EVALUATION OF THE ELDERLY PATIENT WITH WEAKNESS: AN EVIDENCE BASED APPROACH

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EVALUATION OF THE ELDERLY PATIENT WITH WEAKNESS: AN EVIDENCE BASED APPROACH Wil M. Chew, MD, and Diane M. Birnbaumer, MD

In the United States, life expectancy has increased throughout the elderly population (defined here as ages 65 years and up). This segment of the population is projected to rise to 13% of the total US population by the year 2010 with the proportion of those greater than 85 years rising the fastest.74The impact of the increasing elderly population on emergency department (ED) resources will be profound. Previous studies have shown that the use of the ED by the elderly population is proportionally higher when compared with the rest of the p o p ~ l a t i o n . ~ ~ These visits tend to be for more acute conditions and use a greater amount of resources both in terms of time, ancillary tests, and medical and nursing personnel time. The elderly population accounts for a larger share of ambulance transports (36%of total) and hospital (42%)and ICU (48%) admission^.^^, 65 Clearly, as the elderly population rises, so will their use of emergency services. In the current medical economic environment, resources will likely remain static; the efficiency of the ED must increase to handle the increased volume and demand. Because of the altered physiology of the elderly population, either as a result of aging or as a result of other disease processes, many illnesses may present with features that are either atypical or nonspecific in nature.I8,58 Difficult and nonspecific complaints, such as weakness in an elderly patient, must be handled in a judicious, cost-effective,

From the Department of Medicine and the Department of Emergency Medicine, HarborUCLA Medical Center, Torrance, California

EMERGENCY MEDICINE CLINICS OF NORTH AMERICA VOLUME 17 * NUMBER 1 FEBRUARY 1999

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comprehensive, and expeditious manner that benefits both the patient and the ED. This article addresses the evaluation of the elderly patient who presents to the ED complaining of weakness. LITERATURE SEARCH METHODS

As the subject being covered was broad, many keywords were used in a search of Medline from 1970 to the present. Keywords included: elderly, weakness, sepsis, fever, pneumonia, urinary tract infections, electrolytes, dehydration, alcoholism, substance abuse, medications, myocardial infarction, atrophy, malnutrition, autonomic dysfunction, Guillain-Barre, myasthenia gravis, polymyalgia rheumatica, thyroid and adrenal. All abstracts were reviewed and the articles pulled were limited to those clearly addressing the weakness with reference to the subgroup of elderly patients. No articles dealt with weakness in the elderly per se, and much of the data for this article was gleaned from reviewing the article in depth to determine the data directly related to the elderly patient. The clearest evidence was found in articles dealing with myocardial infarction, infections, malnutrition, polymyalgia rheumatica and autonomic dysfunction. The data on the other diseases was less clear but extracted from the literature pertinent to those diseases. EVALUATION: HISTORY AND PHYSICAL EXAMINATION

Typically, the evaluation of any patient in the ED begins with the history and physical examination. Owing to the nonspecific nature of the complaint of weakness, however, a focused history and physical examination may not be possible with this complaint. This chief complaint necessitates a full history and physical examination including complete neurologic examination. If possible, persons familiar with the patient (e.g., family members, caretakers, or the primary care physician) also should be interviewed because they can provide valuable insight about the patient’s living condition, baseline function, and mental status. In some cases, information provided by them may be more accurate than that provided by the patients themselves owing to the patient’s memory or mental status deterioration. Attempts should be made to obtain a full history of present illness, including onset (abrupt versus slow) and duration of symptoms (hours to days to weeks) and precipitating (exertion or positional changes, medication dosing) and mitigating factors (rest). Any associated symptoms should be elicited (nausea, vomiting, chest pain, shortness of breath, change in mental status). Medical history is important because of the high incidence of comorbid disease usually found in the elderly population, which can provide valuable insight into the underlying

