Comprehensive Assessment and Management of the Critically Ill   29  

Michele C. Balas, Colleen M. Casey, Lauren Crozier, and Mary Beth Happ

OVERVIEW

More than half (55.8%) of all intensive care unit (ICU) days are incurred by patients older than 65 years of age (Angus et al., 2006) and this number is expected to increase to unprecedented levels over the next few years as our population ages. For example, it is projected that by the year 2020, more than 350,000 older adults will annually require acute mechanical ventilation for more than 4 days (Zilberberg & Shorr, 2008). Evidence suggests that the characteristics and intensity of treatment for older adults admitted to the ICU have changed significantly over the past decade. The intensity of treatments has increased (e.g., greater use of renal replacement therapy and vasopressors) and ICU survival has vastly improved. There remains, however, a large population of older adults who survive their initial ICU stay and hospitalization but who have high morbidity and mortality over the subsequent years in excess of that seen in comparable controls (Wunsch et al., 2010).

Although critically ill older adults are an extremely heterogeneous group, they do share some age-related characteristics and are susceptible to a variety of geriatric syndromes and complications that may influence ICU treatments and outcomes (Milbrandt, Eldadah, Nayfield, Hadley, & Angus, 2010; Pisani, 2009). In addition to high ICU, hospital, and long-term mortality rates, critically ill older adults are at increased risk for substantial physical, functional, and neurocognitive impairment, psychological distress (e.g., posttraumatic stress disorder, depression, and anxiety), sleep disturbances, and postdischarge institutional care (Balas, Happ, Yang, Chelluri, & Richmond, 2009; Balas et al., 2011; Barr et al., 2013; Brummel et al., 2014; de Rooij et al., 2008; Esteban et al., 2004; Ford, Thomas, Cook, Whitley, & Peden, 2007; Hennessy, Juzwishin, Yergens, Noseworthy, & Doig, 2005; Hopkins & Jackson, 2006; Kaarlola, Tallgren, & Pettile, 2006; Pandharipande et al., 2013; Wunsch et al., 2010). Older age is also one of the factors that may lead to physician bias in refusing ICU admission (Joynt et al., 2001; Mick & Ackerman, 2004), the decision to withhold mechanical ventilation, surgery, or dialysis (Hamel et al., 1999), and an increased frequency of do-not-resuscitate orders (Hakim et al., 1996). Despite these findings, most critically ill older adults demonstrate resiliency, report being satisfied with their quality of life (QOL) after discharge, and, if needed, would reaccept ICU care and mechanical ventilation (Guentner et al., 2006; Hennessy et al., 2005; Kleinpell & Ferrans, 2002). Given their knowledge and expertise, nurses play a key role in facilitating older adult’s ability to survive and successfully rehabilitate from a catastrophic illness.

BACKGROUND AND STATEMENT OF PROBLEM

Chronological age alone is not an acceptable or accurate predictor of poor outcomes after critical illness (Milbrandt et al., 2010). Factors influencing an older adult’s ability to survive a critical illness are multifactorial and include severity of illness, nature and extent of comorbidities, medical diagnosis, mechanical ventilation use, complications, preexisting frailty, malnutrition, and patient preference (de Rooij, Abu-Hanna, Levi, & de Jonge, 2005; Marik, 2006; Baldwin et al., 2014; Wunsch et al., 2010). Other, less well investigated variables include senescence, vasoactive drug use, ageism, decreased social support, and the critical care environment (Ford et al., 2007; Mick & Ackerman, 2004; Tullmann & Dracup, 2000). The onset of new geriatric syndromes for an older hospitalized adult, such as delirium, urinary incontinence, infection, or falls, is also a harbinger of decline that can often be prevented with appropriate and timely ICU nursing interventions (for more information visit www.GeroNurseOnline.org). This chapter presents strategies and rationale for comprehensive assessment of critically ill older adults to guide optimal care management.

ASSESSMENT OF PROBLEM AND NURSING CARE STRATEGIES

Assessment of Baseline Health Status

The performance of a comprehensive assessment of a critically ill older adult’s preadmission health status, functional and cognitive ability, and social support systems helps nurses identify the multiple risk factors that make older adults susceptible to a variety of life-threatening conditions, complications, and frequently encountered geriatric syndromes. Nurses can use these initial assessments to develop an evidence-based, holistic, and individualized plan of care that meets both the elder’s and her or his family’s needs and the goals of care throughout hospitalization. This baseline assessment is also useful to other members of the interdisciplinary ICU team as they develop their own profession-specific plans of care.

