CHAPTER 30. Infusion Therapy in the Older Adult
Beth Fabian, BA, RN, CRNI®∗
The Aging Population, 571
Legal and Ethical Considerations, 572
Gerontological Assessment, 573
The Aging Process, 573
Considerations in Infusion Nursing, 576
Summary, 582
THE AGING POPULATION
With medical advances, infusion nursing faces the challenges of an ever-expanding aging population; the mean age of adults has increased to an unprecedented level. The older adult presents a unique set of concerns for which health care professionals do not yet have a complete solution. Ironically, gerontology, the study of the aged, is one of the newest specialties in the medical world. Primary goals of infusion nursing with the older adult include selecting the correct venous access device, type of therapy, and medication. To achieve these goals, the infusion nurse needs to have a broad understanding of geriatric assessment and the impact the aging and infusion processes will have on the older adult patient.
Gerontology has become a specialty in its own right. The development of gerontological Scope and Standards of Gerontology Nursing Practice (Congdon et al, 2001), in collaboration with the National Gerontological Nursing Association, the National Association of Nursing Administrators of Long Term Care, the National Conference of Gerontological Nurse Practitioners, and the American Nurses Association, set a standard of care for the older adult. The standards directed a holistic approach be incorporated throughout the continuum of care with the elderly patient to achieve the most positive outcome. The role of the infusion nurse is expanding to different health care delivery settings. Chronic diseases such as cardiovascular dysfunction, diabetes, and cancer continue to have a major impact on the world population. The elderly patient can present with all three diseases, thereby significantly increasing the challenges of infusion nursing. Accurate assessment of the older patient by health care professionals ensures timely and less costly interventions.
STATISTICS AND PROJECTED GROWTH
According to the United Nations Department of Economic and Social Affairs Population Division, the world’s population will increase by 2.5 billion people from 2007 to 2050. Today’s 6.7 billion people will grow to an estimated 9.2 billion in 2050. The 2007 Revision of their World Urbanization Prospects indicates that by 2008 the world population living in urban areas will exceed that of the rural areas. Urban population growth will continue moving beyond the 3.3 billion in 2007 to more than 6.4 billion in 2050 (United Nations, 2008).
The urbanization growth of the population allows for more convenient access to health care. Combined with a sharp reduction in mortality as a result of increasing medical and pharmacological advances, a declining birth rate, and increased longevity, the growing population is also an aging population (United Nations, 2008). The United Nations World Population Prospects: The 2006 Revision estimates that from 2005 to 2050, the growth in the population aged 60 or older will account for half of the total worldwide population. In 2005 the number of persons aged 60 or older was estimated at 673 million. By the year 2050 that number will exceed 2 billion. The most dramatic increases will be in the developing countries, where the older population is expected to grow from 171 million in 1998 to 1594 million in 2050. This reflects a shift of the over 60 population—comprising 64% of the population in 2005 to nearly 84% in 2050 (United Nations, 2007). Within the aging population, the 80 or older category is projected to increase from 88 million in 2005 to 402 million in 2050.
These numbers demonstrate the impact this population will have on the health care delivery system. It will tremendously affect the way that health care is delivered and the types of services that are offered. Infusion therapy will advance with various types of medical devices and will be a significant factor in maintaining the expanding (and aging) population. With the dramatic increases in life expectancy and the gradual decline in fertility rates, the proportion of older adults has now exceeded that of younger children for the first time in history. This phenomenon has been termed population aging and has required a shift in health care, focusing on the elderly. Understanding the global implications of population aging will empower the health care professional to provide the best possible care for older adults.
AGING THEORIES
Many theories exist regarding the population and the process of aging. No one theory can fully describe the inevitable aging that the body endures. Eliopoulos (2005) describes the many theories of aging and categorizes them into two areas: biological theories and psychosocial theories. The common denominator in the theories is that currently, no single factor is responsible for the aging process.
Aging is unique for each individual, beginning at conception. Aging depends on nutritional, environmental, educational, genetic, societal, physiological, and spiritual factors. Aging uses the life experiences and shapes the future needs of the older adult. Because of the complexities of the aging process, it is much more difficult to assess the older adult than the younger adult. When assessment is made even more difficult by acute or chronic cognitive deficits in the patient, the role of the infusion nurse becomes extremely difficult.
