The Australian Institute of Health and Welfare (AIHW) report emergency hospitalisations for the elderly (85+ years) are continually rising, with cardiac related conditions common, and coronary heart disease a leading cause of death (17%), followed by dementia (12%).
While the elderly have many similarities with their health complaints, no two patients will ever have the exact signs, symptoms, and health outcomes, nor have they reached their current health state in the same way. Hospitals rarely have the capacity to investigate and treat thoroughly enough, and general medical practitioners are bound by Medicare restrictions which include time spent with patients and the amount of testing and investigations permitted.
The medical system is founded on addressing and relieving symptoms, while a nutritionist will spend time collecting health history, lifestyle trends and diet information, gathering a full picture of what may be occurring for the patient and what led them to that point. Nutritionists can also interpret pathology results, often looking deeper than just ranges, can prescribe gentle nutraceuticals to address deficiencies, and provide dietary advice, aiming to achieve homeostasis, regardless of age and alongside pharmaceutical medications if they are necessary.
Hospitals and doctors surgeries are typically under enormous loads and the number of misdiagnosed patients in the Australian health care system is an increasing problem. While accurate statistics are difficult to gather on this issue, some estimate more than 4,000 people die each year unnecessarily due to errors or misdiagnosis (ABC, 2013).
Case Presentation
A 93 year old elderly female patient had been experiencing acute angina attacks during a respite stay, increasing in severity upon returning to her home two weeks later, leading her to an emergency admission to hospital with symptoms of chest pain, malaise, weakness, confusion, tachycardia, dehydration and clammy skin.
Hospital treatment included anticoagulant medication, myocardial infarction investigation, kidney function investigation, pain relief, and 24-hour cardiovascular monitoring. She remained in hospital for several days, released with beta-blocking medication, and the cessation of the anticoagulant. Urinalysis had not been completed throughout the duration of the stay.
Over the next 10 days, her condition deteriorated and this once fully independent individual, was now dependent with basic tasks such as washing, dressing, getting out of bed or chair and general mobility. She became severely dehydrated, frail and had little to no appetite or taste.
Urine testing with reagent strips indicated the presence of glucose, blood, proteins and ketones and laboratory testing confirmed a urinary tract infection (eColi). The antibiotic Trimethoprim 300mg was prescribed for seven days to treat the infection, however, blood testing revealed many abnormalities including extremely elevated iron ferritin levels and inflammation markers, and low cholesterol, when her pathology history showed levels above reference range. There were many other markers that appeared elevated and out of range, including glucose, liver enzymes and inflammation.
The unusual blood results along with the decline of overall health nine days post hospitalisation, prompted further investigation. Abdominal examination presented with severe tenderness around all aspects of the abdomen including the large intestine, central abdomen and bladder area. This, along with the patient reporting anal blood loss, prompted computed tomography (CT) imaging of the abdominal region.
Daily at-home testing of blood glucose levels, demonstrated consistently elevated fasting glucose levels ranging from 7.0 to 12.0, while daily urinalysis repeatedly showed the presence of glucose and blood.
Imaging results identified a small lesion on the pancreatic tail (intraductal papillary mucinous neoplasia [IPMN]), and gallstones but no malignancy or mass was detected in the bowel, bladder or liver.
Nine days-post hospital admission, her condition had not improved and nutritional supplementation began, focussing on glucose regulation, supporting heart health and gastrointestinal health post anti-biotic treatment. Medically, there was little to treat with only the continuation of the beta-blocker.
The patient’s condition began to improve after ten days of nutraceutical intervention, and she began reclaiming her strength and independence. Within five weeks of the supplementation regime, she had returned to her full mobility and strength, with blood investigations demonstrating a continual return to her baseline levels.
Using the blood pathology, imaging investigations, and physical examination results, it is most likely the patient was suffering with acute pancreatitis. Although all her blood markers had not yet reached severe levels, reviewing baseline pathology and continual testing, indicated a trend towards this prognosis and this may explain the sudden and severe decline in her health, further complicated by a urinary tract infection. Gallstones, pancreatic duct obstruction, or alcohol abuse often triggers pancreatitis.
The high iron ferritin levels could be attributed to the consistently elevated glucose levels and inflammation, with anaemia initially presenting due to frequent anal blood loss.
Supplementally, treatment with magnesium commenced, justified by the widespread deficiency in the general population, especially in the elderly, its necessity in the biochemical functioning of hundreds of metabolic pathways, its positive influence on heart and muscle health and blood glucose regulation.
In an in vivo study conducted by Schick et al, 2014, the effects of magnesium supplementation demonstrated significantly reduced premature protease activation and severity of pancreatitis.
As the patient had been presenting as pre-diabetic for a number of years, daily supplementation of chromium, alpha lipoic acid and cinnamon was prescribed, to further facilitate the regulation of blood glucose and reduce the risk of cardiovascular impairment, which was later ceased as her condition improved and her glucose regulation was managed through diet.
The third supplement prescribed was a probiotic, comprised of Saccharomyces cerevisiae (Boulardii) (SB), Lactobacillus acidophilus, Lactobacillus plantarum and Bifidobacterium lactis with a therapeutic aim to counteract the anti-biotics prescribed for the UTI, as well has aiding in elimination of any residual pathogenic bacteria. SB has demonstrated positive effects on restoring bowel health post antibiotic treatment, a protective effect against eColi overpopulation, and potentially protecting and reducing symptoms in inflammatory bowel disease. L. acidophilus and B. lactis have demonstrated positive effects in restoring a healthy microbiome following antibiotic therapy, and significantly reduced the numbers of antibiotic-resistant enterococci.
A vitamin B complex with CoQ10 was prescribed to provide overall essential nutrients for energy production, neurotransmitter synthesis, adrenal and liver support. As the client had periods of low food intake and most likely low nutrient absorption, the supplement was trialled for tolerance, continued throughout the duration of the recovery and ceased at full recovery.
Severe illness in the elderly frequently leads to high mortality rates, often attributed by concomitant diseases and complications. Recent research has demonstrated mortality rates of around 17% in patients aged over 80 years with acute pancreatitis.
The co-management of this patient by a holistic nutritionist working together with a general medical practitioner provided the framework for effective investigations that provided enough evidence to prescribe nutraceuticals within safe and therapeutic levels, taking into account the patient’s age and poor presenting condition. The unusual blood results, abnormal discomfort and sudden decline in health, were all consistent of acute pancreatitis, although not officially diagnosed.
Due to her age (93), the prognosis of a full recovery was very low. Typical medical management of a condition such as this includes analgesics for pain, the correction of hypovolemia, correction of hyperglycaemia with insulin and treatment in a high-dependency unit for severe cases. This patient however, received at-home care by family and external carers and gentle nutraceutical intervention, demonstrating a full recovery without further need for hospitalisation.