atypical presentation means

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Atypical Presentation

Diseases, particularly infections, often manifest with atypical features in older adults.  Signs and symptoms are frequently subtle in the very old.  These may initially involve nonspecific declines in functional or mental status, anorexia with reduced oral intake, incontinence, falls (Htwe et al., 2007), fatigue, (Hall, 2002), or exacerbation of chronic illness such as heart failure or diabetes (High, 2009).  

Assessment of the older patient should note any changes from baseline (including those that are subtle and nonspecific) in functioning, mental status and behavior (e.g., increased/new onset confusion), appetite, or exacerbation of chronic illness (High, 2009; Watters, 2002).  This is especially important in individuals with cognitive impairment who are unable to describe symptoms.

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
• 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

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

Amella, E. (2004). Aging changes: Effects on presentation of illness.  American Journal of Nursing.

Bischoff HA, et al. (2003). Identifying a cut-off point for normal mobility: a comparison of the timed 'up and go' test in community-dwelling and institutionalized elderly women.  Age Ageing;32 (3), pp. 315-20.

Blazer DG. (2003). Depression in late life: review and commentary.  Journal Gerontoogical A Biol Sci Med Sci;58 (3), pp. 249-65.

Ebersole P. Age-related changes. (2004). In: Ebersole P, et al., editors.  Toward healthy aging.  Human needs and nursing responses. Philadelphia: Mosby; pp. 79-108.

Fletcher, K. (2004). Geriatric emergencies part 1: Vulnerability and primary prevention. Topics in Advanced Practice Nursing, 4 (2), 1–3. Retrieved from https://www.medscape.com/viewarticle/477731. Evidence Level V.

Gurleyik G, Gurleyik E. (2003). Age-related clinical features in older patients with acute appendicitis.  Eur J Emerg Med.  Sep;10(3):200-3

Ham, R., Sloane,D. & Warshaw,G. (2002).  Primary Care Geriatrics: A Case Based Approach . pp 32-33.St Louis, MO:Mosby. Reprinted with permission from Elsevier.

Horgas A, McLennon S. (2004). Pain management. In: Ebersole P, et al., editors. Toward healthy aging.  Human needs and nursing responses. Philadelphia: Mosby; pp. 229-50

Flacker JM. (2003).What is a geriatric syndrome anyway?  Journal American Geriatrics Society;51(4) , pp. 574-6.

Fletcher, K., Forch, W. (1999). Acute symptom assessment. Determining the seriousness of the presentation.  Lippincott s Primary Care Practice, 3 , pp. 216-28.

Wilson, JF. (2004). Frailty and its dangerous effects might be preventable.  Annals of Internal Medicine, 21 , pp 489-92.

• Advance Directives
• Age Related Changes
• Assessing Cognition
• Catheter-Associated UTI Prevention
• Comprehensive Assessment and Management of the Critically Ill
• Elder Mistreatment (EM)
• Frailty and its Implications for Care
• Function-Focused Care (FFC) Interventions
• General Surgical Care
• Heart Failure (HF)
• Hydration Management
• Iatrogenesis
• Managing Patients with Hip Fracture
• Nutrition in Aging
• Optimize Mealtimes in Dementia
• Oral Healthcare
• Pain Management
• Perioperative Care
• Physical Restraints
• Pressure Injury (PI) Prevention
• Sensory Changes
• Skin Tear Prevention
• Substance Misuse and Alcohol Use Disorders
• Urinary Incontinence
• Expressing suicidal thoughts
• Frequent physical complaints
• Multiple medications
• Pulling out tubes
• Refusing to eat/drink
• Sleep problems
• Sudden change in function
• Unable to control stool
• Unable to control urine

More Information

• Elder Mistreatment Assessment
• Alcohol Use Screening and Assessment for Older Adults
• Assessing and Managing Delirium in Persons with Dementia
• Assessing Nutrition in Older Adults
• Assessing Pain in Older Adults with Dementia
• Assessment of Fear of Falling in Older Adults: The Falls Efficacy Scale-International (FES-I)
• Assessment of Nociceptive versus Neuropathic Pain in Older Adults
• Avoiding Restraints in Patients with Dementia
• Brief Evaluation of Executive Dysfunction: An Essential Refinement in the Assessment of Cognitive Impairment
• Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia
• Changing the Landscape of Health and Healthcare Equity
• Integrating the Geriatric Surgery Verification (GSV) Program with the 4Ms: Discharge Case Study
• APRN Case Study: Management of Urinary Incontinence
• APRN Case Study: Medications and Adverse Outcomes in Older Adults
• Behavioral Health in Primary Care (BHPC) Series
• Care of Older Adults in Long-Term Care: HHA/CNA Series
• Care of Older Adults in Long-Term Care: PCP Series
• Care of Older Adults in Long-Term Care: RN/IP Series
• Care of Older Adults in Rural America (COA-RA) Series
• Care of Older Adults in the Long-Term Care Setting (COA-LTC) Series

Atypical Presentations of Critical Illness in Older Adults

Authors: Kimberly Bambach, MD, Katherine Buck, MD

Edited By:  Angel Li, MD, Shan W. Liu MD, SD

Updated:  August 16, 2021

An 88 year old female with a history of hypertension, GERD, and gastritis presents with abdominal pain and fatigue for the past three days. Her abdominal pain is “everywhere” and does not feel more prominent in a specific region. She denies fever, but endorses chills and generalized weakness. She reports poor appetite over the past three days with persistent nausea but no vomiting or diarrhea. She has never had similar symptoms before and has no history of prior abdominal surgeries. Vital signs are as follows: HR 90, BP 98/53, T 97.5° F, RR 18, SpO2 99% on room air. On examination, she appears uncomfortable. Her abdomen is soft with diffuse mild abdominal tenderness to palpation but no rebound tenderness or guarding. The remainder of her examination is normal.

30 minutes after you have evaluated the patient, the nurse calls you to inform you that her blood pressure is now 80/49.

By the end of this module, the student will be able to: 

• Appreciate that critical diagnoses often present atypically in older adults
• Describe factors affecting emergency care of older adults including physiologic changes of aging, medication effects, intrinsic factors, and social factors
• Discuss the hallmarks and limitations of history and physical exam in the evaluation of older adults with critical illness
• Recognize signs and symptoms of sepsis in older adults
• Create a broad differential for older adults presenting to the Emergency Department with atypical chest pain and abdominal pain
• Provide a rationale for labs and imaging choices in older adults with vague symptoms

Introduction

Older adults, defined as age 65 and older, often present to the Emergency Department (ED) with disease processes that confer high morbidity and mortality. However, identifying critical pathology is challenging and requires a high index of suspicion. Signs of critical illness in older adults may be subtle or atypical, meaning that their presentation often deviates from typical “illness scripts”, which represent the patterns in history or physical exam associated with a specific disease process.  Atypical presentations occur for many reasons, including the physiological changes of aging, medication effects, and factors that limit history or physical exam (Table 1). 

Typical findings in geriatric patients, such as fever or leukocytosis, may be absent due to immunosenescence, an age-related decline in immunity. Pain perception may be altered due to age related changes in the nervous system. For this reason, peritoneal signs in the acute abdomen may be absent. Polypharmacy or medication effects can also blunt or mask physiologic responses to illness or place patients at risk for adverse effects. It is also important to consider how multiple comorbidities and lack of physiologic reserve increase diagnostic complexity. Older adults may also have cognitive decline or limited social support that limit the history of the present illness or exacerbate the underlying illness.

