8/10/2009

ATYPICAL OBJECTIVES: THE LEARNER…

PRESENTATIONS | Will be able to assess an older adult for atypical
presentation of disease(s)
IN OLDER ADULTS | Will be able to identify the clinical relevant signs
and symptoms of an atypical presentation of
illness in an older adult
| Will be able to identify important resources to
help guide the nursing assessment of an older
adult believed to have an atypical presentation of
an illness
1 If you think you know what
you’re looking for, think again!
(Amella, 2004)
2

ADDING TO THE CONFUSION…

“NO SINGLE, CHRONOLOGICAL | Older adults (over 65) take more medications
TIMETABLE OF HUMAN AGING | This polypharmacy leads to…
a potential change in mental status
EXISTS”
y
y which may be mistakenly be attributed to old age
and/or delirium

| No “Gold Standard” definition exists

y atypical signs and symptoms may occur in place of
other more traditional symptoms associated with the
3 One conclusion from a longitudinal study on
disease
aging that has tracked individuals from age 20 to
over age 90
4

GERIATRIC SYNDROME?
| Early definition: conditions experienced by older | Dr. J. Flacker (2003) proposes that
persons that occur intermittently rather than conditions are geriatric syndromes IF…
continuously or a as a single episodes (1991)
y They are multifactorial
| Geriatric syndromes have been viewed as
y Occur primarily in older persons
conditions in which “symptoms
symptoms… are assumed to
result not solely from discrete diseases but also y And result from interaction between
from accumulated impairments in multiple | identifiable patient-specific impairments
systems” (1995) | identifiable situation-specific stressors
| and interventions improving the contributing factors
| It is “multiple abnormalities that run together to
cause a single phenomenology” (2003)

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TRADITIONAL MEDICAL THE GERIATRIC

Dementia
SYNDROME Moon faceies
SYNDROME
Buffalo hump Dehydration

Truncal
obesity Severity of
illness
Delirium
Cushing’s Easily bruised Sensory
S Syndrome
impairment
Syndrome
Skin thinning
Medication
effects
Osteoporosis
Sleep
disturbances

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Muscle
Older age
weakness

NURSING CARE OF OLDER ADULTS… WHAT CONSTITUTES ATYPICAL

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PRESENTATION?
| Complicated by physical changes of aging
and multiple medical problems | Atypical presentation of illness to include:
| Nursing assessment is essential y vague presentation of illness
y altered presentation of illness
| Requires a recognition that the assessment
y non-presentation of illness
of acute,, chronic and/or complex
p illness may
y
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present atypically
| Early recognition can improve plans of care

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CLASSIC S/SX
EXAMPLES OF CASE REPORTS OF AN ATYPICAL
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OFTEN PART OF AN ATYPICAL PRESENTATION

Signs and Symptoms
Acute confusion
ƒ among older adults
(for example delirium”)
ƒ Failure to eat or
drink (for example,
anorexia)
PRESENTATION OF DISEASE IN OLDER ADULTS
Signs and Symptoms
| Case reports of atypical presentation of diseases
ƒ Functional decline
| Pain is often an acute heralding feature associated
ƒ Reduced mobility
with the onset of many diseases but not in older
adults
ƒ Generalized
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weakness
ƒ Failure to develop a
fever in light of ƒ Falling Case Study
leukocytosis Gastrointestinal ulcer or reflux disease, myocardial
ƒ Lack of pain with a ƒ Fatigue infarction or a urinary track infection most always
presents with pain among younger adults. These
disease known to cause pain
same diseases occurring among older adults do not
(such as gastric ulcer ƒ Urinary however, necessarily present with pain as a
disease) Incontinence 11
manifestation 12

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EXAMPLES OF CASE REPORTS OF AN ATYPICAL CLASSIC AND VARIANT SYMPTOMS

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PRESENTATION OF DISEASE IN OLDER ADULTS OF AN ACUTE MYOCARDIAL INFARCTION (MI)

Case Study Classis signs observed Atypical presentation

ƒ Older adults with acid-related diseases of the with an MI of MI
gastrointestinal track pain reported was subtle, atypical or Sub-sternal chest pain Mild or absent pain
absent Radiating pain to neck, jaw
Acute confusion
or arm
ƒ Older adult women with coronary heart disease, atypical Shortness of
symptoms were present during
d i theh infarction
i f i

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Mild or absent dyspnea

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breathe/dyspnea
Diaphoresis
ƒ MIs in older adults can include vague and non-specific Electrocardiogram evidence
symptoms such as minimal or no chest pain, no shortness of infarction
of breath or acute confusion
No electrocardiogram
evidence or Non-Q wave
infarction or silent

(no symptoms) Myocardial infarction

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CLINICAL MANIFESTATIONS OF INFECTION IN CLINICAL MANIFESTATIONS OF INFECTION IN

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RESIDENTS OF LONG-TERM CARE (CONT)
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RESIDENTS OF LONG-TERM CARE

Clinical Manifestations of Infections: Clinical Manifestations of Infections:
Pertains to infections of the urinary tract, respiratory, Pertains to infections of the urinary tract,
skin and soft tissue, gastrointestinal and/or bacteremia respiratory, skin and soft tissue, gastrointestinal
and/or bacteremia
Atypical findings of
Typical findings of infection
infection Typical findings of Atypical findings of
Fever Change in mental status infection infection
Cough and yellow sputum Afebrile (15 percent of
Change in cognition function Erythemia and purulence of
(respiratory infection)\ bacteremic patients who are
eye (conjunctivitis)
elderly are afebrile)
Decline in physical function ( for
example: inability to perform Tachypnea (respiratory rate
Heat, redness, purulence and greater than 25 breaths/minute)
activities of daily living or new
skin breakdown (pressure sore
onset of incontinence, falling or
infected) Dehydration (clinical observation
failure to cooperate in
coupled with laboratory assays
rehabilitation) 15 16
of elevated

