Simposio inter-societario SIGG-FADOI

La complessit del malato anziano

ricoverato in ospedale

Presentazione atipica dei sintomi

Giovanni Mathieu
Presidente Nazionale FADOI

Firenze, 30 novembre 2007

Atipicality

one of the intellectual challenges

of the
clinical medicine of old age
Sherman FT, Geriatrics 2003

Modified manifestations
9 atypical
9 non-specific
9 insidious onset
9 silent existence
9 missed diagnosis

Modified manifestations
9 atypical
9 non-specific
9 insidious onset
9 silent
existence
Altered presentations
9 missed
diagnosis
9 diminished, absent pain
9
9
9
9
9

depressed temperature regulation

depressed thirst mechanism
confusion, restlessness, hallucinations
generalized deterioration
vague, poorly-defined constitutional
symptoms

Factors complicating assessment in the elderly

Presence of multiple pathologies

9 85% have 1 chronic disease, 30% have 3 or more
9 one systems acute illness
stresses others reserve capacity
9 one diseases symptoms
may mask another
9 one diseases treatment
may mask another symptom

Polypharmacy
9 too many drugs
9 30% of geriatric hospitalizations drug-induced

Characteristics of atypical presentation

9
9
9
9

personality
behavior patterns
higher/lower pain thresholds
patient with psychiatric/cognitive diseases

Communication problems
9
9
9
9
9
9

diminished sight
diminished hearing
diminished mental faculties
depression
poor cooperation
limited mobility

Characteristics of atypical presentation

9
9
9
9

personality
behavior patterns
higher/lower pain thresholds
patient
with
psychiatric
/cognitive
diseases
Do not assume confused

Do not assume confused

Communication
or
disoriented problems
patient
9
9
9
9
9
9

diminished sight
diminished hearing
is justmental
senile
diminished
faculties
depression
poor cooperation
limited mobility

Error of planning ..

(wrong plan to achieve aim)

Error of execution..

(action does not go as intended)

intended)

- forget to attend for planned consultation

- does not notify about lateness
- forget to cancel clinical appointment
-

forgets
forgets
forgets

to
to
to

report informations
bring relevant items to consultation
take treatment

- fails to read medication label and instructions

Buetow S, Lancet 2007

Error of planning ..

(wrong plan to achieve aim)

Error of execution..

(action does not go as intended)

intended)

- forget to attend for planned consultation

illness
-Response
does not notifyto
about
lateness
- forget to cancel clinical appointment

seek tohelp
for
only small part
-9forgets
report
informations
- forgets to bring relevant items
consultation
oftosymptoms
- forgets to take treatment

9 perceive symptoms as just getting old

- fails to read medication label and instructions

9 delay seeking treatment

Buetow S,

Lancet 2007

Epidemiologia dellIMA nelle ICU in Italia

lo studio BLITZ
Sintomi allesordio (n = 1.927)
9 dolore tipico
1.561
9 dolore atipico
223
9 senza dolore
143
Angina prodromica (n 1.259)
9 angina da sforzo (min < 2 mesi)
9 angina a riposo > 48 h
9 senza dolore < 48 h

81%
11,6%
19%
7,4%

150
235
293

7.8%
12.2%
15.2%

Di Chiara A, Eur Heart J 2003

Epidemiologia dellIMA nelle ICU in Italia

lo studio BLITZ
Sintomi allesordio (n = 1.927)
9 dolore tipico
1.561
Anginal
equivalents 223
9 dolore
atipico
9 shortness
of breath143
9 senza
dolore

81%
11,6%
19%
7,4%

9 dyspnea, palpitations, syncope,

general weakness,
Angina prodromica
(n 1.259) dizziness
9 exercise
-induced
9 angina
da sforzo
(min < 2pain
mesi) 150
7.8%
- riposo
9 angina a
in the >abdominal
48 h
region, 235
back, 12.2%
jaw,
9 senza dolorearm
< 48- hmore commonly 293
in the15.2%
left

arm - or shoulder

Di Chiara A, Eur Heart J 2003

IMA misconosciuto-pazienti a rischio

9
9
9
9

donne di media et pre/peri-menopausa

anziani di entrambi i sessi
diabetici
drug abusers (cocaina, amfetamine)