Table 1: Factors contributing to atypical presentations in older adults

Initial actions and primary survey.

Evaluation of older adults in the ED begins with evaluation of the ABCs. Evaluate the patient for signs of aspiration or airway obstruction, inadequate respirations, and poor perfusion which indicate critical illness. This helps to establish if the patient is “sick” or “not sick”. 

Critically ill patients require rapid intervention before proceeding with the history. Initial actions include establishing IV access (two large bore IVs if hemodynamically unstable), administering supplemental O2 if hypoxic, and placing the patient on the monitor. Obtain a STAT point of care glucose in any patient with altered mental status, as hypoglycemia is a common cause of encephalopathy. A STAT ECG in a patient with vague symptoms or a patient who is ill appearing can indicate myocardial ischemia or arrhythmia.

Atypical Presentations

Older adults with high-risk pathology may have chief complaints that are vague and they may under report symptoms. Patients often describe malaise- they just “don’t feel right”. Sepsis, for example, may present with a chief complaint of fatigue, anorexia, weakness, or confusion rather than fever or a localizing symptom. For example, sepsis due to a urinary tract infection often presents as altered mental status in older adults. In a patient with an acute surgical abdomen due to appendicitis, abdominal pain may be diffuse rather than localized to the right lower quadrant or periumbilical regions. A patient with a STEMI may not have chest pain at all and may simply feel tired, nauseated, or have isolated jaw, arm, shoulder, or abdominal pain. For this reason, it is important to maintain a high index of suspicion for critical illness. 

Falls are also a common presentation for ill geriatric patients and the patient may require a trauma assessment. However, it is important to consider medical illness as well and explore why the patient may have fallen. How was the patient feeling prior to the fall? Was the fall mechanical or due to another process such as syncope? 

It is important to elucidate the patient’s baseline functioning when obtaining a history. Understanding the patient’s ability to perform the activities of daily living (ADLs) can aid with diagnosis and management and give context to their ED presentation. One tool that can aid in elucidating important components of the patient’s history is the 4Ms Framework of an Age Friendly Health System: Mobility, Medications, Mentation, and what Matters. Has there been a decline in mobility? Was a new medication started for the patient recently or were they experiencing adverse effects of a medication? Is the patient’s cognition at baseline? What are their goals of care and what matters most for their quality of life? Asking these questions can provide important clues that aid with diagnosis and management. 

History should include information from collateral sources, particularly if the patient is cognitively impaired. EMS providers can provide important history including history regarding the patient’s home environment. If the patient presents from a care facility and no representative is available in the ED, documentation and history is often sparse. It is important to call the sending facility to obtain additional information. The patient’s family or support persons are also a valuable source of medical history. They can also provide important information on the patients goals of care. 

As symptoms are often vague, a thorough physical exam is crucial. The patient should be completely undressed to avoid missing important physical exam findings. In a patient with symptoms or signs concerning for sepsis, for example, it is important to completely undress them to visualize the skin for a potential source as decubitus ulcers, foot ulcers, and signs of GU infection are often missed.

Differential Diagnosis

Considering a broad differential diagnosis is critical in the care of older adult patients. Table 2 categorizes the broad range of symptoms that may be indicative of an acute coronary syndrome. Female patients in particular are more likely to present with atypical symptoms other than chest pain, and this can lead to a delay in diagnosis and appropriate care. Atypical symptoms are a significant independent risk factor for in-hospital mortality.

Table 2: Atypical symptoms of acute coronary syndromes

For patients with abdominal pain, consider both intra and extra-abdominal causes including chest pathology. Referred pain from the chest, genitourinary system, and hips can cause abdominal pain. Older adult patients are at high risk for vascular pathology such as aortic dissection or acute myocardial infarction due to atherosclerosis. Infectious, obstructive, and metabolic etiologies are also important considerations. Table 3 contains a broad differential diagnosis for the geriatric patient with diffuse abdominal pain.

Table 3: Differential Diagnosis for Diffuse Abdominal Pain

Diagnostic testing.

Diagnostic testing should be guided by the patient’s history and physical examination findings, but it is wise to cast a wider net with diagnostic testing when symptoms are vague or atypical. 

Initial evaluation for abdominal pain or infectious symptoms includes:

• Complete blood count with differential
• Complete metabolic panel
• Urine analysis
• Blood cultures

In older adults with chest pain, initial evaluation includes:

• Basic metabolic panel
• Consider D-dimer based on risk stratification tools such as Wells score and clinical gestalt

Point of care ultrasound is a very useful modality for detecting life threats. A FAST (focused assessment with sonography in trauma) exam evaluating for free fluid in the pericardial, peritoneal, and pelvic spaces can rapidly identify internal hemorrhage. The chest can be interrogated with cardiac and IVC windows to assess volume status and provide an estimate of cardiac function. Pulmonary views can also detect pneumothorax, pleural effusions, or pneumonia. 

A STAT chest X-ray can also be obtained to evaluate for free air under the diaphragm in the older adult with abdominal pain. 

The decision to obtain CT imaging is always a risk/benefit analysis. There should be a low threshold to obtain CT imaging in older adults because the risk of radiation-induced malignancy in their lifetime is low and the risk of acute life threatening pathology is high.

Medications

When there is concern for infection or sepsis, initiating antibiotics early can improve clinical outcomes. Older adults are particularly vulnerable to adverse effects of medications including antibiotics. Fluoroquinolones, for example, can precipitate delirium, tendinopathy, QT prolongation, and increased risk of aortic pathology and should be reserved for when other antibiotic choices are contraindicated. It is also important to consider how any medications may interact with the patient’s home regimen, such as warfarin. It is important to adequately treat the patient’s pain as well. Geriatric patients are particularly vulnerable to sedation and respiratory depression caused by opioid analgesics due to changes in pharmacokinetics associated with aging and polypharmacy, so reduction in dosing along with frequent reassessment should be considered. 

Specialty Consultation

Laboratory tests and imaging findings help determine which specialty service consultations are indicated.  For example, consultation with General Surgery is indicated in patients with peritoneal signs on exam (rigidity, rebound tenderness, or guarding) or acute surgical findings on CT such as a perforated viscus or appendicitis. Patients who are critically ill or unstable will likely require medical or surgical ICU admission. Social workers and case managers are instrumental in assisting with social aspects of the patient’s care and discharge planning. In critically ill patients who wish to pursue comfort care or a hospice model of care, palliative care consultation can help navigate the patients goals and disposition.

 Pearls and Pitfalls

• Critical illness often presents atypically in older adults: maintain a high index of suspicion for the critical pathology in the older adult with vague symptoms.
• Peritoneal signs are often absent in the geriatric acute abdomen due to decreased pain perception.
• Fever and leukocytosis are often absent in patients with acute infection due to immunosenescence. 
• A broad differential diagnosis is necessary in older adults due to lack of localizing symptoms.
• Acute coronary syndromes may present without chest pain, particularly in older adults and female patients.
• Check the patient’s medication list for beta blockers that blunt tachycardia or other medications that may mask symptoms.
• Obtain collateral history to guide next steps in management.
• Establish the patient’s goals of care.
• Have a low threshold for labs and CT imaging. In geriatric patients with acute abdominal pain, CT is the modality of choice. 
• Manage and treat pain when appropriate, while being mindful of dose and drug interactions.

