Falls, weakness, decline in function, dizziness, or altered mental status can be among the many symptoms of atypical presentation of illness in older patients. Rather than considering these changes to be a normal part of the aging process, atypical presentation requires that clinicians look beyond the typical signs and symptoms of disease to find a correct diagnosis or imminent acute illness in older patients, said Cassandra Vonnes, DNP, GNP-BC, APRN, AOCNP, CPHQ, FAHA, in a poster session at the Gerontological Advanced Practice Nurses Association (GAPNA) 2022 Annual Conference held September 15 to 17 in Orlando, Florida.
Atypical presentation of illness in older adults may stem from decreased physiologic reserve, altered volume regulation, changes in the autonomic nervous system, inappropriate prescribing, and immune dysregulation, explained Dr Vonnes, who is Geriatric Oncology NICHE Coordinator at Moffitt Cancer Center. She presented 3 case studies to demonstrate potential diagnostic zebras.
Altered Mental Status
The first case involved a 78-year-old man whose wife noticed that he skipped cutting the grass and missed his regular golf date, both of which he does weekly. He also skipped breakfast, was not interested in the news, and was confused about what day of the week it was.
The patient collapsed at home and emergency medical services (EMS) was contacted; in the emergency department, free air in the abdomen was found on computed tomography scan. In the operating room, ruptured diverticula were found. The patient developed septic shock, renal failure, and acute respiratory distress syndrome and died when taken off the ventilator.
The second case involved an 80-year-old woman with a history of hypothyroidism who has been taking levothyroxine daily. She is typically active and helps with cooking and cleaning at her daughter’s house where she lives. She recently experienced 2 falls in the house that she attributed to being clumsy and getting up too quickly from a seated position. For the past 2 days, she has returned to bed after breakfast.
In the morning, her daughter could not wake her and called EMS. Initial 12-lead electrocardiogram showed Q waves in V1 and V2 and poor R wave progression indicating a previous anterior wall myocardial infarction and left ventricular hypertrophy. She went into ventricular fibrillation, received 2 defibrillator shocks, and was intubated. Echocardiography showed akinesis of the anterior wall and a 15% ejection fraction. The decision was made to use conservative measures and not resuscitate her; she later died.
An 84-year-old man living in a Veterans Affairs assisted living facility has a history of hypertension, benign prostatic hyperplasia, and osteoarthritis and has been taking naproxen sodium twice daily. He typically eats meals and plays cards with several friends at the facility, but 2 of those friends recently died within the past 2 to 3 months. He complains of nausea and stomach discomfort and is placed on a proton pump inhibitor (PPI). The staff notes that he has been irritable and not sleeping well.
He is referred to a gastroenterologist and esophagogastroduodenoscopy is performed with no pathology noted. His primary care provider prescribes zolpidem for sleep. He fell in the night when he got up to use the bathroom and the zolpidem was discontinued. After the fall, a VA nurse practitioner treating the patient in the emergency department administered the Geriatric Depression Scale after noting the relationship between his symptom onset and the death of his friends. His score on this scale was 9 indicating depression. The NP started him on sertraline daily. At a 2-week follow-up appointment with his primary care physician, he reports sleeping better and socializing more and has discontinued the PPI.
These case studies demonstrate that education related to the symptoms of falls, weakness, decline in function, dizziness, and altered mood should be provided to older patients, families, and direct care teams, Dr Vonnes explained. Accurate diagnosis or detection of imminent acute illness in older patients requires looking beyond typical sign and symptom clusters, Dr Vonnes added.
“Gerontological advanced practice nurses in acute, primary, and long-term care manage the complex needs of the geriatric population along with challenges of diagnosis due to nonspecific presentations, underreporting of symptoms or atypical presentations of illness,” Dr Vonnes said.
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Vonnes C. Atypical presentation of illness in the older adult: case studies in support of zebras. Poster presented at: GAPNA 2022; September 15-17, 2022; Orlando, Florida.