Mancanza di dolore
-

anziani
donne
diabetici
precedenti IMA
scompenso cardiaco

IMA misconosciuto-pazienti a rischio

9
9
9
9

donne di media et pre/peri-menopausa

anziani di entrambi i sessi
diabetici
drug abusers (cocaina, amfetamine)

Barron, Circulation 1998

Mancanza di dolore
-

anziani
donne
diabetici
precedenti IMA
scompenso cardiaco

Multivariate OR for complaints other than chest pain

Aronow WS, Geriatrics
2003
in 721 ED
patients with AMI

Study
variable

Unrecognized
N
Age
% of AMI presentation MI
OR
(years)
without chest pain

Rodstein, 1956
sex
Aronow, 1985
- men
Aronow
, 1987
- women
Honolulu
Heart
AgeProgramme
(years)
Muller
1990 men
<, 65
Muller, 1990 women
65-74
Nadelmann, 1990
75-84
Sigurdsson, 1995
> 85, 2000
Sheifer

52
115
110
89
46
67

61-92
Mean 82
42%
Mean 82
59%
Mean 61

65-95
32%
65-95
57%
75-85
67%
237
58-62
901 75%
Mean 72

31%
68%
ref
21%
1.59
33%
30%
ref
51%

2.60
43%
3.84
35%
5.76
22%

Gupta, M Ann Emerg Med 2002

Sintomi associati ad IMA nei pazienti anziani

70

Sintomi inusuali di MI

9
9
9
9
9
9
9
9
9
9
9
9

60
dolore
mandibolare, odontalgia
dolore cervicale
50
dolore addominale e disturbi gastrointestinali
nausea, vomito, singhiozzo, eruttazioni
40
esacerbazione o nuova insorgenza di scompenso cardiaco
30
dispnea,
tosse
cardiopalmo e aritmie
20
episodi
sincopali, vertigine, tinnito, pallore improvviso,
sudorazione, cute fredda, malore
10
embolia periferica
sintomi/segni
di ipo-perfusione periferica
0
DISPNEA
DOL. TORACICO
SINT. NEUROL. SINT. G.INTEST.
G.INTEST.
alterazione dello stato mentale, delirium
Rodstein (n=52)
Pathy (n = 387)
Tinker (n = 87)
ansia,
astenia
e
debolezza
generalizzata
Aronow (n = 110)
Bayer (n = 777)
Wroblewski (ninspiegata
= 96)
sintomi neurologici focali, TIA, stroke
Aronow, 2003

HF in elderly patients

AHA-ACC

9 inadequately recognized and treated

9 symptoms of HF frequently attributed

to ageing
9 non invasive cardiac imaging often fails
to reveal impaired cardiac function
9 HF with a preserved LVEF frequently found

HF in elderly patients

AHA-ACC

9 inadequately recognized and treated

9 symptoms of HF frequently attributed

to ageing
9 non invasive cardiac imaging often fails
Congestive
Heart
Failure
to reveal
impaired
cardiac function
9
may
present
as nocturnal
confusion
9 HF
with
a preserved
LVEF frequently
found

9 bed-ridden patients may have fluid

over sacral areas, rather than
feet or legs

Kaplan-Meyer
survival curves
for pts with HF
and preserved or
reduced EF

Owan TE, NEJM 2006

Kaplan-Meyer
survival curves
for pts with HF
and preserved or
reduced EF

Owan TE, NEJM 2006

Kaplan-Meyer
survival curves
for pts with HF
and preserved or
reduced EF

Owan TE, NEJM 2006

Understanding
Understanding diastolic
diastolic heart
heart failure
failure
Patients with diastolic HF vs. systolic HF

tend to be older
more of them are female
more have hypertension
fewer have CAD
show similar rates of DM, AF, renal disease

Acute episodes of DHF are often associated with

hypertensive episodes
the onset of AF
Redfield MM, NEJM 2004

Understanding
Understanding diastolic
diastolic heart
heart failure
failure
Patients with diastolic HF vs. systolic HF
tend to be older
more of them are female
more have hypertension
fewer
capacit
have
renale
CAD a eliminare
show similar rates un
of carico
DM, AF,
di acqua
renal disease
e sale

Acute episodes
DHF are
capacit aoftollerare
unaoften
rapida associated
e abbondantewith
somministrazione di liquidi

hypertensive episodes
the onset of AF pazienti volume sensitive
Redfield MM, NEJM 2004

Initial clinical presentation

Gheorghiade M, Am J Cardiol 2005

Embolia polmonare
Background
Pi di 600.000 casi/anno
60.000-100.000 morti/anno
70% diagnosticati allautopsia

