models. In addition, the growing U.S. population over 65 years old has created greater need for geriatrics physicians, nurses, and other healthcare workforce professionals to provide care for older adult patients across diverse care settings. However, the number of Board-certified geriatricians in the United States has fallen from 10,270 in 2000 to 8,502 in 2010 to 7,300 in 2021.109 Fewer than 1 percent of U.S. physicians are certified in geriatrics.110
Major drivers of the persistently low recruitment into geriatrics care include:
- Compensation and a lack of financial incentives (e.g., despite having advanced fellowship training, geriatricians receive the same or lower compensation than general internists and family physicians),
- Low prestige of the specialty, and
- Limited exposure to strong geriatrics role models during training.110
Some progress has been made in enhancing the amount of geriatrics content in medical and nursing education curriculums, as well as expansion and growth of the geriatrics nurse practitioner workforce.111 But a coordinated national effort to bolster the eldercare workforce is still urgently needed to improve our capacity to provide care for the rapidly growing population of older adults in the United States.
Among older adults, mental illnesses may go undiagnosed because physicians are not trained to recognize mental illness in this population and because of patients’ reluctance to discuss their emotional difficulties.112 Depression or anxiety among older adults may be a longstanding or newly developed problem brought on by the challenges of coping with physical and functional changes, living in isolation, and outliving family and friends.
A 2012 Institute of Medicine report estimated that approximately 5.6 million to 8 million Americans 65 years of age or older had mental health or substance use disorders, with the number predicted to reach 10.1 million to 14.4 million by 2030.113 This report noted that the United States did not have nearly enough professionals with the necessary training to screen, diagnose, and treat older adults with mental illness or substance abuse.
The United States needs to shift the delivery paradigm for mental health for older adults, including training diverse direct care and peer-support providers who can support diagnosis and perform interventions.114 Care models using an interdisciplinary care team approach have been shown to improve quality and outcomes of older adults.
The Geriatric Resources for Assessment and Care of Elders (GRACE)115,116 model incorporates an interdisciplinary team, including a nurse practitioner and social worker, to collaborate with primary care providers and perform assessment and care management in patients’ homes. This model has resulted in decreased hospital admissions within the high-risk group.115,116 The model has been successfully replicated in numerous settings, including both fee-for-service and capitation payment models.
The Program of All Inclusive Care for the Elderly (PACE)117 is an interdisciplinary care model for older adults in the community who need nursing home-level care. It provides high-quality and cost-effective acute and chronic disease management to enrollees in their homes.
