4414Fever in the Elderly
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Transcript of 4414Fever in the Elderly
Fever in the Elderly :How to surmount
The unique diagnostic and therapeutic challenges
• Emergency medicine practice
• October 1999 vol 1, number 5
Definition of elderly • Medical researchers consider elderly > 64yrs
old.• Fever is common compliant. • Elder visited to ES , about 10 % have a fever.• Among,70-90% will be admitted,7-10% will die
within one month .• Fever in elderly should be regarded with
concern. It presence usually presages serious disease.
• Fever in Younger patients, a benign viral syndrome.
• Fever in the elderly is associated with bacterial disease.
Pathophysiology of the development of fever
• Leukocytes was stimulated by infection , toxins, drugs, immune complexes, neoplasm.
• Cytokines release:IL-6, IL-1 ,TNF• Stimulate hypothalamus release PG-E • Affects:vasomotor centers heat production
behavior changes heat conservation
sympathetic nerves heat production
• Elderly people often have a lower baseline temperature
• In addition to the blunted fever response , makes an elderly patient less likely to reach a temperature traditionally considered a fever.
• Older patient are more likely to develope infection than younger adults
• Increased susceptibility is multifactorial • 1) Fragile skin with decreased vasculature and l
ess subcutaneous tissue contributes to slower wound healing and increased risk for skin infection.
• 2) less vigorous cough and decreased mucocillary clearance may predispose to pneumonia, particularly in COPD
• 3) DM , malignancies can diminish the immune response
• 4) Impairments in cell mediated immunity also contribute to increased infection rates.
Definition of fever
• Temperature >101F(38.3C)
sensitivity 40%
specificity 99.7%
If lowering the fever criteria to 99F(37.2C)
sensitivity 83%
specificity 89%
Clinical pathway: Evaluation of fever in the elderly patient
• Fever in elderly patient:
1. Rise of 2 F(1.1C) above baseline
2. Oral temperature of 99 F(37.2 C)
3. Rectal temperature of 99.5 F(37.5C)
• If fever defined as 101F(38.3C), a significant no of elderly have no fever with infection but they have a rise of 2.4F(1.3C)
• If change in temp of at least 2 F from baseline in elderly, indicate a serious underlying infection
Fever in edelderly patient : 1.Rise of 2C above baseline 2.Oral temp of 99F(37.2C)
3.Rectal temp of 99.5F(37.5C)
Temperature >41C
Complete history and physical with review of medical records and
additional information from any caretakers
Hyperthermia,Consider infection,
environmental Exposure
neruoleptic malignant syndrome
If Temp > 41C • Hyperthermia 1 Consider infection 2 Non –infectious life –threateni
ng cause of fever in the elderly a) Environment exposure heat stroke b) Drugs induced Salicylism c) Neuroleptic malignant syn
drome
• Large amount of life threatening fevers in elderly was caused by infection
• But have three condition that are not caused by infection
• Include 1 heat stroke , 2 salicylism, 3 neuroleptic malignant syndrome
• Thyroid storm and sympathomimetic overdose are also occasional causes of the threatening hyperpyrexia
• All of these conditions usually have fever over 103F and altered mental status
• But sepsis and meningitis are more common
• For these reason , aggressive antibiotics was also used while investigating possible non-infectious etiologies
Heats stroke
• Patient’s thermoregulatory mechanisms are unable to adequately respond to heat stress.