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cause of the weakness. A list of medications taken by the patient, including any recent changes, is important because overmedication or drug interactions can be a significant cause of weakness in the elderly. Social history, including any alcohol or drug use, should be sought, as well as a history of nutritional intake. An inquiry into the living and social situation is also warranted because elder abuse is an underappreciated diagnosis. A complete physical examination, including neurologic evaluation, is necessary because of the vast differential diagnosis for these patients. Note any abnormalities in vital signs, paying particular attention to the patient’s general appearance: overall hygiene, nutritional status, oxygenation, and hydration. HEENT examination should look for any signs of new or old trauma suggesting a CNS cause. Hydration status (i.e., mucous membrane appearance, sunken eyes) should be noted. Examine the neck for any signs of meningismus, carotid bruits, or jugular venous distention. A lung examination should be done for signs of impaired oxygen exchange such as poor air movement, wheezes, crackles, rales, or signs of consolidation. Perform a cardiovascular examination for any irregularities in rhythm, any gallops or murmurs as well as palpation of the peripheral pulses. The abdominal examination should note signs of tenderness, masses, or hepatosplenomegaly. A rectal examination should focus on sphincter tone, masses, or heme-positive stool. Inspect the skin and extremities for muscle atrophy, any evidence of abuse (i.e., ecchymosis, fractures), or soft tissue infections (e.g., decubiti or cellulitis). A thorough neurologic examination should also be performed, looking for focal signs of weakness, including cranial nerves, cerebellar function, as well as motor, sensory, and reflex findings. Diagnostic Tests

Typically, any diagnostic tests ordered should be guided by the history and physical examination, pursuing abnormal findings on either the general physical or neurologic examination (including abnormal vital signs). The etiology of weakness when the physical examination shows focal physical findings is often easily discernible with appropriate workup. For the complaint of weakness without any abnormal findings on either history or physical, however, further work-up and disposition become problematic. These difficult and diagnostically challenging patients require a thoughtful approach to their work-up. At minimum, diagnostic testing should include an electrocardiogram, a complete blood count (CBC), serum electrolyte levels (including glucose), a urinalysis, and a chest x-ray. These tests, combined with the history and physical examination, will usually identify most serious causes of weakness in these patients, such as acute myocardial infarction, focal infection, early sepsis, or dehydration. Disposition from the ED depends on the final overall evaluation of the patient. This evaluation should take into account the patient’s living

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situation, functional ability at home, they or their caretaker’s ability to care for themselves, their ability to return to the ED if symptoms worsen, and the general medical condition of the patient. Consultation with the patient’s primary physician is vital in determining the final disposition of the patient, and close follow-up is crucial. SPECIFIC DISEASES

This section describes the pathophysiology and epidemiologic characteristics of some of the important diagnoses that may cause weakness in the elderly. Some of these diseases typically present with focal findings on examination. Others may have no focal findings, or the findings may be nonspecific (Table 1). It is not within the scope of this article to explore in depth every disease that may present with weakness, but rather to touch on those conditions that may bring a patient to the ED with weakness as a typical or atypical chief complaint.

Myocardial Infarction Acute myocardial infarction (AMI) is a serious disease in the elderly. Morbidity and mortality is higher in this group of patients as compared with the younger patients (<55 years old) with studies showing a two- to threefold increase in mortality during initial hospit a l i z a t i ~ nProbably .~~ because of an increased incidence of coronary risk factors (e.g., diabetes, coronary artery disease, and hypertension) in the elderly, this population is at an inherently high risk for having an acute myocardial event.2,67, 68, 73 Coronary artery disease accounts for 70% to 80% of all deaths in this age group.17Elderly patients with AM1 present 77 with one study showing atypically up to 40% to 60% of the weakness was part of the clinical presentation of AM1 in 20% of elderly patients presenting with autopsy-proved AMI.77Proposed mechanisms

Table 1. WEAKNESS IN THE ELDERLY PATIENT DIFFERENTIAL DIAGNOSIS Physical Findings Present ~~

Stroke Guillain-Barre syndrome Eaton Lambert syndrome Botulism Myasthenia gravis

Physical Findings May or May Not be Present

No Physical Findings Present ~

Anemia Postprandial hypotension Medication effects/ interactions

~

Acute myocardial infarction Infection (e.g., UTI, pneumonia, bacteremia, sepsis) Dehydration Malnutrition Muscle dysfunction Hypothyroidism Polymalgia rheurnatica Electrolyte abnormalities.

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for this increase in atypical presentation include dysfunction of the autonomic nervous system, and increased tolerance to pain because sensory neuropathy or increased levels of or increased receptor sensitivity to endogenous o p i o i d ~ . ~ ~Other , factors may include the decreased reliability of the HPI owing to memory problems or dementia of the elderly patient. Because AM1 may present weakness only in the elderly patient, an electrocardiogram is useful in these patients.

