The Older Adult in an Acute Care Setting: Altered Responses to Illness
The elderly person entering the acute care setting is at increased risk for complications, infections, and functional decline. The interdisciplinary team and nursing staff can help avert negative outcomes by being knowledgeable about the physiologic and psy-chological responses of older adults to acute illnesses and by plan-ning and implementing preventive measures. In addition to the interventions discussed in the following paragraphs, general nurs-ing measures that can be taken to avoid complications in the older adult include careful and frequent assessment of vital signs, men-tal status, fluid balance, and skin integrity; prompt identification and treatment of complications; promotion of independent self-care and mobility; assistance with frequent position changes and deep-breathing exercises; alertness to possible medication reactions; and assistance with ADLs and toileting.
Infectious diseases present a significant threat of morbidity and mortality to older people, in part because of the blunted response of host defenses caused by a reduction in both cell-mediated and humoral immunity. Age-related loss of physiologic reserve and chronic illnesses also contribute to in-creased susceptibility. Pneumonia, urinary tract infections, tuber-culosis (TB), gastrointestinal infections, and skin infections are some of the commonly occurring infections in older people.
The effects of influenza and pneumococcal infections on older people are also significant. Estimates place the number of deaths from influenza at 10,000 to 40,000 per year. Hospital-acquired pneumonia is responsible for 300,000 deaths annually in the United States, making it the second most common nosocomial infection (after urinary tract infection) and the leading cause of death from hospital-acquired infection. Many of these deaths in-volve older adults because of their increased vulnerability to in-fection (Smith-Sims, 2001).
The influenza vaccine is prepared yearly to adjust for the spe-cific immunologic characteristics that are present in the influenza viruses at that time. It is an inactivated preparation that should be taken annually in the fall, preferably in November. The pneu-mococcal vaccine has 23 type-specific capsular polysaccharides. Protection lasts 4 years or longer. Revaccination is rarely recom-mended because of the higher incidence of local reaction on sub-sequent immunizations. Both of these injections can be received at the same time in separate injection sites. The nurse should urge older people to receive these vaccines. All health care providers working with older people or high-risk chronically ill people should also be immunized.
TB significantly affects older adults. Case rates for TB are highest among those who are 65 years of age or older, with the exception of persons with HIV infection. Nursing home residents account for the majority of the cases in the older population. Much of the infection rate is attributed to reactivation of old in-fection. Pulmonary and extrapulmonary TB often have subtle, nonspecific symptoms. This is of particular concern in the nurs-ing home, because an active case of TB places patients and staff at risk for infection.
The Centers for Disease Control and Prevention (CDC) guidelines suggest that all new admissions to nursing homes re-ceive a Mantoux test (PPD test) unless there is a history of TB or a previous positive response. All patients whose tests are not posi-tive (a positive test is indicated by induration of more than 10 mm at 48 to 72 hours) should receive a second test in 1 week. The first PPD serves to boost the suppressed immune response that may occur with an older person. Chest x-ray studies and possibly spu-tum studies should be used to follow up on PPD-positive re-sponders and converters. For positive converters, a course of preventive therapy for 6 to 12 months with isoniazid (INH) re-duces the risk of active disease by 70%. All negative testers should be periodically retested. The nurse can facilitate this process within the care facility (CDC, 2000).
Many altered physical, emotional, and systemic reactions to dis-ease are attributed to age-related changes in older people. Useful and reliable physical indicators of illness in young and middle-aged people cannot be relied on for the diagnosis of potential life-threatening problems in older adults. The response to pain in older people may be lessened because of reduced acuity of touch, alterations in neural pathways, and diminished processing of sen-sory data. Research has demonstrated the absence of chest pain in many older adults experiencing a myocardial infarction. Hiatal hernia or upper gastrointestinal distress is often responsible for chest pain in elderly people. Acute abdominal conditions, such as mesenteric infarction and appendicitis, often go unrecognized in elderly people because of atypical signs and absence of pain (Kufrovich, 2001).
The baseline body temperature for older people is about 1°F lower than it is for younger people. In the event of illness, there-fore, the body temperature of an older person may not reach a sufficient elevation to qualify as a traditionally defined “fever.” A temperature of 37.8°C (100°F), in combination with systemic symptoms, may signal infection. A temperature of 38.3°C (101°F) is almost certainly a serious infection that needs prompt atten-tion. A blunted fever in the face of an infection often indicates a poor prognosis. Elevations in temperature rarely exceed 39.5°C (103°F). The nurse must be alert to other subtle signs of infection: mental confusion, increased respirations, tachycardia, and changed facial appearance and color.
The emotional component of illness in older people may differ from that in younger people. Many elderly people equate good health with the absence of old age. “You are as old as you feel” is a belief of many. An illness that requires hospitalization or a change in lifestyle is an imminent threat to well-being. Admission to the hospital is often feared and actively avoided. Economic concerns and fear of becoming a burden to the family often lead to high anxiety in older people. The nurse must recognize the im-plications of fear, anxiety, and dependency in elderly patients. Autonomy and independent decision making are encouraged. A positive and confident demeanor in the nurse and the family pro-mote a positive mental outlook in the elderly patient. In addition to anxiety and fear, older people are at high risk for disorientation, confusion, change in level of consciousness, and other symptoms of delirium if they are admitted to the hospital.
The effect of illness on an aged person has far-reaching repercus-sions. The decline in organ function that occurs in every system of the aging body eventually forces one or more body systems to function at full capacity. Illness places new demands on body sys-tems that have little or no reserve to meet this crisis. Homeosta-sis, the ability of the body to maintain an internal balance of function and chemical composition, is jeopardized. The older person may be unable to respond effectively to an acute illness or, if a chronic health condition is present, he or she may be unable to sustain appropriate responses over a long period. Furthermore, the older person’s ability to respond to definitive treatment is im-paired. These altered responses reinforce the need for the nurse to monitor all of the older adult’s body system functions closely, being alert to signs of impending systemic complication.
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