What is the management for an elderly female patient with intermittent epistaxis (nosebleed)?

Management of Intermittent Epistaxis in an Elderly Female Patient

For an elderly female with intermittent epistaxis, begin with patient education on preventive measures and home management using firm nasal compression for 5-10 minutes, followed by regular application of nasal moisturizers (petroleum jelly or saline gel), while documenting critical risk factors including anticoagulant use, hypertension, and bleeding disorders that are particularly prevalent in this age group. 1, 2

Initial Assessment and Risk Stratification

Document Critical Risk Factors

Since this is intermittent (not active) bleeding, focus on identifying factors that increase bleeding frequency or severity:

• Anticoagulant/antiplatelet medications (warfarin, aspirin, clopidogrel) - present in 15% of epistaxis patients and dramatically increase severity 2, 3
• Hypertension - present in 33% of epistaxis patients and independently associated with more severe bleeding requiring emergency intervention 2, 3
• Personal or family history of bleeding disorders - including von Willebrand disease or hemophilia 1
• Intranasal drug use - including nasal oxygen, CPAP, or topical medication overuse 1, 2
• Prior nasal/sinus surgery - can create vulnerable bleeding sites 2
• Chronic kidney or liver disease - affects coagulation 2

Assess for Hereditary Hemorrhagic Telangiectasia (HHT)

If the patient reports recurrent bilateral nosebleeds or has a family history of recurrent nosebleeds, refer to a specialist to assess for nasal and oral mucosal telangiectasias. 1, 2

Patient Education: Preventive Measures

Daily Nasal Moisturization (Primary Prevention)

• Apply petroleum jelly or nasal saline gel to the anterior nasal septum daily - this simple intervention achieved 93.2% cessation of recurrent epistaxis at 3 months in anticoagulated elderly patients 4, 2
• Use saline nasal sprays regularly to maintain mucosal moisture 1, 2
• Consider a humidifier in dry environments, especially important for elderly patients on nasal oxygen 2

Home Management Instructions for Active Bleeding Episodes

Teach the patient and caregivers this exact sequence:

1. Sit upright with head tilted slightly forward (not backward) - prevents blood from entering the airway or being swallowed 1, 2
2. Apply firm, continuous compression to the soft lower third of the nose for 10-15 minutes without checking - this stops 90-95% of nosebleeds 1, 5
3. Breathe through the mouth and spit out any blood rather than swallowing it 2

When to Seek Medical Attention

Instruct the patient to seek care if:

• Bleeding does not stop after 15 minutes of continuous proper compression 1, 2
• Bleeding duration exceeds 30 minutes over a 24-hour period - this meets the threshold for "severe epistaxis" 1, 2
• Signs of hemodynamic compromise - dizziness, weakness, pallor, or lightheadedness 2

Management During Office Visit (If Patient Presents)

Step 1: Anterior Rhinoscopy

Perform anterior rhinoscopy after removing any blood clots to identify the bleeding source - this is essential before any intervention 1, 2

Step 2: Targeted Treatment Based on Identified Site

If a specific bleeding site is identified:

• Apply topical vasoconstrictors (oxymetazoline or phenylephrine) directly to the site - resolves 65-75% of cases 2, 6
• Perform nasal cautery after anesthetizing the area with topical lidocaine or tetracaine, restricting application only to the active bleeding site 1, 2
• Avoid bilateral septal cautery to prevent septal perforation 2

Step 3: Consider Nasal Endoscopy

For recurrent epistaxis despite prior treatment, perform or refer for nasal endoscopy to examine the nasal cavity and nasopharynx, as elderly patients have higher rates of posterior epistaxis and unrecognized pathology 1, 2

Special Considerations for Elderly Patients

Critical Management Pitfalls to Avoid

DO NOT routinely lower blood pressure acutely during active epistaxis - excessive reduction can cause or worsen renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension 2. Instead, monitor blood pressure and make decisions based on bleeding severity and individual comorbidities 2.

If patient is on anticoagulation:

• Check INR if on warfarin to evaluate therapeutic range 2
• Use resorbable packing materials (Nasopore, Surgicel, Floseal) if packing is needed 1
• In the absence of life-threatening bleeding, initiate first-line local treatments (compression, vasoconstrictors, cautery) BEFORE considering transfusion, reversal of anticoagulation, or medication withdrawal 1

Age-Related Considerations

• Elderly patients have dramatically higher rates of posterior epistaxis (more difficult to control, higher morbidity) and require lower threshold for endoscopic evaluation 2, 3
• 80.34% of geriatric epistaxis patients have accompanying systemic disorders that contribute to bleeding 3
• Advanced age itself increases epistaxis severity and complications independent of other factors 2

Follow-Up and Escalation

Document Outcome

Document the outcome of intervention within 30 days or document transition of care 1

Indications for Specialist Referral

Refer to otolaryngology if:

• Recurrent bleeding despite packing or cautery - evaluate candidacy for surgical arterial ligation or endovascular embolization 1
• Persistent bleeding not controlled by first-line measures 1, 2
• Concern for unrecognized pathology (mass lesion, especially with unilateral symptoms) 2