FOAM v 50 – Geriatrics Emergency Medicine Part 3: Atypical symptoms & Adverse drug effects

Our final post about geriatric emergencies where we list common atypical symptoms and how you approach them, and also why the elderly experience adverse drug effects and what drugs to avoid.


Atypical symtoms and adverse drug effects

“It’s tough to grow old and tough to be their physician…” – quote uknown

Check out the sources for this post:


Atypical symptoms


  • Tired autonomic system – weaker or no response to beta-adrenergic stimulus: pain or fever does not cause the heart rate to go up.
  • Tired immune system – low production of inflammatory mediators such as cytokines = afebrile patients despite infections.
  • Relative hypotension in patients with hypertension – a patient with 120/80 isn’t always excellent at taking his or her medication. It could also be a sepsis waiting for you to take a coffee break.



  • Anatomical changes:

   Loss of muscle mass – less likely to get muscle defense

   Loss of nerve endings – less able to localize pain

   Smaller omentum – less likely to wall off infections = peritonitis in the whole abdomen happens much earlier than in younger patients

  • Think outside the box! Cholecystitis among elderly does not present itself as severe pain in upper right quadrant, fever and high white blood count. Pain in the upper right quadrant could easily be pneumonia. Or ACS. Even urine retention has been described as an epigastric pain by some patients. And don’t forget mesenteric ischemia and appendicitis.
  • On the plus side: these people have lived long lives and experienced a lot. If they tell you that the pain in their belly is not something they have experienced before – something is probably wrong. Find the answer.
  • Constipation can have lethal consequences: delirium, falls and perforation.
  • As long as you don’t know the cause – keep them under close observation.



Often triaged as low priority but this could be anything! Some examples listed below:

  • Acute Coronary Syndrom: Most common symptoms in women > 80 years with ACS is weakness and dyspnea – not chest pain radiating to the left arm.

ECGs is rarely normal and needs to be compared to an previous ECG

Biomarkers such as high sensitivity troponin is tricky to interpret in old patients since high age and low eGFR is associated with persistently elevated troponins.

  • Hemorrhage somewhere in the head: old people have smaller brains which means extra space for accumulation of blood.
  • Urinary Tract Infection – but hold on! White blood cells and bacteria is a common finding in elderly bladders, so the dipstick urine analysis cannot be trusted. Think of other conditions before you settle for UTI.
  • Depression – often noted somewhere in the periphery of medical records but suicide rates among people > 65 years continues to increase. Remember that depression can be a life-threatening condition!


Adverse drug effects

Why elderly patients are predisposed to adverse drug reactions: Polypharmacy + comorbidities + following altered pharmacokinetics:

STOPPP – Screening Tool of Older Persons’ Potentially inappropriate Prescriptions:

  • Long term use of benzodiazepines
  • Duplicate prescriptions from the same drug class
  • Proton pump inhibitor for peptic ulcer disease at full dose > 8 weeks
  • NSAIDs in patients with moderate to severe hypertension
  • Long-term use of opioids
  • Aspirin without adequate cardiovascular risk
  • Warfarin and NSAID used together
  • Beta blocker in patients with COPD
  • Prolonged use of first-generation antihistamines
  • NSAID use in patients with chronic renal failure


More learning

Geri-EM: e-learning website with a lot of available content without membership.

The National Board of Health and Welfare: Updated list (oct-19) of drugs that should be avoided among elderly.

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