Infection, UTI, and Pneumonia

Infection, including bacteremia or sepsis, is another extremely important cause of morbidity and mortality in the aged population. Elderly and overall patients account for 40% to 50% of all cases of bacteremia31f61 case fatality rates for elderly patients with bacteremia ranges from 40% to 60% to even higher when the bacteremia is from gram-negative organisms.44.46.78.79 As with AMI, the initial presenting symptoms can be vague and atypical. The classic signs and symptoms of fever, chills, or hypotension may be absent in the septic or bacteremic elderly patient. Nonspecific symptoms such as weakness, malaise, altered mental status with confusion, or a decreased level of functioning may be the only presenting complaints.21Making diagnosis more difficult is the blunting of the temperature and WBC response to serious infection that has been documented in the elderly population> 12,23* 43*51 most likely the result of a decrease in humoral and cellular immunity. The elderly population is at increased risk for developing serious infection because of several age-related changes. Microaspiration is common in elderly patients making them more prone to develop pneumonia. A decrease in the effectiveness of natural barriers, such as the skin or mucous membranes, leads to an increased risk for developing traumatic breaks in the skin or decubitus ulcers. An increase in co-morbid disease (e.g., hypertension, diabetes, COPD, CHF, a decreased gag response, poor nutrition) also predisposes elderly patients to infections. The patient’s living situation also may contribute to the type of infection acquired (e.g., a patient living at home as compared with a nursing home resident may develop different types of infection. Nursing home residents are more prone to aspiration pneumonia, urinary tract infection, and decubiti as a cause of infections, whereas people who live independently at home may present with community-acquired pneumonia or viral infections. Work-up of the elderly patient suspected of having a serious infection should include a search for a source, both in the history and physical examination and by diagnostic testing (i.e., urinalysis, chest x-ray, blood and urine cultures and CBC with differential), as well as appropriate antibiotic coverage.

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Electrolyte and Fluid Disturbances

Because of a variety of factors, elderly patients are at an increased risk for fluid and electrolyte disturbances when compared with their younger ~ o h o r t s As . ~ a result of both an increased incidence of comorbid diseases2,67, 68, 73 and the increased number of medications that they are prescribed (e.g., diuretics, electrolyte supplements, laxatives), the elderly population is at an increased risk of weakness from these causes. Measuring serum electrolyte levels as well as serum calcium, phosphate, and magnesium levels is an important part of the evaluation of weakness in these patients. Electrolyte disturbances such as hypophosphatemia, hypo- and hyperkalemia, hyper- and hypocalcemia, hyper- and hypomagnesemia, and hyper- and hyponatremia may cause or contribute to weakness. These electrolyte imbalances may be a direct result of the medications the patient is taking or of a chronic indolent decrease in renal function. Studies investigating serum electrolyte abnormalities have included weakness as a qualifying criterion for investigating serum electrolyte levels.42One study showed a 16% incidence of electrolyte abnormalities in elderly patients admitted to the hospital.66 Dehydration alone may cause weakness in the elderly. Dehydration usually is due to decreased fluid intake or increased fluid losses, both of which can be important in this age group. As with electrolyte disturbances, medications (particularly diuretics) can play a role in the hydration status of the patient. An altered baseline mental status may contribute to decreased oral intake of fluids. Impaired communication, feeding and swallowing disorders, depression with decreased intake, poor dietary and oral fluid intake can initiate or exacerbate a patient’s hydration Other contributing factors include worsening renal function. With a decreased ability to concentrate urine may come dysfunction in vasopressin regulation and neurotransmitter and endogenous opioid changes, which may play a role in volume regulation.38,55, 63 Drug Interactions and Substance Abuse

The elderly population has an increased incidence of diseases that require pharmacologic intervention.2,67, 73 The number of medications used by the ambulatory elderly population in some studies is two to three times the amount used by the younger population, and may be up to five times higher in nursing home residents4,45 Obviously, this use of medications increases the risk of potential adverse drug reactions.25, Many drugs can cause weakness either directly or indirectly. Diuretics may cause electrolyte abnormalities, such as hypokalemia or dehydration, causing muscle weakness. Orthostatic hypotension may be caused by antihypertensives (beta-blockers, diuretics), whereas antipsychotics, antidepressants, and sedative-hypnotics such as benzodiazepines or nar-

