Summary
We hope you have added to your knowledge skills and attitudes about Atypical Presentations of Disease in the Older ED Patient. Those vague complaints – weakness, confusion, increased falls, “just not right” – are a frequent component of geriatric presentations in the ED. We need to recognize them as a part of the job of looking after older patients. Though it is harder to develop algorithms for their management than “chest pain,” “head ache,” or “fever,” it is important to have an understanding of their basis and an approach to assessing them Be aware that these vague complaints usually are symptoms of serious disease. Early and accurate diagnosis will make a big difference in your patient’s life – and she’ll thank you for recognizing the importance of her atypical presentation!
You may also want to review the modules on Cognitive Impairment and Medication Management and Falls which all have specific relevance to this topic.
Review the Learning Objectives before proceeding to the Knowledge Check.
At the end of this module you should be able to:
- Explain the link between non-specific symptoms (weakness, fatigue, “dizziness,” confusion, increased falls, functional decline) and life-threatening or treatable conditions
- Describe how adverse drug reactions, drug-drug interactions, and drug-disease interactions can present as “new” medical conditions
- Recognize normal age-related changes in anatomy, physiology, and lab investigations that influence symptom presentation
- List reasons that medical diagnoses in older patients can present with atypical symptoms (altered immune response, decreased adrenergic response, polypharmacy (one drug masks symptoms), cognitive impairment (inability to describe symptoms), decreased psycho-social support (no one around to monitor changes).
Discussion: Summary
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term brown bag biopsy is new!
– elderly people are different from middle-aged adults
– physiological changes linked to aging often mask the signs of an acute pathology
Be vigilant and have a high index of suspicion in the elderly population
Reminder of polymorbid
vague symptoms in elderly are VERY important.
Yep
Everything is on the table for diagnosis. history seems to be key, involve family, nursing home staff, EMS etc. Also getting a good medication history is key and what the pt is actually taking daily.
Basically taking a good history and asking help from family, EMS, etc to flush this out will be key. Any diagnosis is basically on the table with all complaints, especially vague ones.
ok
Will be more broad with evaluation of vague complaints
the specifics about the abdomen – weaker abd muscles causing less rigidity, thinner mucosa meaning fewer nsaids cause bleeding, and smaller omentum meaning cant wall off infections. esp the latter omental one – i had not heard that before
Historia clínica adecuada y extensa, múltiples diferenciales
Detallar bien los síntomas, que significa poco tiempo, no se ve bien, no termino las tareas. Completar información con cuidadores, no dar por sentado el diagnóstico previo documentado en el paciente
i have learned strategies to guide the history in the patient thats usually called “poor historyan”
Tener un diagnóstico diferencial y siempre sospechar y buscar
be very thorough and consider all options
pay closer attention to patients, call relatives or guardians and get more info regarding their co. add for sure a pocket talker to our ed.
Multiple complaints often means multiple diagnosis to rule out.
I will take a broader approach to imaging in the elderly patient; I feel that I already use a fairly broad approach when ordering bloodwork for non specific complaints, but I should probably be more aggressive when ordering imaging.
I have learned that the vague complaint may actually be a sign of serious infection or illness that should not be taken lightly. also, asking the family or digging deeper for more information and a careful examination of the patient all over can prove a most reliable source in pinpointing what’s wrong with the patient.
that geriatrics needed to be treated with open mind when it comes to presentation and not to focus on just the basic differential diagnosis
Pay more attention to non specific symptoms ,drug action and drug interaction ,be cautious to normal vital signs and signs.
Why now and what concerns you most/ what are you most worried about are two of my most informative questions
What have you learned in this module that you will add to your practice? How do you think your practice will change as a result of your learning in this module?
I think overall remembering to cast a wide net re differential diagnosis for an elderly person coming into the ED with vague complaints. Remembering to ask about mood and screen for depression. Remember to get collateral information. Remember to check medications and do a good check with the patient re-what they are taking and how much and which may be new medications. And remembering that normal vital signs and a normal white count does not mean no infection or no sepsis. Doing a mini-cog.
I’ve learned many strategies to help assess older adults in the community.
ok
multiple strategies to get addl info
will this ever end
if you truly learn anything new from this you likely don’t or shouldn’t be practicing adult EM
assume a new normal for elderly
My net will be wider cast when dealing with elderly patients
I was not aware that the WBC’s can stay low even with serious infection.
