Acute illness in young children can present itself in mysterious ways. This is also the case with the elderly and frail.
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Imagine that you are a nursing home doctor. You receive a phone call from a nurse regarding a long-term resident. He is normally sprightly and the life and soul of the party, but struggles with his short-term memory and often has problems finding his way back to his room. He is now unable to get out of bed and is lethargic. He is clutching his lower abdomen, can barely open his eyes when requested to do so, and is completely disoriented as regards time, space and situation. You suspect silent delirium, and perform a thorough clinical examination, including percussion of the abdomen, and find probable bladder attenuation to well above the level of the umbilicus. A catheter is inserted and his delirium ebbs away, almost synchronously with the urine in the tube.
Gabriel García Márques, the Colombian author, wrote what was perhaps his best novel in 1985, Love in the Time of Cholera (1) , three years after being awarded the Nobel Prize in Literature. The book centres around the beautiful and harrowing love story of Florentino Ariza and Fermina Daza. When I read this novel in my student days (perhaps because I was a medical student), the musings of Dr Juvenal Urbino, another central character in the book, particularly resonated with me. He was the husband of Femina Daza and a highly respected doctor in the local community, partly because of his efforts to combat cholera, which periodically ravaged the fictional town of Macondo. Before suffering a fatal fall from a ladder in pursuit of the house parrot hidden behind the magnificence of the mango tree's leaves, he argued that paediatrics is the most honest clinical specialisation. He reasoned that infants never pretend to be sick. Yes, their presentation of illness can be extremely cryptic – but they never put on an act.
I have reread the book as an 'adult', after relatively extensive experience with acutely ill geriatric patients in nursing homes as well as hospitals. It struck me that life in many ways is a circle, with clear similarities between paediatrics and geriatrics.
Geriatrics, and nursing home medicine in particular, has long been one of the areas of specialisation with a poor uptake of personnel. Perhaps because the patients are old and frail, approaching their final phase of life, arriving at the nursing home or the hospital with an armful of diagnoses and typically a list of medicines that amounts to at least one meal.
Infants are not out to deceive us. Nor are those nearing completion of the circle of life
And when the oldest and frailest patients become acutely ill they are often difficult to interpret – just like young children. They regularly have cognitive impairment and chronic disease in other essential organs, such as the kidneys, heart and lungs. When they suffer from infections, electrolyte disturbances, urinary retention, heart attacks and so on, their reactions are not always what we expect. They do not necessarily display local symptoms or fever, they can become delirious when a full bladder creeps towards the epigastrium, and can develop urinary incontinence or start to have falls when the cerebral arteries are blocked by a carotid embolism. And when you place your stethoscope against their skin, it can be difficult to determine whether abnormal respiratory sounds are due to fibrosis, pneumonia or heart failure, or whether the heart murmur of the elderly, febrile patient is an indication of endocarditis or not.
It is perhaps no coincidence that the oldest and frailest patients revert to their childhood when something happens that puts marginal organ reserves to the test. After all, we spend a long time learning how to stand up, walk steadily, behave like humans, control our bladders and bowels, and communicate verbally in a way we can be understood. And what little those of us who reach a ripe old age remember before we die often involves a mother, a father, a sister, a brother – or glimpses of happiness and sadness from early childhood.
Infants are not out to deceive us. Nor are those nearing completion of the circle of life. It is our duty to interpret their manifestations of illness as best we can, even though their enigmatic clinical presentations may frustrate us and render us powerless.
Few probably expected the deeply rational and reflective Dr Urbino to expose his tendency to fall – born of delirium? – from the ladder high above the ground. But for all we know, the leafy mango tree may have taken him back to the fruit-pilfering days of his youth.