Nursing Standard of Practice Protocol: Atypical Presentation 

Ellen Flaherty, PhD, APRN, BC Adjunct Professor, Deanne Zwicker, MS, APRN, BC

The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:

Overview/Definition

Because illness in older adults is complicated by physical changes of aging and by multiple medical problems, it is essential for nurses to recognize more commonly seen atypical presentations of illness in older adults. For example, subtle changes like a decrease in function or a diminished appetite very often are the first signs of illness in an older adult. This section provides specific information on the atypical presentation of illness in older adults.

Risk Factors

• Over age 85 in particular 
• Multiple co-morbidities 
• Multiple medications 
• Cognitive or functional impairment

 

Consequences (of not identifying)

• Increased morbidity and mortality 
• Missed diagnosis 
• Unnecessary use of Emergency Rooms

 

Assessment/Screening Tools

Assessment and Care Strategies: Three strategies to assess for atypical presentation of illness include: (1) Vague Presentation of Illness; (2) Altered Presentation of Illness; and (3) Non-presentation (under-reporting) of Illness.

Vague Presentation of Illness: Table 1 lists some non-specific symptoms, such as falls, confusion or other symptoms that may signify an impending acute illness in an older adult. Changes in behavior or function in an older adult are often a prodrome (symptoms(s) indicative of an approaching disease) of an acute illness, especially for frail older adults. It is essential to take reports seriously from patients, family and non-professional care providers as to subtle symptoms such as mild confusion, changes in ability to perform activities of daily living (ADL), and decreased appetite. Timely identification of acute illnesses with vague presentation enables early treatment of illness resulting in reduced morbidity and mortality and an enhanced quality of life in older adults.

Table 1 Non-specific Symptoms

that may Represent Specific Illness (Ham, 2002)

Confusion

Self-neglect

Falling

Incontinence

Apathy

Anorexia

Dyspnea

Fatigue

Instrument: Standardized mechanisms for nurse's aides to communicate changes in patient's behavior or ability to perform ADL have been developed to ensure the communication between the nurse's aides and the nurses.

• Try This Issue 2 - Katz Index of Independence in Activities of Daily Living (ADL)

Altered Presentation of Illness: Some of the more common altered presentations in older adults are listed in Table 2 below. The presentation of a symptom or a group of symptoms in older adults may present a confusing picture to health care provides. The classic presentation of common illnesses in a general adult population such as chest pain during a myocardial infarction, burning with a urinary tract infection or sadness with depression does not hold true with older adults. For example, a change in mental status is one of the most frequently presenting symptoms at the onset of acute illness in older adults.

Altered Presentation of Illness in Elderly Persons

Illness: Atypical Presentation

Infectious diseases

• Absence of fever
• Sepsis without usual leukocytosis and fever
• Falls, decreased appetite or fluid intake, confusion, change in functional status

 

"Silent" acute abdomen

• Absence of symptoms (silent presentation)
• Mild discomfort and constipation
• Some tachypnea and possibly vague respiratory symptoms

 

"Silent" malignancy

• Back pain secondary to metastases from slow growing breast masses
• Silent masses of the bowel

 

"Silent" myocardial infarction

• Absence of chest pain
• Vague symptoms of fatigue, nausea and a decrease in functional status.
• Classic presentation: shortness of breath more common complaint than chest pain

 

Non-dyspneic pulmonary edema

• May not subjectively experience the classic symptoms such as paroxysmal nocturnal dyspnea or coughing
• Typical onset is insidious with change in function, food or fluid intake, or confusion

 

Thyroid disease

• Hyperthyroidism presenting as "apathetic thyrotoxicosis," i.e. fatigue and a slowing down
• Hypothyroidism, presenting with confusion and agitation

 

Depression

• Lack of sadness
• Somatic complaints, such as appetite changes, vague GI symptoms, constipation, and sleep disturbances
• Hyper activity
• Sadness misinterpreted by provider as normal consequence of aging
• Medical problems that mask depression

 

Medical illness that presents as depression

• Hypo- and hyper- thyroid disease that presents as diminished energy and apathy

Source: Ham, R. (2002). Reprinted with permission of Elsevier publishers.

Depression: Although most depression in older adults is associated with a sad mood, it often presents as a preoccupation with somatic symptoms related to appetite changes, vague GI symptoms, constipation, and sleep disturbances. Also problematic is that clinicians may interpret patient's sad affect as an appropriate reaction to multiple medical problems and thus miss the primary pathology of depression. Older adults are more likely than their younger counterparts to present with an agitated depression. In addition, the diagnosis of depression is complicated by the overlay of multiple medical problems and their corresponding symptoms that mask the depression. (see protocol Depression and Try This: GDS)



Paradoxically, it is equally important to recognize medical illnesses that may present as depression. For example, both hypo and hyper thyroid disease may present as diminished energy and apathy and be miss-diagnosed as depression in older adults. 



