Atypical presentations of older adults at the emergency department and associated factors

Highlights

• The prevalence of atypical presentation of older adults at the ED was a third.

• Absence of fever with a disease known to cause fever was the common presentation.

• UTI and dementia were risk factors associated with atypical presentations.

Abstract

Objectives

The objectives were to determine the prevalence of atypical presentations among older adults at the Emergency Department (ED) of a tertiary care hospital and to identify factors associated with these presentations.

Material and methods

A retrospective medical record audit was randomly reviewed in 633 patients who were aged ≥65 years who attended the ED of Srinagarind Medical School Hospital in 2013. Demographic data were collected and were analyzed using descriptive statistics. Regression analysis was used to analyze the variables associated with the outcomes.

Results

The prevalence of an atypical presentation was 28.6% (181/633 cases). The failure to develop fever with a disease known to cause fever was the most common atypical presentation of illness (34.42%). Independent factors associated with atypical presentations were complicated urinary tract infection (UTI) (odds ratios (OR) 4.66, 95% confidence interval (CI) 2.0, 10.84, p = 0.00) and a background of dementia (OR 3.48, 95% CI 1.38, 8.77, p = 0.008).

Conclusions

The prevalence of atypical presentations of older adults at the ED was about a third. The absence of fever with a disease known to cause fever was the most common atypical presentation. Complicated UTI and demented patients were the independent risk factors associated with the atypical presentations. Early awareness of non-specific presentations and applying comprehensive geriatric assessments among older patients at the ED is recommended.

Introduction

The proportion of older adults at the Emergency Department (ED) is about 12–24% and it tends to increase as a result of population ageing (Rutschmann et al., 2005, Samaras et al., 2010). Age-related physiologic changes can lead to diverse pathophysiologic responses to foreign stimuli. Reduced body reserves and underreporting of symptoms may result in atypical presenting of disease patterns. Additionally, older adults often have multiple morbidities coexisting that can contribute to non-specific presenting symptoms and signs of medical illnesses (Emmett, 1998, Rehman and Qazi, 2013, Rutschmann et al., 2005). One report shows that about a third of persons aged 65–79 years and 70% at the age of 80 years had at least 2 chronic conditions (Fried, Ferrucci, Darer, Williamson, & Anderson, 2004). These characteristics of older adults cause them more delayed and missed diagnoses and consequently lead to increased adverse outcomes including frequent hospitalizations, increased healthcare costs and increased short-term mortality (Rutschmann et al., 2005, Salvi et al., 2007, Samaras et al., 2010). Physicians also feel uncomfortable when assessing older adults compared to the younger ones. This feeling can affect the quality of care (Rutschmann et al., 2005).

Presently, no explicit gold standard definition exists as to what characteristics constitute an atypical presentation for every disease. Common classical signs and symptoms include altered mental level, failure to eat and drink e.g., anorexia, failure to develop temperature or fever or lack of pain in a disease known to cause those conditions, functional decline, reduced mobility, falling, fatigue and urinary incontinence (Emmett, 1998, Gray-Miceli, 2007, Salvi et al., 2007, Samaras et al., 2010). These symptoms are sometimes known as geriatric syndromes which are prevalent in up to a quarter of older adults at the ED, particularly in institutionalized patients (Chou et al., 2009, Rutschmann et al., 2005). Apart from presenting as geriatric syndromes, variant symptoms of specific diseases often occur such as mild or absent chest pain, dyspnea and no electrocardiogram evidence of acute myocardial infarction, unexplained atrial fibrillation, weakness and anorexia in hyperthyroidism, absence of dysuria in urinary tract infection, and diffuse abdominal pain, urinary urgency, absence of fever and tachycardia in patients with acute appendicitis (Canto et al., 2000, Emmett, 1998, Limpawattana et al., 2006; Samaras et al., 2010). Existing factors associated with the greater risk of atypical presentation are an age of 85 years or over, multiple comorbidities, polypharmacy and patients with cognitive and functional impairment (Gray-Miceli, 2007, Salvi et al., 2007).

Thus, it is essential for the ED physicians to recognize the presence of an atypical presentation and the range of potential symptoms of a particular disease in order to lessen difficulties and to improve emergency care and outcomes of older adults. The studies about the prevalence of atypical presentations and the magnitude of contributing factors of the non-specific manifestations are relatively small in Asia. Therefore, the primary objective of this study was to determine the prevalence of atypical presentations and describe the characteristics of atypical presentations of older adults at the ED of a tertiary care hospital and a secondary objective was to identify factors associated with these presentations.