Tiny Tips: weakness MADE NICER

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Editor’s Note: This is a great mnemonic developed by two Canadian medical students Anali Maneshi and Matthew Cherian. This tool serves as a framework for an approach to a common ED presentation. If you have a tiny tip for us please consider sending it along by following our author instructions here

Geriatric patients make up 20% of all visits to Canadian EDs (1). General weakness, which can have a large differential, is a common chief complaint expressed by geriatric patients in the ED (2). A good mnemonic to remember common etiologies for weakness in the elderly is:  “The elderly are MADE NICER.” A consistent framework allows students to produce a comprehensive list of differential diagnoses and focus their history and physical exam.

This mnemonic recognizes that most geriatric patients in the ED do not distinguish between true muscle weakness and generalized fatigue/malaise when using the word ‘weak.’



  • Glucocorticoids, statins, antipsychotics, diuretics, magnesium supplementation, insulin overdose and colchicine among others are commonly known to induce weakness. Make note of recent increases or decreases in dosages of medications such as benzodiazapenes, narcotics, neuroleptics…etc that can be culprits! Medication error, side effects, interactions and changes often result generalized weakness but can also present as true myopathies.


  • Due to occult bleeding, chronic disease, malignancies, and nutritional deficiencies.


  • Hypovolemia, often secondary to diarrhea, diuretics, or vomiting, can manifest as fatigability, postural dizziness, lethargy and/or confusion.


  • Hypoglycemia secondary to insulin overdose, poor nutritional intake or adrenal insufficiency
  • Hyperglycemia causing diuresis and electrolyte abnormalities
  • Hypothyroidism

Neurological conditions

  • A large spectrum of neurological disorders such as: stroke (ischemic or hemorrhagic), subarachnoid hemmorrhage, spinal cord lesions, peripheral nerve disease, plexopathies, neuromuscular junction disease, myopathies, multiple sclerosis, migraines with neurological features, Parkinson’s/ Parkinsonism and postictal paralysis.


  • Epidural abscess can compress the spinal cord resulting in true weakness.
  • Sepsis can manifest as malaise
  • Other viral and bacterial infections can cause generalized weakness


  • Presyncope can be described as weakness. It is important to identify any cardiac causes for presyncope in the ED.
  • Myocardial infarction or unstable angina can manifest as malaise instead of chest pain in the elderly
  • Congestive Heart Failure can be perceived as weakness due to reduced physical activity and/or deconditioning.

Electrolyte imbalance

  • Can lead to generalized or focal muscle weakness. These include hypo/hyperkalemia, hypo/hypercalcemia, hypomagnesemia, and hypophosphatemia.


  • SLE, polymyalgia rheumatica, and temporal arteritis.


1. Melady, D. CAEP 2015 oral presentation: “Is it fit for your grandma?” Found here

2. Wadman MC1, Lyons WL, Hoffman LH, Muelleman RL. Assessment of a chief complaint-based curriculum for resident education in geriatric emergency medicine.  West J Emerg Med. 2011. Nov;12(4):484-8


If you are interested in learning more about Geriatric Care in the ED. Visit Geri-EM an: http://caep.ca/Geri-EM, which fills a training gap in the emergency care of older people.  

photo from flickr

Anali Maneshi

Anali is an EM resident at McGill University. Her interests include medical education, simulation, and geriatric emergency medicine.
BoringEM has been 'bringing the boring' to emergency medicine since 2012. In 2016 this Canadian blog brought its content to CanadiEM.