Case Study Resolution

The patient is resuscitated with IV fluids with improvement in her blood pressure and broad spectrum antibiotics are initiated. Labs are notable for an elevated lactate of 6.0 mmol/L. STAT chest X-ray demonstrates free air under the diaphragm. Once the patient has been stabilized, a CT of the abdomen and pelvis is obtained that demonstrates perforated diverticulitis. General surgery is consulted and the patient is taken to the OR emergently. After her hospital admission, the patient is able to return to her assisted living facility with physical therapy support.

• Perissinotto CM, Ritchie C. Atypical Presentations of Illness in Older Adults. In: Williams BA, Chang A, Ahalt C, Chen H, Conant R, Landefeld C, Ritchie C, Yukawa M. eds. Current Diagnosis & Treatment: Geriatrics, Second Edition. McGraw Hill
• Ragsdale, L. and Southerland, L., 2011. Acute Abdominal Pain in the Older Adult. Emergency Medicine Clinics of North America, 29(2), pp.429-448.
• Brieger D, Eagle K, Goodman S, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126(2):461-469.
• El-Menyar A, Zubaid M, Sulaiman K, et al. Atypical presentation of acute coronary syndrome: a significant independent predictor of in-hospital mortality. J Cardiol. 2011;57(2):165-171.
• Canto J, Rogers W, Goldberg R, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813-822.
• Institute of Healthcare Improvement . (2019). Age-friendly health systems: Guide to using the 4Ms in the care of older adults. Retrieved August 10th 2021, from www.ihi.org/Engage/Initiatives/Age-Friendly-Health-systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf .

EP: 67 – Atypical Presentation of Illness in Older Adults

Atypical Presentation of Illness is when an older adult has an illness or condition that doesn’t show up in the typical textbook definition/ways. – Jamie Smith, MSN, FNP

“Mrs. Jones just isn’t ‘right’ today” . Subtle, non-specific changes in an older adult may be the first sign that family members and caregivers see when an older adult is developing an illness. In today’s episode, we will talk about how changes in mental status (hypo- and hyperactive delirium) can be the first sign of an infection, how some infections are show up differently for younger and older adults (e.g., bladder infections), and how depression shows up differently for younger and older adults.

Jamie Smith MSN, FNP, in this episode of This Is Getting Old: Moving Towards an Age-Friendly World, highlights some salient points on how to recognize atypical presentations of illness among older adults.

Part One Of ‘Atypical Presentation Of Illness In Older Adults’

What Is Atypical Presentation Of Illness?  

Conventional healthcare education teaches the typical symptoms of common illnesses. However, for older adults, these common illnesses do not show up in the same way. The symptoms are usually more subtle and less specific than in younger adults and often are first noticed as a change in mental status, energy level or function (such as a fall or a new onset of losing control of their bladder (incontinence)).

Atypical Presentation of Illness means that an older adult will have little or no typical signs and symptoms that usually indicate a specific illness or diagnosis.  Failure to investigate atypical presentations in older patients, and identify the true medical problem, may result in undesirable outcomes, inaccurate diagnoses, and the wrong treatment for the illness.

Delirium is one way an illness may show up (or “present”) and has been attributed to adverse health outcomes.

The Seriousness Of Deliriousness: Delirium In Older Adults

What is Delirium?

Delirium usually develops quickly in a matter of hours or days. Thus, healthcare providers should be well aware of the signs and symptoms of delirium. Doing so may help them recognize atypical presentations of illness and at best help curtail severe medical conditions.

Delirium is characterized by a sudden change in attention, awareness, and cognition. Delirium may be hypoactive (meaning the person may be more tired or sleepy than usual but the changes in behavior are more subtle) or hyperactive (meaning the person is trying to crawl out of bed or some other active, agitated behavior).

Accurately diagnosing delirium in a patient population prone to dementia, depression, fatigue, and other conditions whose symptoms can mirror those of delirium can be challenging. It is estimated that between 32-66% of delirium cases are missed by healthcare professionals.

This failure to diagnose delirium has two significant consequences for patients.

• First, the patient is presumed to have a condition, often dementia, that they do not have, which leads to false assumptions about prognosis and the possible ordering of inappropriate treatments.
• Second, and of equal importance, missing the diagnosis of delirium may cause clinicians to fail to investigate its underlying medical causes.

Delirium may indicate a life-threatening condition. It carries an increased risk of functional decline and falls, cognitive decline, recurrent hospitalizations, and mortality. In addition, it can take months to clear, and some older adults may never regain their prior functional level.

What does Hypoactive Delirium look like?

Symptoms Of Hypoactive Delirium

Hypoactive delirium is often missed because it doesn’t create a problem for others – basically, this type of delirium is characterized by reduced motor activity, sluggishness, seeming to be in a daze, lack of interest in anything,  and reduced alertness. Symptoms in older adults include:

• The person “isn’t right” – a sudden change in thinking/ mental status, tired (lethargic), staying in bed.
• May or may not have a fever
• Change in baseline vital signs (heart rate, weight loss, change in appetite)

Things that can cause hypoactive delirium include:

• Constipation
• or an underlying infection

Symptoms Of Hyperactive Delirium:

Hyperactive delirium gets attention! This type of delirium is characterized by increased motor activity, wandering hyper alertness, rapid speech, irritability, and combativeness. Among older adults, common symptoms include:

• Behaviors are trying to get out of bed, fighting, fluctuating mental status.

Things to consider when trying to identify the underlying cause of either h

• W ater depletion (dehydration)
• L aboratory results which are abnormal (hyponatremia, WBCs)
• D rugs: delirium is sometimes the direct effect of medication (new medications, toxicity, adverse effects). With that, you can use Beers Criteria for Inappropriate Medication Use in Older Patients to check for polypharmacy.

Part Two Of ‘Atypical Presentation of Illness in Older Adults’

Examples Of How Infections Present Differently …

Younger Adults:   Usually have the textbook or typical symptoms for pneumonia such as fever, cough, having trouble breathing (shortness of breath), and their vital signs will be different.

Older Adults: The onset of pneumonia in older adults usually starts when “she’s not right”. There may be a sudden incontinence, they may be unusually tired, and/or they may falls. You often will NOT see a fever.  They may or may not have a cough, but hypoxia (low oxygen) and tachycardia (heart rate over 100 beats per minutes) are expected.

URINARY TRACT INFECTIONS:

Younger Adults : With UTI, textbook symptoms are experiencing pain or burning with urination, having an abnormal frequency and urgency in urination, and/or flank pain. There may also be blood in the urine as analyzed on laboratory assessments—this isn’t usually visible with the naked eye.

Older Adults: A TUI in an older adult may show up as a sudden loss of bladder control and/or a change in mental status. They may be unusually tired or  may fall.

DEPRESSION:

Younger Adults:   Manifestations of depression among younger adults can be more easily diagnosed through their apparent behaviors.  They can be directly asked or may say they are depressed.