Older people are classified into the following three major groups:
1. Young old: 65 to 74 years
2. Middle old: 75 to 84 years
3. Old old: 85 years and older
The population experiencing the most change is the old-old age group. Advances in medicine and education provide the practitioner a wealth of knowledge about this group (Congdon et al, 2001; Eliopoulos, 2005).
LEGAL AND ETHICAL CONSIDERATIONS
ADVANCE DIRECTIVES
To understand the requests of the older adult in the delivery of health care, there must be a clear understanding of advance directives. The desires of the elderly are often ignored, especially when a metabolic imbalance has rendered the older adult cognitively deficient. Chronic illnesses, medications, and fluid and electrolyte imbalances can impair the patient’s ability to make clear-cut decisions about infusion therapy. The health care professional must advocate for the wishes of the patient. When an elderly person is treated, the entire family is affected. Many complex emotional and ethical issues arise regarding the treatment of the older adult. These issues need to be discussed in a controlled setting, before the onset of an acute illness that requires infusion therapy. The patient may have a variety of documents or persons designated responsible for the plan of care. These may include advance directives, which are legally binding documents set forth by the patient in anticipation of future health care needs. These documents are reviewed before providing any treatment. In the case of infusion therapy, a review is particularly important if the practitioner is not familiar with the patient and has been called as the specialist to perform an invasive procedure.
The living will, a part of the advance directives, is a comprehensive document specifying the holistic aspects of the patient’s care. Another document often used confers a durable power of attorney for health care to a friend, family member, advisor, or guardian. This person is appointed to make decisions when the patient is considered legally incompetent or incapable of making decisions regarding health care (Congdon et al, 2001; Loengard and Boal, 2004).
DO-NOT-RESUSCITATE ORDERS
As with advance directives, do-not-resuscitate (DNR) orders are reviewed with the patient and family before the order is written. A DNR order must be written on the physician’s order sheet and progress notes. A DNR order may be written in the absence of or in conjunction with a living will (Phillips, 2005). The patient or legal guardian must participate in the decision-making process. If the patient resides in a long-term care setting, cardiopulmonary resuscitation (CPR) must be available to the patient if the patient does not have a DNR order. If the facility is unable to perform CPR, the patient must be informed. This is of particular importance to the health care professional consulting on an emergent basis to perform a venipuncture.
INFORMED CONSENT
The initiation of infusion therapy without consent is construed as assault and battery (Phillips, 2005 and Weinstein, 2007). The older adult does not give up the right to refuse treatment. Health care professionals must recognize that the elderly person needs to feel a sense of independence and control over his or her environment. In the acute care setting, much of a patient’s care and environment is out of his or her control. This circumstance must be met with reasoning and discussion, not force.
The patient who is confused does not relinquish his or her rights to refuse treatment. The determination of what is best for the care and safety of the patient must be weighed against a careful evaluation of the patient’s mental and emotional ability to make rational decisions. The patient’s life and safety are always the first priority to the health care provider. If a patient cannot make these judgments, the patient, the family, or the hospital representative can ask the court to appoint a patient advocate to oversee the best interests of the patient. The determination of who will speak for the patient must be made early in the course of care so that proper therapy can be continued with the appropriate consent. See Box 30-1 for additional factors that should be considered when obtaining informed consent from the older adult.
Box 30-1
CONSIDERATIONS FOR THE OLDER ADULT: INFORMED CONSENT
Before informed consent can be obtained, it is necessary to assess the older adult’s mental status. Mental status can be impaired for many reasons. If impaired memory or confusion is due to a reversible condition, it is important to address the underlying condition. If pain is affecting the older adult’s ability to think clearly, appropriate management strategies must be in place before obtaining informed consent.