I was not aware that v/s in geriatrics can vary so much, even in cases as serious as sepsis
Make sure to keep asking questions when vague non specific complaints are given
being comprehensive with my exam even with vague non specific complaints in elderly patients
Vague complaints are to be given utmost importance in elderly
Not much. We’re already in the habit of giving an elderly patient with vague complaints “the works” because it’s the only way to make a differential diagnosis… still going to have to do temp, 12-lead, BGT, stroke assessment, etc. on the bulk of our elderly pts because of vague complaints / poor history.
I learned that an issue with almost any system can present as vague complaints. I’ll keep this in mind when seeing elderly patients.
reflecting on a patient’s age is crucial in forming a differential diagnoses; similar presentations from different age groups can mean very different things. This needs to be weighed in on
Differences in vitals. Use of medicstions
Consider infection, thorough examination of medications
ok
always check meds, consider acs, infectious, (volume status); as further workup consider ct a/p, lp; trust family; consider collateral information;
dig deeper with vague complaints, consider more co-morbidities
to dig deeper to some very vague answers and to ask family members or caregivers for more information on the patient. take a close look at all polymorbidity and polypharmacy issues.
It very rarely is due to just “normal aging”
thorough history including speaking with caregivers and family members, full physical assessments of complaints, keeping differential diagnosis broad to include all possible atypical presentation
focusing more on polymorbidities than comorbidity definition – needing to not anchor vague complaints to quick differential and explore atypical presentations with more suspicion – not identifying source as UTI given liklihood of elderly having bacteria/ white blood cells in uria all the time
more detail questions, asking family members, thinking outside the box to general complaints
That just because they’ve had the same thing before hand doesn’t mean that this is definitley the same, pt might be experiencing something new
casting a wide net is probably indicated in elderly pt with vague but acute complaints
better patient history
True
a
Thats a great question, would like to know the answer
ask more thorough questions, weakness can me a lot in elderly (take everything into consideration)
That the importance of a thorough assessment of the situation by interviewing both patient and spouse/ family member will play a large role on the assessment and diagnosis. Many symptoms may be masked and can easily be missed if you don’t take your time
….
vague complaints and poor historians can be very trying for practitioners, but keep digging
opened up different differentials for complaints
For sure
Expanded my differentials for general weakness in geriatrics
much stuffs
m
really good review.
LOTS OF GOOD INFO
taking calcium supplements can affect antibiotics for UTI
can have a more serious outcome, don’t take menial complaints for granted
Remember that just like kids aren’t little “adults”, the elderly aren’t just older “adults”. Be aware of all the changes/differences in this group and don’t let tunnel vision set in. A general complaint will probably require a more general assessment to avoid missing the root cause(s).
HYEAH
I will think that the complaints from some individuals may not just be from one issue but may be from many of the patients co-morbidity complaints.
Perform ECGs on general weakness complaints, explore various vague symptoms for underlying causes that may be masked by medication or decreased immune responses in the elderly
information
open mind
.
.
.
ok
good reminder of geriatric physiology, thorough history and med review
being comprehensive is important when they come in with vague symptoms
ok
to explore all possible medical causes that can lead to an acute change in behavior or vague weakness
Try to gather info with other members present (helpful if stories contradict), avoid early closure, broad differential and workup.
I love this segment. I think that the older patient with non-specific sxs is such a common presentation. This module really provides a framework to organize the approach and tackle it in a more thoughtful, algorhythmic fashion.
It is helpful to me to remember the similarities between atypical pediatric presentations and atypical presentations in older adults. This helps me pay more attention to vague symptoms as a signal for important problems rather than non-issues
Always ask if they have their medicines with them
Keep the differentials broad for patients presenting with vague symptoms and do not anchor on 1 thing
be more mindful of the atypical presentation s in the elderly and being more astute with evaluations and assessments
Take time and listen
BE aware of vague symptoms and explore other reasons why an elderly patient maybe presenting in those ways. Look at their medications and whatever else they might be taking (OTC). Speak to persons close to them to get a better history in order to arrive at better differentials. Note that their vitals may not be depicting a true picture of what’s really going on, because certain comorbidities and medications can mask their true values.
history and more physical examination
Be more receptive to the concerns voiced by gerontology patients
I will consider that there is a link between the nonspecific symptoms and life-threatening medical conditions. A detailed history of medications, the dose, and any changes made in medications should be reviewed. I will consider the normal age-related changes in anatomy, physiology, and lab investigations of older adults.
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Elderly patients can present atypically – polypharmacies or polymorbidites often change appearance. Poor history collection normally.