Older Adults: On the other hand, older adults may be less social and many have more stigma around mental health. Symptoms include changes in appetite, flat affect, weight loss or gain, change in functional status, pain without an identifiable underlying cause (e.g., pain due to a fall, injury). Medications may cause depression for older adults; or it can be situational, like a grief process or adjustment to living arrangements.

As health care providers, the best way to diagnose depression in an older adult is sitting with the older adult, engaging them in a conversation, and asking them if they’re “feeling sad or blue”.

With older adults, I have learned from speaking with my doctors and peers not just to come out and ask, are you depressed? Because a lot of times, they shut down when you ask him that question. So I sit down with them and  notice little cues that let me know that they’re depressed. –   Jamie Smith MSN, FNP

About Jamie Smith MSN, FNP

Jamie Smith MSN, FNP, is the author of Geriatric Notes. This pocket guide has been recommended and adopted into several nursing programs across the US and won the 3rd place award with the American Journal of Nursing in 2019 (under Gerontologic Nursing). She is a full-time practicing NP in long-term care, trains new clinicians, precepts NP students, and is the Director of Education at Premier Geriatric Solutions.

Geriatric Notes by Jamie Smith MSN, FNP: The Story Behind A Very Helpful Book

Jamie worked five years as a nurse. But she was a geriatric nurse first before becoming a nurse practitioner. New to the profession, she was utterly overwhelmed. So to help cut back on her stress, she ended up carrying a book around—some textbooks like Hazard’s Geriatric Medicine, which is a great source. She knew after a while that she couldn’t keep toting around bulky and massive resources with her.

Consequently, Jamie started making notes of good stuff that the textbooks pointed out that she would need to quit, especially when she’s seeing 20 or 30 patients a day. She wanted to see what she wanted to have handy. So she took everything that she wrote down off to the side and turned it around, made it into a pocket and got it published. Jamie was glad it worked out the way it did because universities across the United States are using it for their students and employees.

Jamie’s book is available here:

https://checkout.jblearning.com/cart/Default.aspx?ref=jblearning **Use the Code: GERIATRIC to save 20% plus free shipping.

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About Melissa:

Melissa Batchelor, PhD, RN, FNP, FGSA, FAAN. I am a nurse, nurse practitioner, nurse educator and nurse researcher with over 25 years of experience in the aging and long-term care healthcare space. You can visit my website at MelissaBPhD.com to learn more about me, how you can work with me directly, and/or support future episodes of the podcast. Within the first 18 months of launching this podcast, we reached a ranking of top 10% globally. I have all of you who’ve been with me on this journey so far to thank for that!

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What Is Atypical Depression?

• What is Atypical Depression?

Atypical depression is considered a type of depression with a “specifier.” Specifiers are additional symptoms or traits that are included in an umbrella diagnosis under disorders such as clinical depression —also called major depressive disorder. Specifiers help to further clarify the specifics of a diagnosis and may suggest certain therapeutic approaches.

Therefore, atypical depression is a specific type of presentation of major depressive disorder. It can also be associated with other mood disorders such as bipolar disorder (a condition involving extreme mood disturbances) or dysthymia , now known as persistent depressive disorder (a chronic, mild to severe depressed mood). So, what is the difference between an atypical depression and one that is not? What causes atypical depression and what type of treatment works best? 

miodrag ignjatovic/Getty Images

What Is Atypical Depression? 

Clinical depression with atypical features (or atypical depression) is a term that defines people’s symptoms when they have symptoms that are not "typical" of a major depressive episode. Usually, depression causes a person to have difficulty sleeping and experience a loss of appetite. But not in those with atypical depression. Atypical features of clinical depression is a DSM specifier used for people who display unusual depressive symptoms such as:  

• Mood reactivity (a person's mood brightens in response to positive events)
• Significant weight gain
• Increase in appetite
• Hypersomnia (sleeping excessively)
• Leaden paralysis (a heavy, leaden feeling in arms or legs)
• A behavioral pattern of being highly sensitive to rejection in personal relationships

The DSM-V is a diagnostic manual that sets the standards for what, exactly, constitutes a specific mental health diagnosis. According to the DSM-V, atypical depression is characterized by mood reactivity (mood brightening in response to positive events), along with two or more of the following symptoms:  

• Oversleeping
• Leaden paralysis (a feeling of extreme heaviness in the legs)
• Interpersonal rejection sensitivity (having a pattern of a long-standing fear of being rejected, which interferes with the ability to form new social connections)

There may also be other "typical" depressive symptoms present, including:

• Severe, ongoing sadness, or feeling hopeless
• Irritability or anxiety
• Loss of interest in hobbies and/or activities that were enjoyed in the past
• Trouble concentrating
• Memory problems
• Trouble making decisions
• Low energy level
• Suicidal thoughts or obsession with death or dying

A diagnosis of atypical depression may start with getting a physical exam, undergoing some lab tests (such as a test for thyroid dysfunction), and other diagnostic measures to ensure that your symptoms are not stemming from a physical illness. After which, you may be referred to a mental health professional. They will perform a thorough diagnostic evaluation, which usually includes:

A psychiatric evaluation: This includes many in-depth questions about your thoughts, feelings, and patterns of behavior; your answers will be compared to the criteria in the DSM-V that spells out which symptoms indicate a person has atypical depression.

A family history: This is to find out if you have any family members with atypical depression, particularly when it is linked with bipolar disorder. Bipolar disorder (sometimes called manic depressive disorder) in the family has been linked with atypical depression.

Atypical Depression and Mood Disorders

In addition to atypical depression being a specifier for major depressive disorder, it may also be a specifier for other mood disorders. The DSM-5 criteria for atypical depression indicates that atypical features may be a specifier for major depressive episodes when:  

• A major depressive episode is the most recent mood episode in bipolar (note bipolar disorder may involve extreme mood swings, including an extremely excitable, expansive or irritable mood called mania, often alternating with periods of depressive moods).
• Atypical features can be a specifier for persistent depressive disorder (dysthymia).

Incidence of Atypical Depression

According to Harvard Health, atypical features occur in approximately 20% of depressive episodes in people with mood disorders. The Harvard Health report goes on to explain that atypical features are two to three times more common in women than in men and that in general, depression is twice as common in women than it is in men. Depression with atypical features:

• Starts at an earlier age (some experts believe that atypical depression usually begins before age 20).
• Is chronic (long-term) and lasts longer than depression without atypical features
• Is more likely to occur in people with bipolar disorder and seasonal affective disorder (depression linked with specific seasons of the year)

The exact cause of atypical depression is unknown, but it has been linked with some factors. Atypical depression is known to:

• Begin earlier than other types of depression
• Have more of a chronic (long-term) course
• Have abnormal or impaired neurotransmitters (brain chemicals that work to transmit signals from one nerve cell to another)
• Be more likely when other family members have atypical depression (particularly when it is linked with bipolar disorder)

Risk Factors for Atypical Depression

Factors that may make a person more prone to having atypical depression include:

• Having a history of bipolar disorder
• Familial link to people with atypical depression, bipolar disorder or alcoholism
• Substance abuse (including alcohol or drug abuse)
• Trauma (particularly during childhood)
• Environmental stressors (such as living with a person who is abusive)
• Stressful events in life (such as the death of a loved one)

Interestingly, atypical depression was first identified as a diagnosis that was different from clinical depression because studies discovered that these individuals responded better to a specific type of antidepressant, called MAO inhibitors (compared to other types of antidepressants).  

