Establishing clinical diagnosis is a process based on the history of patient’s symptoms, clinical signs, and additional information obtained from laboratory tests, chest X-ray and other available data. In elderly patients, the diagnostic process is often more difficult due to blurred clinical picture, overlapping of disease symptoms with signs of aging, and comorbidities. Inadequate geriatric education of medical staff may result in errors in clinical judgment, especially in relation to the oldest-old and cases where knowledge of age-related changes and comprehensive geriatric assessment play crucial role in formulating diagnosis. Thus, recognizing a new disease in an elderly patient is a challenging task, with a considerable risk of under- and over-diagnosis.

Respiratory symptoms are among the most common reasons for medical consultation at all ages. In older adults, limited respiratory capacity may present as functional decline while, on the other hand, low exercise performance should be differentiated with dyspnea. Clinical cases described below show how complicated the process of reaching a proper diagnosis in senior patients can be. The presentation of ten cases was divided into the following parts: medical history, clinical signs and diagnostic tests results, preliminary diagnosis and treatment, disease course, final diagnosis. At the end of each case description there is a short commentary elucidating reasons of difficulties or errors in establishing the proper diagnosis.

An obese seventy-five-year-old woman with arterial hypertension treated for the last 20 years reported significant dyspnea after climbing two flights of stairs. Consultant cardiologist advised body mass reduction and continuation of pharmacological treatment of hypertension. A detailed history and analysis of symptoms by a consulting geriatrician revealed that the patient occasionally heard „an orchestra of wheezing” in her chest and had suffered from mild asthma in her childhood. The patient did not notice symptoms of allergy. She was referred for spirometry; it revealed bronchial obstruction with a positive response to bronchodilators. The above lead to formulating a new diagnosis: non-allergic asthma. New medication including long-acting bronchodilating agent and inhaled corticosteroid was introduced with prompt and significant improvement of symptoms – the patient could climb two flights of stairs without dyspnea. Thus, the diagnosis of non-allergic asthma was confirmed in this obese hypertensive elderly patient with limited exercise capacity.

The above case exemplifies a phenomenon quite common in care of geriatric patients; under-diagnosis of diseases due to ascribing symptoms to old age itself or to other diseases. In this case, low exercise capacity and dyspnea were erroneously interpreted as a result of obesity and impaired cardiovascular function. Simple and widely accessible test, spirometry, revealed respiratory cause of the patient’s complaints.

An eighty-year-old woman regularly visiting a cardiologist due to stable ischemic heart disease, arterial hypertension and heart failure, decided to visit a geriatrician for the purpose of general medical check-up. The outpatient geriatric clinic was located on the second floor and the patient entered the clinic after climbing two flights of stairs, since the elevator had been temporarily out of order. The geriatrician was amazed to find signs of severe respiratory distress in the patient, including: breathing rate of 30/min with prolonged expiratory phase, mild wheezing, and relatively low transcutaneous hemoglobin saturation (92%). The patient had history of 40 years of smoking. Spirometry showed severe obstruction (forced vital capacity FEV₁ < 50% predicted value) with no improvement after inhaling short acting beta-adrenergic agent. The diagnosis of chronic obstructive pulmonary disease (COPD) was established and the patient was given prescription for a long acting bronchodilator – tiotropium and referred for further assessment to an outpatient pulmonary clinic.

This case reflects several problems found in a patient with COPD: under-diagnosis of COPD in a person with confirmed cardiovascular disease (CVD), lack of active screening for COPD in a person with a long-term history of smoking, underreporting of symptoms by elderly patients with comorbidities. Paradoxically, the specialist care delivered by a cardiologist could have delayed the recognition of COPD due to lowered alertness of the primary health care physician and similarity of cardiovascular and pulmonary symptoms. Elderly patients with CV, especially smokers, should be screened for other diseases including COPD and patients with COPD should be actively diagnosed for CVD, since the comorbidity level in this group of patients is high.