• Increase in body temperature leading to organ dysfunction and failure
• Temp usually excess of 41C (106F)• Classic heatstroke, precipitants include exposure to high
ambient temperature, • patient with a preexisting disease ( coronary artery dise
ase , diabetes, alcohol , and obesity )or medication ( phenothiazines, anticholinergics, sedatives, diuretics) that limits thermoregulation
Heat stroke S/S Symptoms• Fever• Altered mental status
(agitation, confusion)• Headache • Dizziness• Weakness• Anorexia • Stupor
Sign• Hyperthermia • Altered mental status (coma , s
tupor, agitation)• Hot, dry skin ( not universal )• Neurological deficits in severe
cases• Oliguria ( may be sign of rhabd
omyolysis in exertional heat stroke)
• Hypotension• ECC changes• Disseminated intravascular co
agulation(DIC)
Work up of stroke
• Rule out other cause of elevated temp (culture , and LP when indicated)
• Urinalysis , CPK , creatinine to rule our rhabdomyoslysis
• Electrolytes• Elvaluate for multiorgan dysfunctin (eg, liver functio
n tests and chest x-ray• PT, PTT (anticipation of DIC)• ECG (may show ST depression,T wave changes)
Treatment of stroke • Rapid cooling with evaporative methods( water sprayed on disrobed
patient along with use of fans)• Cooling should exceed 0.1 to 0.2 C/min with aggressive treatment u
ntil temp reaches 39C(102F), do not overshoot.• Use continuous rectal probe monitoring• O2 • Antibiotics• Benzodiazepines for shivering • Aspirin or acetaminophen should not be given• If rhabdomyolysis is present, fluid should be alkalinized and furose
mide administered to keep urine output at 100 ml/hr.• IV are generally indicated but should be used with care to avoid pul
monary edema • Complication include cardiovascular dysfunction (including CHF ), D
IC acute renal failure , rhabdomyolysis , seizure , liver injury (very common) , ARDS, electrolyte disorders, and death.
Drug induced hyperthermiaDrugs that cause muscular hyperactivity• Amphetamines• Designer amphetamines• Monamine oxiddase inhibitors• Cocaine• Methaqualone • Lithium• Antipsychotics• Tricyclic antidepressants• Halothane, cocaine, succinylcholine (malignant hyperthermia)• Lysergic acid diethylamide(LSD)• Phencyclidine (PCP)• Strychnine• Isoniazid (INH)• Sympathomimetics (theophylline, ephedrine, pseudoephedrine)• Serotonin syndrome(MAOIS+SSRIs, TCAs. Meperidine, dextromethorphan ,tryptopha
n )
Drug induced hyperthermia
Drugs that cause hypermetabolism • Salicylate • Thryoid hormone • Dinitrophenol • Symmpathomimetics • Ethanol withdrawal • Sedative hypnotic withdrawalDrugs that impair thermoregulation• Ethanol • Antipsychotics (Phenothiazines)
Drug induced hyperthermia
Drugs theat impair heat dissipation
• Anticholinergics
• Skeletal muscle relaaxants
• Antipsychotics
• Sympathomimetics
Salcylates poisoning
Symptoms• Mild or early poisoning (1 to 12 hours after acute
ingestion): nausea , vomiting , abdominal pain , headache, tinnitus, dizziness , fatique
• Moderate or intermediate poisoning (12 to 24 hours after ingestion ): fever, sweating , deafness, lethargy, confusion , hallucinations, breathlessness
• Severe or late poisoning ( greater than 24 hours after acute ingestion or unrecognized, untreated chronic ingestion ): coma, seizures, fever
Salcylates poisoning
• Sign• Mild or early: lethargy , ataxia , mild agitation , h
yperpnea, mild abdominal tenderness• Moderate or intermediate: fever, asterixis, diaph
oresis, deafness, pallor, confusion , slurred speech, disorientation .agitation , hallucinations, tachycardia, tachypnea, orthostatic hypotension
• Sever or late : dehydration , coma , seizures, hypothermia or hyperthermia , tachycardia, hypotension, respiratory depression, pulmonary edema, arrhythmias , papilledema
Treatment of Salcylates poisoning
• Rapid cool patient• Alkalinize urine with D5W with 3 ampules of sodi
um bicarbonate begin drip at 150ml/hr and target urine pH of 7.5
• Monitor serum electrolytes• Consider dialysis for renal failure if persistent aci
demia , pulmonary edema , deterioration despite supportive care, or severe mental status changes or coma , in the aged with comorbid disease.
