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Atypical Presentation of Illness in the Elderly

Aging Article   (10,592 Views 4 Comments)
VickyRN VickyRN (New Member) New Member

VickyRN is a Nurse Educator with over 23 years in experience.

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Nursing staff at the continuing care retirement community have noticed that Sarah Jones, age 94, is not her usual self. Over the past 24 hours, the elderly resident has become uncharacteristically lethargic and refuses to eat. For brief transient periods of time, she becomes agitated and confused before slipping back into a quiet somnolent state.

Atypical Presentation of Illness in the Elderly

Sarah is sent to the emergency room at the local hospital for an evaluation. In the emergency room, it is discovered that Sarah has a raging urinary tract infection and is becoming septic. She is kept in the hospital for several days to eradicate the infection with powerful intravenous antibiotics. The curious thing is that Sarah never once complained of pain, discomfort, burning, or frequency with urination and has remained afebrile with a normal white blood cell count throughout the entire episode.

Any subtle, nonspecific, blunted, and unusual manifestations that occur outside of the normal range of signs and symptoms of a particular acute illness are known as atypical presentation. Adults aged eighty and above, especially those with multiple chronic conditions and medications, cognitive impairment, or functional loss, are at greatest risk for developing atypical presentation.

With advanced age the body does not respond in the typical manner to illness because of the physical changes of aging, the cumulative effect of multiple medical conditions, and diminished physiologic reserve to deal with physical or emotional stress.

Atypical presentation of illness in the senior population can manifest in various ways. For example, the familiar warning signs and symptoms of disease may be modified in some way or may be absent. Or, as in Sarah's case, the presentation may appear to be totally unrelated to the actual disease state, such as confusion, lethargy, or anorexia in an older adult suffering from a urinary tract infection or pneumonia.

Atypical manifestations may include anorexia, confusion, dizziness, falls, fatigue, shortness of breath, new-onset incontinence, lethargy, level of consciousness changes, malaise, nausea, self-neglect, and unexplained weight loss. Fever, cough, and pain may be absent, while white blood cell count may be normal or low. Subtle changes such as a decrease in functional status or appetite are often the first signs of illness in an elderly patient. Delirium, a sudden change in mental status with fluctuating consciousness, is one of the most common presentations and an ominous sign. This is because patients with delirium face a poorer prognosis than those with the same illness who do not have delirium.

It is essential for nurses to conduct careful comprehensive assessments of older adults to identify vague presentations of illness so that life-saving treatment measures can be implemented early and consistently. Timely recognition and treatment of illness will reduce mortality and morbidity and promote optimal health-related quality of life in the senior population.

A simple strategy is to compare the presenting signs and symptoms with the elder's normal baseline. Medical history provided by the family can provide important clues as to what is normal and abnormal for the older adult and what may be the underlying cause of the atypical presenting signs and symptoms.

References

Atypical presentation

Gathering "pearls" of knowledge for assessing older adults

VickyRN, PhD, RN, is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is a Professor in a large baccalaureate nursing program in North Carolina.

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Excellent, Vicky! So many nurses who are new to geriatric care, or who have never taken the time to learn how the minds and bodies of older adults process illness, are caught unawares by atypical presentation.

I've seen it a thousand times: an elder who's always been steady on her feet suddenly starts falling, or one who was always fastidious about her appearance stops putting on lipstick and comes to the table with messy hair, or a gentleman who has always been a hearty eater is noted leaving half his meals uneaten. So often these are manifestations of something as simple as a urinary tract infection. But if the care staff doesn't know this, they have no idea where to start when it comes time to investigate the root cause of the condition change, and in the meantime the older adult suffers. Keep up the good work!

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I was a new nurse of maybe a month, and one of my 90 year old residents started acting strangely. Very lethargic, poor appetite, shaking. I checked her vitals and blood sugar, which was within normal limits. Called the Dr., who suggested testing her urine. I didn't realize at the time that she might have a UTI, which she did.

Thanks for the article :)

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I have worked Geri-psych for the last three years, which also is how long I have been a nurse I am greatful to have started in this field it helped me see how close mind and body work together. I have seen on numerous occasions that residents change during illness.

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