Preexisting Cognitive Impairment

Several anatomic and physiological changes occur in the aged central nervous system (Table 29.1; Miller, 2009). When these age-related changes are combined with the stress of acute pathology, multiple comorbidities, and polypharmacy, critically ill older adults are particularly vulnerable to a number of commonly encountered ICU syndromes such as pain, oversedation, and delirium (Balas et al., 2007; Barr et al., 2013; McNicoll et al., 2003; Pisani, Murphy, Van Ness, Araujo, & Inouye, 2007). High rates of preexisting cognitive impairment (31%−42%) are also reported in older adults admitted to both medical and surgical ICUs (Balas et al., 2007; Pisani, Redlich, McNicoll, Ely, & Inouye, 2003). It is unfortunate that this cognitive impairment is often unrecognized by both the older adults’ family and health care providers (Balas et al., 2007; Pisani et al., 2003). Dementia, a progressive terminal illness, is commonly seen in the ICU setting with one recent study finding that nearly one in 10 nursing home residents with advanced cognitive impairment and severe functional impairment had an ICU stay before death (Fulton, Gozalo, Mitchell, Mor, & Teno, 2014). Given these collective findings, relatives or other caregivers should be asked for baseline information about memory, executive function (problem solving, planning, organization of information), and overall functional ability in daily living before the critical care admission (Kane, Ouslander, & Abrass, 2004). (See Chapter 6, “Assessing Cognitive Function.”) Because knowledge of an older adult’s preadmission cognitive status may also assist in treatment decisions, ICU clinicians should consider familiarizing themselves with dementia screening tools, such as the Informant Questionnaire of Cognitive Decline in the Elderly (IQCODE), which were specifically designed for proxy administration (Jorm, 1994).

Psychosocial Factors

Critical illness often renders older adults physically unable to effectively communicate with the health care team. The inability to communicate may stem from multiple factors, including physiological instability, tracheal intubation, and/or sedative and narcotic use (Happ, 2000, 2001). Family members or significant others are therefore a crucial source for obtaining important preadmission information such as the older adult’s past medical and surgical history, drug and alcohol use, nutritional status, home environment, infectious disease exposure, medication use, religious preference, and social support systems. Further, the lack of presence of family or a significant other threatens the nurse’s ability to obtain accurate data about the person, which is often needed to make important care management decisions and end-of-life discussions (see Chapter 4, “Health Care Decision Making”).

TABLE 29.1

Age-Associated Changes by Body System in the Older ICU Patient

ICU, intensive care unit; IGA, immunoglobulin A; IGG, immunoglobulin G; IGM, immunoglobulin M.

Sources: Bickley (2008); Marik (2006); Menaker and Scalea (2010); Miller (2009); Pisani (2009); Rosenthal and Kavic (2004); Urden et al. (2002).

Functional Ability and Frailty

Assessing preadmission frailty and functional status is essential when caring for critically ill older adults because many studies have found them to be important prognostic indicators in this population (Baldwin et al., 2014; Daubin et al., 2011; Magnette et al., 2015). The Katz Index of Activities of Daily Living (KATZ ADL; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963), the Functional Independence Measure (FIM; Kidd et al., 1995), and Fried’s Frailty Index (Fried et al., 2001) have been recommended for use with an older critically ill population (see Chapter 7, “Assessment of Physical Function”). On admission to the ICU, nurses should also investigate whether the older adult uses glasses, hearing aids, or other devices to perform activities of daily living. Having these assistive devices available to the older adult while he or she is in the ICU is important to enhance both communication, cognition, and rehabilitation.

Assessment and Interventions During the ICU Stay

Although a full discussion of the physiological changes that accompany normal aging is beyond the scope of this chapter, in the following sections we aim to provide readers with (a) an overview of the major age-related changes to organ systems and description of how these changes often manifest on physical examination (see Table 29.1), (b) a discussion of atypical presentations of some common ICU diagnoses, and (c) a description of interventions that may decrease risk for untoward medical events for critically ill older adults (also see Protocol 29.1). Common nursing interventions that benefit multiple organ systems will only be discussed in the first section in which the intervention is introduced. These interventions include encouraging early, frequent mobilization/ambulation; obtaining timely and appropriate consults (e.g., physical, occupational, speech, respiratory, and nutritional therapy); providing proper oral hygiene and adequate pain control; securing and ensuring the proper functioning of tubes/catheters; maintaining normothermia, deep vein thrombosis (DVT) prophylaxis, and reviewing/assessing medication appropriateness. The importance of these interventions and vigilance to these elements of nursing care cannot be overstated.