25-35% mortali se non

trattati

comune
ti uccide
ci sfugge
individuarla fa
la differenza

2-8% mortali anche se

trattati

Tabas S, ACEP 2002

Morgenthaler TI, Mayo Clin Proc 1995

Embolia polmonare
Background
Pi di 600.000 casi/anno

60.000-100.000 morti/anno
the silent killer of
70% diagnosticati allautopsia

the elderly
comune

ti uccide
ci sfugge
25suspect
-35% mortali
se
non
in any patient with
individuarla fa
trattati
sudden onset of dyspnea
when
la differenza

cause cannot be quickly identified

2-8% mortali anche se

trattati

Tabas S, ACEP 2002

Morgenthaler TI, Mayo Clin Proc 1995

Embolia polmonare
Background
Pi di 600.000 casi/anno

60.000-100.000 morti/anno
the silent killer of the elderly
comune
Pulmonary allautopsia
embolism should be
70% diagnosticati

ti uccide
considered in the differential
ci sfugge
25suspect
-35% mortali
se
non
diagnosis
of
in any patient with

individuarla fa
sudden
onset
of dyspnea
when
every
syncopal
event
la differenza

trattati

cause
cannot
be
quickly
identified
that
presents
to
the
ED,
even
in the
2-8% mortali anche se
face of cardiac dysrhythmias and
trattati
normal
pulse
oximetry
values
Tabas
S, ACEP
2002
Wolfe, J Emerg Med 1998
Morgenthaler TI, Mayo Clin Proc 1995

embolia polmonare
critica e non critica
dispnea
dolore toracico
tosse
sincope
emottisi

81,7%
48,8%
20,3%
13,6%
6,6%

I.CO.P.E.R., Lancet 1997

Non esiste correlazione
diretta tra gravit del
quadro clinico e dimensione
e/o localizzazione dellembolo

Morgenthaler TI,
Mayo Clinic Proc 1995

Embolia polmonare fatale

SINTOMI
Dispnea
Sincope
Stato mentale alterato
Ansia
Dolore toracico
Sudorazione
Dolore pleuritico

59%
27%
20%
17%
10%
9%
8%

SEGNI
RR > 16/m
Tachicardia
Rantoli
T > 37.8
Edemi declivi
Ipotensione improvvisa
Cianosi

66%
54%
42%
30%
26%
20%
12%

Venous thromboembolic disease in the

elderly patient
atypical, subtle and enigmatic

traditional vital sign abnormalities found in

patients who have VTE may be absent in the
older patient, and presentations such as

isolated syncope without chest pain or

dyspnea are common

by having an appreciation for the subtle and

atypical presentations of VTE, they will
be in a position to significantly lower morbidity
and mortality in the older patients
Rogers RL, Clin Ger Med 2007

Venous thromboembolic disease in the

elderly patient
atypical,Incidence
subtle and of
enigmatic
VTE
traditional vital sign abnormalities found in
patients who have VTE may be absent in the
older patient, and presentations such as

isolated syncope without chest pain or

dyspnea are common
Anderson FA,

by having an appreciation for the subtle and

Arch Int Med 1991
atypical presentations of VTE, they will
be in a position to significantly lower morbidity
and mortality in the older patients
Rogers RL, Clin Ger Med 2007

The atypical presentation of

infection in old age

Berman P, Age and Ageing 1987

Absent or blunted temperature

nelle infezioni dellanziano
meccanismi fisiopatologici non completamente
chiariti
ridotta risposta termoregolatoria
alterazioni quali/quantitative sia nella
produzione che nella risposta dei pirogeni
endogeni (IL-1, IL-6, TNF)
disfunzione ipotalamica circum-ventricolare

Pneumonia

atypical signs & symptoms

Tuberculosis

decline in mental status: confusion, disorientation,

lethargy
Pneumococcal bacteremia
decline in functional status
weight loss, nutritional deficits
Urinary tract infections
anorexia, nausea, vomiting
complaints of weakness
Meningitis
delayed or low grade
fever
atypical
presentation
may
be seen in certain groups
no typical
signs of the
disease
symptoms often vague, mirror those of other
chronic
Endocarditis
conditions
in the elderly

