What are the causes of cold sweats and chills in an elderly woman?

Cold Sweats and Chills in Elderly Women: Causes and Evaluation

Cold sweats and chills in an elderly woman most commonly indicate serious bacterial infection requiring urgent evaluation, but acute coronary syndrome must also be considered as these are recognized symptoms of cardiac ischemia in this population.

Life-Threatening Causes Requiring Immediate Action

Acute Coronary Syndrome (ACS)

• Cold sweats are specifically identified as a commonly associated symptom of ACS in both men and women, with increased frequency of atypical presentations in elderly patients 1
• Elderly women frequently present with anginal equivalents rather than classic chest pain, including cold sweats, shortness of breath, nausea, and lightheadedness 1
• Diaphoresis (cold sweats) combined with hemodynamic instability represents a high-likelihood feature of ACS 1
• If cold sweats occur with any chest discomfort, arm pain, shortness of breath, or symptoms lasting >20 minutes, activate emergency medical services immediately 1

Sepsis and Bacteremia

• Bacterial infections with bacteremia carry 18-50% mortality in elderly patients, with 50% of deaths occurring within 24 hours despite appropriate therapy 2
• Cold sweats and chills (rigors) are classic manifestations of bacteremia and systemic infection 2, 3
• Altered mental status combined with cold sweats/chills indicates sepsis until proven otherwise 2, 3, 4
• Hypotension or shock accompanying these symptoms predicts bacteremia and significantly increases mortality 2

Most Common Infectious Causes

Urinary Tract Infection/Urosepsis

• Accounts for 50-55% of bacteremia cases in elderly patients 2
• May present with fever, shaking chills, and hypotension rather than classic dysuria 1
• Incidence of 0.1-2.4 cases per 1,000 resident-days in long-term care facilities 1

Pneumonia/Respiratory Tract Infection

• Accounts for 10-11% of bacteremias in elderly patients 2
• Occurs at 10-fold higher rate in nursing home residents compared to community-dwelling elderly 1
• Tachypnea >25 breaths/minute is 90% sensitive and 95% specific for pneumonia 3

Skin and Soft Tissue Infections

• Common in patients with diabetes mellitus, pressure ulcers, or functional limitations 3, 5
• Can progress rapidly to bacteremia in elderly patients 5

Critical Atypical Presentations in Elderly Women

Do not rely on fever alone—20-30% of elderly patients with serious infection may be afebrile 6

Nonspecific Functional Decline

• Infection is present in 77% of episodes of "functional decline" in geriatric patients 4
• New or worsening altered mental status is a common presentation of sepsis 3, 4
• Falls, decreased mobility, or new incontinence may be the only signs 4

Temperature Considerations

• Basal body temperatures in frail elderly are often lower than standard 37°C 2
• Fever definition: single oral temperature ≥37.8°C (100°F), repeated temperatures ≥37.2°C (99°F), or increase ≥1.1°C above baseline 2, 4

Immediate Diagnostic Approach

Within First Hour

• Obtain vital signs including temperature, heart rate, blood pressure, respiratory rate 1
• Assess mental status for new confusion or altered consciousness 2, 3
• Perform focused examination: respiratory rate, hydration status, skin examination, chest examination 3

Laboratory Evaluation (Within 12-24 Hours)

• Complete blood count with manual differential to assess bands and immature forms 1, 2
• Leukocytosis predicts mortality in bacteremia even without fever 1, 2
• Blood cultures before antibiotics if signs of sepsis present 2, 3
• Urinalysis first—only obtain urine culture if pyuria present (do not culture asymptomatic bacteriuria, which occurs in 15-50% of elderly) 1, 2

Additional Testing Based on Presentation

• ECG if any concern for ACS (cold sweats with chest discomfort, arm pain, shortness of breath, nausea) 1
• Lactate level if sepsis suspected 3, 4
• Chest radiograph if respiratory symptoms or tachypnea present 3

Noninfectious Causes to Consider

In Patients with Underlying Diseases

• Rheumatic diseases and vasculitis (including temporal arteritis and polymyalgia rheumatica) account for 25-31% of fever cases in elderly 5, 7
• Solid tumors and hematological malignancies account for 12-20% 5, 7
• Drug-related fever occurs in 6% of cases 7

Key Distinction

• Elderly patients with no underlying diseases generally have infectious causes 5
• Noninfectious causes are responsible for fever in an important proportion (24%) of patients with underlying diseases 5

Transfer Criteria to Acute Care

Immediate transfer required if any of the following present 2, 3:

• Hemodynamic instability or hypotension (systolic BP <90 mmHg) 4
• Respiratory distress or tachypnea >25 breaths/minute 3
• Altered mental status or new confusion 2, 3
• Suspected bacteremia with high mortality risk 2
• Suspected ACS with symptoms >20 minutes 1

Critical Pitfalls to Avoid

• Do not attribute cold sweats and chills solely to age-related changes or baseline dementia—new symptoms combined with systemic signs indicate serious illness until proven otherwise 2
• Do not obtain urine cultures without urinalysis first, as asymptomatic bacteriuria is nearly universal in catheterized patients and present in 15-50% of non-catheterized elderly 1, 2
• Do not delay blood cultures if bacteremia is suspected—mortality is time-dependent 2
• Do not dismiss cardiac causes in elderly women presenting with atypical symptoms like cold sweats without chest pain 1