Respiratory System

Because respiratory reserve decreases with aging (see Table 29.1; Pisani, 2009), respiratory status can become the most tenuous component of an older adult ICU patient’s recovery. Common pulmonary changes in aging elevate an older adult’s risk for aspiration, atelectasis, pneumonia, and acute lung injury (Pisani, 2009; Rosenthal, 2004; Rosenthal & Kavic, 2004; Urden, Stacy, & Lough, 2002). These risks are further heightened in older adults who undergo thoracic or abdominal surgery; sustain rib fractures or chest injury; receive narcotics or sedatives; have tubes that bypass the oropharyngeal airway; or who are weak, deconditioned, dehydrated, and have poor oral hygiene (Menaker & Scalea, 2010; Nagappan & Parkin, 2003; Rosenthal, 2004; Rosenthal & Kavic, 2004; Urden et al., 2002).

Caring for the older adult who requires mechanical ventilation is particularly challenging. Although debate exists as to whether age influences outcomes in this population, evidence suggests that chronic ventilator dependency disproportionately affects older patients, whether as a complication of a critical illness or as a result of a chronic respiratory system limitation (Esteban et al., 2004; Zilberberg, de Wit, & Shorr, 2012). Patients who require 4 or more days of mechanical ventilation are more likely to die in the hospital, or, if they survive, to spend a considerable amount of time in an extended care facility on discharge, experience an increased risk for hospital readmission, suffer from continued morbidity, and experience a decreased QOL (Carson, Bach, Brzozowski, & Leff, 1999; Chelluri et al., 2004; Douglas, Daly, Brennan, Gordon, & Uthis, 2001; Douglas, Daly, Gordon, & Brennan, 2002; Kahn et al., 2013). These patients, and their family members, frequently experience symptoms of depression and posttraumatic stress disorder (PTSD) following discharge from the ICU (Douglas, Daly, O lylas, & Hickman, 2010; Griffiths, Fortune, Barber, & Young, 2007; Jubran et al., 2010). Of the few studies that specifically examined the effect of age on outcomes in prolonged mechanical ventilation, researchers recently found that 87% of individuals aged 65 years and older requiring prolonged mechanical ventilation in the long-term acute care hospital (LTACH) setting either died in the LTACH or were transferred back to an acute care hospital (Dermot Frengley, Sansone, Shakya, & Kaner, 2014). Only 22% of the older adults in this study were “successfully weaned” (i.e., removed from mechanical ventilation), and of those “weaned,” 38% had to be placed back on the ventilator and only 41% were able to have their tracheostomies removed. Equally discouraging is the fact that only 4% of the entire cohort was ever discharged home, an exceedingly important patient- and family-centered outcome. These potential consequences should be included as part of a discussion of treatment options and postdischarge follow-up with older adults and their families.

The aforementioned findings also highlight the need for the ICU team to aggressively pursue means of early ventilator liberation. Fortunately, the evidence base supporting effective ventilator discontinuation strategies has strengthened substantially over the past decade. For example, we now know that daily interruption of sedative and analgesic infusions until a patient is awake and able to follow simple instruction (now referred to as spontaneous awakening trials [SATs]), leads to significant reductions in the duration of mechanical ventilation and ICU length of stay (LOS; Kress, Pohlman, O hlmang, & Hall, 2000), less use of diagnostic tests for unexplained mental status changes (Kress et al., 2000), and fewer complications (Schweickert, Gehlbach, Pohlman, Hall, & Kress, 2004). Further benefit is found when SATs are coordinated with spontaneous breathing trials (SBTs), and daily checks to determine a patient’s ability to breathe spontaneously without ventilator assistance (Ely et al., 1996, 1999). Patients receiving both SATs and SBTs, in a well-designed, multisite randomized controlled trial (RCT), spent significantly more days breathing without ventilator assistance, were discharged from the ICU and hospital earlier, had shorter duration of coma, and were less likely to die compared to patients treated with SBTs alone (Girard et al., 2008). It is important to note that SATs and SBTs are associated with few adverse events and no known long-term cognitive or psychological harm (Jackson et al., 2010; Kress et al., 2003). An even more recent study from the Centers for Disease Control’s Wake Up and Breathe Collaborative found enhanced performance of paired, daily SATs and SBTs was associated with a 2.4-day decrease in mean duration of mechanical ventilation, a 3.0-day decrease in ICU LOS, a 6.3-day decrease in hospital LOS, and a 37% decrease in the odds of ventilator-associated events (VAEs; Klompas et al., 2015).