Pneumonia

atypical signs & symptoms

Tuberculosis

decline in mental status: confusion, disorientation,

lethargy
Pneumococcal bacteremia
decline in functional status
weight loss, nutritional deficits
Urinary tract infections
anorexia, nausea, vomiting
complaints of weakness
Meningitis
delayed or low grade
fever
atypical
presentation
may
be seen in certain groups
no typical
signs of the
disease
symptoms often vague, mirror those of other
chronic
Endocarditis
conditions
in the
elderly
delay
in
diagnosis
and/or
therapy

higher risk of dying

Appendicitis with perforation

a remind to internist
Murray HW,
Med J 1980
Unusual presentation
of South
appendicitis

pseudoneoplastic/progressive sigmoid
narrowing
acute urinary retention, scrotal abscess,
vaginal discharge, pyelo-ureteral
dilatation/hydronephrosis, perinephric
abscess, bladder tumor with painless
gross hematuria
delirium, falls
migratory pain, recurrent/chronic

Appendicitis with perforation

a remind to internist
Murray HW,
Med J 1980
Unusual presentation
of South
appendicitis

pseudoneoplastic/progressive sigmoid
narrowing
acute urinary retention, scrotal abscess,
vaginal discharge, pyelo-ureteral
dilatation/hydronephrosis, perinephric
abscess, bladder tumor with painless
gross hematuria
Geriatric
delirium, acute
falls perforated appendicitis
atypical
symptoms
lead to a /difficult
migratory
pain, recurrent
chronic diagnosis
Majeski J, South Med J 1998

Atypical presentation of abdominal

pathologic conditions
high risk patients geriatric people

frequently elderly patients with acute

surgical abdomens present with normal
temperature and leukocytes count
9 approximately

only 14% of the patients

older than 50 years with appendicitis had

generalized pain and tenderness

9 rebound tenderness is less likely in elderly

patients with appedicitis

Potts FE, J Gerontol Biol Sci Med Sci 1999

Atypical presentation of abdominal

pathologic conditions
high risk patients geriatric people

frequently elderly patients with acute

Has misdiagnosis of appedicitis decreased over time?
surgical abdomens present with normal
temperature and leukocytes count
among 63.707 non-incidental appendicectomy
had14%
appendicitis
25.8%
patients, 84.5%
9 approximately
only
of the and
patients

with
perforation
older
than 50 years with appendicitis had
generalized
pain and tenderness
the incidence
of misdiagnosis
increased 8% yearly
in patients older than 65 years

9 rebound tenderness is less likely in elderly

common misdiagnoses include gastroenteritis,

patients with appedicitis
pelvic inflammatory disease or UTI

Potts FE, J Gerontol

SciJAMA
Med Sci
1999
FlumBiol
DR,
2001

Spondylitis and Spondylodiscitis

Back pain in an elderly man

more than just a fall
9 pazienti a rischio: anziani, diabetici, neoplastici,
HIV+, immunodepressi, emopatici, valvulopatici,
ustionati, m. Crohn fistolizzato, SAPHO Syndrome
(synovitis, acne,pustolosis, hyperostosis and
9 procedure
invasiveinvasive
: cateterismo vescicale,
osteitis), manovre
cateterismo venoso/arterioso, biopsia prostatica,
anestesia spinale, terapia antalgica epidurale,
rachicentesi, interventi chirurgici extrarachidei
(splenectomia,
pancreatectomia
Wong EB, Med
J Aus 2000)

Spondylodiscitis
9 in a survey of over 2.5 years,
22 cases of septic discitis were identified,
suggesting an annual incidence of 2/100.000/years

9 73% of patients were aged 65 years

9 in

91% of patients back pain was the

presenting symptom, with neurological signs

evident in 45% of patients

9 fever > 37.5 C was present in 68% of patients

and a marked elevation of ESR in 91%
9 elevated serum leukocyte count
lacked diagnostic sensitivity
Hopkinson N, QJM 2001
Friedman JA, Surg Neurol 2002

Pitfalls
9 vertebral ospteomyelitis mimicking
chronic pancreatitis
Dig Dis Sci 1996
9 cervical spine infection presenting as angina
Hosp Med 1999
9 bacterial endocarditis revealed
by infectious discitis
Rev Rheu Engl Ed 1996
9 brucella spondylitis mimicking lumbar
disc herniation
Paraplegia, 1995