Infectious Diseases: The lack of typical signs of infection in older adults is common. Older adults with sepsis may not present with the usual leukocytosis and fever but rather with a decreased appetite and or functional status. Considering the frequency of infections in older adults, more often affecting the urinary tract, the respiratory tract, the skin or the GI tract, an infection should be suspected with any change in condition, including falls, a decrease in food or fluid intake, confusion, and/or a change in functional status (See protocol Function).



Acute Abdomen: Most patients suspected of having an "acute abdomen" present with a series of complaints and or signs such as pain, diminished or absent bowel sounds, and fever. Atypical nursing assessment would also include vital signs, recording a patient's intake and output and possibly their abdominal girth. However, in older adults an acute abdomen may present silently with mild discomfort and constipation with some tachypnea, and possibly some vague respiratory symptoms. Therefore, it is extremely important for nurses to recognize those patients with significant bowel disturbances and a change in food or fluid intake.

Malignancy: A comprehensive physical exam is vitally important in older adults who may not be aware of hidden masses. For example, breast masses in older women may be very slow growing and exist for some time before they are discovered during a work up for back pain secondary to bone metastases. Silent masses of the bowel especially those from the ascending colon, may exist without major symptoms due to reduced neuronal sensitivity in the GI tract.

Myocardial Infarction: Most myocardial infarctions in older adults do NOT present with clinical symptoms such as chest pain. Clinicians need to be astute to patients at risk who present with vague symptoms of fatigue, nausea, and a decline in functional status. When patients do present with a more classic picture of an acute event, a more common complaint than chest pain is shortness of breath. 

Pulmonary Edema: Older adults experiencing pulmonary edema will often exhibit specific clinical signs associated with CHF such as increased fluid retention, fatigue, and possibly dyspnea. However, the patient may not subjectively experience or recognize the classic symptoms such as paroxsymal nocturnal dyspnea, or coughing. More typically the onset is insidious and presents as a change in function, decreased food or fluid intake, or confusion.

Thyroid Disease: Although patients will often present with the classis signs and symptoms of both hypothyroidism and hyperthyroidism, it is not uncommon to see altered presentation of both. For example, hyperthyroidism may present as "apathetic thyrotoxicosis" whereby a patient presents with fatigue and a slowing down as opposed to the classic thin, hyperactive hyperthyroid patient. Also, hypothyroidism, classically seen presents as fatigue and weight gain and instead may present with confusion and agitation.

Non-presentation of Illness

A host of illnesses in older adults may go unrecognized for many years and significantly impact quality of life and are summarized in Table 3.

Table 3 "Hidden" Illness in Older Adults (Ham, 2002)

Depression

Incontinence

Musculoskeletal stiffness

Falling

Alcoholism

Osteoporosis

Hearing loss

Dementia

Dental Problems

Poor nutrition

Sexual dysfunction

Osteoarthritis

Factors that contribute to the under-reporting of illnesses are:

• The insidious nature of the onset of the illnesses and the vague symptoms associated with these problems
• A tendency on the part of patients and families to regard many of these symptoms as a "normal" part of aging
• Reluctance of older people to complain about problems because of concerns as to being ignored or generating burdensome tests
• Communication deficits including hearing impairments, poor vision, and speech problems

Expected Outcomes

 

Patient will:

• Experience fewer iatrogenic outcomes from atypical presentation of illness
• Understand their risk for altered presentation of illness
• Be more aware of signs and symptoms to report to health care provider

 

Healthcare providers will:

• Use of a range of interventions to prevent, alleviate, or ameliorate altered presentation of illness in older adults
• Document and communicate each individual's altered presentation of illness on chart and between levels of care
• Increased their knowledge about altered presentation in the elderly

 

Institutions will:

• Provide educational material related to atypical presentation of illness
• See decreased morbidity and mortality due to atypical presentation of illness
• See improved documentation of altered presentation of illness
• Staff will receive ongoing education related to identification of altered presentation of illness

 

Follow-up Monitoring:

• Monitor high risk individuals for potential atypical presentation of illness
• Document and communicate presenting atypical symptom(s) on problem list and between levels of care

Atypical Presentation of Common Geriatric Emergencies

• Acute abdomen with constipation and decreased appetite, rather than severe pain
• Pneumonia with vague chest pain and dry cough, rather than fever
• Depression with agitation, rather than dysphoria
• Infection with falls, rather than fever or elevated white count
• Sepsis with functional decline and generalized weakness, rather than fever
• Myocardial infarction with dyspnea and confusion, rather than chest pain
• Heart failure with fatigue, rather than dyspnea

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description