ACUTE GERIATRICS Sepsis in the older person: The ravages of time and bacteria Ellen BURKETT , 1,2 Stephen PJ MACDONALD , 3,4,5 Christopher R CARPENTER , 6 Glenn ARENDTS , 3,5 Carolyn HULLICK , 7,8 Guruprasad NAGARAJ 9,10 and Tiffany M OSBORN 6,11 1 Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia, 2 School of Medicine, The University of Queensland, Brisbane, Queensland, Australia, 3 Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia, 4 Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia, 5 Discipline of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia, 6 Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA, 7 Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia, 8 Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia, 9 Emergency Department, Liverpool Hospital, Sydney, New South Wales, Australia, 10 School of Medicine, The University of Sydney, Sydney, New South Wales, Australia, and 11 Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA Pearl is an 84 year old woman in your ED with a 2 day history of leth- argy. She is usually cognitively intact and has a history of hypertension, congestive cardiac failure, mild renal impairment and Parkinson’s disease. She lives in an aged care facility and mobilises with a four-wheeled walker. She has a temperature of 37.9  C and feels lethargic. She has neither other specific symptoms nor signs, although appears confused. Her blood pressure (BP) is 90 systolic and she has a pulse of 70/min. Does Pearl have septic shock? If so, what is the source and how should we manage her? Why talk about sepsis in the older person? Sepsis is overwhelmingly a disease of older people (Fig. 1), with patients over 65 years of age accounting for two-thirds of sepsis cases. 1 With inci- dence rates increasing 20% faster than younger patients, older people account for the most rapid escalation of longitudinal incidence. 2 When presenting to the ED with sepsis, older people are more unwell, with higher levels of both potentially reversible organ dysfunction and mortality than younger people. 3 The association between age, severity of illness and comorbidities is complex. Although age, lactate and comorbid- ities are independently associated with mortality, each variable influ- ences outcomes of the others. 4 For survivors, sepsis is often a life- changing illness associated with high levels of morbidity, especially if severe enough to warrant admission to the ICU. Although sepsis mortal- ity in Australia and New Zealand has fallen steadily since 2000, the odds of being discharged to a reha- bilitation facility have increased three-fold in the same period. 5 One- third of survivors in two multicentre sepsis trials had not returned to their previous level of functioning at 6 months. 6 Prompt recognition is therefore important to optimise out- comes and minimise complications. 7 Age increases the risk of infection, bacteraemia as a result of infection and sepsis through many mecha- nisms (Fig. 2). Pearl may have any or all of the following: 8–10 • Immunosenescence with marked decline in cell-mediated and humoral immune function with increasing age • Lack of control of pro- inflammatory cytokines by anti- inflammatory mechanisms • An increased pro-coagulant state with resultant micro-thrombotic ischaemic organ injury, and sepsis-induced apoptosis • Comorbidities that increase expo- sure to infection (e.g. Pearl’s Parkin- son’s disease resulting in decreased cough reflex with increased risk of aspiration; reduced bladder empty- ing; increased falls and associated wounds and so on) and diminish physiological reserve (e.g. her car- diac failure) • Medications that may be associ- ated with immunosuppression or reduction in cardiopulmonary responses to infection • Increased rates of indwelling med- ical devices • Increased multiresistant organisms associated with increased rates of hospitalisation, institutionalised living and antibiotic use • Malnutrition and frailty. 11 Identification of sepsis in the older person Emergency physicians are taught that sepsis presents atypically in Correspondence: Dr Ellen Burkett, Department of Emergency Medicine, Princess Alex- andra Hospital, Ipswich Road, Wooloongabba, QLD 4102, Australia. Email: ellen. burkett@health.qld.gov.au Ellen Burkett, MBBS, FACEM, Senior Staff Specialist, Senior Lecturer; Stephen PJ Macdonald, BSc, MBChB, PhD, FRCP, FACEM, Senior Lecturer, Emergency Physi- cian; Christopher R Carpenter, MD, MSc, Emergency Physician, Associate Professor; Glenn Arendts, MBBS, MMed, PhD, FACEM, Associate Professor; Carolyn Hullick, BMed, DipPaed, FACEM, Emergency Physician; Guruprasad Nagaraj, FACEM, FRCEM, Emergency Physician; Tiffany M Osborn, MD, MPH, Professor. Accepted 10 January 2018 © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine Emergency Medicine Australasia (2018) 30, 249–258 doi: 10.1111/1742-6723.12949