Generalized Non-Focal Weakness in the Elderly

Authors:  Joshua Kim, DO (@joshekim, Emergency medicine resident, Cook County Hospital) and Sean Dyer, MD (@spyderEM, Attending Physician, Cook County Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Just prior to shift change, you see a 74-year-old male who presents with generalized weakness that started about a month ago.  He says he has noticed that he has been feeling much more tired and that he feels like he can’t do as much as he used to.  He does not focalize his weakness but notices that he wakes up in the morning just feeling exhausted. He has a prior history of hypertension and type 2 diabetes and he reports he is taking all of his medications and there are no recent changes in his medications. He states he used to work as a factory worker for 40 years but has recently moved to a new apartment. He is a regular smoker and has been drinking more, denies any illicit drug use.

VS include BP 139/87, HR 84, RR 13, O2 Saturation 97%, T 98.7.

What are the next steps? How should we approach an elderly patient with generalized weakness?

Background

Regardless of experience, the complaint of weakness in an elderly patient proves challenging, as it is a vague and non-focal complaint that takes time to tease out the nuances. Nemec et al. (14) reviewed 218 elderly patients presenting to the ED with a non-specific complaint and evaluated their 30 day outcomes. Nearly 60% of the population had a serious condition, defined as potentially life-threatening or those requiring early intervention to prevent health status deterioration within 30 days. Nemec consequently found a median of 4 comorbidities (most common were hypertension, coronary artery disease, and dementia) as well as a 6% mortality rate within 30 days (14). Thus, this article seeks to aid in the evaluation of the elderly patient with generalized non-focal weakness to help you determine who is at higher risk of having one of these serious conditions.

Historical Elements/Exam

• A thorough history is necessary in the evaluation of an elderly patient (1).
• Determine the duration of the weakness and if there were any inciting events.
• How does the weakness manifest?
  • Are they having difficulty getting out of bed? Are they noticing they can’t hold onto their morning coffee? Is it more prominent at the end of their day? Is it dominant in the lower extremities vs upper extremities? Has it progressed?
  • Be sure to have a thorough review of systems as it may help further guide your workup (e.g. if there is a history of melena think malignancy and or anemia, if there is lightheadedness think cardiac).
• Nearly 5.7% of US residents aged 65 or above have major depressive illness, and it is generally underdiagnosed, thus taking a thorough social history is crucial (18).
  • Inquire about living situation, any recent change in family or friends.
• Medication review is also a key aspect, as nearly 11% of elderly admissions were from adverse reactions to medications (8). Be sure to inquire about any new medications, and be wary of benzodiazepines, anticholinergics, and anti-hypertensives, as they may cause weakness.
• A thorough physical exam should be performed with particular attention to the following:
  • Volume status (dry/moist oral mucosa, tenting of skin, flattened JVD)
  • Neurological (orientation, inattention, muscle strength, Cranial nerves 3-12, sensorium, gait)
  • Skin (bruising, skin breakdown, rash, cellulitis) **Make sure to turn your patient**
  • Pulmonary (abnormal lung sounds suggesting infection or fluid overload)

Differential Diagnoses/Work Up

• For the elderly patient, make sure to evaluate the common etiologies of weakness, as they have a profound effect on this patient population. Nemec et al. (14) categorized the etiologies of their elderly patients in their observational study of those evaluated for non-specific complaints in the ED and found that 60% were infectious, 18% metabolic dysfunctions, 10% malignancy. Rutschmann et al. found that an infectious etiology (24%) in the elderly (age < 65) with a non-specific complaint requiring admission was the most common unifying diagnosis (18).

Infection

• Infection in the ‘weak elderly’ patient should be high up on the differential and always be carefully evaluated by physical exam and labs, as it may lead to further metabolic derangements.
• Infectious etiologies are responsible for nearly one third of all mortalities in patients aged 65 and above (13) and nearly 90% of deaths from pneumonia are in this same patient population.
• Have a low threshold to order further imaging if you are suspicious of an infectious source (e.g. chest xray, CT abdomen/pelvis). 

