Acute appendicitis is a common surgical emergency that traditionally presents with well-characterized symptoms such as right lower quadrant pain, fever, and leukocytosis. However, the clinical landscape of appendicitis undergoes a significant transformation in older adults, where the condition not only becomes less frequent but also considerably more dangerous. In individuals aged 65 years and above, acute appendicitis is often underdiagnosed or misdiagnosed, leading to delayed treatment and disproportionately high rates of complications, including perforation, abscess formation, generalized peritonitis, and mortality [1,2].

Aging is accompanied by a series of physiological and immunological changes that obscure the classical symptomatology of abdominal diseases. Diminished inflammatory response, sensory blunting, comorbid chronic illnesses (e.g., diabetes mellitus, cardiovascular disease), and altered mental status can all contribute to atypical or even silent presentations of acute appendicitis in the elderly [3,4]. Consequently, while younger patients typically report a classic migratory pattern of abdominal pain from the periumbilical region to the right iliac fossa, older adults are more likely to present with non-specific or misleading signs such as generalized abdominal discomfort, anorexia, constipation, lethargy, urinary symptoms, or even confusion and delirium [5].

This atypical presentation poses a diagnostic dilemma for clinicians. Elderly patients are more likely to be initially misdiagnosed with conditions such as urinary tract infection, diverticulitis, mesenteric ischemia, or gastroenteritis. These delays in diagnosis are not benign. Multiple studies, including population-level analyses and global evaluations like the POSAW study, have shown that elderly patients are at markedly increased risk of perforation, sepsis, and death from appendicitis, with mortality rates ranging between 5–15%, compared to <1% in younger patients [6,7].

From a diagnostic standpoint, traditional tools such as the Alvarado score or reliance on laboratory markers like leukocytosis and C-reactive protein (CRP) are less reliable in older adults due to altered immune responses and atypical lab profiles. In this context, imaging—particularly contrast-enhanced computed tomography (CT)—has emerged as a diagnostic cornerstone, offering high sensitivity and specificity and enabling timely surgical intervention [8].

Therapeutically, laparoscopic appendectomy has revolutionized the management of appendicitis, providing minimally invasive access with reduced postoperative pain, fewer wound infections, shorter hospital stays, and faster recovery times—even in elderly patients with comorbidities [9]. Meanwhile, recent trials have explored non-operative management (NOM) with antibiotics in select elderly patients deemed unfit for surgery. While NOM offers an alternative to high-risk surgery, it is associated with recurrence rates of up to 30% within the first year and raises concerns regarding missed diagnoses of neoplastic appendiceal pathology in the elderly [10].

By synthesizing recent evidence from randomized trials, meta-analyses, and international guidelines, this review underscores the urgent need for greater awareness of age-specific disease presentation and a multidisciplinary, evidence-based approach to managing acute appendicitis in the growing elderly population.

This review aims to (1) describe atypical clinical presentations of acute appendicitis in elderly patients, (2) evaluate contemporary diagnostic and therapeutic strategies, and (3) propose geriatric-specific management recommendations.

This was a prospective observational study conducted in the Department of General Surgery at Meenakshi Medical College, Kanchipuram, Tamil Nadu, India, over a period of 18 months from January 2023 to June 2024. The study was approved by the Institutional Ethics Committee.

Study Population

The study included elderly patients aged ≥60 years who were diagnosed with acute appendicitis either clinically or radiologically and underwent surgical or conservative management.

Inclusion Criteria

• Patients aged 60 years and above.
• Clinical features suggestive of acute appendicitis (right lower quadrant pain, fever, leukocytosis).
• Radiological confirmation via ultrasound or CT abdomen.
• Patients who underwent either operative or non-operative management.

Exclusion Criteria

• Patients with chronic abdominal conditions mimicking appendicitis.
• Patients who refused consent.
• Cases with incidental appendiceal findings during surgery for other conditions.