Sepsis

Cortisolemia dopo intervento chirurgico

Insufficienza
Insufficienza Surrenalica
Surrenalica Acuta
Acuta
squilibrio tra richieste dellorganismo vs. capacita di
secrezione dei surreni

emergenza medica
da prendere sempre in considerazione in

caso di sincope o shock ndd

It continues to be difficult to diagnose

corticosteroid insufficiency in
patients with critical illness
Cooper MS, NEJM 2003

meccanismi patogenetici

vulnerabilit della giunzione cortico-midollare

patogenetici
fattorimeccanismi
favorenti farmaco
-correlati

9 aumentato metabolismo del cortisolo

rifampicina, fenitoina, fenobarbitale

9 inibizione della steroidogenesi

ketoconazolo, amino-glutetimide,
taxani, alcaloidi della vinca

vulnerabilit della giunzione cortico-midollare

Ipo
-surrenalismo acuto
Ipo-surrenalismo
acuto
forme cliniche
FORMA PSEUDO-CARDIACA

ipotensione, shock ipo-volemico, sincope

FORMA PSEUDO-COLERICA

vomito, disidratazione, ipotermia

FORMA PSEUDO-APOPLETTICA

agitazione, convulsioni, coma, febbre

FORMA PSEUDO-PERITONITICA

dolori addominali, resistenza addominale, vomito

FORMA FULMINANTE

ipovolemia acuta

SEGNI

Insufficienza
Insufficienza Surrenalica
Surrenalica Acuta
Acuta
Quando sospettarla?
OBIETTIVI

iperpigmentazione
ipotensione arteriosa
tachicardia
perdita di peli
vitiligo
amenorrea
intolleranza al freddo

SINTOMI
debolezza e fatica
anoressia, nausea, vomito
dolori addominali/lombari
mialgie, artralgie
vertigini posturali/ sincope
craving verso il sale
cefalea, confusione, agitazione
perdita di memoria
depressione
febbre, sudorazione, disidratazione

SEGNI

Insufficienza
Insufficienza Surrenalica
Surrenalica Acuta
Acuta
Quando sospettarla?
OBIETTIVI

iperpigmentazione
ipotensione arteriosa
tachicardia
perdita di peli
vitiligo
amenorrea
intolleranza al freddo

SINTOMI
debolezza e fatica
anoressia, nausea, vomito
dolori addominali/lombari
mialgie, artralgie
vertigini posturali/ sincope
craving verso il sale
cefalea, confusione, agitazione
QUADRO CLINICO
perdita
di memoria
instabilit emodinamica
(stato
iper-dinamico)
depressione
infiammazione progressiva
senza fonti evidenti
febbre,
sudorazione, disidratazione
disfunzione multi-organo
(IRA)
ipoglicemia

Hyperthryroidism

Hyperthryroidism

Hyperthyroidism in the elderly vs young

Atypical signs and symptoms in elderly

patients with hypothyroidism
confusion
behavioral changes
macrocytic anemia
peripheral neuropathy
dementia-like behavior
memory impairment
myopathy
depressed affect
muscle weakness
R Rizzolo, "Thyroid disease," in Primary Care Geriatrics: A Case-Bosed Approach
R J Ham, P D Sloane, eds (St Louis: Mosby-Year Book, 1997) 447-455

Geriatric Abuse & Neglect

Contributing factors

advanced age: average

mid-80s
multiple chronic diseases
patient lacks total
dependence
sleep pattern disturbances
leading to nocturnal
wandering, shouting
family has difficulty
upholding commitments

Primary findings
Trauma
inconsistent with
history
History that
changes with
multiple tellings

10 Principles of
Geriatric Emergency Medicine
1) presentation is often complex

2) common diseases present atypically

3) co-morbidity must be considered

4) polypharmacy is common

5) cognitive impairment must be recognized

6) tests may have different normals - variability

7) decreased reserve must be recognized

8) support systems may not be adequate

9) baseline functional status must be known

10) psychosocial issues must be addressed

10 Principles of
Geriatric Emergency Medicine
1) presentation is often complex

Tieni a mente le malattie

co-morbidity must be considered
che
veramente
contano
polypharmacy is common

2) common diseases present atypically

3)
4)

5) cognitive impairment must be recognized

e comincia da quelle
decreased reserve must be recognized
che systems
possono
essere
fatali
may not
be adequate
support

6) tests may have different normals - variability

7)

8)

9) baseline functional status must be known

10) psychosocial issues must beJ.W.

addressed
Hurst