Neuroleptic malignant syndrome• Precipitants : neuroleptic drugs( phenothiazines, butyrophenones, th
ioxanthenes)Symptoms• Elevated temp • Rigidity • Dyspnea• Tremor • Urinary incontinence • Dysphagia• Diaphoresis• Drowsiness• Confusion• Agitation
Neuroleptic malignant signs
• Elevated temperature (usually 38.5 to 42C)• Rigidity (classic lead pipe, which may be localized,
trismus, masked facies and dyskinesia)• Altered level of consciousness (from confusion and
agitation to lethargy , stupor, coma and mutism)• Autonomic dysfunction (tachycardia ,labile blood pr
essure , diaphoresis , tachypnea , hyperreflexia , pallor and dysrhythmias cardiac arrest)
Neuroleptic malignant Workup
• Diagnosis is established clinically and by exclusion
• Urinalysis (check for myoglobinuria) and creatinine phosphokinase to rule out rhabdomyolysis.
• BUN , Cr, LFTs , electrolytes, CA and Mg.
• Drugs level are typically normal.
Treatment of Neuroleptic malignant
• If infection is suspected, antibiotic administration is reasonable pending culture results
• Treatment is focused on the alleviation of symptoms and prevention of complication and consists of hydration, fever reduction , benzodiazepine sedation, and maintenance of appropriate fluid and electrolyte balance.
• Dantrolene sodium 2.5mg/kg/d iv , maxiumumof 10mg/kg/d (if muscle relaxation required)
• Some authorities bromocriptine 2.5mg -10mg po q8h ,• Benzodiazepines for muscle rigidity.• Amantadine 100mg bid (preferred for NMS in Parkinsons dis
ease)
Differential diagnosis• . • The predominant cause of fever in elderly,PUS have respiratory , urinary tract, and soft tissue infectious.• Bacteremia and sepsis had 40% occurred in elderly and estimated 6
0% will be deaths • Gangrene of the appendix and gallbladder are more common in eld
erly • 60% of tetanus and majority of shingles occur in the elderly.
Infection
• Endocarditis
• Pneumonia • Bacterial meningitis • Sepsis • Cholecystitis • Urinary tract infection • Tuberculosis• Appendicitis
Relative Mortality when compared with young adults
• 2-3x• 3x• 3x• 3x• 2-8x• 5-10x• 10x• 15-20x
If infectious diagnosis is missed, will increase mortality in the older adult
Differential diagnosis• If infectious diagnosis is missed, will increase mortality in
the older adult. • The predominant cause of fever in elderly, PUS have respiratory , urinary tract, and soft tissue infectious.• Bacteremia and sepsis had 40% occurred in elderly and
estimated 60% will be deaths • Gangrene of the appendix and gallbladder are more com
mon in elderly • 60% of tetanus and majority of shingles occur in the elde
rly.
Final diagnoses of febrile Elderly presenting to ED
Infection 89.4 %• Respiratory tract infections 31.5 % pneumonia 24.9% bronchitis 6.0% pharyngitis /Sinusitis . 1.3% • Urinary tract infection 21.7%• Skin /soft tissue infection 5.3 %• Bacteremia/sepsis 17.7%• Cholecystitis /Biliary tract 3.0 %• Diverticulitis /Abscess 2.3 % • Colitis/Enteritis 2.3 % • Meningits /Encephalitis 1.1 %• Osteomyelitis 1.1 % • Appendicitis 0.6 % • Epididymitis/Prostatitis 0.6 %• Viral syndrome 2.6 %Noninfectious 10.4%Diagnosis Unknown 5.7%
ED evaluation
• Ask family members or caretakers about recent falls, anorexia, decreased activity, new incontinence, or confusion
• elderly behavioral change ---hint of an underlying infection
• At least 75% of all episodes of functioal decline in elderly are due to infection
Historical clues to infections in the elderly
• Acute confusion or delirium• Change in functional status • Change in behavior• Anorexia• Weight loss• weakness • Lethargy • Recurrent falls• New urinary incontinence
Fever of unknown origin UFO
• UFO is defined as temp >38.3C , lasting longer than three wks without a diagnosis after one wks of hospital investigation
Diagnosis of UFO in the elderlyGeneral class ification Specific causes % subtotal
Infection Intraabdominal abscess 12%
Tuberculosis 6 %
Infective endocarditis 10%
orther 7%
Collagen vascular diseases Temporal arteritis 19%
Polyarteritis nodosa 6%
Orther 3%
Neoplasms Primary tumors lymphomas /hematologic cancerDegenerative CNS disorder
9%
Neurologic Degenerative CNS disorder 10%
Hemolytic cardiopulmonary Hemolytic disease
thrombophlebitis
Gastrointestinal Inflammatory bowel disease
Alcoholic hepatitis /cirrhosis
Granuloma hepatitis
Rheumatologic endocrine Stills disease
Pheochromocytoma
Hyperthyroid
Pharmacological psychogenic Drugs fever
Factitious
unknown 9%
Toxicity ?Unstable vital signs?Acute change in mental status?