Metabolic/ Hematologic

• Dehydration
  • Elderly patients are very sensitive to fluid changes, and dehydration is a common fluid/electrolyte problem seen in this population (10). Warren et al. found that in nearly 700,000 Medicare patients aged 65 and above, dehydration was one of the top 5 diagnosis in 6.7% of patients and as the principal diagnosis in 1.4% of patients (19).
  • It is important to determine the etiology of their dehydration (e.g. infection, stroke, elder abuse) and treat the appropriate cause.
  • Be wary of doing orthostatic vital signs, as their reliability has been dubious. A study done by Koziol-McLain showed that amongst euvolemic patients, 43% had positive orthostatics suggesting hypovolemia (9).
• Electrolyte abnormalities
  • Hyponatremia is common, and Mannesse et al. (12) found that in geriatric wards nearly 4.5% of patients were found to have severe hyponatremia (serum sodium <125 mM).
  • The elderly are very susceptible to electrolyte abnormalities, and small fluctuations may cause more drastic effects.
  • If your standard BMP doesn’t already include a Magnesium and Phosphorous, considering checking it in these patients.
• Kidney Injury
  • Elderly patients typically have multiple comorbid conditions and are prone to acute kidney injury or acute on chronic kidney injury. Elderly patients over the age of 70 were found to have a 3.5 higher incidence of acute renal failure compared to younger patients (15).
  • Be wary of uremic encephalopathy or uremia leading to multiple other etiologies of weakness such as anemia, dialysis dementia, uremic pericarditis, cardiac tamponade, or heart failure (4) as they can lead to increased mortality and morbidity.
• Anemia
  • Rohrig et al. (16) found that nearly 54% of admitted patients had anemia which has been correlated to increased physical impairment (7).
  • Depending on the clinical condition of the patient and how severe the anemia the patient may need to be admitted or given close follow up for further investigation. Furthermore, anemia may sometimes be the only clue one may have for a more sinister process (e.g. melena, malignancy etc.).

Malignancy

• Historical signs of weight loss/night sweats/chronic cough/melena.
• Ask if there has been age appropriate cancer screenings as well as family history of malignancies.
• If there is high clinical suspicion, pursue further imaging based on the suspected malignancy.

Endocrine

• Hypothyroid
  • Consider if patients have complaints of cold intolerance, fatigue, weight gain, constipation, dry skin, or myalgias.
  • Physical exam may show a goiter, decreased deep tendon reflexes, or bradycardia/hypotension.
  • Consider this with hyponatremia and low blood glucose.
  • If clinically suspicious, consider a screening TSH.
• Adrenal Insufficiency
  • Consider in patients who are taking long term corticosteroids such as patients who have rheumatological disorders.
  • Patients may present with shock though complaints may be very non-specific (e.g. weakness, fatigue, confusion, lethargy).
  • A serum cortisol should be obtained if clinically suspected though it is unreliable in patients who have protein disturbances (nephrotic syndrome, cirrhosis).
  • If suspected, one should administer dexamethasone 4mg IV as it will not be detected on serum cortisol assays thus not interfering with further work up.

CVA

• Should always be considered amongst the elderly population. Though typically this will not present with global, generalized weakness, close evaluation for focal neurologic deficits is recommended.
• If patients have an abnormal neurological exam, a CT Head should be considered, along with neurological consultation.

ACS/Arrhythmias

• In a review by Canto et al. (2) with nearly 430,000 patients that were confirmed to have an acute myocardial infarction, nearly one-third had no chest pain upon initial presentation to the hospital. Gupta et al. found that 7% of patients that were diagnosed with an acute MI (n=721) had the chief complaint of weakness.
• An ECG should always be ordered not only to evaluate for potential infarction but to assess for arrhythmias such as bradycardia/conduction delays/heart block as a source of weakness.
• Consider a troponin if clinical suspicion is high.

Social/Psych

• Depression
  • A diagnosis that is often not considered in the ED, depression in the elderly is a significant public health problem and is often unrecognized and inadequately treated (11). Epidemiologically, incidence ranges from 1-5% amongst individuals aged 65 and older (6).
  • Always obtain a thorough social history including living situation.
  • Ask a few screening questions such as if they have been feeling more down or depressed lately or any suicidal/homicidal ideation.
• Elder Abuse
  • A review of elder abuse in 2015 by Dong (3) found that the prevalence in North and South America was in the range of 10% in elders who were cognitively intact and up to 47% in those with dementia.
  • A difficult diagnosis to make, it is important to ask if the person in charge of caring for this patient is neglecting, abusing, or exploiting them and to ask questions to gauge how much the elderly person must rely on others for their daily activities.
  • Keep a high clinical suspicion and report if suspected. Patients may require admission.