History and physical examination has to be more thorough, with lower threshold for testing
look for atypical presentations
Elderly medicine is not adult medicine
To pay better care to the complaints by elderly patients
can’t cross anything off the differential
see a lot of geriatrics, this will be helpful
Keep “atypical presentations” in the back of your mind
Be specific with your history – timing can be important
“Normal” vitals may not be normal in the elderly.
Keep differential broad for vague complaints. Start with gallbladder exam before going to CT in some patients. Make sure med list is up to date. Get pharmacy involved to help with this.
need to be vigilant and not use “normal” parameters let down my suspicion of a serious diagnosis. the typical is atypical in the elderly.
need to really take the whole picture into consideration with the elderly, nothing is really normal and everything needs to be analyzed critically
A wide variety of diagnoses can present atypically in the geriatric population!
I will be ore aware about atypical presentation i.e. some infection with normal Temp
I will be thinking much more broadly
Nice infromation
We need to ask more questions.
great
really liked this
follow up questions when a patient is being vague
in depth assessments/ follow ups
ok
great points
follow up on vague symptoms
To be more thorough on vague presenting symptoms and those with multiple complaints.
vague complaint even with normal vitals = thorough workup to r/o serious etiology
History, add labs. re evaluate
Need to ask the right questions!
keep ur mind open and aware when taking history
Caution with elderly patients
old patients hide pathology
ok
need more ways to get more info
explore answers with more detailed questions. listen to family or friends. unlikely to be just normal aging. Broader work-ups are needed
explore further into each statement they make
always dig deeper with elderly pts
great summary infomration
exactly
k
okay sounds good
more thorough history,physical exam,review of meds.and follow up
very very informative as eldderly people are not children but adults that must be fully assessed
it is very important to assess thoroughly and use the rule out technique as presentations may be atypical and important diagnoses may be missed or misinterpreted.
To have a lower index of suspicion for serious ailments in geriatric pts with vague complaints and order more imaging to rule these atypical presentations out.
very interesting
I am more likely to screen for depression after learning from this module.
how v/s dont reflect full picture in elderly
always review medications, clarify the “just not right” complaint, low threshold for broad work up
when assessing elderly patient it is important to conduct a thorough assessment, to involve family members as the elderly are poor historians, must not to be quick to discount what the patient is saying as age related.
Using the brown bag biopsy for sure. Exploring in details vague symptoms. Try to Incorporate as many sources of information when patient is cognitively impaired. To think broad and explore serious health conditions when patient or family mention “not himself”. Taking into consideration the physiological changes with the elderly body as it doesn’t respond with hallmark signs and symptoms. Thinking about the normal adult vitals are not normal for these frail patients that are on beta and alpha blockers with stiff pipes and subtle hints.
Take a thorough and detailed history followed by a complete physical exam along with evaluating medications and liberally pursuing other studies.
Elderly patients are complex
!!!
great points
changed my whole perspective of assessments with older adults.
UTI as a diagnosis of exclusion in the geriatric patient with confusion or vague complaints.
continued eval
looking for more clues. Looking at all presenting signs. Looking for acute/chronic changes. Understanding how the aging physiology may factor in.
anything is possible in the elderly
we have a very aged population here
consider wide differential
don’t blow anything off
Being extremely thorough in assesment to get the full picture
atypical presentation — need to be open-minded when diagnosis
include support systems when interviewing the Pt
polypharmacy — explore medications with a patient, go thru new meds
consider all body systems,
Aprendí a indagar más sobre los síntomas vagos que pueden presentar los pacientes adultos y son causa de manifestaciones más graves
will be more thorough in reviewing meds and prior charts
I learned about obtaining a more complete history and medication review and the importance of seemingly normal findings in the older adult
A more thorough assessment on elderly patients, greater history taking and vital variations
ok
never make assumptions, vague complaints in the older population can be serious issues
Never make assumptions, don’t ignore vague symptoms, be able to interpret normal VS as possibly not normal for that pt and use the family as a valuable resource
Very informative and great content
yes
there are different things to keep in mind with elderly patients and changes in aging
Elderly patients present atypically requiring MD/NP to think more broadly in terms of Ddx and investigations.
Don’t brush off vague complaints in elderly. Get a better Hx and Px, and usually investigations.
