Atypical Presentations Inthe Elderly

Front 1

the first sign of acute illness in the older pt may be

Back 1

functional or cognitive impairment

causes: loss of physiological and functional reserve with nml aging
-underreporting of sx by caregiver

Front 2

infxs

Back 2

-immune system changes predispose to infx in general
-pul changes --> PNA
-urologic changes --> UTI
-up ti 75% of frail elderly present without FEVER

Front 3

PNA

Back 3

-classic signs may be absent
-may present with: weakness, dec ADLs, poor appetitie
- Tachypnea +/- SOB is the most reliable sign of acute pulmonary condition
-differential count useful
-CXR

Front 4

UTI

Back 4

-frequency, urgency, dysuria --> more common in elderly in the absene of UTI, less common as a sign of UTI
-atypical sx: incontience, fecal impaction, lethargy, dec appetite, dehydration, confuson!

Front 5

UTI diagnostic w/u

Back 5

-UA: may not have large # of white cells, lecocyte esterase and nitrites may be neg
-Tachypnea +/- SOB is the most reliable sign of acute pulmonary condition
-urine C&S: High incidence of asymptomatic bacteriuria;Multiple organisms may not be contamination

Front 6

Myocardial ischemia

Back 6

-asx CAD increased with age
-Of elderly with known CAD, 21-68% can have “silent” disease
-Horizontal or downsloping ST depression > 1mm (.08sec after J-point) for > 1min. detected on 24hr. ambulatory EKG without angina

Front 7

atypical MI sx

Back 7

-vague or poorly localized CP
-referred pain as isolated throat, sholder, or abd pain
-dyspnea

Front 8

MI diagnostic w/u

Back 8

-EKG: more likely to have underlying disease (LVH, BBB) which makes interpretation difficult
-Enzymes: may not be elevated enough for diagnosis if undernourished
-what to do?: exercise or pharm stress testing, echo, nuclear medicine studies

Front 9

CAD tx

Back 9

1. antplt drugs
2. bblockers
3. nitrates
4. CCBs
5. ACEI
6. lipid lowering drugs
7. thrombolytics/revascularization

Front 10

TIME method- heart attack survival plan

Back 10

-talk with pts
-Investigate
-Make a plan
-Evaluate

Front 11

CHF

Back 11

-classic sx may not be present
-new onset Pul edem less clear
-no exertional dyspnea if not exertion!
-no orthopnea if dont sleep flat for other reasons

Front 12

CHF atypical sx

Back 12

Confusion, weakness, falls, anxiety
tiredness/fatigue/insomnia
non-productive cough
baseline rales more common, so may not be new
venous stasis vs. new leg edema

Front 13

CHF w/u

Back 13

-echo!

Front 14

acute abdomen

Back 14

-usual sx may be absent: no fever, no tachycardia, less tenderness on palpation, less well-localized abd pain

Front 15

Acute cholecystitis

Back 15

- > 50% of people over 70 have gallstones
-most common cause of acute abdominal disease and abd surgery in elderly
-emergency cholecystectomy carries 3-10x greater motality

Front 16

acute choly atypical presentation

Back 16

-clinical findings do not correlate with severity of dz!
-25% have no previous biliary sx, but some have GI sx
-acute cholecystitis, complications more likely with minimal findings
-higher mobidity and mortality

Front 17

acute appendicitis

Back 17

- 5% of acute abdominal emergencies in the elderly
-Delay in diagnosis 4 times greater
-Blood supply limited, lumen narrower, wall fibrotic and weak
-30-60% perforated, 5-15% mortality

Front 18

appendicitis presentation

Back 18

-initial vague abd pain --> analgesics
-only 35% have classic central pain shifting to RLQ; RLQ pain presents later
-fewer have fever, guarding, rebound
-more have distention, mass, SBO
-less leukocytosis, more leukopenia
-

Front 19

GERD

Back 19

-prevalence increases with age
-elderly more likely to develop severe dz
-more likely to be poorly diagnosed or undiagnosed in elderly

Front 20

GERD sx

Back 20

-typical sx less frequent: heartburn or acid regurgitation
-an older pt with GERD may present with atypical sxs: dysphagia, vomiting, wt loss, anemia and or anorexia

Front 21

approach to GERD for elderly

Back 21

- endoscopy as initial diagnostic test, irrespective of the severity or duration of their symptoms
-includes asymptomatic elderly with a past history of GERD
-may identify esophagitis and hiatus hernia (important prognostic indicators)
-may also reveal complications of GERD

Front 22

Meds and GERD

Back 22

-Medications commonly prescribed for elderly patients which may promote GERD: nitrates, CCBs, benzos, anticholinergics and TCAs
-Other drugs directly damage the esophageal mucosa: potassium salts, iron sulphate, asa, NSAIDs
-used with caution in elderly pts!

Front 23

hyperthyroidism

Back 23

-classic signs absent
-PE: thyroid may not be enlarged; eye findings frequently absent
-atypical pres: fatigue, wt loss, anorexia, constipation (triad), lethargy, depression, atrial dysrhythmias, CHF, angina

Front 24

hyperthyroidism and screening tests

Back 24

-should be performed on any older person with fatigue, wt loss, lethargy or irregular heart beat

Front 25

hypothyroidism

Back 25

-Classic symptoms present in many elderly without the disease: dry skin, cold intol, fatigue
-Classic symptoms not present in elderly with the disease: wt gain, goiter
-impt atypical presentations: depression, cognitive dysfunction
-clasic TFTs difficult to interpret in elderly

Front 26

depression

Back 26

-incidence ~15% >65
-suicide twice as prevalent in the group >85 than in any other age group
-Elderly less likely to admit to feelings of depression (trouble with DSM IV)

Front 27

depression atypical sx

Back 27

-cognitive deficit
-pain, poor physical function
-GI complaints
-agitations, anxiety