A seventy-eight-year-old woman was referred to a hospital due to increasing dyspnea and productive cough. The patient reported that problems with breathing had started 25 years before, and claimed that she had never smoked. She had never been hospitalized due to respiratory symptoms, but had regular yearly visits at an outpatient pulmonary clinic. Physical examination revealed slim posture, increased respiratory rate (25/min), prolonged expiratory phase, abnormal percussion and wheezing. Chest X-ray revealed diffuse emphysema. The patient presented a result of pulmonary function tests performed 6 months prior to the current exacerbation indicating severe airflow obstruction with an increased residual volume (RV) and an abnormally high respiratory resistance (RR) of 300% of the reference value. The diagnosis of COPD was evident. The patient was admitted to the hospital and treated with bronchodilators with moderate effect during the 24 first hours. Due to the absence of expected improvement of symptoms, on the second day of hospitalization the patient was given prednisolon (0.5 mg per kg of body mass). Rapid and significant reduction of symptoms was reported by the patient and control pulmonary function tests showed slightly improved FEV₁ and FVC accompanied by a significant reduction of RV and RR. Moreover, a detailed medical history taken by a medical student revealed clinical features typically occurring in asthma, not COPD, such as: evolution of dyspnea from rapid onset and quick resolution of symptoms (attacks) to more chronic course of the disease with advancing age, intolerance of non-steroid anti inflammatory drugs (NSAID) presenting as acute dyspnea and rush, as well as significant improvement after introducing inhaled steroids in the past. The diagnosis was revised and changed to severe aspirin-induced asthma with airway remodeling.

There are three main issues to be discussed in the above case. COPD is often erroneously diagnosed in patients with asthma due to the change of the disease course to more chronic with advancing age. In some cases, an overlap syndrome (asthma with coexisting COPD) is established, especially in patients with chronic asthma and multiple risk factors for COPD. The quality of spirometry in the elderly is a topic of debate and depends on many variables including the level of experience of the pulmonary function test technician and the quality of equipment. However, this case exemplifies yet another problem: severe and slightly reversible airway obstruction with emphysema and severely increased respiratory resistance in a patient with a long term history of asthma symptoms. It is believed that this rather rare phenomenon is a result of advanced airway remodeling due to asthma and occurs in some patients with chronic asthma and a long history of symptoms. Chronic lung hyperinflation observed in all obstructive airway disorders and considered reversible may transform in some patients into emphysema with irreversible destruction of lung parenchyma. In the case described above, there were two key factors warranting a proper diagnosis of asthma: a detailed history taken from the patient and availability of repetitive pulmonary function tests.

An eighty-two-year-old man with dyspnea and history of 40 years of smoking was referred to a hospital from an outpatient medical center with a written diagnosis of COPD exacerbation. The patient was brought to the emergency room of the hospital by an ambulance on a cold winter morning, wearing a big hat, woolen scarf and a winter coat. Because of this outfit, physical examination of the patient was not readily possible, however a specific pattern of breathing focused attention: his respiratory rate was 30 per minute and each breath was accompanied by stridor – a wheezing sound during inspiration. Only after removing the woolen scarf and the coat it became evident that the patient’s problem was located in the area of his neck – a large mass or tumor deforming the neck was visible on the right side of the neck, with skin unchanged. The patient admitted that the growing tumor had been present for some time. The patient was immediately referred for laryngological consultation and a laryngeal tumor causing severe narrowing of the larynx was diagnosed. After performing immediate tracheotomy the symptoms of dyspnea and loud breathing resolved. The patient was referred for further specialist treatment to an ORL unit.

Differential diagnosis of dyspnea is one of the basic clinical tasks for medical students and young doctors, however it may be challenging even for experienced medical staff, especially when a combination of unfavorable factors occurs. As described in the above case, the patient was referred to a hospital from an outpatient clinic and probably by a medical doctor who knew the patient and treated him for COPD. Dyspnea reported by the patient at the outpatient clinic was assumed to be the result of COPD exacerbation. However, careful analysis of dyspnea and the way of breathing would have surely facilitated earlier diagnosis of upper airways obstruction. If the patient would have been asked whether it was more difficult to breathe in or out, he would have certainly indicated problems with inspiration characteristic for upper airway obstruction. Moreover, observed tachypnoe with audible stridor should have prompted careful inspection of upper airways. Additional unfavorable factors were cold weather and the patient’s winter outfit with a scarf completely hiding his neck tumor. The patient did not understand a possible relationship between slowly growing neck tumor and dyspnea. In summary, a detailed examination of the patient can prevent medical errors. One diagnosis (in this case COPD) does not exclude other medical problems affecting the same system (in the presented case COPD and neck tumor caused respiratory signs and symptoms due to a combination of upper and lower airways obstruction).