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cotics may result in a subjective feeling of weakness." Systemic steroids causing steroid myopathies can also directly cause muscle weakness.39 Drug abuse, dependence, and withdrawal often go unrecognized in elderly patients, and may be causes of weakness. Benzodiazepines and other psychoactive drugs are widely prescribed to the elderly population, with studies showing that up to 25% of elderly patients were 53 Owing to the altered pharmacokinetics, prescribed these medications.20* pharmacodynamics, and cerebral response to these medications in the elderly, there is an increased sensitivity to their clinical effects and Signs and symptoms of benzodiazepine toxicity include drowsiness, respiratory depression, confusion, and weakness. Alcohol withdrawal can also manifest itself as weakness in the elderly.l0Alcoholism has been shown in some studies to affect a significant proportion of elderly patients in the ED, with estimates of up to 14%.', 71 Withdrawal can express itself in various signs and symptoms, including tremors, weakness, nausea, vomiting, fever, hypertension, tachycardia, and tachypnea. Elderly patients may suffer an increase in alcohol withdrawal symptoms, with increased cognitive impairment, somnolence, and weakness.l0 A careful history probing the use of prescription drug use and alcohol consumption is useful in determining the cause of weakness in the elderly patient. Age-related Weakness, Muscle Atrophy, and Malnutrition

The physiology of aging causes declines in function in all organ systems, including the musculoskeletal system. It is well documented that there is a decrease in muscle mass in the elderly owing to a reduction of both the size and number of muscle fibers.", 28, 41 This decrease in muscle mass leads to a proportional decrease in muscle strength and force generated, which may lead to a subjective feeling of weakness. Further confounding factors include history of recent inactivity or bedrest. Muscle strength declines with inactivity, with reported One week of bedrest losses of 1%to 3% for every day of imm~bility.~~ for any reason will cause a 7% to 20% decline in muscle strength, resulting in objective signs of weakness. Elderly patients who start with less muscle mass are particularly prone to these effects of immobility. Nutrition also plays an important role in strength and conditioning. Many factors predispose the elderly to decreased nutritional intake and malnutrition, including chronic disease states (cancer, pulmonary and cardiac diseases), medications, dementia, and depression.22,52, 72* 75 Decreased nutritional intake or anorexia can cause weakness directly through muscle wasting, also causing weaknes~.'~ Malnutrition can also cause impaired immunocompetence and an increase in complications from chronic disease states, predisposing patients to indirect causes of weakness such as sepsis or myocardial infar~ti0n.l~ Difficult to diagnose in the ED, these effects of age-related muscle wasting, immobility, and

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malnutrition can be surmised with a careful history and physical examination.

Autonomic Dysfunction Causing Hypotension Hypotension of any etiology may cause weakness, as well as a constellation of other symptoms such as fatigue, dizziness, lightheadedness, and syncope. In addition to orthostatic hypotension as a result of dehydration and medications, elderly patients are susceptible to other causes of hypotension, including postural hypotension secondary to autonomic neuropathy and postprandial hypotension.%,57 Autonomic neuropathy, whether it is due to primary failure or secondary to other disease states (e.g., diabetes) can affect both vasomotor and cardiac nerves.14As a result, the ability of the body to compensate for intravascular pooling in the peripheral circulation on standing by increasing heart rate or peripheral vascular resistance is impaired.30 Postprandial hypotension (the hypotensive effect of meal ingestion) affects the elderly population preferentially5,35, 54, 56 Although the mechanism for this hypotension is uncertain, an inadequate response to splanchnic blood pooling is the general explanation for this phenomen01-t.~~ This syndrome occurs primarily in elderly people with hyperten47, 60, 8o sion, diabetes, renal failure, and Parkinson’s di~ease.~,

Guillain-Barre Syndrome Classic Guillain-Barri. syndrome is usually characterized by antecedent illness (e.g., URI or gastroenteritis symptoms) followed days but usually weeks later by neurologic sequelae such as ascending weakness. The incidence is approximately 1.1 in 100,000, with no particular predilection for any age group. This demyelinating disease may be linked to autoimmune destruction of peripheral nerve myelin sheaths. It typically presents with symmetric ascending motor weakness that progresses over a period of days to weeks. Other symptoms can be present, such as paresthesias and cerebellar signs, as well as cranial neuropathies causing diplopia and facial weakness. In advanced cases, the potential for respiratory compromise is real, and respiratory status should be monitored closely. Although one might expect the elderly population to present in a different manner secondary to the waning immune and musculoskeletal system, one study has shown that this is not the case.6 The elderly population presents similarly to the younger population, with proximal limb weakness and areflexia, although bulbar and cerebellar finding were less common. Antecedent illness was also less common among the elderly. The study also concludes that the prognosis for recovery is independent of age. Respiratory status should be assessed and moni-

