Atypical Presentations

Question 1

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?

Answer 1

Atypical Presentations

Common in elderly population

Question 2

Atypical Presentations
usually includes one of the three features

Answer 2

1. Vague presentation of illness
2. Altered presentation of illness
3. Non-presentation of illness (underreporting)
   - SOB walking up stairs (think it’s just “old age”)

Question 3

prevalence with Atypical Presentations increases with what?

Answer 3

age
With the aging of the world’s population, atypical presentation of illness will represent an increasingly large portion of illness presentations

Question 4

risk factors for atypical presentations

Answer 4

Age (especially >85 years)
Multiple medical conditions
Polypharmacy
Cognitive impairment
Functional impairment

Question 5

classic sx of Acute Coronary Syndrome (ACS)

Answer 5

Crushing substernal chest pain
Shortness of breath
Nausea
Diaphoresis

Question 6

atypical sx of ACS

Answer 6

1. Dyspnea
2. Mild pain, or even no pain
3. New-onset fatigue, dizziness, or confusion
4. Predominant GI sx
   - Pyrosis (heart burn) / Dyspepsia / Nausea

Question 7

The proportion of MI patients who have chest pain and diaphoresis declines with ?

Answer 7

age
less than 50% of MI patients older than 80 years complain of chest pain

Question 8

what is the most common initial symptom in persons older than 80 years old

Answer 8

Dyspnea

Question 9

Up to 20% of patients older than 85 have what type of complaints

Answer 9

neurologic

Question 10

what initial testing is often nondiagnostic in older adults because of preexisting conduction system disease

Answer 10

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)

Question 11

Definitive Diagnosis of STEMI or NSTEMI requires what?

Answer 11

1. abnormal cardiac biomarker elevation - Troponins I & T (gold standard)
   - more sensitive and specific compared to CK-MB

Question 12

Guidelines state that older patients receive the same treatment for ACS as younger patients but with addition of what?

Answer 12

with close monitoring for adverse events

Question 13

Pneumonia in older adults can be what types?

Answer 13

1. Community acquired
2. Nosocomial acquired
3. Skilled nursing facility acquired - MC infection in skilled nursing facility

Question 14

what type of pneumonia is common among the geriatric that is Associated with oropharyngeal dysphagia, Regurgitation of gastric contents

Answer 14

aspiration pneumonia

Question 15

presentation of pneumonia

Answer 15

1. Can present with:
   - General malaise
   - Confusion
   - Loss of appetite
   - Functional decline
2. May be absent
   - Fever / chills
   - Pleuritic chest pain
   - cough

Question 16

scoring assessment for pneumonia?
what does each final result mean?

Answer 16

CURB65

1. Predicts mortality
2. 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%)

Question 17

Cardinal features of Apathetic thyrotoxicosis

Answer 17

1. apathy and depression (opposite of a younger patient)
2. Chronic - fatigue and slowing down
3. Cardiac dz
4. Weakness of proximal muscles

Thyroxine levels are not elevated

Question 18

Subclinical Hypothyroidism presentation

Answer 18

1. may present with few to no complaints
2. sx akin to the normal aging process
3. Confusion/agitation/reduced cognitive function
4. May see increased intestinal transit
5. Increased IOP
6. Higher LDL
7. changes in cardiac performance, including CHF
8. High TSH and normal free T4
9. +/- tx with Levothyroxin – may improve LDL, but not known to dec. CV or all-cause mortality

Question 19

presentation of overt hypothyroidism? tx?

Answer 19

1. Subclinical can become overt hypothyroidism
2. High TSH and low free T4
3. Treat with Levothyroxin
   - Start with low initial dose
   - Increase q 4-6 weeks until normalization of TSH levels

Question 20

are Acute Abdomen problems in older adults recognizable?

Answer 20

Often under recognized
As much as 40% of older adults are misdiagnosed

Question 21

MCC of abd pain? (5)

Answer 21

Cholecystitis
Bowel obstruction
Diverticular disease
Complications of cancer
Medication side effects

Question 22

presentation of acute abdomen

Answer 22

1. Pain may be diffuse and mild OR asx
2. May lack fever
   - Sometimes present with hypothermia
3. May lack elevated WBC
4. May have reduced rebound tenderness
   - Due to decreased abdominal wall musculature

Question 23

why is the mortality rate and complications of the acute abdomen much greater in older adults?

Answer 23

Because of these delayed presentations and difficult diagnoses
A wide ddx needs to be considered with vague abdominal complaint in an elderly patient

Question 24

The most common fluid and electrolyte problem in older adults

Answer 24

dehydration

Question 25

dehydration is a result from what?

Answer 25

1. normal age-related physiologic changes - Decrease in total body water - Alterations in thirst perception - Reduced renal function leading to decreased urine-concentrating ability

Question 26

risk factors of dehydration

Answer 26

Infection Tube feedings Medication – related side effects Delirium Mobility disorders

Question 27

presentation of dehydration

Answer 27

1. vague or even absent 2. VS may not be helpful 3. Skin turgor is not reliable 4. Intake – output charts likely inaccurate in the setting of incontinence 5. Oral dryness may be misleading - mouth breathing - meds with anticholinergic properties

Question 28

meds such as ? may _mask usual tachycardic_ response seen in volume depletion

Answer 28

BB

Question 29

dehydration May manifest only as _____ or slight ___

Answer 29

constipation orthostatic hypotension

Question 30

new infection typically presents with what?

Answer 30

**fever, leukocytosis** | even in older adults

Question 31

commonly, the presentation of an infection in the elderly population may be:

Answer 31

Vague symptoms No fever No elevation in WBCs No localizing signs

Question 32

why do Older adults generally have a lower basal body temperature?

Answer 32

Due to reduced muscle mass Temperature of >99.1°F (37.3°C) may be more likely to be indicative of infection

Question 33

Change in ____ and _____ is sometimes the only sign of underlying infection

Answer 33

functional mental status

Question 34

Delay in recognizing acute illness can lead to

Answer 34

Adverse health outcomes Prolonged hospitalization Iatrogenesis/negligence Increased risk of death

Question 35

for Atypical Presentations – Symptoms to look for…

Answer 35

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)