The Geriatrics “Profanisaurus.” Volume 2 –  The diagnostic myths that do not die

Dan Thomas is an ST5 based in the Mersey Deanery (HENW) and is the Clinical Quality Representative on the BGS Trainees Council. He tweets @dan26wales

In 2013 Professor David Oliver wrote a blog, the Geriatrics “Profanisaurus”, a list of words and phrases that should be banned, he encouraged other ‘BGS-ers to join in the fun and add their own “unutterables”.

My contribution to this list is some frequently encountered diagnoses that should be approached with scepticism.

‘Bilateral cellulitis’: If both legs are infected then the person should be unwell. Usually red legs are caused by a combination of underlying pathology; acute lipodermatosclerosis, venous hypertension, venous stasis dermatitis, lymphoedema or panniculits. The legs are hot and swollen but in the context of someone who is afebrile with minimal inflammatory response. The reason they are not responding to antibiotics is because they do not have an infection.

‘Loss of consciousness ?TIA:  A transient ischaemic attack is an episode of neurological deficit cause by focal ischaemia to the brain. Consciousness is maintained by the ascending reticular activating system which can’t be affected by one discrete thrombotic event.

‘Off legs/fall/Confusion – treat as UTI’:  – ‘UTI’ as a diagnosis can often be taken to mean ‘IDK’ (I don’t know). The list of presentations that UTI seems to cause is long and the term ‘acute trimethoprim deficiency syndrome’ has been adopted by some. When UTI diagnoses are audited then only 17- 40% meet recognised criteria. Urine dipstick should not be used to confirm a diagnosis of UTI in those over the age of 65 due to the prevalence of asymptomatic bacteriuria in this age group and the high false positive rates.

UTI is a clinical diagnosis; it should be symptom led not dipstick led. If a person has a UTI then they should have urinary symptoms (of which ‘smells strongly of urine’ is not) often with a fever and inflammatory response. A history of urinary symptoms can be difficult to obtain in older people with cognitive impairment. That is not a reason to make UTI the default diagnosis on ward round, resulting in the true cause of the person’s presentation being missed. No evidence exists that treating bacteriuria improve outcomes in people with delirium, falls and other geriatric syndromes.

‘Deterioration in Dementia’:  Dementia is a syndrome with numerous causes all of which have their own disease trajectories. It is neurodegenerative and for that reason most will usually progress over months to years, not hours to days. Often the diagnosis being missed is delirium, common in hospital settings, yet under recognised, with a 2-3 fold increase in length of stay, 2 fold increase in falls and 3 fold increase in mortality.  A cause needs to be rapidly identified and treated.

It is important that we challenge these diagnoses. Getting it wrong adversely affects patient care for example the frail older person with ‘urosepsis’ (wrongly diagnosed based on a positive dipstick) who develops pulmonary oedema secondary to aggressive fluid resuscitation, or the patient admitted for 48 hours of intravenous antibiotics for bilateral cellulitis who then deconditions on the ward resulting in a prolonged length of stay.

This blog should not be seen as a stick (dipstick?!) to beat the other specialties with. It is to start a discussion on how do we spread the message of good Geriatrics medicine beyond the bubble of twitter where hashtags such as #uroskeptic and #dontbeadipstick circulate.  Education as a sole intervention for anything rarely works, but then how else do we get the message across that diagnosis such as the ones above are rarely acceptable?

Read Professor David Oliver’s original BGS blog The Geriatrics “Profanisaurus.” Words and phrases we should ban?

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