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
less 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
threatening cause
of fever in the elderly
a) Environment exposure
heat stroke
b) Drugs induced
Salicylism
c) Neuroleptic malignant
syndrome

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 noninfectious etiologies

Heats stroke
Patients 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
disease , 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 ,
stupor, agitation)
Hot, dry skin ( not universal )
Neurological deficits in severe
cases
Oliguria ( may be sign of
rhabdomyolysis in exertional
heat stroke)
Hypotension
ECC changes
Disseminated intravascular
coagulation(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
function 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
until 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
furosemide administered to keep urine output at 100 ml/hr.
IV are generally indicated but should be used with care to avoid
pulmonary edema
Complication include cardiovascular dysfunction (including CHF ),
DIC acute renal failure , rhabdomyolysis , seizure , liver injury (very
common) , ARDS, electrolyte disorders, and death.

Drug induced hyperthermia

Drugs 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
,tryptophan )

Drug induced hyperthermia

Drugs that cause hypermetabolism
Salicylate
Thryoid hormone
Dinitrophenol
Symmpathomimetics
Ethanol withdrawal
Sedative hypnotic withdrawal
Drugs 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 ,
hyperpnea, mild abdominal tenderness
Moderate or intermediate: fever, asterixis,
diaphoresis, 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
sodium bicarbonate begin drip at 150ml/hr and
target urine pH of 7.5
Monitor serum electrolytes
Consider dialysis for renal failure if persistent
acidemia , 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,

thioxanthenes)
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
pressure , 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
disease)

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
60% will be deaths
Gangrene of the appendix and gallbladder are more common in
elderly
60% of tetanus and majority of shingles occur in the elderly.

If infectious diagnosis is missed, will increase mortality in the older adult

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

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
common in elderly
60% of tetanus and majority of shingles occur in the
elderly.

Final diagnoses of febrile Elderly presenting to ED

Infection
Respiratory tract infections
pneumonia
bronchitis
pharyngitis /Sinusitis .
Urinary tract infection
Skin /soft tissue infection
Bacteremia/sepsis
Cholecystitis /Biliary tract
Diverticulitis /Abscess
Colitis/Enteritis
Meningits /Encephalitis
Osteomyelitis
Appendicitis
Epididymitis/Prostatitis
Viral syndrome
Noninfectious
Diagnosis Unknown

89.4 %
31.5 %
24.9%
6.0%
1.3%
21.7%
5.3 %
17.7%
3.0 %
2.3 %
2.3 %
1.1 %
1.1 %
0.6 %
0.6 %
2.6 %
10.4%
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 elderly

General class ification

Specific causes

Infection

Intraabdominal abscess

12%

Tuberculosis

6%

Infective endocarditis

10%

orther

7%

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

Collagen vascular diseases

Alcoholic hepatitis /cirrhosis

Granuloma hepatitis

subtotal

Toxicity ?
Unstable vital
signs?
Acute change in
mental status?
No
Source for
fever?
Pneumonia
UTI
Soft-tissue
infection
Meningitis

1.Order the following :chest x-ray ,

urinalysis and urine culture, and
YES
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

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, 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:
Grams 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
costovertebral angle tenderness.
Suprapubic tenderness indicate cystitis
Prostatitis
Pain in the perineum , radiating to the thighs and penis,
voiding 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
tenderness 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