The nurse should assess any sensory deficits, such as vision or hearing, provide written consent forms that are printed in an easy-to-read font, and adapt spoken information for any hearing deficits. The use of unfamiliar language should be avoided, and written material should be provided at the patient’s reading level. Pausing periodically allows the patient time to process the information given, and can enhance comprehension. The nurse may have to adapt the signed consent process if the older adult has developed upper extremity problems, such as fine tremors or eye-hand coordination or range-of-motion limitations.
The nurse must be knowledgeable about advance directives and existing health care proxies.
From Infusion Nurses Society: Policies and procedures for infusion nursing for the older adult, Norwood, Mass, 2004, Author.
GERONTOLOGICAL ASSESSMENT
HOLISTIC APPROACH TO CARE
The older population is a very diverse group. Everyone ages differently, taking into consideration climate, geographic locations, family size, life skills, and experiences. Individual variations in biological characteristics tend to be greater in the older population than in the younger population. This diversity makes it difficult to categorize older people. The health care professional needs to do a complete, holistic assessment of the older adult before initiating therapy. All aspects of life need to be respected when an older person requires infusion therapy. It is important to take into account that this particular generation has survived many global changes and medical advances. This generation has seen the advances in antibiotic therapy and has witnessed the virtual eradication of diseases such as polio and whooping cough. Decisions regarding infusion therapy are very important to the process of completing therapy with the fewest complications and the most positive outcomes for the older adult (Hogstel, 2001).
ACTIVITIES OF DAILY LIVING
Activities of daily living are a common criterion used by health care professionals to determine the care that an elderly person will require in the event of an illness. Determining a patient’s optimal level of functioning is a key component when addressing this issue.
In the holistic plan for care, bathing, dressing, housekeeping, mobility, and cognitive function are factors in determining overall wellness. When infusion therapy is considered, other factors need to be identified before initiating therapy (Box 30-2).
Box 30-2
FACTORS TO CONSIDER BEFORE INITIATING THERAPY
• What were the locations of prior IV cannulations? Determine degrees of phlebitis, if known.
• Will the patient be receiving occupational or physical therapy? If so, the catheter should not be placed in the affected arm because of increased risk of manipulation of the catheter.
• Can the patient or caregiver be taught to take care of the infusion site, dressings, and medication administration?
If there is a question about the patient’s cognitive level, many quick and easy assessments can be performed to determine whether the patient understands the impending therapy. It is important to have an understanding of the patient’s entire 24-hour day. Issues such as insomnia, depression, or sundowner’s syndrome are some common examples that may complicate care (Fetter, 2003).
THE AGING PROCESS
CARDIOVASCULAR FUNCTION
Changes occurring in the cardiovascular system of the older adult are one of the most important systemic changes that should be assessed by the health care professional. With advancing age, the left atrium enlarges to enhance ventricular filling. In most healthy older adults, a fourth audible heart sound can occur from the enlargement. The overall size of the heart increases in mass; the increase is estimated at 1 gram per year in men and 1.5 grams per year in women after the age of 30 (Phillips, 2005 and Weinstein, 2007). In both genders, the intraventricular septal thickness increases with age, creating a stiffness in the ventricular walls. This impedes the heart’s ability to contract and relax. The heart valves may also become thicker and less flexible from lipid accumulation, collagen degeneration, and fibrosis. Decreased efficiency of the heart muscle reduces the cardiac output by approximately 1% per year in adulthood (Hogstel, 2001). The vessels have greater peripheral resistance because of calcium deposits, crosslinking of collagen, and a reduction in elastin content. The capillary walls are thicker, which may impede the effective exchange of nutrients. In older adults, the venous elasticity also slowly declines, making the veins more difficult for venipuncture. The body’s ability to store blood volume is reduced, and the peripheral valve efficiency is decreased. In areas of high venous pressure, the adult is at risk for varicosities. The older adult’s lack of mobility may also impair venous return.
RESPIRATORY FUNCTION
Assessment of the respiratory system is paramount to providing the best possible care for the geriatric patient. The respiratory system changes begin with an overall decrease in vital capacity resulting from the loss of elastic recoil and decreased respiratory mass. There is an increase in dead space along with a decrease in the amount and effectiveness of the cilia along the tracheobronchial tree (Hogstel, 2001 and Eliopoulos, 2005). Because of the loss of elasticity and decreased effectiveness of the alveoli, the older adult is at increased risk for respiratory tract infections and dyspnea.