Data Collection

Data was collected using a pre-structured proforma including:

• Demographic details: Age, sex, comorbidities.
• Clinical presentation: Symptoms, duration, atypical features (e.g., confusion, urinary symptoms).
• Diagnostic modalities: Laboratory parameters, ultrasound findings, CT scans.
• Management approach: Conservative management (antibiotics, observation) or surgical (open or laparoscopic appendectomy).
• Intraoperative findings: Appendix location, perforation, gangrene, abscess.
• Postoperative outcomes: Complications, length of hospital stay, mortality.

Outcome Measures

• Incidence of atypical presentations.
• Diagnostic delay and its correlation with complications.
• Surgical outcomes and postoperative morbidity.
• Effectiveness of conservative vs. surgical treatment in selected cases.

Statistical Analysis

Data was entered into Microsoft Excel and analyzed using SPSS version 26.0. Descriptive statistics were used to summarize categorical and continuous variables. Chi-square test and t-test were used to compare outcomes between groups. A p-value of <0.05 was considered statistically significant.

Presentation: Only 25-40% of elderly patients exhibit classic signs; many experience vague discomfort, confusion, or decline in function. Diagnosis: Laboratory markers (e.g., leukocytosis, CRP) are less predictive; normal values are common. Contrast-enhanced CT offers >95% sensitivity and specificity. Intervention: Laparoscopic appendectomy is favored for its reduced wound infections, quicker ambulation, and lower pain scores compared to open surgery. Medical Management: Antibiotic therapy alone may be an option in high-risk cases but is associated with a recurrence rate of ~30% within a year. Outcomes: Mortality rates in elderly appendicitis patients are 4-8 times higher than in younger individuals. Early mobilization, optimised pulmonary function, and delirium prevention are crucial.

Table 1: Clinical Presentation of Appendicitis in Elderly Patients

Table 2: Diagnostic Accuracy of Laboratory and Imaging Tools in Elderly

Table 3: Management Strategies and Outcomes in Elderly with Appendicitis

Table 4: Postoperative Complications in Elderly vs. Younger Adults

Table 5: Comparative Summary – Key Differences in Appendicitis by Age Group

In geriatric populations, appendicitis often mimics other common abdominal and systemic conditions, necessitating a high index of suspicion. The absence of classical signs should not delay imaging, especially when patients present with unexplained deterioration in functional status or altered mental state. Relying on clinical scoring systems alone (e.g., Alvarado Score) may be misleading in this demographic due to atypical symptom profiles and confounding comorbidities [11-16].

CT imaging remains the gold standard and should be employed liberally in the elderly to reduce diagnostic uncertainty. When diagnosed early, laparoscopic appendectomy is the optimal intervention. However, its feasibility must be assessed case-by-case based on comorbidities, frailty index, and intraoperative findings. [17]

While some studies advocate for antibiotic-first approaches, these are best reserved for patients with significant surgical risks. Current evidence does not yet support it as a default treatment modality for older adults with uncomplicated appendicitis, especially given recurrence and re-hospitalization rates. [18]

Importantly, a multidisciplinary approach—involving surgeons, anesthesiologists, geriatricians, nutritionists, and physiotherapists—greatly enhances perioperative care and reduces mortality. Geriatric-specific care bundles including early mobilization, respiratory therapy, tight glucose control, and minimization of sedatives can mitigate age-associated surgical risks [19].

The management of appendicitis in older adults demands a high level of clinical suspicion and judicious use of diagnostic imaging. Laparoscopic appendectomy remains the preferred intervention when feasible, offering better outcomes than open surgery. Non-operative management, while an option for select individuals, requires careful selection and robust follow-up due to recurrence risks. Finally, integrating geriatric principles into perioperative care is crucial to improving recovery trajectories and reducing postoperative complications in this vulnerable population.

Acute appendicitis in older adults presents diagnostic and management challenges due to its atypical clinical presentation and high risk of complications. Early CT imaging, timely laparoscopic surgery, and comprehensive geriatric perioperative care form the cornerstone of optimal management. Increased awareness and adherence to age-specific protocols can significantly improve survival and postoperative recovery in this vulnerable population.

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