Elderly patients need more thorough ROS with thorough PE (head to toe) as well as collateral and will present atypically.
take time to listen to the patient and family and get the best history possible. Don’t assume the obvious look at other health conditions that may be causing the patient his symptoms
agree
heatcare professionals should be aware that approach to treating elderly patients is different from the rest
a lot of investigating for vague complaints
will be through with H and P and work up in elderly presenting to ED with vague complaints.
more broad differential on many patients. Very helpful
very helpful with going around a “vague” history
Looking beyond the vitals
elderly patients should be seen in a more intricate manner
Just like in neonates, normal exam accounts for little
normal visits don’t rule out sickness
normal vitals dont rule out illness
normal vital signs can occur, and can still represent serious illness
Agreed
older population will present with different signs of diagnosis, there for what we consider normal maybe their abnormal, therefor we have to listen, they know their health better then us.
listen carefully, vitals may not be abnormal
When approaching the elderly patient it is important to consider all causes of their vague symptoms.
I learned that to diagnose and identify issues in the elderly population can be a very complex process and requires a certain level of knowledge and critical thinking in order to provide the best quality care possible
a much better understanding of atypical presentations and how important it is to be broad in your evaluation and workup. History should include all sources available.
good module.
Needing a team to help manage
importance of thorough assessment
investigate vague responses given by older adults
believe people when they tell you things
helpful
Vitals are not always the best indicator of one’s health
helpful
k
Vitals are not always the best indicator of one’s health – need to delve further into health history and explore other options.
health history, meds, lab values, other symptoms
thorough assessment of health history, integrating meds, considering lab values
ok
The importance of a through history, listening to everything, don’t assume that “normal” is normal especially in elderly clients
Polymorbidity acknowledges that with multiple chronic problems, they are all active and interacting at the same time
conducting a thorough health history using the new strategies recommended in this module.
les différentes causes d’être un mauvais historien
Broader diff dx
importance of taking time to tease out the particulars of the history, be aware of broad differential
Never take Geriatric patients at their face value. Always, always look deeper.
Old patient are just not old adults.
There are many explainations to unspecific complaints
helpful
agree with all points
geriatric patient is not a old adult
when vague symptoms are present a full history must be obtained
stop looking for an elevated white count
Elderly should be treated differently from middle-aged adults, especially when thinking about atypical presentations of common pathologies.
yes
don’t treat elderly like adults
atypical presentations
anatomic and physiologic changes
historical factors
Any geriatric patient can present with any constellation of symptoms and have just about any diagnosis!
Always think about medications:
-beta blocker: can’t increase their HR
-tylenol: won’t see a fever
-consider an LP (last resort)
-MI’s don’t typically present with CP.
Chronology of the symptoms.
What is different than the usual
understanding the physiological and medication changes
the difference in the geriatric population
I have learned the effect of polymorbidities in seniors and how complex that they are to obtain good reliable histories for. I learned the value of using multiple resources to obtain a picture of their history and to not jump to conclusions to quickly when assessing seniors. All of this learning, I will take back to employ in my daily practice!
Use of multi/polymorbidity as an overarchign diagnosis + ensuring broad differential + ensuring as much collateral from different sources as possible!
Basically every geriatric patient that is vague or weak needs a full and broad work-up.
Remembering that vague symptoms can represent serious health issues.
Feeling more justified ordering cardiac labs in the patient over 80 with weakness.
vague complaints equals more investigations and collateral history
Be vigilant; maintain high index of suspicion – REINFoRCED these behaviours
ok
be very specific in hong down specific complaints
this module made me understand how elderly population present their diseases
when vague symptoms are present a full history must be obtained
this module help me understand how to better care for the older adult population. often they will present with a vague symptoms it is important to further investigate to have a proper diagnosis
Very interesting. Now I’ll be more efficient when taking history of a gero patient.
approach history taking differently- allow more time and ask relevant questions to ascertain as much information as possible. Avoid premature closure of interview and ask relatives consistently what their views are.
Diferentisl diagnosis for weakness
very nice
we need to listen and take everything into consideration
It is important to listen to elderly patients as well as knowing atypical SS.
Great
Alot of things
This module re-enforces the difficult challenges we face when dealing with elderly pat’s. As a paramedic I see the pt’s in their living environments and all the information that I can gather there. As an ER nurse I see the pt’s often after they are brought in by ambulance. I always read the ambulance report because it tells you a lot about their environment and how they presented at home.
reinforces my current knowledge
Elderly patients often present with vague complaints and warrant more extensive investigations than the typical middle-aged patient. Collateral information is a key part of history taking. Differentials must remain broad regardless of presentation and anchoring must be avoided.
it will
Less emphasis on the presenting complaint, need a more in depth assessment
Older people can present with vague complaints with serious illness.
Get more information, investigate further to get to the root of the problem/sickness.
listen to relatives
do not be fooled with normal vitals
increased risk of skin infections
Need to carefully listen to the elderly patient. Be cautious and be aware that an atypical complaint can mean something serious.