Older patients with preexisting obstructive or restrictive lung disease who are mechanically ventilated either in the ICU or in long-term care facilities are also at increased risk for ventilator-assisted pneumonia (VAP) and VAEs (Buczko, 2010). To minimize these complications, nurses should aggressively exercise standard VAP precautions, including elevating the head of the bed to at least 30º, providing frequent oral care, maintaining adequate cuff pressures, using continuous subglottic suctioning, avoiding the routine changing of ventilator circuit tubing, assessing the need for stress ulcer and DVT prophylaxis, turning the patient as tolerated, providing optimal hygiene, and advocating for weaning trials as early as possible (American Association of Critical Care, 2004; Munro & Ruggiero, 2014; Sinuff et al., 2013; Torres, Ferrer, & Badia, 2010). One recent pilot RCT also found that a new standardized oral care program for poststroke survivors led to reductions in methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus colonization (from 20.8% to 16.7%; Chipps et al., 2014). Finally, recent advances in techniques and applications of noninvasive ventilation provide an exceedingly useful means of managing respiratory compromise, thus potentially avoiding mechanical ventilation, in the older adult population (Muir, Lamia, Molano, & Cuvelier, 2010).

Nurses should consider that older adults with common respiratory pathology often do not present with symptoms traditionally considered “hallmarks of infection”—fever, chills, and other constitutional symptoms. In fact, the typical signs of pneumonia—fever, cough, and sputum production—can be absent in older adults, with only 33% to 60% of older patients presenting with a fever (Bellmann-Weiler & Weiss, 2009). Instead, older patients with either sepsis or pneumonia can often present with acute confusion, tachypnea, and tachycardia (Girard & Ely, 2007). This vague symptomatology can delay diagnosis, and important antibiotic administration, leading to poorer outcomes (Iregui, Ward, Sherman, Fraser, & Kollef, 2002).

Cardiovascular System

Because so many older adults live with hypertension, peripheral vascular disease, or coronary artery disease (CAD), individual responses to treatment can dramatically differ depending on the severity of the illness and any preexisting comorbidities. Even the “disease free” older adult may experience a decrease in the ability to respond to stressful situations as a result of the many changes that accompany cardiovascular aging (see Table 29.1; Pisani, 2009).

Cardiovascular-associated aging changes ultimately render the myocardium less compliant and responsive to catecholamine stimulation, can cause ventricular hypertrophy, and predispose the older adult to the development of a number of different types of arrhythmias (Nagappan & Parkin, 2003; Rosenthal & Kavic, 2004; Urden et al., 2002). During times of stress, an older adult achieves an increase in cardiac output by increasing diastolic filling rather than increasing heart rate (Nagappan & Parkin, 2003; Rosenthal & Kavic, 2004; Urden et al., 2002). The practical implication of this finding is that older adults often require higher filling pressures (i.e., central venous pressures in the 8−10 range, pulmonary artery occlusion pressures in the 14−18 range) to maintain adequate stroke volume and may be especially sensitive to hypovolemia (Rosenthal & Kavic, 2004). However, over hydration of the older adult should also be avoided as it can lead to systolic failure, poor organ perfusion, and hypoxemia with subsequent diastolic dysfunction (Rosenthal & Kavic, 2004). Careful monitoring of hemodynamic and fluid status is therefore essential to optimize the older patient’s cardiac status (see Chapter 30, “Fluid Overload: Identifying and Managing Heart Failure Patients at Risk of Hospital Readmission”).

Cardiac complications are among the highest causes of mortality in the older surgical patient, not only because of the increased likelihood of coronary disease but also because of the effects of aging on the myocardium (Fleisher et al., 2009). The 2009 the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Focused Update on Perioperative Beta Blockade incorporates important new information regarding the risks and benefits of perioperative beta blockade (Fleisher et al., 2009). In this update, a Class I indication for perioperative beta-blocker use exists, for continuation of a beta blocker in patients already taking the drug. In addition, several Class IIa recommendations exist for patients with inducible ischemia, CAD, or multiple clinical risk factors who are undergoing vascular (i.e., high risk) surgery and for patients with CAD or multiple clinical risk factors who are undergoing intermediate-risk surgery. It is important to note that initiation of beta-blocker therapy in lower risk groups requires careful consideration. Initiation well before a planned procedure with careful titration perioperatively to achieve adequate heart rate control, while avoiding frank bradycardia or hypotension, is suggested. Finally, routine administration of perioperative beta- blockers, particularly in higher fixed-dose regimens begun on the day of surgery, is no longer advocated.

