Variable Vitals
We think of vital signs as the most objective, reliable, and useful part of the physical exam. Not so for older people! For several reasons older people may not become tachycardic, febrile, or hypotensive when “they’re supposed to!”
Important Note
It’s reasonable to think of the normal older person as being like a beta-blocked immunocompromised 50 year old.
- The CNS and CV ability to respond to beta-adrenergic stimulation is markedly decreased with age. Tachycardia may be minimal or absent with physiologic stress;
- The immune system produces fewer cytokines, leukotrienes and other inflammatory markers. A fever may be a very late response to infection (if at all). An infection can certainly exist even with a normal or low temperature;
- The peripheral vasculature is less elastic (“stiff pipes”). Hypotension does not develop until much later in a hypovolemic or septic situation;
- Medications can also alter vital signs. Half of all older people are on beta-blockers so it may not be possible to mount a tachycardia. Many older people take 4 gm of acetaminophen a day, further masking a fever;
- The lower metabolic rate and the fact that older ED patients are usually in bed mean that O2 Saturation is often in the normal range (>92%). A walk test, even brief, may reveal some important changes in saturation.
For example: You see an 80 year old afebrile, normotensive, sinus rhythm, Sat 95%, “Just not herself.”
- Could she have sepsis, pneumonia, peritonitis?
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Discussion: Variable Vitals
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ok
very true
stuck at 94% completed no idea why
so important to know that the elderly won’t show the same change in vital signs with illness
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any variation in v/s is important in the elderly
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very important to keep so many factors in mind when it comes to presentation of the elderly.
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thank you for this insightful discussion.
thank you
VITALS SIGNS
HYEAH
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compensating
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pneumonia
Wide differential
I love that pearl of wisdom in the important note box. I’m gonna put that in my pocket, walk around with it and drop it like its hot the next chance I get.
yes
very true
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okay yes
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okay
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Ok
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Too much weight put on vitals.
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vertigo
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ok
Challenging patients
sepsis, can always be concidered
okay
vertigo
thank you
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maybe may be not
complete wu
true
Excellent information.
xxx
feel I have good understanding
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very true
Agreed
good point
These are very informative topic
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ok
anything is possible
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interesting
interesting to know about vital signs in older people
so true
gpod points
okay
great points
great point
further assessment needed
agreed. symtpoms can be for any medical issues
further assessment should be done. primary hcp can request blood work to verify a diagnosis.
And I often recheck vitals in patients. They may have a normal temp at triage and mount a fever later…
In older patients, any discussion of not feeling themselves should set off alarms.
stay broad
normal vitals and vague c/o is the hardest pt
We often put a lot of weight on vital signs when assessing a patient. It is obvious that this is a very dangerous practice in seniors!
Vitals hard to interpret
Good point on angina of the aged
vital signs are just tools to evaluate patients but however, further assessment need to be done to have a definite diagnosis.
Interseting
yes
Body function will change
Excellent
Very important as we often rely on vital signs.
“It’s reasonable to think of the normal older person as being like a beta-blocked immunocompromised 50 year old” – I love this!
CTAS modifications for older adults would be very helpful
That’s a really good question. Who do we start to talk to initiate something like that?
https://www.ncbi.nlm.nih.gov/pubmed/28756798
Guidance when Applying the Canadian Triage and Acuity Scale (CTAS) to the Geriatric Patient: Executive Summary: Bullard et al. CJEM 2017
CTAS is adjusted for paediatrics, why not older adults?
makes sense
She could have anything!
again, never think normal when dealing with geris
could have anything!
vitals just one tool. overall clinical acumen-a from the doorway look best initial assessment.
sepsis its always in my mind
El peor error es pensar que un paciente no tiene nada por su comportamiento
Just because they appear normal doesn’t mean you can relax.
Stable vitals are reassuring but does not exclude serious illnessess
morbid
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ccc
Geriatric patients in ER may present with everything or nothing and any in between for the same diagnosis.
We have to think widely and consider every possibility..
I also find that looking at the Anion gap is quite helpful
getting a lactate is often useful to screen for life threatening presentations
med misuse is a huge factor in atypical presentations
Agreed. A significant functional decline in the elderly (75 and up) is ANGINA OF THE AGED.
this presents a challenge to triage nurses…since much of our CTAS scoring relates to vital sign abnormalities…perhaps this should be adjusted for age?