What are the signs of sepsis in geriatric patients?

Signs of Sepsis in Geriatric Patients

Geriatric patients often present with atypical signs of sepsis, with changes in functional status being the most common presentation rather than classical fever and other typical symptoms.

Atypical Presentations

• Mental Status Changes:

  • New onset or worsening confusion or altered mental status 1, 2
  • Delirium 2
  • Agitation or aggression (new or worsening) 1

• Functional Decline:

  • Decreased mobility 1, 2
  • Falls (new or increased frequency) 1, 2
  • Decreased functional status or activities of daily living 1, 2
  • Failure to cooperate with staff 1

• Altered Continence:

  • New or worsening incontinence 1, 2

Temperature Changes

• Modified Fever Definition for Geriatrics:
  • A single oral temperature ≥37.8°C (100°F) 1, 2
  • Repeated oral temperatures ≥37.2°C (99°F) 1, 2
  • Rectal temperature ≥37.5°F (99.5°F) 1, 2
  • An increase in temperature of ≥1.1°C (2°F) over baseline 1, 2
  • Hypothermia (core temperature <36°C) may also indicate sepsis 1

Cardiovascular Signs

• Blood Pressure Changes:

  • Systolic blood pressure <90 mmHg 1, 2
  • Mean arterial pressure <70 mmHg 1, 2
  • Decrease in systolic blood pressure >40 mmHg from baseline 1, 2

• Other Cardiovascular Signs:

  • Heart rate >90 beats per minute or >2 standard deviations above normal for age 1
  • Decreased capillary refill or skin mottling 1, 2

Respiratory Signs

• Breathing Pattern Changes:
  • Tachypnea: >30 breaths per minute 1
  • Arterial hypoxemia (PaO₂/FiO₂ <300) 1, 2
  • Dyspnea 1

Laboratory Findings

• Inflammatory Markers:

  • Elevated C-reactive protein or procalcitonin >2 standard deviations above normal 1, 2
  • Hyperlactatemia (>3 mmol/L) 1, 2

• Organ Dysfunction Markers:

  • Acute oliguria (urine output <0.5 mL/kg/h for ≥2 hours) 1, 2
  • Creatinine increase ≥0.5 mg/dL 1, 2
  • Coagulation abnormalities (INR >1.5 or aPTT >60 seconds) 1
  • Thrombocytopenia (<100,000/μL) 1, 2
  • Hyperbilirubinemia (total bilirubin >4 mg/dL or >70 μmol/L) 1, 2

Gastrointestinal Signs

• Digestive System Changes:
  • Absence of bowel sounds (ileus) 1, 2
  • Decreased fluid intake 1
  • Decreased dietary intake 1
  • Nausea with or without vomiting 1

Urinary Signs

• Urinary Changes:
  • Change in urine color or odor 1
  • Cloudy urine 1
  • Decreased urinary output 1
  • Urinary retention 1

Other Important Considerations

• Infection is present in 77% of episodes of "functional decline" in geriatric patients 1, 2
• Sepsis in older adults is often associated with urinary tract infections, which are the most common cause of sepsis in this population 3
• Pneumonia is the second most common cause of sepsis in elderly patients and carries the highest mortality 3
• Absence of typical signs does not rule out sepsis - the only clue may be subtle changes like failure to eat 3
• Older adults are at higher risk of death from sepsis due to preexisting conditions and delayed diagnosis 4

Clinical Pitfalls to Avoid

• Do not wait for fever to suspect sepsis in geriatric patients, as they may present with normal or even low temperatures 1
• Do not dismiss subtle changes in mental status or function as "normal aging" - these may be the earliest signs of sepsis 1, 2
• Do not delay antibiotic therapy when sepsis is suspected - time from initial presentation to first antibiotic dose should not exceed one hour 3
• Do not overlook the possibility of sepsis in patients with nonspecific complaints such as weakness, malaise, or fatigue 1
• Do not rely solely on standard laboratory values, as elderly patients may have altered baseline values 2