Older Patients, Wiser Care

Heart Attacks at 65 and Older: The Symptoms Aren't Always What You'd Think

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Dear Dr. K:

My 88-year-old mother who has Alzheimer's dementia just had a heart attack, but her symptoms weren't like what I thought (crushing pain in chest, etc.). My sister and caregiver noticed she wasn't herself--no sparkle in her eyes, no energy--but little else. Then she just slumped over. Is it because she's a woman, or because she's 88? Are there things we should have been watching for?

Keeping an eye out for a heart attack in someone like your mother is definitely challenging. That's because she belongs to two groups that are known to often have heart attacks without the classic symptom of chest pain: She's a woman, and she's older.

Over the past few decades, medical research has shown that women, as well as older people of either gender, often have heart attack symptoms that are very different from the so-called "classic" chest pain and/or pressure that middle-aged men tend to experience.

These different symptoms often include shortness of breath, weakness, and fatigue. Other possible symptoms include nausea, vomiting, sweating, palpitations, or pain in the jaw, neck, arm, or upper belly. Some women and older men even have poor sleep for a few days before their heart attack. And although many do get chest pain or chest discomfort, at least 30-40 percent may not have any chest pain at all.

The trouble is, there are lots of things that can make an older person feel weak and tired. For instance, even though heart attacks are common, it's far more common for me to find my patients' weakness and fatigue are due to something like a cold, a medication side effect, or a urinary tract infection. And for the many older people who live with chronic shortness of breath (due to ongoing health problems such as chronic obstructive pulmonary disease or congestive heart failure), it can be hard for a caregiver or doctor to distinguish a bad day in the life of a chronic disease from a new urgent problem like a heart attack.

Finally, it's of course even trickier to evaluate the symptoms of someone who has Alzheimer's or another dementia. Memory and thinking problems often make it hard for the person to describe symptoms accurately. People with dementia are also particularly likely to develop delirium (a state of worse than usual mental confusion), which can make them either more agitated or quieter than usual when a heart attack is stressing the body.

My prescription:

So what's a caregiver to do, in order to not miss a heart attack?

"¢ Always pay attention to any significant change in physical or mental function in an older person, especially if there's a diagnosis of Alzheimer's or other dementia. The fact that you've noticed a change over hours or days is probably more important than trying to figure out just what symptoms might correspond to what disease.

"¢ Get a change in energy or function promptly evaluated by a medical professional. Unless your loved one looks really unwell (i.e. is really struggling to breathe, can no longer stand up, having chest pain, or anything else that looks scary to you), in most cases it's reasonable to start with a phone call to an advice nurse. Advice nurses (who manage phone lines at most medical practices) are trained to ask questions meant to help figure out whether an urgent care visit or emergency room visit is needed. Of course, if you're ever in doubt about what to do, it's safest to call 911.

"¢ If you're particularly concerned about a possible heart attack: To check for signs of an ongoing, or perhaps impending, heart attack, doctors offices and emergency rooms almost always start by checking an electrocardiogram. You may also want to ask if blood can be drawn to check for cardiac enzymes (which are released by damaged heart muscle cells).

"¢ Remember that in an elderly person, most changes in physical or mental function end up not being due to heart attacks. Make sure the doctor also checks for other common problems such as infection, low blood pressure, uncontrolled pain, or medication side effects.