Zebras

• Though they are zebras for a reason, it is always good to be mindful of the less common etiologies of weakness in patients.
• Myasthenia gravis
  • Consider when weakness is progressive throughout the day associated with diplopia/ptosis and weakness made worse with exercise.
• Lambert-Eaton
  • Similar to myasthenia gravis though due to antibodies to acetylcholine receptors, patients may report fluctuating weakness that gets progressively better with sustained movement or exercise.
  • Classically associated with Lambert Eaton’s sign where hand grip improves after 5 seconds.
• Guillain-Barre Syndrome
  • Classically associated with Campylobacter jejuni infections and presents with ascending paralysis.
  • Patients may have a history of recent illness and may have progressive weakness with loss of deep tendon reflexes.
• Lyme disease
  • Particularly within regions endemic to ticks.
  • Inquire about rashes and recent travel.
  • If suspicious, a thorough physical exam of the skin to look for the tick is required. 

Take Home Points

• As mentioned, a thorough history and physical exam are crucial to the evaluation of elderly patients with non-focal generalized weakness.
• A CBC, BMP, Accucheck, and ECG are always warranted in the evaluation of generalized weakness in the elderly.
• Use your clinical history and exam to guide further lab testing and imaging as appropriate in each individual patient.

References / Further Reading

1. Anderson RS. Generalized weakness in the geriatric emergency department patient: an approach to initial management. Clinics in geriatric medicine. 2013:91-100.
2. Canto JG. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283(24):3223-3229.
3. Dong XQ. Elder Abuse: Systematic Review and Implications for Practice. Journal of the American Geriatrics Society. 2015;63:1214-1238.
4. Foley, Mathew et al. Ch. 90: End-Stage Renal Disease. In: Tintinalli J. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition. Vol 7. McGraw-Hill Education ; 2010.
5. Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med. 2002 Aug;40(2):180-6.
6. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: Results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatr. 2005;62:1097–106.
7. Juárez-Cedillo T, Basurto-Acevedo L, Vega-García S, et al. Prevalence of anemia and its impact on the state of frailty in elderly people living in the community: SADEM study. Ann Hematol. 2014;93(12):2057–2062.
8. Kongkaew C. Hospital admissions associated with adverse drug reactions: a systematic review of prospective observational studies. The Annals of Pharmacotherapy. 2008:1017-1025.
9. Koziol-McLain J, Lowenstein SR, Fuller B. Orthostatic vital signs in emergency department patients. Annals of emergency medicine. Jun 1991;20(6):606-610.
10. Lavizzo-Mourey RJ. Dehydration in the Elderly: A Short Review. Journal of the National Medical Association. 1987;79:1033-1038.
11. Lebowitz BD. Diagnosis and treatment of depression in late life. Consensus statement update. JAMA. 1997;278:1186-1190.
12. Mannesse CK et al. Prevalence of hyponatremia on geriatric wards compared to other settings over four decades: A systematic review. Ageing Res. Rev. 2013, 12, 165–173.
13. Mouton CP. Common infections in older adults. American Family Physician. 2001:257-268.
14. Nemec M., et al. Patients presenting to the emergency department with non-specific complaints: The Basel Non-specific Complaints (BANC) Study. Academic Emergency Medicine 2010, 17:284-292.
15. Pascual J. Incidence and prognosis of acute renal failure in older patients.Journal of the American Geriatrics Society.January 1990:25-30.
16. Rohrig G et al. Prevalence of anemia among elderly patients in an emergency room setting. European Geriatric Medicine 2014;5(1):3-7.
17. Rutschmann O et al. Pitfalls in the emergency department triage of frail elderly patients without specific complaints. Swiss Medical Weekly. 2005;135:145-150.
18. VanItallie TB. Subsyndromal depression in the elderly: underdiagnosed and undertreated. Metabolism: clinical and experimental. 2005:39-44.
19. Warren JL. The burden and outcomes associated with dehydration among US elderly, 1991. American Journal of Public Health. 1994;84:1265-1269.