Antidepressants are medications that help regulate brain chemistry. Atypical depression is said to respond very well to a category of antidepressant medications called monoamine oxidase inhibitors (MAOIs), and other antidepressants (such as serotonin reuptake inhibitors or SSRIs) may also be effective. In addition, atypical antipsychotics such as Vraylar (cariprazine) may be used with antidepressants for treatment.

Side Effects of Medication

Many drugs that treat mental health disorders have significant side effects. The common side effects of MAOI’s may include:

• Loss of appetite
• Diarrhea or constipation
• Lightheadedness
• Low blood pressure
• A reduced sex drive
• Muscle spasms
• Weight gain
• Trouble urinating
• Paresthesia (a tingling sensation in the skin)

Potentially serious or life-threatening interactions (such as a hypertensive crisis) can occur with MAOIs. It's important to keep a restricted diet when taking these medications in order to avoid tyramine, a substance found in certain foods (including some cheeses).

In addition, other medications that affect the neurotransmitter serotonin should be avoided, as a serious medical condition known as serotonin syndrome can occur.

The good news about side effects from antidepressants is that most often improve after you have taken the medication for a while. It’s important to discuss any side effects with the prescribing healthcare provider. Your healthcare provider may change your prescription if the side effects don’t subside in a timely manner.

Psychotherapy

Psychotherapy, also referred to as “talk therapy,” involves meeting with a mental health professional (such as a counselor or a therapist). Psychotherapy has been found to be highly effective in those with atypical depression.  

Treatment for atypical depression usually involves helping a person with the condition to learn better ways of coping, these may including:

• How to notice unhealthy thoughts or behaviors and how to make changes once these patterns are identified.
• How to cope with various problems by implementing problem-solving processes?
• How to deal with troubling relationships and experiences
• How to set (and attain) realistic goals?
• How to lessen depressive symptoms
• How to implement healthy lifestyle changes (such as quitting drugs or alcohol)  

A Word From Verywell

With an accurate diagnosis and proper treatment, most people can learn to live with atypical depression, and many get relief from their symptoms. If you have symptoms of atypical depression, be sure to talk to your primary healthcare provider; don’t be afraid to ask for a referral to a mental health professional to get a thorough evaluation/diagnostic assessment. This is the first step to being proactive about your mental health. 

Mental Help.net. An American Addiction Centers Resource. DSM Specifiers for Major Depression.

Quitkin FM. Depression with atypical features: diagnostic validity, prevalence, and treatment. Prim Care Companion J Clin Psychiatry. 2002;04(03):94-99. doi:10.4088/pcc.v04n0302

Lieber, A. Psycom. Atypical depression: An overview of depression with atypical features .

Singh T, Williams K. Atypical depression .  Psychiatry (Edgmont) . 2006;3(4):33-39.

Harvard Health. Atypical Depression.

Łojko D, Rybakowski JK. Atypical depression: current perspectives . Neuropsychiatr Dis Treat. 2017 Sep 20;13:2447-2456. doi: 10.2147/NDT.S147317

Cleveland Clinic. Atypical depression management and treatment .

By Sherry Christiansen Christiansen is a medical writer with a healthcare background. She has worked in the hospital setting and collaborated on Alzheimer's research.

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The association of typical and atypical symptoms with in-hospital mortality in older adults with COVID-19: a multicentre cohort study

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Note: *As collected on chart. IQR = interquartile range; SD = standard deviation.

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Note: Symptoms were adjusted for age (each 5-year increase), sex, clinical frailty scale, and total number of comorbidities using a multivariable model for each symptom. 95% CI = 95% confidence intervals.

Association of typical and atypical symptoms by age, frailty, place of residence, and comorbidities

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Definition of atypical

• exceptional
• extraordinaire
• extraordinary
• preternatural
• uncustomary

Examples of atypical in a Sentence

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'atypical.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

see typical

1845, in the meaning defined at sense 1

Phrases Containing atypical

• primary atypical pneumonia

Dictionary Entries Near atypical

A-type star

Cite this Entry

“Atypical.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/atypical. Accessed 3 Jun. 2024.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Atypical bacterial pneumonia.

Dustin R. Stamm ; Holly A. Stankewicz .

Affiliations

Last Update: July 31, 2023 .

• Continuing Education Activity

Pneumonia is a lower respiratory tract infection, specifically involving the pulmonary parenchyma. Viruses, fungi and bacteria can cause pneumonia. The severity of pneumonia can range from mild to life-threatening, with uncomplicated disease resolving with outpatient antibiotics and complicated cases progressing to septic shock, acute respiratory distress syndrome (ARDS) and death. It affects all age groups, accounts for over 2 million emergency visits annually, and is a leading cause of mortality in both adults and children. Atypical micro-organisms are known to cause a disproportionate disease burden in children and adolescents. This activity reviews the causes, presentation and diagnosis of atypical bacterial pneumonia and highlights the role of the interprofessional team in the management of these patients.

• Identify the bacteria known to cause atypical pneumonia.
• Review the presentation of a patient with atypical bacterial pneumonia.
• Outline the treatment and management options available for atypical bacterial pneumonia
• Explain the interprofessional team strategies for improving care coordination and communication regarding the management of patients with atypical pneumonia.
• Introduction

Pneumonia is a lower respiratory tract infection, specifically involving the pulmonary parenchyma. Viruses, fungi, and bacteria can cause pneumonia. The severity of pneumonia can range from mild to life-threatening, with uncomplicated disease resolving with outpatient antibiotics and complicated cases progressing to septic shock, acute respiratory distress syndrome (ARDS) and death. [1]  It affects all age groups, accounts for over 2 million emergency visits annually, and is a leading cause of mortality in both adults and children. Atypical micro-organisms are known to cause a disproportionate disease burden in children and adolescents. Atypical organisms are difficult to culture.  They present subacutely and with progressive constitutional symptoms. [2]

While streptococcus pneumonia accounts for about 70% of cases, the rest are caused by atypical organisms.

Pneumonia is acquired when a sufficient volume of a pathogenic organism bypasses the body’s cough and laryngeal reflexes and makes its way into the parenchyma. This can occur from being exposed to large volumes of pathogens in inspired air, increasingly virulent pathogen exposure, aspiration or impaired host defenses. Given the different environments in which one may acquire pneumonia, the diagnosis is often broadly classified into community-acquired or hospital-acquired. [1]  It may be further classified as viral, bacterial, or atypical bacteria based on the suspected pathogen requiring treatment.  Atypical pneumonia is acquired from various sources. There are a vast number of pathogens that are considered atypical, but the most commonly identified are mycoplasma pneumoniae which are associated with close living conditions like at school and military barracks, legionella from stagnant water sources, Chlamydophila pneumoniae, Coxiella brunette, and Francisella tularensis from various mammalian sources. [3]

Mycoplasma pneumoniae is responsible for the vast majority of atypical respiratory infections. However, only about 10% of patients who acquire mycoplasma will develop pneumonia. Mycoplasma pneumoniae infection tends to be more common with advancing age, especially the elderly. The infection can occur all year round and outbreaks in small communities is common (Eg schools, homes). The organism is transmitted from person to person and the infection usually spreads slowly. Once the organism is acquired, the symptoms may take 4-20 days to appear and include malaise, cough, myalgia and sore throat. The cough is often dry and worse at night. Most cases of Mycoplasma pneumoniae infection are mild and resolve on their own. Mycoplasma can also cause a variety of extrapulmonary symptoms like erythema nodosum, urticaria, erythema multiforme, aseptic meningitis, Guillain Barre syndrome, and cerebral ataxia. Individuals with preexisting lung disease may develop empyema, pneumothorax or even respiratory distress syndrome.