Complete history and thorough physical examination important keeping with atypical presentation.
How to flush out the symptoms by asking more probing questions and listening to the spouse
ecg for all elderly with vague symptoms. Prompting why presenting today if things going on longer.
Being more paranoid about subtle presentations
Ensuring to do a broad work up for vague issues
proper assessment is very important
older adults present differently than adults and thus the approach to hx, ax and ddx should be altered
thorough assessment and history taking. Can’t rely on normal VS
More attention to cognitive assessment in patients that have vague multiple complaints
I hadn’t realized that normal vital signs can be pathologic for elderly people.
What changed that prompted today’s visit?
Any changes to meds?
Wider initial screen if no focal finding
Derm exam
Low threshold for CT Head/CT Abdo/CXR.
Depression screening.
What is new and when did it happen
Take the time to investigate all complaints uncovered in the H&P and wide differential list.
the typical presentation it is not what they will show us…
Remembering that vague symptoms can represent serious health issues.
Beware the diagnosis of UTI.
Gather as much information as possible from all sources when treating the elderly.
Obtain a detailed Hx of presenting problem (including list pf meds), identify physical &/or mental impairments, identify what is different then their “normal”. Dismiss nothing, investigate everything.
Dig deep for information and clues.
Do not accept a non-answer as an answer, find someone who knows the Pt’s history
use other sources for history taking. Take a closer look at lab work
good review
Great PEARLS
great strategies for getting to the bottom of the “generally unwell” patient
good review
great!
Knowledge is power
lots to consider once again
Great information! Definitely need to pry a little more and understand exactly what the patient is telling me. Keep the list of diff Dx long until you have testing showing you a clear direction.
I learned a good approach for investigating
Good reminder to dig deeper with investigations even when (or especially when) the vital signs &/or basic labs look “normal”
multiple factors can affect elderly patients presentation and being though is important.
This module provided multiple ways to extract information from the geriatric pt. It was also a good refresher on the difference in physiology in geriatrics compared with the middle aged.
Reminded me of the importance of taking a thorough history in all older people.
thanks for the information
Fantastic differentials
remember that normal age related changes can mask underlying problems
more detailed history taking will help guide investigations differentials in the management of an elderly patient
Detailed history and examination. Need to be more aware of vague symptoms and presentations as well as correlate seemingly normal vital signs in relation to this history of presenting complaint as well as the medications the patient is on.
older patients may have a sorpresive diagnosis
Hay que abordar mejor al paciente
mejorar la entrevista de mi parte
Abrir la mente
Open Mind!!!
This module has expanded possible differentials that I should consider when talking to patients with vague presenting complaints. And that I should delve a bit more to elicit was their medical emergency may be.
Although UTI is a possible cause of atypical presentation, I will however, consider other causes before settling on its diagnosis.
This module has helped me in considering more differentials when I see an elderly patient with a complaint of generalized weakness
I will have less assurances when the aged pt. presents with nonspecific complaints and normal VS.
Excellent module
Listen exactly and read exactly medical history
i learned a lot
xx
don’t assume pt should be declining simply d/t age
yyy
thorough exams are key, pick up on vague cues and dig deeper!
vague symptoms should not be taken lightly
I need to get a more specific history, especially time and what is “new”. Be open to all causes of symptoms. I hope to provide better diagnosis and care of older patients.
Everything is possible with geriatric patients.
Take a history beyond the history you are told.
normal = abnormal
Don’t call an old person a “vague historian”. That is a finding. Not an excuse for not knowing what is happening with your patient.
One needs to carefully evaluate all the information from cognitive testing, falls screen, depression, delirium screening, plus the labs, medications, urinalysis, ECG, CT of head, cardiac biomarkers to make an accurate diagnosis.
need to really take the whole picture into consideration with the elderly, nothing is really normal and everything needs to be analyzed critically
more thorogh investigation despite normal vitals
Being more careful with what appear to be “normal” vitals
focusing on what’s new, why now
ruling out more broad differentials
more thorough and patiently take a medication hx
–importance of looking at meds playing a role, brown bag bx, asking family members
Broad differential. The fact that the immune response and catecholamine response is blunted so they are like a betablocked immunosuppressed 80 yr old. The fact that any change, even minor, could be a sign of significant dz.
Keep an open mind and consider multiple possibilities.
need to be vigilant and not use “normal” parameters let down my suspicion of a serious diagnosis. the typical is atypical in the elderly.
Multiple strategies to assist in obtaining collateral history and a review of the phsyiologic changes of aging.