Here are some examples of atypical presentation of congestive heart failure in older patients. Note that the atypical presentation is in the history, not in the physical examination or chest x-ray.

1. An-83-year-old woman with dementia was noted to have episodes described as anxiety attacks in which she became quite agitated, tossed and turned continuously in bed, and had panting respirations. The attacks lasted for 10-15 minutes and subsided apparently spontaneously. On physical examination the patient had both tachypneic, tachycardia, an S3 gallop, and pulmonary rales during but not between attacks. EKG showed myocardial ischemia during one episode of anxiety, and a CXR taken shortly after an episode showed pulmonary edema.

   This case is an example of atypical presentation of both myocardial ischemia and consequent congestive heart failure. The patient did not describe either chest pain on shortness of breath. Indeed, her dementia limited her ability to describe symptoms in the same way a cognitively intact patient would. Dementia is a common cause of atypical presentation of disease in older patients.

2. A 92-year-old male was observed to be less attentive and less interested in eating. When his attention was engaged, he was found to be confused about time and location. Physical examination and chest x-ray were characteristic of congestive heart failure. With appropriate treatment of congestive heart failure, he returned to his baseline state of attentiveness and cognition, and his appetite returned to normal.

3. An-87-year-old woman was found to have blue toes by the nurse who also noted that she was becoming uncooperative and combative. Before coming to see the patient, the physician ordered a blood count, electrolytes, BUN and creatinine. The serum sodium was slightly low and the BUN and creatinine had increased from previous values. Physical examination and CXR were characteristic of congestive heart failure. The patient cooperation improved and the blue toes assumed normal color when the congestive heart failure was treated.

   These latter two case demonstrate how congestive heart failure can develop slowly and lead to more subtle symptoms. Note how often the brain bears the brunt of reduced perfusion. In the last case reduced perfusion also affected the distal extremities and the kidneys. Classic symptoms of congestive heart failure -- orthopnea, exertional dyspnea and paroxysmal nocturnal dyspnea -- were not present.