Chlamydia pneumoniae is also a common cause of infection of the lung. The organism is acquired after inhalation of contaminated aerosolized droplets. However, the incubation period is long and symptoms are usually mild. chlamydia pneumoniae infection is most common in elderly people. The infection presents with a sore throat, cough and a headache that can last for many weeks or months. The chest x-ray may show a mild infiltrative process. Death is rare but can occur in patients with comorbidities.

Legionella pneumoniae is the most pathogenic of the atypical bacteria that cause lung infection. Several serotypes exist and infection tends to occur in close quarters. Spread from other humans is rare; most cases are due to inhalation of the pathogen from water systems like humidors, whirlpools, respiratory therapy equipment, water faucets, and air conditioners. Places for water stagnates allows for the organism to proliferate. Individuals at risk for legionella may have diabetes, malignancy, renal or liver failure and may have had recent plumbing done in the home. Once acquired, the patient may present with altered mental status, cough, fever, and respiratory distress. At least 20-40% of patients develop diarrhea. Blood work may reveal leukocytosis and the sputum gram stain may show accumulation of inflammatory cells without any organism. Of the atypical organisms, legionella has a severe course and the illness can quickly become severe if not treated promptly. While extra pulmonary symtoms are rare, many patients develop severe respiratory distress often requiring mechanical ventilation.

• Epidemiology

It is estimated that 7% to 20% of community-acquired pneumonia is secondary to atypical bacterial microorganisms. Given their intra-cellular nature, they are not visible on gram stain and are difficult to culture [4] ; therefore, the true number of cases is unknown, but given similar treatments, specific etiology is often unnecessary. There is a preference for younger individuals, with age being the only reliable predictor in adults.

• Pathophysiology

When the inoculating organisms overwhelm the host defenses, it causes a proliferation of the infectious agent. The pathogen replicating initiates the host immune response, and further inflammation, alveolar irritation, and impairment occur. This leads to the following signs and symptoms; cough, sputum production, dyspnea, tachypnea, and hypoxia. [1]  Atypical infections result in less lobar consolidation. Therefore, patients do not usually appear toxic; hence the common term “walking pneumonia.”

Atypical organisms are an inclusive term for organisms difficult to culture and not apparent on gram stain. Given their intracellular nature, they are difficult to isolate and often challenging to treat because antibiotics must be able to penetrate intracellularly to reach their intended target. They are also grouped based on their subacute presentation and similar constitutional symptoms.

• History and Physical

Patients often present with prolonged constitutional symptoms. Although not found to be predictive, it is traditionally taught that patients with atypical infections will present gradually and have a viral prodrome including a sore throat, headache, nonproductive cough, and low-grade fevers. [2]  They rarely have an obvious area of consolidation on auscultation/imaging compared to pneumococcal pneumonia. Additionally, extra-cardiopulmonary symptoms are often seen; for example, mycoplasma infections are loosely associated with rashes, and bullous myringitis and Legionella is classically associated with gastrointestinal ailments and electrolyte abnormalities.

In a nontoxic-appearing patient, especially in the outpatient setting, a high clinical suspicion is all that is needed to pursue empiric treatment. In ill-appearing individuals or patients in whom the diagnosis is uncertain, a chest x-ray is the diagnostic gold standard.  Lab work often complements and further serves to help risk-stratify individuals and direct treatment. Decision-making is only supplemented by lab studies. Some providers may check a complete blood count to test for leukocytosis and a left-shift, or complete a pro-calcitonin test to help differentiate viral versus bacterial etiology.  [5] [6] [7] Patients who are admitted to the hospital have urinary antigen tests and viral PCRs, allowing for detection of legionella, chlamydia, and mycoplasma. When patients appear toxic, it is also important to obtain blood cultures and sputum cultures, if possible, [2]  to help with antimicrobial stewardship and the de-escalation of antibiotics.

Classic imaging findings in atypical pneumonia include patchy infiltrates, sometimes bilateral in distribution, and interstitial patterns.  They are less commonly associated with lobar consolidations and complicated parenchymal findings such as empyema and ARDS.

• Treatment / Management

Atypical organisms such as M. pneumoniae, which is the most common, lack cell walls; therefore, beta-lactam antibiotics are not recommended. One does not have to perform blood cultures before initiating treatment. However, sputum should be obtained for gram stain and culture. In hospitalized patients, antibiotics should be started within 4 hours.

First-line treatment is the macrolide family of antibiotics, although resistance is emerging. Azithromycin is the most common and is available in intravenous and oral formulations; the short treatment course of just 5 days increases patient compliance. Alternate outpatient antibiotics include fluoroquinolone and tetracycline. These are frequently utilized in older or more toxic-appearing individuals when more pyogenic organisms are also considered. In patients requiring hospital admission for presumed community-acquired pneumonia, a broadened approach is frequently utilized, and a beta-lactam such as ceftriaxone is added to azithromycin. [1]

Clinician tools such as the CURB 65 score and the pneumonia severity index are frequently utilized to determine if outpatient or inpatient medical treatment is most appropriate. [5] [8] Well-appearing individuals in whom an atypical organism is suspected can be managed with outpatient antibiotics and symptomatic care.

Treatment failures are not uncommon due to antibiotic resistance, poor compliance and inability to tolerate oral medications. In addition, some patients may have obstructing lung lesions or an incorrect diagnosis.

Close to 50-60% of patients may have a parapneumonic effusion on the chest x-ray. If this fluid does not resolve, empyema is common. Aspiration and drainage of the fluid are highly recommended if the pH is less than 7.2.

In children less than 5, atypical pathogens are not common but if suspected the treatment is amoxicillin for 7-14 days. Macrolides are recommended for children more than 5 years old. Children who develop atypical pneumonia are more likely to need hospitalization and often require parenteral therapy as well as oxygen supplementation.

Elderly patients with atypical pneumonia often have altered mental signs and another comorbidity which also increase the risk for aspiration. These individuals should also be covered for anaerobes.

Criteria for Admission

• Respiration rate more than 30 bpm
• Oxygen saturation less than 90% on room air
• Hypotension
• Severe lung disease, COPD, emphysema,
• Heart failure, diabetes
• Altered mental status
• Differential Diagnosis

The differential diagnosis for pneumonia typically spans cardiac, respiratory, and musculoskeletal systems. From the cardiac system, pericarditis and myocarditis can present in the setting of viral symptoms and should be considered. In the respiratory system, one must differentiate between upper and lower respiratory tree. The upper respiratory system includes pharyngitis, sinusitis and more emergent conditions such as epiglottitis and retropharyngeal abscess. For the lower respiratory tree, a chest x-ray will differentiate bronchitis/bronchiolitis versus pneumonia. It further complicates the diagnosis when an abnormal infiltrate is found on chest x-ray; in these cases, one must differentiate between atypical/viral/bacterial pneumonia, polymicrobial aspiration, and sterile chemical pneumonitis. Other noninfectious respiratory mimickers include asthma and COPD. [2]  Lastly, it is important to consider musculoskeletal complaints such as costochondritis and rib dysfunction; however, they frequently lack constitutional symptoms.

