Atypical Presentations Flashcards
When an older adult presents with a disease state that is missing some of the traditional core features of the illness that are usually seen in younger patients.
what is this called?
Atypical Presentations
Common in elderly population
Atypical Presentations usually includes one of the three features
- Vague presentation of illness
- Altered presentation of illness
- Non-presentation of illness (underreporting)
- SOB walking up stairs (think it’s just “old age”)
prevalence with Atypical Presentations increases with what?
age
With the aging of the world’s population, atypical presentation of illness will represent an increasingly large portion of illness presentations
risk factors for atypical presentations
Age (especially >85 years)
Multiple medical conditions
Polypharmacy
Cognitive impairment
Functional impairment
classic sx of Acute Coronary Syndrome (ACS)
Crushing substernal chest pain
Shortness of breath
Nausea
Diaphoresis
atypical sx of ACS
- Dyspnea
- Mild pain, or even no pain
- New-onset fatigue, dizziness, or confusion
- Predominant GI sx
- Pyrosis (heart burn) / Dyspepsia / Nausea
The proportion of MI patients who have chest pain and diaphoresis declines with ?
age
less than 50% of MI patients older than 80 years complain of chest pain
what is the most common initial symptom in persons older than 80 years old
Dyspnea
Up to 20% of patients older than 85 have what type of complaints
neurologic
what initial testing is often nondiagnostic in older adults because of preexisting conduction system disease
ECG
Other nondiagnostic reasons include:
LBBB
presence of ventricular pacemaker
prior infarct
left ventricular hypertrophy
metabolic abnormalities
drug effects (ex: loop diuretics can cause hypokalemia)
Definitive Diagnosis of STEMI or NSTEMI requires what?
-
abnormal cardiac biomarker elevation - Troponins I & T (gold standard)
- more sensitive and specific compared to CK-MB
Guidelines state that older patients receive the same treatment for ACS as younger patients but with addition of what?
with close monitoring for adverse events
Pneumonia in older adults can be what types?
- Community acquired
- Nosocomial acquired
- Skilled nursing facility acquired - MC infection in skilled nursing facility
what type of pneumonia is common among the geriatric that is Associated with oropharyngeal dysphagia, Regurgitation of gastric contents
aspiration pneumonia
presentation of pneumonia
- Can present with:
- General malaise
- Confusion
- Loss of appetite
- Functional decline - May be absent
- Fever / chills
- Pleuritic chest pain
- cough
scoring assessment for pneumonia?
what does each final result mean?
CURB65
- Predicts mortality
- Death risk at 30 d increases as score increases
- Confusion
- Urea - >7 mmol/L
- Respiratory rate - >30
- Blood pressure - <90/60
- Age > 65
Scoring
- 0 (.6%)
- 1 (3.2%)
- 2 (13%)
- 3 (17%)
- 4 (41.5%)
- 5 (57.5%)
Cardinal features of Apathetic thyrotoxicosis
- apathy and depression (opposite of a younger patient)
- Chronic - fatigue and slowing down
- Cardiac dz
- Weakness of proximal muscles
Thyroxine levels are not elevated
Subclinical Hypothyroidism presentation
- may present with few to no complaints
- sx akin to the normal aging process
- Confusion/agitation/reduced cognitive function
- May see increased intestinal transit
- Increased IOP
- Higher LDL
- changes in cardiac performance, including CHF
- High TSH and normal free T4
- +/- tx with Levothyroxin – may improve LDL, but not known to dec. CV or all-cause mortality
presentation of overt hypothyroidism? tx?
- Subclinical can become overt hypothyroidism
- High TSH and low free T4
- Treat with Levothyroxin
- Start with low initial dose
- Increase q 4-6 weeks until normalization of TSH levels
are Acute Abdomen problems in older adults recognizable?
Often under recognized
As much as 40% of older adults are misdiagnosed
MCC of abd pain? (5)
Cholecystitis
Bowel obstruction
Diverticular disease
Complications of cancer
Medication side effects
presentation of acute abdomen
- Pain may be diffuse and mild OR asx
- May lack fever
- Sometimes present with hypothermia - May lack elevated WBC
- May have reduced rebound tenderness
- Due to decreased abdominal wall musculature
why is the mortality rate and complications of the acute abdomen much greater in older adults?
Because of these delayed presentations and difficult diagnoses
A wide ddx needs to be considered with vague abdominal complaint in an elderly patient
The most common fluid and electrolyte problem in older adults
dehydration
dehydration is a result from what?
- normal age-related physiologic changes
- Decrease in total body water
- Alterations in thirst perception
- Reduced renal function leading to decreased urine-concentrating ability
risk factors of dehydration
Infection
Tube feedings
Medication – related side effects
Delirium
Mobility disorders
presentation of dehydration
- vague or even absent
- VS may not be helpful
- Skin turgor is not reliable
- Intake – output charts likely inaccurate in the setting of incontinence
- Oral dryness may be misleading
- mouth breathing
- meds with anticholinergic properties
meds such as ? may mask usual tachycardic response seen in volume depletion
BB
dehydration May manifest only as _____ or slight ___
constipation
orthostatic hypotension
new infection typically presents with what?
fever, leukocytosis
even in older adults
commonly, the presentation of an infection in the elderly population may be:
Vague symptoms
No fever
No elevation in WBCs
No localizing signs
why do Older adults generally have a lower basal body temperature?
Due to reduced muscle mass
Temperature of >99.1°F (37.3°C) may be more likely to be indicative of infection
Change in ____ and _____ is sometimes the only sign of underlying infection
functional
mental status
Delay in recognizing acute illness can lead to
Adverse health outcomes
Prolonged hospitalization
Iatrogenesis/negligence
Increased risk of death
for Atypical Presentations – Symptoms to look for…
Acute confusion (delirium)
Anorexia (change in appetite)
Absence of pain, or pain in alternate location
Generalized weakness
Fatigue
New urinary incontinence
New functional decline (change in mobility)
