What is deterioration

An emergency room case?

"AZ deterioration" is a frequently documented symptom in older patients. While the unspecific decline in well-being in younger years is usually not due to a serious health disorder, the same symptoms often result in a serious illness in older age. Therefore, especially in the case of AZ deterioration in older patients who have developed quickly, one should listen carefully and give the indication for admission rather generously.

The term AZ deterioration, the increasing impairment of the general condition, is not clearly defined and is often used synonymously with the term “nonspecific complaints” [2, 9]. In the emergency rooms, the proportion of patients with unspecific symptoms is high and increases significantly with age. About 20% of patients in the emergency department who are over 75 years of age show unspecific symptoms [11, 15]. The proportion of patients with AZ deterioration in this age group is around 20% higher than the percentage of emergency room patients with typical emergency medical key symptoms, because only about 12% of patients go to an emergency room because of chest pain and about 7% because of shortness of breath [ 7, 10]. In a study with around 13,000 patients in a Swedish emergency room, AZ deterioration was one of the five most common diagnoses [14]. The average age of these patients was 82 years, the proportion of women was 55.6%. 78.2% were admitted to the hospital and 7.5% of these patients died during the hospital stay [14]. Due to the demographic development with the significant increase in elderly and very old patients, which is already dubbed the "Silver Tsunami", a further significant increase in patients with AZ deterioration is to be expected in the future [1].

Underestimation of the AZ deterioration

75% of the patients with the symptom AZ deterioration are referred by general practitioners or on-call doctors, the remaining 25% are brought to the emergency room by family members [1]. Occasionally these patients are seen as an unpopular challenge in the emergency room. A study from Switzerland was able to show that patients over 65 years of age have an increased risk in the emergency room that the severity of their health disorder will not be recognized or underestimated [5]. This could be based on two misconceptions:

  1. that AZ deterioration is not an expression of an illness, but a general sign of aging
  2. that AZ deterioration cannot be treated or is only treatable to a limited extent.

However, both ideas are wrong.

About 60% of older patients with AZ deterioration have illnesses that require acute treatment and are often of high relevance to emergency medicine [9]. Knowledge of the diseases and pathomechanisms that lead to a deterioration in AZ in old age means that these patients can be perceived as an exciting diagnostic challenge. The clinical mortality of elderly patients with AZ deterioration is comparatively high at around 6 to 7.5% and is thus higher than the mortality of patients with chest pain, which is less than 5%, albeit without differentiating between age groups [7, 9, 14 ]. Many of the patients with AZ deterioration improve rapidly and significantly after finding the correct diagnosis and the resulting therapy despite their older age, sometimes even during treatment in the emergency room.

Features and delineation of AZ deterioration

The leading symptom of AZ deterioration is a general weakness that usually develops within several hours or a few days. Often the deterioration in health is more likely to be noticed by relatives and caregivers than by the patients themselves. Sometimes the decrease in physical performance is also accompanied by a decrease in mental capacity. As a result, many patients in the emergency room cannot say why they were brought to the hospital. Confabulations or references to previous or existing complaints are then common. These often implausible statements can be helpless attempts at explanations by the patient, but which inexperienced doctors encounter incomprehension and can lead to misjudgments.

The generalization of the weakness distinguishes the AZ deterioration from the localized weakness [10]. The focal weakness of an extremity, in which the suspicion of a stroke is more likely, therefore does not meet the criteria for AZ deterioration, for example.

The usually rapid progression of the decrease in performance within hours to days differentiates the deterioration of the AZ from the frailty in old age, the so-called frailty, which usually develops much more slowly over weeks or months [4]. The deterioration in AZ is also separated from dementia by its faster course, but also by the presence of physical symptoms, which are usually not in the foreground during dementia reduction.

Unspecific symptoms and older age

A large number of diseases can present themselves in older people with the picture of a deterioration in AZ. With increasing age, specific symptoms of even serious illnesses become rarer and instead express themselves as a worsening of AZ [2]. A few examples illustrate this: Even highly septic patients often show only slightly elevated temperatures and only a moderate increase in leukocytes and other inflammatory parameters in old age [2]. The difficulties in diagnosing appendicitis in elderly patients are also well known due to the often only minor local symptoms [2, 8]. About two thirds of heart attack patients over the age of 85 no longer have chest pain, but rather other symptoms, for example shortness of breath or deterioration in AZ [6, 8].