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tored closely because severe respiratory compromise, leading to intubation and assisted ventilation, can occur in 15% to 30% of patients. Myasthenia Gravis and Cholinergic Crisis

Myasthenia gravis is another autoimmune disease that affects the neuromuscular junction and can present as weakness. Age at onset is usually 20 to 30 years for women and 40 to 50 years for men with a prevalence of 1.5 in 100,000. Acetylcholine receptor antibodies are produced, which block the receptors at the motor endplate, causing muscular weakness. Typical myasthenic crisis presents with muscle weakness (usually bulbar, i.e., ptosis and diplopia, but can also be limb weakness) that worsens with use and exercise, and improves with rest. Symptoms usually progress over weeks to months. On examination, muscle weakness (proximal more than distal and symmetric) may be present, as well as the aforementioned bulbar signs. A patient with myasthenia gravis presenting with acutely worsening weakness may be experiencing either a myasthenic or a cholinergic crisis. The elderly population may be susceptible to either. Anything that can alter muscle responsiveness may have an adverse affect. Concurrent medications that may alter electrolyte imbalances, muscle responsiveness, or drug activity levels, either directly or indirectly, can precipitate either crisis. Elderly patients with their increased incidence of multiple medication usage, decreased mental status (which can lead to decreased medical compliance) can be at increased risk for these types of crisis. Patients in both types of crisis will present with severe muscular weakness, but the cholinergic crisis is characterized by symptoms suggestive of excess cholinergic activity. Signs and symptoms such as sweating, salivation, lacrimation, miosis, tachycardia, and GI upset can be present. Eaton Lambert Syndrome is a paraneoplastic syndrome that can mimic myasthenia gravis on presentation, with limb and girdle weakness. It is associated with carcinoma of the lung and is postulated to be due to a defect in presynaptic acetylcholine release in the neuromuscular junction. Polymyalgia Rheumatica

PoZymyalgia rkeumatica is a clinical syndrome of muscle pain and stiffness that is found predominantly in the elderly population, with an incidence of 50 new cases per 100,000 per year in patients greater than 50 years of age.15 It is a diagnostic challenge because of the lack of rigorous diagnostic criteria7,29, 37 and the frequency of presentation with atypical symptoms. Typically, polymyalgia rheumatica is characterized by pain and morning stiffness in the neck, shoulder, and pelvic girdle. Atypical symptoms include mild muscle weakness, distal extremity pain,

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and synovitis.15,29, 48 Weakness is generally regarded as a finding incompatible with polymyalgia, but unwillingness or inability to use muscles can lead to secondary weakne~s.~ One small study, however, showed weakness accompanying myalgias in up to 28% of patientsA8 Symptom onset occurs over the course of days to weeks. Polymyalgia rheumatica is also associated with temporal arteritis, with some studies showing an association of 15% to 20% of temporal arteritis with polymyalgia rhe~matica.'~, 33 Diagnosis of polymyalgia rheumatica is not universally agreed on7 29,37 because it relies greatly on the history and physical examination, and a few laboratory tests, which, if negative can eliminate diseases that present in a similar manner (eg., rheumatoid arthritis, SLE, polymyositis). In cases of polymyalgia rheumatica, a dramatic response to lowdose corticosteroid therapy (often within 24 to 48 hours) is characteristic. A positive response to steroid therapy is now considered an important feature in making the diagnosis.

Hypothyroidism and Adrenal Insufficiency

Thyroid failure from any cause (primary, secondary, or tertiary) can cause hypothyroidism, which can present as myriad nonspecific symptoms, including paresthesias, fatigue, cold intolerance, weakness, weight gain, and musculoskeletal pain. Hypothyroidism has an increased predilection for women and has a peak incidence in the seventh decade.70As in other diseases in the elderly, the initial presentation can also be altered. Studies have shown that there is a lack of clinical signs or symptoms in elderly patient^.^,^* In one prospective study, there was a decrease in the clinical signs as well as a decreased incidence of four classic signs: chilliness, paresthesias, weight gain, and cramps, making the diagnosis extremely difficult to make.I6 Weakness and fatigue were the two symptoms most frequently reported, however. Adrenal insufficiency is another endocrine cause of weakness that may be encountered in the elderly population. Weakness and fatigue has been reported in up to 95% of patients with acute adrenal insufficiency. Exogenous steroid administration that suppresses the hypothalamic pituitary axis is the commonest cause of adrenal insuffi~iency.~~ An acute stressor causing an exacerbation of a chronic adrenal insufficiency can precipitate an adrenal crisis, however. Examples of such stressors include myocardial infarction, diabetes mellitus, surgery, infection, and ETOH intoxication. Other causes of adrenal insufficiency include metastatic infiltration of the adrenal gland. The elderly population is at increased risk for suffering from adrenal insufficiency owing to the increased incidence of illnesses that require exogenous steroids, metastatic cancer, and the co-morbid diseases listed earlier that may cause an exacerbation of a chronic insufficiency.