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| The importance of recognizing the presence of an | Consequence of not recognizing atypical

atypical presentation and the range of possible presentation directly affects the delivery of quality
symptoms, can not be over stated: it’s an essential health care to older adults across all practice setting
consideration when caring for older adults.
| Atypical
yp p
presentations are recognizable
g
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| Older adults over age 85, those with multiple

comorbidites and medications, and those older adults
with cognitive or functional impairment are at | Therefore must be identified in the nursing
greatest risk for developing atypical presentation. assessment of an older adult on a consistent basis

IMPORTANT IMPORTANT
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DETECTION OF ATYPICAL

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THE PROBLEM-FOCUSED HISTORY
PRESENTATION
| In the history, detection of atypical presentations of
| Detection contingent upon a thorough nursing disease require nurses to first modify their standard
assessment. selection of questions asked to elicit a particular
problem by, thinking beyond the classic symptoms
1. Detection of an atypical presentation requires a
associated with a particular disease entity.
comprehensive, but problem- focused history.
| Because part of any atypical presentation may
2 It requires a focused physical examination,
2. examination and

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include alteration in level of consciousness and or
3. It requires critical analysis of this data into a cognitive impairment, its very important that
determination of whether or not an atypical history taking be obtained from reliable caregivers
presentation may exist. or healthcare providers who can accurately report
the older adults’ recent history.

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THE PROBLEM-FOCUSED HISTORY THE PROBLEM-FOCUSED HISTORY

| When unable to report an accurate history and
caregivers are absent, review the medical | Relay information obtained to
record or discuss with the primary care primary care providers for prompt
provider to create an accurate historical detail. intervention.
| In some clinical situations,
| Critically analyze if this symptom might be a
management by the primary care

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part of an atypical presentation.
providers may rely on other
measures such as cardiac
enzyme assay to establish a
diagnosis.

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DETERMINING IF AN ATYPICAL
THE FOCUSED PHYSICAL EXAMINATION PRESENTATION EXISTS
| Physical examination rests on observing or | Based on the presenting symptoms and/or
actively looking for certain “tell tale signs” which signs, the nurse caring for the older adult
may be part of an atypical presentation begins to formulate an impression of whether
y This includes changes in behavior such as or not an atypical presentation exists or is
restlessness or agitation,
g , anxiety
y and changes
g in likely.
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cognition
y All of these signs are readily observable on physical
examination.

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DETERMINING IF AN ATYPICAL DETERMINING IF AN ATYPICAL

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PRESENTATION EXISTS PRESENTATION EXISTS
What you can do
| Nursing interventions for validating signs of
z Vital signs may be taken more frequently atypical presentation include general
measures such as:
z Core or rectal temperature may be more accurate
and essential in determining the presence of y more frequent vital signs
conditions
diti such
h as h
hypothermia
th i related
l t d tto d il iintake
daily t k andd output
t t

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y
bacteremia
y daily weights
z Daily intake and output of oral fluids may be y observations for pain, function and behavior
required to rule out such conditions as dehydration
along with other types of laboratory work-up such as
serum electrolytes, BUN and creatinine

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DETERMINING IF AN ATYPICAL DETERMINING IF AN ATYPICAL

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PRESENTATION EXISTS PRESENTATION EXISTS
| Whenever an atypical presentation is | Having a protocol available at a facility can assist
suspected, clinical judgment will guide in the step-by-step approach to interventions, which
appropriate nursing intervention. is often helpful in managing certain conditions.
| Atypical presentation can actually be a | Nursing care of the older adult will need to reflect
medical emergency,
emergency as in the case of acute immediate versus interim versus follow-up
follow up nursing

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myocardial infarction, time is of the essence in interventions, whereby all interventions are
terms of selecting appropriate nursing prioritized according to the medical stability of the
intervention. patient and nursing judgment.
| Clinical practice guidelines provide useful
interventions for nurses when caring for an older
adult believed to have an atypical presentation,
Remember
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provided that these guidelines address this issue. 28
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REFERENCES
CONCLUSION
| Amella, E. J. (2004). Presentation of illness in older
adults. American Journal of Nursing, 104(10), 40-51.
| When nurses caring for older adults | Bradway, C. (2007). Atypical presentation in older
routinely detect and act upon important adults with complex illness. Paper presented at
Geriatric Nursing Education Conference Institute:
signs and symptoms associated with atypical Portland, OR.
presentation, important health outcomes can | Carlson, D. S., & Pfadt, E. (2009). Clinical coach for
b realized.
be li d effective
ff ti nursingi care off older
ld adults.
d lt Philadelphia,
Phil d l hi
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PA: F.A. Davis.

| Flacker, J. M. (2003). What is a geriatric syndrome
anyway? Journal of the American Geriatrics Society,
51, 574-573.
| Flaherty, E., & Zwicker, D. (2005). Atypical
presentation. Retrieved August 7, 2009 from
http://consultgerirn.org/topics/atypical_presentation
/want_to_know_more
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