The older adult compensates for the flattening diaphragm and decrease in the capacity of respiratory muscles by using abdominal accessory muscles for respirations. These muscles make breathing increasingly difficult for the patient. Surgeries with anesthesia can make the older patient more prone to aspiration. The blood oxygen level decreases by 10% to 15% (Eliopoulos, 2005). Oxygen perfusion decreases and the elderly are more prone to hypoxemia. Care and consideration should be given to the amount of medication, number of infections, and co-morbidity when determining respiratory function. Hypoxemia can result in cognitive impairment, which can be misconstrued in the older adult. Swallowing deficits can result in right lower lobe and right middle lobe pneumonia that is often undiagnosed and undertreated because of inadequate assessment skills.
ENDOCRINE FUNCTION
The body’s immune system changes with the normal aging process. The immune system becomes hyporesponsive to foreign antigens and hyperresponsive to self (Phillips, 2005). These changes can result in decreased resistance to infection, increased incidence of cancers, and increased autoimmunity. Infusion nurses must consider that older adults may be more susceptible to infection and may not show the same signs and symptoms of infection they did when they were younger (Hogstel, 2001 and Eliopoulos, 2005). Because of this change, the use of aseptic technique and appropriate use of antimicrobial agents with all infusion-related procedures are essential.
The pituitary gland loses weight and vascularity with age, and there are changes in the thyroid gland. Hypothyroidism is a common diagnosis in the elderly that is often misdiagnosed because of its vague symptomatology, such as mild depression, weight gain, chest pain, atrial fibrillation, and cold intolerance.
Acquired immunodeficiency syndrome (AIDS) also affects older adults. Human immunodeficiency virus (HIV) may be misdiagnosed or missed entirely in the elderly because the early symptoms of fatigue, anorexia, and weight loss can be misinterpreted. Cognitive impairment, for example, is often diagnosed as Alzheimer’s disease or dementia rather than a symptom of HIV. About 10% of adults over the age of 50 are diagnosed with HIV/AIDS. This percentage is thought to be low as a result of misdiagnosis (Hogstel, 2001 and Eliopoulos, 2005).
Because the risk of pregnancy is eliminated, older adults need education on barrier protection. Also, the introduction of sildenafil citrate (Viagra) has led to a significant increase in sexual activity among older adults (Hogstel, 2001). Care and consideration should be given to the older adult’s sexual history when the early symptoms of HIV occur. The health care professional cannot be lax in using standard precautions, such as wearing gloves, during a venipuncture on the older adult (INS, 2006).
GASTROINTESTINAL FUNCTION
The gastrointestinal function of the older adult can be complex and requires a comprehensive assessment. The life experiences and nutritional status of the older adult define and shape his or her future health and welfare. Co-morbidities, such as a cardiovascular accident or hypertension, can lead to inadequate flow to the gastrointestinal tract or dysphagia.
The dentition of the elderly does not change with age (Eliopoulos, 2005 and Hogstel, 2001). However, studies have shown that by the age of 65, many elders are edentulous. Poor dental hygiene in younger years leads to loss of teeth, which impairs proper chewing of food. The salivary glands secrete less ptyalin and amylase as age advances and the saliva becomes more alkaline. The taste buds also atrophy with a decrease in discrimination between salt and sweet flavors.
By the age of 60, gastric secretions decrease by 20% to 30% (Hogstel, 2001 and Eliopoulos, 2005). A decrease in pepsin secretion may hinder protein digestion, and decreased hydrochloric acid and intrinsic factor levels can lead to malabsorption of iron, vitamin B 12, calcium, and folic acid. Pernicious anemia is also a concern for the older adult.
Constipation or diarrhea is not attributable to the aging process as was once commonly believed (Eliopoulos, 2005). A slight decrease in intestinal motility comes with aging but does not lead to chronic changes in bowel patterns. The health care practitioner should pay attention to the medications that the patient is taking. Polypharmacy, the taking of multiple medications, in the elderly is a common problem; this practice can produce an array of side effects, including the loss of fluids and electrolytes.