The vast majority of patients in whom an atypical infection is suspected can be managed successfully as an outpatient. There is usually a complete resolution of symptoms and a low morbidity and mortality. Treatment is often uneventful in the absence of significant comorbid conditions, vital sign abnormalities, and a toxic appearance.  As with all clinical disease, not every case follows the expected course. Close follow-up and compliance are necessary to monitor for disease progression.

• Deterrence and Patient Education
• The public should be encouraged to get vaccinated with the annual flu.
• Elderly individuals should also get the pneumococcal vaccine
• Enhancing Healthcare Team Outcomes

The diagnosis and management of atypical pneumonia is often difficult because laboratory results are not always immediately available, hence clinical acumen is necessary. The infection is best managed by an interprofessional team that includes an emergency department physician, infectious disease consultant, nurse practitioner, internist, radiologist, and a pharmacist. Because diagnosis is often delayed, one should never delay treatment if atypical pneumonia is suspected. The pharmacist should educate the patient on medication compliance and the importance to have the annual flu vaccine. Nurses should closely monitor patients for respiratory distress, nutrition, and mental status changes. If the patients are managed as outpatients, an infectious disease nurse should follow the patients in a clinic to ensure that recovery is occurring.

The majority of patients are managed as outpatients without sequelae. However, some atypical pneumonia may not follow the usual course and may result in severe symptoms, which require admission. [9] [10] To avoid the morbidity and mortality, it is important to follow these patients until full resolution of symptoms is obtained.  [11] Close communication between the interprofessional team is vital to obtain improved outcomes.

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Chest X-ray of Mycobacterium Avium-Intracellulare Pneumonia. Contributed by S Bhimji, MD

Disclosure: Dustin Stamm declares no relevant financial relationships with ineligible companies.

Disclosure: Holly Stankewicz declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Stamm DR, Stankewicz HA. Atypical Bacterial Pneumonia. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Atypical presentation of an epiphrenic esophageal diverticulum 20 years post fundoplication: a case report and review

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Dana Tasabehji, Mohammad Jarrah, Mohamad Mokadem, Atypical presentation of an epiphrenic esophageal diverticulum 20 years post fundoplication: a case report and review, Journal of Surgical Case Reports , Volume 2024, Issue 5, May 2024, rjae316, https://doi.org/10.1093/jscr/rjae316

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Esophageal diverticulum is a rare condition characterized by the herniation of the esophageal mucosa outside the esophageal wall. Here, we explore the prevalence of ED and its associated esophageal dysmotility. We also shed light on the potential impact of previous surgical interventions, such as Nissen’s fundoplication, on the development of ED. This manuscript presents the case of a 72-year-old woman with a history of Nissen’s fundoplication surgery who experienced worsening symptoms of dysphagia, heartburn and postprandial cough. Despite exhibiting a normal motility pattern, upper endoscopy revealed a large epiphrenic esophageal diverticulum. The patient underwent successful surgical resection with myotomy, resulting in the resolution of symptoms with no complications. This case highlights the rarity of symptomatic ED and the need to recognize it while choosing the optimal treatment modality.

Esophageal diverticulum is an uncommon entity that involves herniation of the esophageal mucosa outside the esophageal wall, with a prevalence ranging from 0.06% to 4% according to radiologic and endoscopic series [ 1–4 ]. These diverticula may occur in various locations, with different nomenclature based on the location. Diverticula in the pharyngoesophageal area are known as Zenker’s diverticulum, and those distally are referred to as epiphrenic diverticula (ED) [ 1 ]. ED are protrusions of the esophageal lumen originating in the distal third of the esophagus near the diaphragm [ 5–7 ]. Radiological studies, mainly contrast esophagography, show a prevalence of ED at ~0.0015% in the USA, 0.77% in Japan, and 2% in Europe [ 8–10 ]. The estimated prevalence of ED is 1 in 5 compared to Zenker’s diverticulum [ 5 ]. Patients can be asymptomatic or might present with features of dysphagia, regurgitation, or compressive symptoms due to mechanical pressure from increasing size [ 4 , 11 ]. Here, we present a case of a patient with a symptomatic esophageal ED who had a surgical history of Nissen’s fundoplication and no underlying esophageal motility disorder on manometry. With surgical resection of the diverticulum, the patient’s symptoms resolved with no complaints afterwards.

A 72-year-old woman with a past medical history of coronary artery disease and chronic gastroesophageal reflux disease (GERD) with hiatal hernia status postsurgical correction by Nissen’s fundoplication 20 years ago, presented with worsening episodes of intermittent dysphagia, heartburn, and postprandial cough of ~2 years duration but worsening symptoms over the past 2 months. She denies any symptoms of food regurgitation, nausea, vomiting, appetite, or weight changes. Upon her initial clinic evaluation, she had normal vital signs and unremarkable findings on the physical exam. The decision was made to start her empirically on a proton pump inhibitor, assuming her symptoms are related to GERD, to which she did not respond appropriately. A subsequent upper endoscopy revealed a large epiphrenic wide-mouthed ED ( Fig. 1 ). Additionally, an esophagram showed a 6.0 × 5.0 cm epiphrenic ED with a 3.3 cm neck ( Fig. 2 ). High-resolution esophageal manometry (HREM) was performed; thereafter, revealing a normal motility pattern ( Fig. 3 ). She was then referred to cardiothoracic surgery for consideration of surgical repair. She was initially advised to follow a dysphagia-specific diet and wait conservatively on her symptoms, but no changes were observed in her clinical course over 6 months. The patient subsequently underwent a successful uncomplicated esophageal diverticulectomy with myotomy, conducted through a lateral thoracotomy. During surgery, an esophagogastroduodenoscopy (EGD) revealed an ED at 35 cm in the gastroesophageal (GE) junction at 40 cm in the epiphrenic region. A standard posterior lateral thoracotomy was performed in the serratus-sparing fashion, and the pleural space was entered at the seventh intercostal space. The esophagus was encircled with a Penrose drain lifting it up, and it was freed from the periaortic tissue, and the ED cleared off all muscle fibers. The diverticulum was excised from the esophagus using a purple load stapler with an EGD scope in place to prevent esophageal narrowing. A myotomy was performed from the GE junction proximally, with negative leak testing. The muscle layer was then imbricated over the area of diverticulectomy, and a chest tube was inserted for drainage. A postoperative esophagram confirmed no presence of an ED ( Fig. 4 ). Immediately after the surgery, the patient had a complete resolution of her symptoms, and during her 1-year follow-up visit, she remained asymptomatic.

Large epiphrenic ED visualized on upper endoscopy.

X-ray esophagram fluoroscopy showing a 6.0 × 5.0 cm epiphrenic ED with a 3.3 cm neck.