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CONCLUSION

The diificult or challenging patients in the ED are those with very nonspecific complaints. Unfortunately, elderly patients, owing to their altered physiology, for whatever reason will often present with nonspecific or vague complaints. The weak and elderly patient without focal findings on history and physical examination is one of those challenges. The authors have suggested an approach to this type of patient that is hoped can serve as a rational guideline in the work-up. A thorough history and physical examination with complete neurologic evaluation and selected laboratory tests (CBC, Chem-7, ECG, UA, and chest x-ray) can serve as an aid in their disposition. Ultimately, however, disposition will most likely be based on clinical intuition, with psychosocial problems as well as subjective and objective physical and laboratory findings being taken into account. References 1. Adams WL, Magruder-Habib K, Trued S, et al: Alcohol abuse in elderly emergency department patients. J Am Geriatr SOC40:1236-1240, 1992 2. Aguirre FV, McMahon RP, Mueller H: Impact of age on clinical outcome and postlytic management strategies in patients treated with intravenous thrombolytic therapy: Results from the TIM1 I1 study. Circulation 90:78-86, 1994 3. Bahemuka M, Hodkinson HM: Screening for hypothyroidism in elderly inpatients. Br Med J 2:601403, 1975 4. Beers MH, Storrie M, Lee G: Potential adverse drug interactions in the emergency room. AM Intern Med 112:61-64, 1990 5. Bellomo G, Santucci S, Aisa G, et al: Meal-induced arterial blood pressure variations in the elderly. Gerontology 34311-314, 1988 6. Bercoff E: Does age play a role in clinical presentation of hypothyroidism? J Am Geriatr SOC42984-986, 1994 7. Bird HA, Esselinckx W, Dixon AS, et al: An evaluation of criteria for polymyalgia rheumatica. Ann Rheum Dis 38434439, 1979 8. Bradley SF, Kluger MJ, Kauffman CA: Age and protein malnutrition: Effects on the febrile response. Gerontology 33:99-108, 1987 9. Brooks RC, McGee SR Diagnostic dilemmas in polymyalgia rheumatica. Arch Intern Med 157162-168, 1997 10. Brower KJ, Mudd S, Blow FC, et a1 Severity and treatment of alcohol withdrawal in elderly versus younger patients. Alcoholism: Clinical and Experimental Research. 18:196-201, 1994 11. Brown M, Hasser EM: Complexity of age-related change in skeletal muscle. J Gerontol 51zB117-123, 1996 12. Castle SC, Norman DC, Yeh M, et al: Fever response in elderly nursing home residents: Are the older truly colder? J Am Geriatr SOC39:853-857, 1991 13. Chapman KM, Nelson RA: Loss of appetite: Managing unwanted weight loss in the older patient. Geriatrics 49:5459, 1994 14. Christensen NJ: Catecholamines and diabetes mellitus. Diabetologia 16:211-224, 1979 15. Chuang TY, Hunder GG, Ilstrup DM, et al: Polymyalgia rheumatica: a 10-year epidemiologic and clinical study. Ann Intern Med 11:471483, 1982 16. Doucet J, Trivalle C, Chassagne P, et al: Cardiovascular disease in elderly patients. Mayo Clin Proc 71:184-196, 1996 17. Duncan AK, Vittone J, Fleming KC, et al: Cardiovascular disease in elderly patients. Mayo Clin Proc 71:184-196, 1996