INTEGUMENTARY FUNCTION
The integumentary system is the largest and most complex organ in the body. The skin can divulge a wealth of information to the health care professional during assessment. Accurate skin assessment can help determine hydration status, potential for infection, amount of sun exposure, and attention to personal appearance. The skin plays a key role in influencing self-esteem and appearance in the older adult.
The skin is the first body system affected by venipuncture. Changes in the skin, texture, depth, and integrity result from the natural aging process and from the onset of certain disease states. The changes affect all layers of the skin, including the epidermis, the dermis, and the superficial fascia (Eliopoulos, 2005).
The epidermis, the outermost layer of the integumentary system, has four cellular layers. The stratum corneum consists of dead squamous cells that form a protective barrier for the body. The stratum granulosum helps organize the keratin layer. The stratum spinosum produces the fibrous portion of the keratin layer. The basal cell layer is responsible for pigmentation. These layers play a role in thermal regulation of the body. With aging, the epidermis becomes thinner, thereby resulting in decreased healing rates and barrier protection. The cell replacement rate of the stratum corneum declines by 50% in the older adult (Eliopoulos, 2005).
The dermis is the middle layer of the skin consisting of protein structures, blood vessels, nerve endings, and appendages such as hair follicles and nails. As the body ages, the dermis decreases in thickness by 20% (Eliopoulos, 2005). The number of sweat glands and nerve endings also decreases. In regard to nerve endings, this is of particular importance in relation to pain perception and tactile sensation. The infusion nurse should consider the lack of sensation when performing a venipuncture and minimize catheter manipulation. This will help decrease the risk of a serious infiltration caused by the patient being unable to feel the pain or pressure caused by fluid leaking into the tissue. Because of the decreased thickness, the skin is at great risk for tears, which can lead to ulceration. Caution should be taken during insertion and removal of a venous access device and removal of the tape securing the device.
The subcutaneous layer of fat in the skin helps provide insulation from cold and serves as a shock absorber from blunt trauma. As the body ages, this layer becomes thinner and redistributes to the abdomen and thighs. With the thinning of this layer, the older patient is more at risk for hypothermia and skin tears.
SENSORY FUNCTION
Sensory functional changes occurring in the elderly can have a dramatic impact on quality of life. These changes, both normal and those associated with a disease process, can be misdiagnosed as a cognitive functional loss. Care and consideration should be given to accurate assessment of all functions when initiating infusion therapy (Hogstel, 2001 and Eliopoulos, 2005).
If the patient’s visual acuity is impaired, the patient may appear withdrawn and unable to participate in the plan of care. Cataracts and glaucoma are easily treated with medications and surgery if detected in a timely manner.
Hearing deficits are also thought to be a part of the normal aging process. The deficits are usually part of the high-frequency range (Hogstel, 2001 and Eliopoulos, 2005). One of the most common reasons for hearing loss is increased cerumen in the ear canal. This can lead to gait disturbances and more commonly a withdrawal from daily activities. The ear canal curves as the person ages, and proper visualization is important in cleaning the ear canal.
Olfactory deficits can be another area for assessment in the elderly population. Some studies have shown an olfactory deficit in response to smells such as smoke. This is of importance to the patient at home, where the risk of fire is greater for the elderly population.
Tactile sensation is decreased and the skin is more susceptible to injury with aging. Infiltration may go unnoticed because of the skin’s decreased integrity and loose skin folds. A large amount of fluid may infuse subcutaneously before the patient experiences pain. Phlebitis may develop without pain but with significant vein inflammation resulting from the decreased sensitivity of the skin’s nerve endings (Hogstel, 2001 and Eliopoulos, 2005). Close monitoring of infusions, especially with potentially irritating medications, must be performed often because severe tissue necrosis, infection, or compartment syndrome can be the catastrophic result (Weinstein, 2007).
The elderly person with a peripheral catheter may not be able to alert the nursing staff of pain at the insertion site resulting from chemical or mechanical phlebitis. Caution should be exercised in the selection of the appropriate venous access device.
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