The Challenge of Infections in Frail Elderly: The Story of Mr. Nilsson

Abstract

rectally. One morning nursing assistants (NA) observed that Mr. Nilsson was behaving differently, e.g. he did not feel well, expressed as "expression in the eyes", less appetite, lethargy and general signs of illness. They also observed respiratory symptoms. The NA continued to report about his changed condition for the next few days to the registered nurse (RN), who noted that he might have a cold but took no further action as he did not have a fever. His ear temperature was 37.6°C in the morning and 36.8°C in the afternoon the first day, and 37.2°C in the morning and 37.3°C in the evening the second day. Day six Mr. Nilsson's temperature is 38.1°C and hence the RN informs the general practitioner (GP), who takes no further action. There is no more RN documentation about his condition until day 16, when the RN order paracetamol due to increased body temperature (38.9°C). The next morning the nurse contacts the GP who prescribes antibiotics due to suspected pneumonia. The condition worsens and Mr. Nilsson dies on day 24. See flowchart over the 24 days in figure 1. DiscussionThis case illustrates the process from the first signs and symptoms of infection to diagnosis in an elderly person with severe cognitive decline and physical impairment. It is well known that nonspecific symptoms and lack of specific ones are common in NHR [9-11], contributing to a delayed diagnosis and treatment [10]. These atypical signs are observed as absence of fever, weakness, falling, weight loss, physical dysfunction and cognitive decline [3,7,[12][13][14]. In addition, early signs of infection are very similar to, and also as diffuse as, signs of acute illness [12,15,16]. Changes, such as lethargy, weakness, decreased appetite, agitation, disorientation, dizziness, falls and delusions are reported to have high predictive values for acute illness in frail elderly [16]. The complexity of detecting infections in NHR can be explained by difficulties in understanding and interpreting non-specific signs and symptoms and co-existing chronic diseases that blur the clinical picture. An individual that normally is confused, anxious and restless may become apathetic and infirm, or vice versa, when infection is suspected. On the other hand, an individual who normally is unrestrained could become more confused, aggressive, anxious and restless. As specific symptoms are often lacking [9][10][11] the presence of fever, in terms of > 38°C, is often evaluated as a significant symptom of illness and an important reason for taking further action. However, fever in frail NHR has been reported to be lower than traditionally stated [17][18][19]. In addition, the effects on body temperature from medication with paracetamol daily have to be considered. AbstractSigns and symptoms of infection in Nursing Home Residents (NHR) are often atypical with a lack of specific ones, causing a delay in diagnosis and treatment. The complexity of detecting infections in NHR can be explained by difficulties in understanding and interpreting non-specific signs and symptoms ...