Normal motility pattern on high-resolution manometry test in a patient with epiphrenic ED.

Normal X-ray esophagram fluoroscopy postdiverticulectomy with myotomy surgery.

ED, or epiphrenic diverticula, are uncommon protrusions of the esophageal mucosa located in the lower esophagus near the gastroesophageal junction [ 12 ]. The exact cause of ED is not fully known, but it is believed to be associated with increased intraluminal esophageal pressure and underlying esophageal motility disorders [ 2 , 13 ]. Symptoms can vary depending on the size of the diverticulum and coexisting morbidities [ 14 ]. Diagnostic workup typically includes a barium swallow study, upper endoscopy, and high-resolution esophageal manometry (HREM) [ 15–17 ]. It is important to perform HREM before intervention to incorporate any discovered dysmotility into the treatment plan [ 4 , 18 , 19 ]. However, it is worth noting that in rare cases, motility disorders may not be identified, as seen in our patient [ 20 ]. Surgical treatment is recommended for symptomatic patients and those with large diverticula [ 21 ]. The standard approach is diverticulectomy with myotomy [ 22–31 ], although less invasive techniques like laparoscopy and per-oral endoscopic myotomy (POEM) are gaining popularity [ 32–35 ]. The choice of surgical technique varies, with some studies advocating for myotomy alone [ 26 , 28 ] and others suggesting a combination of myotomy and fundoplication [ 31 ]. In our patient's case, she presented with symptomatic ED following a history of Nissen's fundoplication. There is limited research exploring the impact of previous surgical interventions, such as fundoplication, on the development of ED [ 18 ]. Surgical intervention was warranted due to the patient's symptomatic presentation and large diverticulum, resulting in complete resolution of her symptoms [ 25 ]. While traditional surgical approaches are effective, less invasive methods such as laparoscopy and POEM offer reduced postoperative morbidity and mortality [ 21 , 27–30 , 32–35 ]. POEM, in particular, is gaining traction for its minimally invasive nature and ability to avoid the need for diverticulectomy [ 32–35 ]. Further research is needed to determine the optimal treatment modality for ED and to explore the correlation between ED and previous fundoplication surgeries.

In conclusion, ED is a rare condition that can cause various symptoms in the lower esophagus near the GE junction. It is associated with increased esophageal pressure and underlying motility disorders. Diagnosis typically involves imaging and HREM, which often reveal abnormal motility patterns. Surgical treatment is recommended for symptomatic patients and those with large diverticula, with diverticulectomy and myotomy being the standard approaches. However, less invasive techniques, like laparoscopy and POEM, are emerging as alternative options. The impact of previous surgical interventions, specifically fundoplication, on the development of ED requires further investigation. Future research will provide a better understanding of the optimal treatment modality and outcomes for ED.

None declared.

This work was supported by the VA Merit Review Program (I01 BX004774), The University of Iowa Department of Internal Medicine and Fraternal Order of Eagles Diabetes Research Center.

All data related to this manuscript are patient-protected and are available upon request by contacting the corresponding author.

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• deglutition disorders
• esophageal diverticula
• esophageal motility disorder
• upper gastrointestinal endoscopy
• cell motility
• fundoplication
• postprandial period
• surgical procedures, operative
• acquired supradiaphragmatic diverticulum of esophagus
• diverticulectomy
• esophageal mucous membrane

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What is Memorial Day? The true meaning of why we celebrate the federal holiday

For many Americans, Memorial Day is more than a long weekend and an unofficial start to the summer season. The real meaning of the holiday is meant to honor all U.S. soldiers who have died serving their country.

Originally called Decoration Day, Memorial Day's history goes back to the Civil War. It was was declared a national holiday by Congress in 1971, according to the U.S. Department of Veterans' Affairs.

Although Veterans Day in November also honors military service members, Memorial Day differs by honoring all military members who have died while serving in U.S. forces in any current or previous wars.

The late-May holiday has also evolved into an opportunity for Americans to head to the beach or lake , travel to see friends and family , or even catch a Memorial Day parade .

Here's what to know about the history and the reason behind why we observe Memorial Day.

Memorial Day weather: Severe storms could hamper your travel, outdoor plans for Memorial Day weekend

When is Memorial Day?

One of 11 federal holidays recognized in the U.S., Memorial Day is always observed on the last Monday of May. This year, the holiday falls on Monday, May 27.

Why do we celebrate Memorial Day?  

The origins of the holiday can be traced back to local observances for soldiers with neglected gravesites during the Civil War.

The first observance of what would become Memorial Day, some historians think, took place in Charleston, South Carolina at the site of a horse racing track that Confederates had turned into a prison holding Union prisoners. Blacks in the city organized a burial of deceased Union prisoners and built a fence around the site, Yale historian David Blight wrote in  The New York Times  in 2011.

Then on May 1, 1865, they held an event there including a parade – Blacks who fought in the Civil War participated – spiritual readings and songs, and picnicking. A commemorative marker was erected there in 2010.

One of the first Decoration Days was held in Columbus, Mississippi, on April 25, 1866 by women who decorated graves of Confederate soldiers who perished in the battle at Shiloh with flowers. On May 5, 1868, three years after the end of the Civil War, the tradition of placing flowers on veterans’ graves was continued by the establishment of Decoration Day by an organization of Union veterans, the Grand Army of the Republic. 

General Ulysses S. Grant presided over the first large observance, a crowd of about 5,000 people, at Arlington National Cemetery in Virginia on May 30, 1873.

This tradition continues to thrive in cemeteries of all sizes across the country. 

Until World War I, Civil War soldiers were solely honored on this holiday. Now, all Americans who’ve served are observed. 

At least 25 places in the North and the South claim to be the birthplace of Memorial Day. Some states that claim ownership of the origins include Illinois, Georgia, Virginia, and Pennsylvania, according to Veterans Affairs.

Despite conflicting claims, the U.S. Congress and President Lyndon Johnson declared Waterloo, New York, as the “birthplace” of Memorial Day on May 30, 1966, after Governor Nelson Rockefeller's declaration that same year. The New York community formally honored local veterans May 5, 1866 by closing businesses and lowering flags at half-staff. 

Why is Memorial Day in May? 

The day that we celebrate Memorial Day is believed to be influenced by Illinois U.S. Representative John A. Logan, who was elected to the U.S. House of Representatives as a Democrat in November 1858, and served as an officer during the Mexican War.

It is said that Logan, a staunch defender of the Union, believed Memorial Day should occur when flowers are in full bloom across the country, according to the  National Museum of the U.S. Army.

Congress passed an act making May 30 a holiday in the District of Columbia in 1888,  according to the U.S. Congressional Research Service.

In 2000, the National Moment of Remembrance Act – which created the White House Commission on the National Moment of Remembrance and encourages all to pause at 3 p.m. local time on Memorial Day for a minute of silence – was signed into law by Congress and the President.

What is the difference between Memorial Day and Veterans Day?

Memorial Day and Veterans Day both honor the sacrifices made by U.S. veterans, but the holidays serve different purposes.

Veterans Day, originally called “Armistice Day,” is a younger holiday established in 1926 as a way to commemorate all those who had served in the U.S. armed forces during World War I.

Memorial Day honors all those who have died.