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18. Eliastam M Elderly patients in the emergency department. Ann Emerg Med 18:12221229, 1989 19. Evans WJ: Exercise, nutrition and aging. Clin Geriatr Med 11:725-734, 1995 20. Finlayson RE, Davis LJ: Prescription drug dependence in the elderly population: Demographic and clinical features of 100 inpatients. 21. Fontanarosa PB, Kaeberlein FJ, Gerson LW, et al: Difficulty in predicting bacteremia in elderly emergency patients. Ann Emerg Med 21:842-848, 1992 22. Fredrix EW, Soeters PB, Rouflart MJ, et a1 Resting energy expenditure in patients with newly detected gastric and colorectal cancers. Am J Clin Nutr 53:1318-1322, 1991 23. Gleckman R, Hibert D Afebrile bacteremia-a phenomenon in geriatric patients. JAMA 248:1478-1481, 1982 24. Goldberg RJ, Gore JM, Gunvitz JH, et al: The impact of age on the incidence and prognosis of initial myocardial infarction: The Worchester Heart Attack Study. Am Heart J 117543-549, 1989 25. Gosney M, Tallis R Prescription of contraindicated and interacting drugs in elderly patients admitted to hospital. Lancet 2564-567, 1984 26. Grimby G, Saltin B: The aging muscle. Clin Physiol3:209-218, 1983 27. Halar EM, Bell K R Contracture and other deleterious effects of immobility. In Rehabilitation Medicine: Principles and Practice. Philadelphia, WB Saunders, 1990, pp 11131133 28. Harper CM, Lyles YM: Physiology and complications of bed rest. J Am Geriatr SOC 36:1047-1054, 1988 29. Healey LA: Long-term follow-up of polymyalgia rheumatica: Evidence for synovitis. Semin Arthritis Rheum 13:322-328, 1984 30. Hilsted J: Blood pressure regulation in diabetic autonomic neuropathy. Clin Physiol 5:49-58, 1985 31. Holloway WJ: Management of sepsis in the elderly. Am J Med 80143-148, 1986 32. Hurley J R Thyroid disease in the elderly. Med Clin North Am 67497-516, 1983 33. Huston KA, Hunder GG, Lie JT, et al: Temporal arteritis: A 25-year epidemiological, clinical, and pathologic study. Ann Intern Med 88:162-167, 1978 34. Jansen RW, Hoefnages W H Influence of oral and intravenous glucose loading on blood pressure in normotensive and hypertensive elderly subjects. J Hyperten 5:501-503,1987 35. Jansen RW, Lenders JW, Thien T: Antihypertensive treatment and postprandial blood pressure reduction in the elderly. Gerontology 95:363-368, 1987 36. Jansen RW, Lipsitz L A Postprandial hypotension: Epidemiology, pathophysiology, and clinical management. Ann Intern Med 122:286-295,1995 37. Jones JG, Hazleman BL: Prognosis and management of polymyalgia rheumatica. Ann Rheum Dis 401-5, 1981 38. Kirkland J, Lye M, Goddard F: Plasma arginine vasopressin in dehydrated elderly patients. Clin Endocrinol 20:451456, 1984 39. Lacomis D, Samuels MA: Adverse neurologic effects of glucocorticosteroids. J Gen Intern Med 6:367-377, 1991 40. Lechin F, van der Dijs B, Benaim M Benzodiazepines: Tolerability in elderly patients. Psychother Psychosom 65171-182, 1996 41. Lexell J, Taylor CC, Sjostrom: What is the cause of the aging atrophy? Total number, size and proportion of different fiber types studied in whole vastus lateralis muscle from 15- to 83-year-old men. J Neurol Sci 84275-294, 1988 42. Lowe RA, Wood AB, Bumey RE: Rational ordering of serum electrolytes: Development of clinical criteria. Ann Emerg Med 16260-269, 1987 43. Marco CA, Schoenfeld CN, Hansen KN, et al: Fever in geriatric emergency patients: Clinical features associated with serious illnesses. Ann Emerg Med 2618-24, 1995 44. McCue JD: Gram-negative bacillary bacteremia in the elderly: Incidence, ecology, etiology, and mortality. J Am Geriatr SOC35213-218, 1987 45. Medicare: Prescription drug issues: Report to the chairman, special committee on aging, US Senate. Washington DC, General Accounting Office, 1987 46. Meyers RB, Sherman E, Mendelson MH: Bloodstream infections in the elderly. Am J Med 86:379-384, 1989

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Address reprint requests to Diane M. Birnbaumer, MD Department of Emergency Medicine Harbor-UCLA Medical Center 1000 W. Carson Street, Box 21 Torrance, CA 90509