Symptoms of a myocardial infarction and congestive heart failure may be blunted in critically ill older adults (Menaker & Scalea, 2010; Pisani, 2009), requiring the need to monitor for nonspecific and atypical presentations in this patient population, including shortness of breath, acute confusion, or syncope. Worsening clinical status or difficulty weaning from mechanical ventilation should prompt the ICU team to investigate the possibility of myocardial ischemia in this population (Pisani, 2009).

Neurological System

The central and peripheral nervous system changes that accompany aging may partially explain why older adults often present to emergency departments or the ICU with acute mental status changes. These acute mental status changes often represent an atypical presentation of an acute illness, including alterations caused by infection, an imbalance of electrolytes, or drug toxicity. A thorough physical examination, with follow-up testing, must be conducted in order to accurately diagnose the etiology of an older adult’s new-onset neurological/mental status changes as well as a thorough review of medication use.

Age-related changes to the neurological system, when coupled with acute pathology and the ICU environment, increase a critically ill older adult’s risk for cognitive dysfunction, falls, restraint use, oversedation, alterations in body temperature, and anorexia. Most important, these changes also elevate the risk for delirium, which occurs in up to 70% of older adults admitted to an ICU (Balas et al., 2007; McNicoll et al., 2003; Peterson et al., 2006) and is associated with increased morbidity, mortality, length of hospital stay, and poor functional outcomes (Balas et al., 2009; Ely, Inouye, et al., 2001; Morandi, Jackson, & Ely, 2009). Pain, sleep deprivation, visual impairment, illness severity, prior cognitive impairment, dehydration, comorbidities, laboratory abnormalities, multiple medications, chemical withdrawal syndromes, infections, fever, windowless units, and ICU length of stay place the critically ill older adult at risk for delirium (Morandi et al., 2009). Although management of delirium in hospitalized patients is discussed more fully in Chapter 17, “Delirium: Prevention, Early Recognition, and Treatment, clinicians must be particularly aware of the interconnectedness of delirium, mechanical ventilation, and immobility in the critical care environment. Nurse-led, interdisciplinary, multicomponent strategies, such as the Awakening/Breathing Coordination, Delirium Monitoring/Management, and Early Mobility (ABCDE) bundle have been shown to improve outcomes in the critically ill population. One recent study found patients treated with the ABCDE bundle, spent 3 more days breathing without mechanical ventilator assistance, experienced a near halving of the odds of delirium, lower mortality, and increased odds of mobilizing out of bed at least once during their ICU stay (Balas et al., 2014).

In addition to the physical barriers to speech imposed by mechanical ventilation, older adult patients are at greater risk for impaired communication than their younger counterparts because of preexisting vision and hearing impairments and cognitive or language impairments (Bartlett, Blais, Tamblyn, Clermont, & MacGibbon, 2008; Happ et al., 2015; Happ, Tate, & Garrett, 2006; Patak et al., 2009). Accurate interpretation of patient messages, including pain and symptom descriptions, may be difficult and frustrating for patients and care providers. Partnering with speech–language pathologists on tools and techniques to facilitate patient comprehension and communication can improve this process (Happ et al., 2006).

A multilevel communication intervention, composed of nurse training, algorithm-guided assessment and communication tool selection, and the provision of communication tools to the ICU, demonstrated improved frequency of communication, successfulness of communication about pain and other symptoms, and less patient-reported difficulty with communication (Happ et al., 2014). Age and delirium status effected communication performance and content. When patients tested positive for delirium, communication exchanges with their nurses were less successful. Delirium was also associated with the identification of fewer patient symptoms and more complaints of dry mouth (OR: 3.60, 95% CI [1.1, 11.83]; p = .03). Older age was associated with more symptom complaints of pain (OR: 2.12, 95% CI [1.12, 4.00]; p = .02), drowsiness (OR: 0.41, 95% CI [0.17, 0.98]; p = .04), and feeling cold (OR: 0.31, 95% CI [0.11, 0.88]; p = .03; Tate et al., 2013).

Achieving adequate pain control for critically ill older adults is of utmost importance, both related to and independent of its relationship to delirium; however, the nurse also needs to avoid over sedation and undertreatment of pain in this population as both are associated with multiple negative outcomes, including distress, delirium, sleep disturbances, and impaired mobility (Barr et al., 2013; see Chapter 18 “Pain Management”). A number of tools exist to assess a critically ill patient’s level of sedation and delirium status. The Richmond Agitation and Sedation Scale (RASS; Sessler et al., 2002) and the Confusion Assessment Method-ICU (CAM-ICU; Ely, Margolin, et al., 2001) are two of the most common in the critical care setting. (See Resources for additional information on these tools and Protocol 29.1 for interventions to reduce delirium.)