1.Order the following :chest x-ray , urinalysis and urine culture, and blood culture .Evaluate need for LP 2 Administer stat broad –spectrum Antibiotics. If no obvious source, Consider: third –generation cephalosporin plus aminoglycoside or imipenem.3 Admit the patient
YES --
Source for fever?PneumoniaUTISoft-tissue infection Meningitis
No
S/S of pneumonia in Elderly patients
• > 65% absent fever
• > 65% Change in mental status
• 10 % recent falls
• > 50 % lack cough, sputum
• Likewise ,less to have classic symptoms of weight loss , night sweats and hemoptysis
PE of pneumonia
• Elderly with pneumonia (about 26-75%) had Tachypnea>30 breath /min
• A fast RR may precede other clinical findings of pneumonia by as much as 3 or 4 days.
• Pulse oximetry
• Presence of crakles
pneumonia
• One study, 75 yr old elderly with chest complaints or fever, >80 % had chest x-ray finding.
• Other study,¼ elderly patients had acute confusion with pneumonia patch in chest x-ray.
• Despite elderly had pneumonia, acutely ill and dehydrated patient may lack a characteristic infiltrate.
• On the other hand, COPD ,and CHF may obscure x-ray finding
pneumonia
• WBC : WBC increase , indicate infection WBC decrease , indicate worse prognosis• Sputum culture: Gram’s stain may help in diagnosis. Not recommended unless TB or fungus suspected, does not assist EP in making diagnosis• Blood culture: 28% pneumonia cases will be positive does not assist EP in making diagnosis
Urinary tract infection
• Dysuria , urgency , frequency , fever, chills , nausea, flank and costovertebral pain may be attenuated or even absent.
• Instead altered mental status , vomiting abdominal tenderness, respiratory distress
s/s Of Pyelonephritis In Elderly patients
Sign/Symptom• Gastrointestinal symptoms• Pulmonary symptoms• Constitutional symptoms• Costovertebral angle tenderness• Irritative voiding symptoms
Frequency
11%
14%
20%
50%
54%
Urinary tract infection
• Fever• Chills• Nausea• Flank and costovertebral pain • Altered mental status • Vomiting • Abdominal tenderness• Respiratory distress• rales
PE of Genitourinary
• Costovertebral angle tenderness indicate Upper UTI • But less than half of the elderly with pyelonephritis had c
ostovertebral angle tenderness.• Suprapubic tenderness indicate cystitis• Prostatitis• Pain in the perineum , radiating to the thighs and penis, v
oiding urine is painful and the stream is thin , frequency of micturition , high fever.
• A rectal examination reveals tender, swollen gland. The urine may or may not grow pathogenic organisms on culture.
• Exam of the external genitalia may reveal redness, tenderness, or discharge.
Intra-abdominal infection in elderly
• Most common: appendicitis , cholecystitis and diverticulitis.
• Elderly usually lack of focal tenderness.• Even GI perforation , peritonitis can occur
without pain or fever. • Elderly with appendicitis, 60% death.• Complication such as Gangrene ,
perforation, abscesses, peritonitis, more than the younger.
PE of Intra-abdominal infection in elderly
• Abdominal tenderness is an important finding• Cholecystitis :74-84 % RUQ pain or
epigastric pain.• Appendicitis :most case had RLQ pain• Diverticulitis :2/3 case had LLQ pain • Elderly patients have no significant abdominal te
nderness with surgical emergency : 25% Cholecystitis , 34%appendicitis ,13-30% diverticulitis
Diagnostic abdominal infection
• CBC/DC
• LFT, amylase, lipase
• If cholecystitis , RUQ sonography is
considered.
Diverticulitis disease is generally made clinically , though complication such as obstruction and abscesses are best seen on CT