When it comes to acute conditions, not all patients can be treated the same way. Due to specific complications and pathologies, the elderly in particular are a special group of patients. Their management requires a tailored approach and may pose challenges for treating physicians. The Refresher Course on ‘Acute conditions in the elderly’ aims to provide a practical update on acute conditions in geriatric patients, focusing specifically on the emergency room.
With age, the frequency of multimorbidity increases, making patients more vulnerable to acute conditions and further disease. Among other challenges needed to be overcome when treating elderly patients, separating the process of ageing from the disease itself and making a thorough differential diagnosis can be difficult. Therefore, diagnostic imaging of older patients requires special knowledge. Radiologists must be familiar with common and uncommon findings and typical emergency symptoms that might aid the differential diagnosis and be useful for guiding therapeutic decisions.
One typical emergency symptom in the elderly is fever. It can have many causes that, undiagnosed and untreated, might lead to serious consequences, as Prof. Ingrid Millet, from the Medical Imaging Department at Lapeyronie Hospital, Montpellier University, France, will explain in her presentation.
Fever is one of the key signs of infection. However, although the presence of a fever in elderly people is more likely to be associated with a serious viral or bacterial infection than in a younger patient, it is not a reliable physical finding of an infectious process in the elderly.
“As the immune system is altered and the normal temperature is naturally lower in older people, fever should be considered when the temperature is greater than 37.2°C,” said Millet, noting at the same time that fever in the elderly is always a serious symptom. “Unlike in adults or paediatric patients, in whom fever is often indicative of a benign viral infection, fever in older patients is always associated with a severe process. CT should be promptly required even without IV contrast in order to boost the management in the emergency department.”
Common causes of fever in elderly people include pneumonia, bacterial endocarditis, cholecystitis, urinary tract infection and intestinal diseases such as enteritis and colitis. Malignancy can also be a cause. “Malignancy should always be ruled out with acute chest and abdominal imaging. It is quite common in elderly people and often revealed by complications such as abscesses, perforation or necrosis leading to pain and fever,” Millet explained.
Another serious pathology crucial to rule out is intestinal ischaemia. “Indeed, when the intestinal mucosa is damaged by an ischaemic process, it causes a bacterial translocation from the intestinal lumen to the bowel wall and vascular system, leading to sepsis. Septic shock is one of the main complications to be expected in elderly patients with high fever and might lead to hypovolemia and, in further consequence, to stroke, non-occlusive mesenteric ischaemia and death,” she said.
After Millet’s presentation, Dr. Francesca Iacobellis, from the Department of General and Emergency Radiology at the A. Cardarelli Hospital in Naples, Italy, will discuss postoperative complications in the elderly.
Figure B: 86-year-old woman with right upper quadrant pain without fever. CT at a venous phase shows a perforated (arrow) calculous cholecystitis. Prompt cholecystectomy was done, and final histology revealed a gallbladder adenocarcinoma (provided by Prof. Ingrid Millet).
As the population in many societies is getting older, there is an increase in demand for (often major) surgeries within this population, which is at higher risk of acute postoperative complications, making it important to utilise accurate preoperative risk stratification techniques, which are applicable to elderly patients. “Due to major surgical risks, acute postoperative complications are more fearsome in the elderly compared to younger patients. Early detection and correct characterisation of possible complications are essential in order to optimise patient management and outcome,” Iacobellis said.
There is no question that major perioperative complications increase with age. However, the risk of complications is not solely defined by age; many other factors also play a role, according to Iacobellis. “The evidence shows that in the elderly, the possibility of developing postoperative complications is more related to common geriatric syndromes, such as functional and cognitive impairment and frailty, than to chronological age. Furthermore, there are specific complications depending on the type of surgical procedure.” The list of common complications in the elderly is long, ranging from respiratory complications such as atelectasis, pleural effusion, pneumonia, pulmonary oedema, acute respiratory distress syndrome and pulmonary embolism, to surgical site infections such as urinary tract infections and sepsis to anastomotic leakage, bleeding, postoperative ileus, vessel thrombosis and many more.
Figure D: Enhanced CT of the abdomen in arterial and venous phases showing arterial active bleeding in the bowel lumen, occurring after abdominal surgery in an elderly patient (provided by Dr. Francesca Iacobellis © A. Cardarelli Hospital, Naples).
CT is the diagnostic method of choice in the emergency setting to detect and characterise acute postoperative complications in the elderly. “In almost all cases, the morphology and distribution of pulmonary parenchymal alterations allow a detailed diagnosis, leading to an appropriate therapeutic approach. The intravenous injection of contrast medium paves the way to diagnose vascular complications such as pulmonary embolism or active haemorrhage, while the characterisation of the bleeding, if arterial or venous in nature, and its quantification, facilitates the decision between strict monitoring, embolisation or an operative approach, and helps to establish the most appropriate therapeutic management. Furthermore, the detailed description of the dimensions of fluid collections and their relationships with adjacent organs leads to the decision between conservative therapy, percutaneous or surgical drainage,” said Iacobellis.
Another expert providing guidance in this session will be Dr. Mateusz Wykretowicz, from Poznan University of Medical Sciences, Poland. He will discuss confusion in the elderly, addressing specific pathologies on acute imaging and complications that can be expected in the confused elderly.
Refresher Course
RC 1817 Acute conditions in the elderly
- A. Confusion in the elderly: what can we expect in imaging of acute conditions?
Mateusz Wykretowicz; Poznan/PL - B. Grandparent has a high fever and thoracic/abdominal pain
Ingrid Millet; Montpellier/FR - C. Postoperative complications in the elderly
Francesca Iacobellis; Naples/IT
FURTHER READING
Kutaiba N, Perchyonok Y, Yeoh M (2017) Computed tomography of the brain for elderly patients in the emergency department. ECR 2017 / C-1648: myESR.org/171648
El Saeity N, Simelane T, Ramesh N (2018) Role of Radiology in trauma of geriatric patients. ECR 2018 / C-1900: myESR.org/181900
Lanotte SJ, Larbi A, Michoux N et al (2019) Value of CT to detect radiographically occult injuries of the proximal femur in elderly patients after low-energy trauma: determination of non-inferiority margins of CT in comparison with MRI. Eur Radiol. doi: 10.1007/s00330-019-06387-2: european-radiology.org/6387
Kang EY, Yong HS, Lee KY, Oh YW (2018) A radiologic review of acute aspiration pneumonia in the elderly. ESTI ESCR 2018 / P-0019: myESR.org/1819