Gastrointestinal System

Common age-related changes to the gastrointestinal (GI) system can predispose older ICU patients to complications during their ICU stay, ranging from altered presentation of illness to issues of medication effectiveness (see Table 29.1). Older adults also experience changes in their body composition (i.e., decrease in lean body mass) and energy use that can potentiate the effect of medications on these GI-system changes.

It is ironic that although many conditions affecting the GI system are more common in older adults (e.g., constipation, under- and malnutrition, gastritis) their presence is not fully explained by the aging processes (Urden et al., 2002). When assessing the GI function of a critically ill older adult, it is important for the nurse to realize that age may blunt the manifestations of acute abdominal disease. For example, pain may be less severe, fever less pronounced or absent, and signs of peritoneal inflammation, such as muscle guarding and rebound tenderness, may be diminished or even absent (Bickley, 2008). Because of changes in the secretion of gastric enzymes, the stomach wall of older adults can be more susceptible to acid injury, especially in the face of critical illness. The practice of routine stress ulcer prophylaxis in the critically ill patient, part of the VAP bundle and common in many ICUs, however, has more recently been challenged as a potential contributor to pneumonia with more narrow indications that have been assumed, even in mechanically ventilated patients (Herzig, Howell, Ngo, & Marcantonio, 2009; Logan, Sumukadas, & Witham, 2010; Marik, Vasu, Hirani, & Pachinburavan, 2010).

Delayed gastric emptying may predispose older adults to abdominal distension, nausea, vomiting, aspiration, and constipation. This delayed motility is especially true in the postoperative period, when many older adults are immobile and receiving narcotics. Many older adults take multiple medications, which along with age-related changes such as altered thresholds for taste and smell, a hypersensitive hypothalamic satiety center, and oropharyngeal atrophy, can inhibit their intake of solids and liquids (Menaker & Scalea, 2010). This baseline GI functionality, in combination with their critical illness, must be proactively addressed. The nurse needs to be alert for ill-fitting dentures, swallowing difficulties, silent aspiration, and the possibility of decreased saliva production (either resulting from salivary dysfunction or the use of drugs, such as sympathomimetics). These alterations can lead to insufficient mastication and can combine with other risk factors that put the older ICU patient at risk for aspiration. Aspiration should be considered a life-threatening situation, requiring immediate nursing intervention. Consultation with a speech–language pathologist may also be warranted.

Older adults facing stress from illness, injury, or infection are also at high risk for protein-calorie malnutrition, as evidenced by low serum albumin and prealbumin levels, a decline in hepatic function, decreased muscle mass and strength, and dysfunction in those tissues with high cell turnover (Nagappan & Parkin, 2003; Rosenthal & Kavic, 2004). These changes lead to a breakdown in barrier function, increased susceptibility to infection, delayed wound healing, fluid shifts, deconditioning, and further impairment in absorption of essential nutrients (Rosenthal, 2004). Thus, early enteral or parental nutritional support is crucial (see Chapter 10, “Nutrition”).

Reductions with age in the activity of the drug-metabolizing enzyme system and blood flow through the liver influences the liver’s capacity to metabolize various drugs (Kane et al., 2004; Menaker & Scalea, 2010). Splanchnic blood flow is further compromised in states of shock or even mild hypotension. These changes may predispose older adults to adverse drug reactions (Urden et al., 2002). For example, drugs, like warfarin, that work directly on hepatocytes may reach their therapeutic effect at lower doses (Rosenthal & Kavic, 2004). Common pharmacological agents used in the critical care setting and their common side effects often experienced by the gerontological patient are given in Table 29.2 (see Chapter 20, “Reducing Adverse Drug Events”).

Last, many older adults have diabetes and even those older adults without preexisting diabetes may experience elevated blood glucose levels as a result of medications and a stress response to critical illness. Therefore, glycemic control in the older ICU patient may be more difficult because of a declining glucose tolerance associated with aging. Although initial studies indicated tight control of blood sugar, with blood glucose levels of 80 to 110, optimized recovery and outcomes (Humbert, Gallagher, Gabbay, & Dellasega, 2008; van den Berghe et al., 2001), a more recent study has revealed that this tight control actually increases mortality (Bouillon et al., 2009).