Two approaches try to explain why unspecific symptoms occur significantly more often in older age than in younger phases of life, even with severe illnesses. On the one hand, the performance of all physical systems decreases with increasing age. This could also affect the intrathoracic and intra-abdominal pain perception and thus make it understandable why older patients feel little or no pain even with heart attacks or severe intra-abdominal inflammation. Second, the decline in performance in old age also affects the defense mechanisms. This could explain why, for example, the rise in fever and inflammation parameters are often not very pronounced in elderly patients. Yet these patients are seriously ill.

The common age-related decline in many bodily functions could also explain why in old age the disease of one system quickly affects others, which in total leads to the presentation as AZ deterioration. If one takes as a basis that the gap between the average and maximum performance of most body functions is reduced in old age, then the interconnectedness of these organ functions explains that the disease of one system can quickly lead to a disruption of several other functions. In younger periods of life, when the reserves of the individual organ functions are greater, the disruption of one system must be much more pronounced until it affects the other functions.

Causes of AZ deterioration

The number of diseases and injuries that can lead to AZ deterioration in old age is large. Overview 1 gives an overview only in excerpts with an attempt at a nosological subdivision.

The diagnoses that are particularly important from an emergency medical point of view, either because of their dangerousness or their frequency, are summarized in Overview 2. Due to the limited amount of data, this is an empirical and incomplete list.

60% of the diagnoses found in patients with AZ deterioration are infections, 18% concern metabolic disorders and 10% are oncological origin [1, 9]. Urinary tract infections and pneumonia dominate the infections, often also erysipelas and intra-abdominal inflammation. Worsening renal insufficiency and electrolyte imbalances, especially hyponatremia, are also common diagnoses. The simultaneous prescription of two or more diuretics or ACE inhibitors seems to play an important role [13]. AZ deterioration due to medication and interactions play a major role in older people [8]. A study on 633 patients with AZ deterioration found a medication or interaction as the cause in 12.2%, which was initially only recognized in 40% of the cases [12]. 83% of the medication-related deteriorations in AZ were severe [12].

Heart attacks are increasingly expressed in old age not by pain but by other symptoms, for example shortness of breath or deterioration in AZ [6, 8]. After the age of 85, the majority of infarct patients no longer show pain, but only 2 to 6% of these patients are asymptomatic [3]. Hyperglycaemia in decompensating diabetes mellitus, often in connection with the accompanying desiccosis, is also an essential differential diagnosis of AZ deterioration. Slowly developing subdural hematomas can initially present as AZ deterioration in old age. Elderly people with a combination of unsteady gait and anticoagulation are particularly at risk for the development of these hematomas, whereby a fall event is often not reported or not remembered.

Diagnostic procedure

AZ deterioration in old age can be caused by a variety of different diseases and injuries. At the same time, the risk of underestimating the underlying health disorder is great and the lethality of AZ deterioration in older people is comparatively high. For these reasons, the indication for admission to the clinic should be given rather generously, at least in the case of AZ deterioration with faster disease dynamics.

The clarification of unspecific symptoms in the emergency room cannot be symptom-oriented, but must be system-oriented. The knowledge of the particularly important and frequent causes of a deterioration in AZ in older age (overview 2) helps to structure the procedure [1]. The importance of the history of AZ deterioration should not be overestimated, because some of the patients suffer from pre-existing dementia, in other patients the decline in mental performance is a concomitant symptom of the AZ deterioration and other patients do not notice the AZ deterioration themselves or have difficulty naming them.

The physical exam can provide clues as to what is happening, but in most cases further examinations will be required. As a standard, the blood should be examined for changes in the blood count, inflammation parameters, blood sugar, electrolytes and metabolic parameters, and the urine should be tested for signs of infection. A chest x-ray and ECG recording should also be standardized. The threshold for determining troponin should be rather low and may be reached even if there are unspecific indications of ischemia. In view of the frequent accumulation of medication intake in older people, a medication history is essential. Cranial computed tomography (CCT) is not a routine part of the diagnostic work-up of AZ deterioration unless there are focal neurological abnormalities or indications of a fall involving the head [1]. Overview 3 summarizes the clarification scheme in case of AZ deterioration in older age.

The therapy for AZ deterioration results from the underlying disease. It is sometimes impressive how quickly many patients with AZ deterioration recover once the underlying health disorder is identified and treated, even in old age.

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Conflicts of Interest: none declared