Transitioning to Adult-Gerontology
APRN Education: Slide Library
Assessment and Management of Atypical
Presentation of Illness in Older Adults
Author: Deanna Gray-Miceli, PhD, RN, GNP-BC, FAANP
Adult-Gerontology APRN Slide Library
• The APRN Slide Library is a resource of
“Transitioning to Adult-Gerontology
APRN Education” a project of AACN and
the Hartford Institute for Geriatric
Nursing 2010-2012
• The project is funded by the John A.
Hartford Foundation
Adult-Gerontology APRN Slide Library
"All materials are jointly copyrighted by the American
Association of Colleges of Nursing (AACN) and The Hartford
Institute for Geriatric Nursing, College of Nursing, New York
University or are used with permission from the original source.
Permission is hereby granted to reproduce, post, download,
and/or distribute, this material for not-for-profit educational
purposes only, provided that the American Association of
Colleges of Nursing (AACN) and The Hartford Institute for
Geriatric Nursing, College of Nursing, New York University are
cited as the source. They may not be used for ANY commercial
or other purpose."
Available at www.hartfordign.org
E-mail notification of usage to: [email protected]
Further information about the APRN program can be found at
www.aacn.nche.edu/APRN Gerontology.htm
Purpose of the APRN Slide Library –
Atypical Presentation of Illness
• To provide APRN faculty with an overview of atypical
presentation of illness in older adults*
• To introduce APRN faculty to print and web
resources on assessment, diagnosis & management
of atypical presentation of illness
• To provide APRN faculty with slides on atypical
presentation to use in class & to share with APRN
students
* These slides have been modified from slides prepared for the Geriatric
Nursing Education Consortium (GNEC) program (www.aacn.nche.edu)
Adult-Gerontology APRN Slide Library
Web Resources
http: //www.ConsultGeriRN.org Try This ® and How to Try This
General Assessment Series, e.g.
• Assessment of Pain in Older Adults
http: //www.ConsultGeriRN.org Try This ® and How to Try This
Dementia Assessment Series, e.g.
• Recognition of Dementia in Hospitalized Older Adults
http: //www.ConsultGeriRN.org select Evidence-based
Geriatric Topics, e.g. protocol on Atypical Presentation of
Illness
Source Books: Geriatrics
Auerhahn, C., Capezuti, E., Flaherty, E., & Resnick, B. (eds.) (2007). Geriatric Nursing
Review Syllabus: A Core Curriculum in Advanced Practice Geriatric Nursing, 2nd
Edition: New York: American Geriatrics Society. (3rd Edition, May, 2011)
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A concise & comprehensive text developed by the American Geriatrics Society (AGS) & the
NYU Hartford Institute for Geriatric Nursing , adapted for APRNs from the AGS Geriatrics
Review Syllabus: A Core Curriculum in Geriatric Medicine, 6th Edition
Authored by > 100 interdisciplinary experts in care of older adults
59 chapters on prevailing management strategies, extensive reference, appendix with
assessment instruments, 100 case-oriented, multiple choice questions and a self-assessment
tool. (www.americangeriatrics.org/.../the_geriatric_nursing_review_syllabus_2nd_edition/
Auerhahn, C. & Kennedy-Malone, L. (2010). Integrating Gerontological Content into
Advanced Practice Nursing Education. New York: Springer Publishing Co.
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Clear, user-friendly guidelines for integrating gerontological content into non-gerontological
APRN programs
Detailed lists of print resources and e-Learning materials
Utilizes a competency-based framework
“Success stories” written by APRN faculty who have integrated gerontological content into
non-gerontological courses
Atypical Presentation of
Illness - Introduction



APRNs in all practice settings need to recognize
acute, chronic and/or complex illness in older adults
may present atypically
Integral to the history and physical is the ability to
determine if an older adult is presenting atypically
Early diagnosis of atypical presentation of illness
reduces morbidity and mortality, and reduces the rate
of co-morbidity from treatable geriatric syndromes
Atypical Presentation: Definition
Atypical presentation is defined as non-specific symptoms
occurring outside of the normal rubric of traditional signs and
symptoms, which may signify an impending acute illness in an
older adult.
Non-specific signs and symptoms may include:
Confusion
Unexplained change in behavior or function
Falls
Incontinence
Apathy
Poor appetite; anorexia
Dyspnea
Fatigue or excessive sleepiness
Atypical Presentation

Atypical presentation of illness can
include:
 vague presentation of illness
 altered presentation of illness
 non-presentation of illness
Classic Signs and Symptoms of Atypical Presentation
of Illness in Older Adults
Signs and Symptoms



Acute confusion (for example
“delirium”)
Failure to eat or drink (for
example, anorexia)
Failure to develop a
temperature or fever in light of
leukocytosis
 Lack of pain with a disease
known to cause pain (such as
gastric ulcer disease)
Signs and Symptoms