Genitourinary System

Preservation of the older adult’s preadmission renal status is one of the goals of ICU care. Common age-related changes in the genitourinary (GU) system decrease the older adult’s ability to excrete ammonia and drugs, diminish his or her capacity to regulate fluid and acid–base balance, and often impair their ability to properly empty the bladder (Nagappan & Parkin, 2003; Rosenthal & Kavic, 2004; Urden et al., 2002). The coupling of these common age-related changes with conditions commonly seen in the ICU environment, such as hypovolemia, shock, sepsis, and polypharmacy, render the older adult at increased risk for acute renal failure, metabolic acidosis, and adverse drug events (Yilmaz & Erdem, 2010). The increased prevalence in the older population of asymptomatic bacteriuria also exacerbates an older ICU patient’s infection risk related to Foley catheter use (Richards, 2004; see Chapter 22, “Prevention of Catheter-Associated Urinary Tract Infection”).

TABLE 29.2

High-Risk Medications Commonly Used in Older ICU Patients^a

CNS, central nervous system; GI, gastrointestinal.

^aAdapted from Beers (1997); Bonk, Krown, Matuszewski, and Oinonen (2006); Fick et al. (2003).

^bSeverity rating—Adverse effects of medications rated as high or low severity based on the probability of event occurring and significance of the outcome (Logan et al., 2010; van den Berghe et al., 2001).

^cIdentified in Logan et al. (2010) as seven most commonly prescribed Beers medications used in older hospitalized patients.

The nurse must take into consideration an older patient’s baseline cardiovascular status relative to his or her renal function. If an older patient was typically hypertensive before hospitalization, for example, this patient’s renal vasculature may be accustomed to a pressure to perfuse the kidneys that is higher than normal. Furthermore, common indicators of dehydration, such as skin turgor, should be considered an unreliable sign in an older adult, related to loss of subcutaneous tissue (Sheehy, Perry, & Cromwell, 1999). Although the Cockroft and Gault formula (see Chapter 20) has been derived to estimate creatinine clearance in the healthy aged, care must be taken when applying this formula to critically ill older patients or to those patients on medications that directly affect renal function (Rosenthal & Kavic, 2004). Finally, the nurse should be especially cognizant of medications known to contribute to renal failure, including aminoglycosides, certain antibiotics, and contrast dyes, and closely monitor laboratory results as warranted (Urden et al., 2002).

Immune/Hematopoietic System

The changes that occur in the aged immune and hematological system mainly involve altered T and B cell functioning and a decrease in hematopoietic reserve (Nagappan & Parkin, 2003; Rosenthal & Kavic, 2004; Urden et al., 2002; see Table 29.1). The consequences of these changes include an increased susceptibility to infection, increases in autoantibodies and monoclonal immunoglobulins, and tumorigenesis (Rosenthal & Kavic, 2004). These common aging changes, coupled with the stress, malnutrition, and number of invasive procedures seen in the critical care environment, may heighten the older adult’s risk for a nosocomial infection. Furthermore, because an older adult’s ability to mount a febrile response to infection diminishes with age (related to a decline in hypothalamic function), the older patient may even be septic without the warning of a fever (Urden et al., 2002) and instead may exhibit only a decline in mental status. Close assessment of other nonfebrile signs of infection (restlessness, agitation, delirium, hypotension, and tachycardia) is essential and warranted.

Although recent research suggests that giving blood more liberally to patients may be associated with worse patient outcomes, these findings may not necessarily apply to the older adult population for several reasons: (a) the chronic anemia often seen in aging; (b) the exclusion of many older adults from previous clinical trials; (c) research findings that suggest higher transfusion triggers in older patients with acute myocardial infarction actually decreases mortality; and (d) the association of low hemoglobin levels with increased incidence of delirium, functional decline, and decreased mobility (Rosenthal & Kavic, 2004).

Skin and Wounds

Older adults are at high risk for skin breakdown in the ICU setting resulting from of elastic, subcutaneous, and connective tissues; a decrease in sweat gland activity; and a decrease in capillary arterioles supplying the skin with age (Bickley, 2008; Urden et al., 2002; see Table 29.1). Because the skin changes that occur in older adults can cause difficulty with thermoregulation, can heighten the risk for skin breakdown and intravenous (IV) infiltrations, may delay wound healing, and can make hydration assessment difficult, the nurse should make every effort to prevent heat loss, carefully monitor hydration status, and conduct thorough skin assessments (Bickley, 2008; Urden et al., 2002; see Chapter 24 “Preventing Pressure Ulcers and Skin Tears”).

