Atypical Presentation of Illness in Elders Mary J. Dyck, PhD, RN, LNHA Professor

Objectives Identify the clinically relevant signs and symptoms of an atypical presentation of illness in an older adult. Describe the impact of comorbidities, functional changes, and potential threats to autonomy/independence with atypical presentation.

Introduction Nursing care of older adults in any practice setting requires a recognition that illness may present atypically. Assessment is key to recognizing an atypical presentation. Early recognition can improve plans of care, reduce risk for fatality and/or prolonged hospitalization, and reduce rates of comorbidity from treatable geriatric syndromes. (Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

How do you know it is an atypical presentation?

Background: What Constitutes an Atypical Presentation? Atypical presentation of illness includes: Vague presentation of illness Refusal or failure to eat or drink New onset of falling Altered presentation of illness Absence of pain with conditions/diseases known to produce pain Non-presentation of illness Severe infection with a fever (Gray-Miceli, Aselage, & Mezey, 2010; Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

Case Report Behavior Change Example A 73 y.o. man with dementia and difficult behaviors, including anxiety and agitation. The behaviors were attributed to the dementia. When treated with medications for this “behavioral” problem, it was revealed that the agitation was associated with physiological blood pressure change and surges of catecholamine. He was later diagnosed with pheochromocytoma. (Gray-Miceli, Dowling-Castronovo, & Bradway, 2008) Behavior Change Example

Case Report Mental Status Change Example A conservative older woman in a nursing home stopped her wheelchair beside me. She started asking questions about my sex life. We obtained a urine specimen, which was leukocyte and nitrate positive on dipstick. Antibiotics were started that day. Within a few days she was alert and oriented and NOT asking inappropriate questions. Case Report Mental Status Change Example

Importance of Recognition Essential consideration when caring for older adults Greatest risk of atypical presentation Older adults over age 85 years Multiple comorbidities and medications Cognitive of functional impairments (Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

Consequences of Not Recognizing Lack of treatment for potentially modifiable diseases and/or geriatric syndromes Increased morbidity Increased mortality Affects quality of care for all older adults in all settings (Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

Assessing for Atypical Presentations More frequent vital signs Daily intake and output Daily weights Assessing pain, function, behavior, and mental status (Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

Classic Signs and Symptoms Associated with Atypical Presentation Delirium Falls Dehydration Decrease in appetite or failure to eat or drink Pain or lack of pain Change in functional status Change in mobility Dizziness Urinary incontinence Weakness or fatigue (Amella, 2006; Gray-Miceli, Dowling-Castronovo, & Bradway, 2008)

Delirium Infection Pain Dehydration Hypoxia Metabolic disturbances Untreated anemia Nutritional deficiencies Drug toxicity Psychological trauma (Amella, 2006)

Falls Investigate circumstances related to a fall Possible problems Environmental Health-related Possible problems Cardiac Musculoskeletal Neurologic Change in mental status Sensory Functional Continence Psychological (Amella, 2006)

Dehydration Common in elders Common causes Decreased muscle mass Blunted thirst response Common causes Vomiting Diarrhea Fever (Amella, 2006)

Change in Functional Status Significant Active people Extremely limited mobility Possible causes Anemia Thyroid disease Infection Cardiovascular or respiratory insufficiency Standardized assessment tools Rehab referral (Amella, 2006)

Dizziness Common complaint with aging Illnesses Anemia Arrhythmia Depression Infection Ear disease MI Eye problems Stroke Cerumen impaction Drug toxicity (Amella, 2006)

Incontinence Possible reversible causes Rehabilitation UTI Limited mobility Metabolic problems Rehabilitation (Amella, 2006)

Atypical Presentations of Diseases Infection Alterations in GI Status Cardiac Disease

Infection Infection rates rise Increased mortality rates Lower core body temperatures Slowed inflammatory responses (Amella, 2006)

Types of Infections Pneumonia UTIs Skin infections – missed Increased respiratory rate Decreased appetite Decreased functioning UTIs Incontinence Increased confusion and/or delirium Falls Skin infections – missed (Amella, 2006)

Alterations in GI Status GI bleeding Dehydration Crampy abdominal pain GI obstruction Cramps Stringy stool or diarrhea Vague complaints of being unwell Diverticulosis Diffuse pain Low-grade fever Appendicitis – misdiagnosed as bowel obstruction (Amella, 2006; Martinez & Mattu, 2006)

Cardiac Disease MI Heart failure Symptoms EKG Often no EKG evidence Sudden onset of dyspnea Anxiety Confusion EKG Often no EKG evidence Heart failure Decreased appetite Weight gain of 2 – 3 pounds Complaints of poor sleep (Amella, 2006)

Conclusions Assessment is critical! Decreased complications Decreased health risks Unnecessary use of emergency rooms Early detection Prompt management (Amella, 2006; Flaherty, 2010)

References Amella, E. J. (2006). Presentation of illness in older adults. AORN Journal, 83(2), 372-389. Flaherty, E. (2010). Want to know more: Atypical presentation. Hartford Institute for Geriatric Nursing. http://consultgerirn.org/topics/atypical_presentation/want_to_know_more Gray-Miceli, D., Aselage, M., & Mezey, M. (2010). Teaching strategies for atypical presentation of illness in older adults. Journal of Gerontological Nursing, 36(7), 38-43. Gray-Miceli, D., Dowling-Castronovo, A., & Bradway, C. (2008). Atypical presentation in older adults with complex illness: Urinary incontinence. AACN, JAHFIGN. [GNEC presentation]. Martinez, J. P., & Mattu, A. (2006). Abdominal pain in the elderly. Emergency Medicine Clinics of North America, 24, 371-388.