Functional decline

Reduced mobility

Generalized weakness

Falling

Fatigue

Urinary Incontinence
Atypical Presentation and
Delirium
Case Study

Delirium is a common
manifestation of an atypical
presentation of illness

For information and resources
on delirium, See Slide Library:
Delirium
over 60 percent of
frail hospitalized
older adults with
atypical
presentation
experienced
delirium
Classic and Variant Symptoms
of an Acute Myocardial Infarction (MI)
Classic signs observed with an MI
Substernal chest pain
Radiating pain to neck, jaw or arm
Shortness of breathe/dyspnea
Atypical presentation of MI
Mild or absent pain
Acute confusion
Mild or absent dyspnea
Diaphoresis
Electrocardiogram evidence of
infarction
No electrocardiogram evidence or Non-Q
wave infarction or silent
(no symptoms)
Myocardial infarction
Clinical Manifestations of Infection in
Residents of Long-term Care Facilities
(Infections of the urinary tract, respiratory, skin and
soft tissue, gastrointestinal and/or bacteremia)
Typical findings of infection
Atypical findings of infection
Fever
Change in mental status
Cough and yellow sputum (respiratory
infection)
Change in cognition function
Heat, redness, purulence and skin
breakdown (pressure sore infected)
Decline in physical function ( for example:
inability to perform activities of daily living or
new onset of incontinence, falling or failure to
cooperate in rehabilitation)
New onset of skin lesions (scabies infestation
in the institutionalized setting)
Clinical Manifestations of Infection in
Residents of Long-term Care Facilities
(continued)
Typical findings of infection
Atypical findings of infection
Afebrile (15 percent of bacteremic patients
who are elderly are afebrile)
Tachypnea (respiratory rate greater than 25
breaths/minute)
Dehydration (clinical observation coupled with
elevated laboratory assays, e.g. BUN)
Case Reports of Atypical Presentation of Illness
in Older Adults

Case reports of atypical presentation of illnesss among older adults,
particularly those of advanced age are very common, spanning from
diseases afflicting the central nervous system to the gastrointestinal and
cardiovascular systems

Pain is often an acute heralding feature associated with the onset of many
diseases in younger adults, but the same can’t be said of pain presentation
with diseases in older adults
Case Report
Gastrointestinal ulcer or reflux disease, myocardial infarction or a
urinary tract infection generally present with pain among younger
adults. These same diseases do not however, necessarily present
with pain in older adults
Case Reports of Atypical Presentation of Illness
in Older Adults
Case Reports
Older adults with acid-related diseases of the gastrointestinal tract due to
medications, peptic ulcer disease or gastro-intestinal reflux disease
[GERD], pain reported was subtle, atypical or absent
Older adult women with coronary heart disease, atypical symptoms were
present during the infarction; and for these women a delay in diagnosis
occurred
Myocardial infarction in older adults, particularly those of advanced old
age can include vague and non-specific symptoms such as minimal or no
chest pain, no shortness of breath or acute confusion
Case Reports of Atypical Presentation of Illness
in Older Adults

Change of behavior or function is an early marker of an underlying health
problem or serious condition in an older adult
Case Reports
73 year-old man with dementia and behavioral difficulty including anxiety and agitation
were wrongly attributed to dementia
When treated with medications for this “behavioral” problem, the agitation was found to
be associated with physiological blood pressure change and surges of catecholamine, later
diagnosed as a pheochromocytoma
Note: Behavioral agitation and anxiety of a new onset and duration was a symptom
indicating a potential problem. The physical sign of escalation of blood pressure correlated
with this symptom of behavioral agitation to further confirm that something other
dementia was occurring.
Atypical Presentation of Illness: Patients at
Greatest Risk
Older adults:
 Over age 85
 With multiple comorbidities; the "frail" elderly
 On multiple medications
 With cognitive or functional impairment
IMPORTANT
Atypical Presentation:
Diagnosis
 Diagnosis of atypical presentation is contingent on:
1. Knowledge as to it's prevalence among older adults
2. A problem- focused history
3. A focused physical examination
4. Critical analysis and heightened awareness of the
possibility for any given older patient
Problem-Focused Hx & PE

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The APRN Hx and PE should actively assess for “tell tale
signs” that may be part of an atypical presentation
These include changes in behavior such as restlessness or
agitation, anxiety or changes in cognition
Note that physical findings such as fever or leukocytosis
are often absent or modified in atypical presentation
Atypical Presentation: Diagnosis
APRN Actions
• Assess for pain and delirium using standardized, validated scales.
• Order frequent vital signs and core or rectal temperature to
determine the presence of hypothermia related to bacteremia
• Initiate strict I & O, assess oral mucosa for dehydration; check serum
electrolytes, BUN/ creatinine & CBC
•Calculate the glomerular filtration rate;a djust medications &
fluids according ly
• Order chest Xray & urinalysis
Atypical Presentation: A Systems
Approach
 Facility level protocols to identify atypical presentation
can assist in the step-by-step approach to interventions
 Protocols should reflect immediate, interim, and followup actions, whereby interventions are prioritized
according to the medical stability of the patient
 Clinical practice guidelines can be useful in managing
older adults thought to be presenting atypically,
provided that they specifically address this issue
Conclusion

When APRNs caring for older adults routinely detect and act
upon important signs and symptoms associated with atypical
presentation of illness, important health outcomes can be
realized.