Another important intervention related to the prevention of skin and muscle breakdown in critically ill older adults is early, frequent mobilization. A strategy for whole-body rehabilitation, achieved by the use of SATs, SBTs, and physical therapy-driven early exercise and mobilization, has proven to be safe and well tolerated by mechanically ventilated patients (Schweickert et al., 2009). Patients treated with this intervention experienced significantly shorter duration of delirium and coma, had more ventilator-free days, and were more likely to return to independent functional status at hospital discharge than were controls. Numerous studies have shown active mobilization can be initiated safely in ICU settings (Li, Peng, Zhu, Zhang, & Xi, 2013), resulting in improved physical function (Li et al., 2013), reduced duration of mechanical ventilation (Chen et al., 2012; Malkor, Karadibak, & Yildirim, 2009), shorter LOS (Malkor et al., 2009; Morris et al., 2008), and lower 1-year mortality (Chen et al., 2012) (see Chapter 14, “Preventing Functional Decline in the Acute Care Setting”).

Family Engagement

Interactions with family members can be therapeutic for critically ill patients (Black, Boore, & Parahoo, 2011), and help them to make sense of the experience (Davidson, Daly, Agan, Brady, & Higgins, 2010); they may also ameliorate the stress and trauma experienced by patients and family during and after ICU hospitalization (Bergbom & Askwall, 2000; Jones et al., 2010). Family members support patients’ psychological well-being by providing reassurance, hope, information, a sense of normality, and distraction from the ICU environment and illness experience (Black et al., 2011; Happ, Swigart, Tate, Hoffman, & Arnold, 2007; Karlsson, Forsberg, & Bergbom, 2010; Morse & Pooler, 2002; Riggio, Singer, Hartman, & Sneider, 1982; Williams, 2005). They also provide reorientation, detect signs of delirium, and serve as proxy or shared decision makers (Black et al., 2011; Happ, 2000; Happ, Swigart, Tate, Arnold, et al., 2007; Happ, Swigart, Tate, Hoffman, et al., 2007; White, Braddock, Bereknyei, & Curtis, 2007; White et al., 2007; Williams, 2005). Family presence has been associated with significantly longer duration of ventilator weaning trials among adult patients weaning from prolonged mechanical ventilation in the ICU (Miller, 2009). Family interventions in the ICU have focused on providing basic information about the environment, patient condition and treatment (Azoulay et al., 2002; Black et al., 2011; Medland & Ferrans, 1998), advice and coaching on family presence or caregiving (Black et al., 2011; Daly et al., 2010; Davidson et al., 2010), and decision-making support (Curtis et al., 2011; Daly et al., 2010; Lautrette, Ciroldi, Ksibi, & Azoulay, 2006; White et al., 2007) with mixed results on patient–family anxiety, depression, and PTSD. For example, an information leaflet improved family members’ comprehension of the ICU patient’s diagnosis and prognosis but did not affect anxiety or depression (Azoulay et al., 2002).

Black et al. (2011) tested the effect of a family psychological support intervention facilitated by nurses on patient delirium and psychological recovery. Intervention group patients showed less delirium than usual care (29%−77%), and had significantly lower Sickness Impact Profile scores at 4, 8, and 12 weeks after the intervention (p < .001). The use of diaries written by health providers and family visitors to help patients to make sense of the memories and ICU experience following discharge were associated with a decrease in patients’ PTSD (Jones et al., 2010); however, the impact on family caregivers’ anxiety has been equivocal (Kloos & Daly, 2008). Davidson tested the feasibility and acceptability of a family visiting kit and supportive coaching intervention with family members of mechanically ventilated patients in an ICU (Davidson et al., 2010). Families found the kit materials (workbook, cognitive recovery tools, personal care items and information on available services) helpful. The toolkit did not, however, meet their communication needs; the effect on patient or family outcomes was not tested.

Family members are commonly required to act as decisional surrogates for older adult patients in the ICU. This role is known to confer emotional stress, burden, and psychological sequelae (depression, anxiety, PTSD) for some family caregivers, particularly for those family members involved in decisions to limit or withdraw life-sustaining treatments (Gries et al., 2010; McAdam, Fontaine, White, Dracup, & Puntillo, 2012). Nurses play a crucial role in integrating palliative care in the ICU and improving end-of-life care and support for critically ill older adults and their family members (Krimshtein et al., 2011; Nelson et al., 2010; White et al., 2012). Skills-training programs and resources for nurses include the End-of-Life Nursing Education Consortium (ELNEC-Critical Care and ELNEC Geriatric), Improving Palliative Care in the ICU (IPAL-ICU), and the American Association of Critical-Care Nurses E-learning program on Palliative and End-of-Life Care.

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