PROBLEM	INTERVENTION
Bathroom
Getting on and off toilet	Raised seat; side bars; grab bars
Getting in and out of tub	Bath bench; transfer bench; hand-held shower nozzle; rubber mat; hydraulic lift bath seat
Slippery or wet floors	Nonskid rugs or mats
Hot water burns	Check water temperature before bath; set hot water thermostat to 120° F or less Use bath thermometer
Doorway too narrow	Remove door and use curtain; leave wheelchair at door and use walker
Bedroom
Rolling beds	Remove wheels; block against wall
Bed too low	Leg extensions; blocks; second mattress; adjustable-height hospital bed
Lighting	Bedside light; night-light; flashlight attached to walker or cane
Sliding rugs	Remove; tack down; rubber back; two-sided tape
Slippery floor	Nonskid wax; no wax; rubber-sole footwear; indoor-outdoor carpet
Thick rug edge/doorsill	Metal strip at edge; remove doorsill; tape down edge
Nighttime calls	Bedside phone; cordless phone; intercom; buzzer; lifeline
Kitchen
Open flames and burners	Substitute microwave; electrical toaster oven
Access items	Place commonly used items in easy-to-reach areas; adjustable-height counters, cupboards, and drawers
Hard-to-open refrigerator	Foot lever
Difficulty seeing	Adequate lighting; utensils with brightly colored handles
Living Room
Soft, low chair	Board under cushion; pillow or folded blanket to raise seat; blocks or platform under legs; good armrests to push up on; back and seat cushions
Swivel and rocking chairs	Block motion
Obstructing furniture	Relocate or remove to clear paths
Extension cords	Run along walls; eliminate unnecessary cords; place under sturdy furniture; use power strips with breakers
Telephone
Difficult to reach	Cordless phone; inform friends to let phone ring 10 times; clear path; answering machine and call back
Difficult to hear ring	Headset; speaker phone
Difficult to dial numbers	Preset numbers; large button and numbers; voice-activated dialing
Steps
Cannot handle	Stair glide; lift; elevator; ramp (permanent, portable, or removable)
No handrails	Install at least on one side
Loose rugs	Remove or nail down to wooden steps
Difficult to see	Adequate lighting; mark edge of steps with bright-colored tape
Unable to use walker on stairs	Keep second walker or wheelchair at top or bottom of stairs
Home Management
Laundry	Easy to access; sit on stool to access clothes in dryer; good lighting; fold laundry sitting at table; carry laundry in bag on stairs; use cart; use laundry service
Mail	Easy-to-access mailbox; mail basket on door
Housekeeping	Assess safety and manageability; no-bend dust pan; lightweight all-surface sweeper; provide with resources for assistance if needed
Controlling thermostat	Mount in accessible location; large-print numbers; remote-controlled thermostat
Safety
Difficulty locking doors	Remote-controlled door lock; door wedge; hook-and-chain locks
Difficulty opening door and knowing who is there	Automatic door openers; level doorknob handles; intercom at door
Opening and closing windows	Lever and crank handles
Cannot hear alarms	Blinking lights; vibrating surfaces
Lighting	Illumination 1 to 2 feet from object being viewed; change bulbs when dim; adequate lighting in stairways and hallways; night-lights
Leisure
Cannot hear television	Personal listening device with amplifier; closed captioning
Complicated remote	Simple remote with large buttons; universal remote control; voice control–activated remote control; clapper
Cannot read small print	Magnifying glass; large-print books
Book too heavy	Read at table; sit with book resting on lap pillow
Glare when reading	Place light source to right or left; avoid glossy paper for reading material; black ink instead of blue ink or pencil
Computer keys too small	Replace keyboard with one with larger keys

Modified from Rehabilitation Engineering Research Center on Aging (RERC-Aging), Center for Assistive Technology, University at Buffalo.

Vulnerability to Environmental Temperatures

Given the nation’s growing problems with supply and costs of energy, many older adults are exposed to temperature extremes in their own dwellings. Environmental temperature extremes impose a serious risk to older persons with declining physical health. Preventive measures require attentiveness to impending climate changes, as well as protective alternatives. Early intervention in extreme temperature exposure is crucial because excessively high or low body temperatures further impair thermoregulatory function and can be lethal.

Thermoregulation

To be vigilant or aware of older adults at risk, it is important to understand the basis of thermal vulnerability. Neurosensory changes in thermoregulation delay or diminish the older person’s awareness of temperature changes and may impair behavioral and thermoregulatory response to dangerously high or low environmental temperatures (Chapter 4). Decline in thermoregulatory responsiveness to temperature extremes as one ages is well documented, yet these changes vary widely among individuals and are related more to general health than to age. The delicate equilibrium required to maintain thermal balance at any age involves the generation or replacement of body heat at about the same rate as heat is lost to the environment.

A number of physiological changes associated with aging affect heat generation, distribution, and conservation. The aging of the skin, with the loss of subcutaneous fat, is a factor in temperature regulation. Heat conservation is especially affected by changes in body density, water content, and insulation that accompany aging. Circulatory impairment and changes in vascular responsiveness affect the distribution of heat carried by blood. As a result, thermoregulatory sensitivity declines with age, and both cooling and warming responses appear to be blunted. Many of the drugs taken by older people affect thermoregulation by affecting the ability to vasoconstrict or vasodilate, both of which are thermoregulatory mechanisms. Other drugs inhibit neuromuscular activity (a significant source of kinetic heat production), suppress metabolic heat generation, or dull awareness (tranquilizers, pain medications). Alcohol is notorious for inhibiting thermoregulatory function by affecting vasomotor responses in either hot or cold weather.

Economic, behavioral, and environmental factors may combine to create a dangerous thermal environment in which older persons are subjected to temperature extremes from which they cannot escape or that they cannot change. Caretakers and family members should be aware that persons are vulnerable to environmental temperature extremes if they are unable to shiver, sweat, control blood supply to the skin, take in sufficient liquids, move about, add or remove clothing, adjust bedcovers, or adjust the room temperature. Economic conditions often play a role in this vulnerability, such as when an older person cannot afford air conditioning or adequate heating. During winter months, the older person may try using little or no room heat to either reduce or eliminate the high cost of fuel. Fear of unsafe neighborhoods in some urban areas prompts many elders to keep doors and windows bolted throughout the year. Although most of these problems occur in the home setting, older adults with multiple physical problems who reside in institutions may be especially vulnerable to temperature changes.

Temperature Monitoring in Older Adults

Diminished thermoregulatory responses and abnormalities in both the production and response to endogenous pyrogens may contribute to differences in fever responses between older and younger patients in response to an infection. Up to one-third of older people with acute infections may present without a robust febrile response, leading to delays in diagnosis and appropriate treatment, as well as increased morbidity and mortality (Outzen, 2009). Careful attention to temperature monitoring in older adults is very important, and often this technical task is not given adequate attention by professional nurses.

Frail older adults have lower baseline temperatures than healthy younger persons. In one study, the mean oral baseline temperature of randomly selected nursing home residents was 36.3° C (97.34° F). Therefore, a temperature of 98.34° F can represent one degree of elevation and may be significant in indicating infection. It is important to remember that acute infection in older adults frequently presents with a change in functional status, regardless of whether or not there is a temperature elevation. Fever in older adults can be defined as a persistent oral or TM temperature ≥37.2° C (98.96° F) or a persistent rectal temperature ≥37.5° C (99.5° F). Temperatures reaching or exceeding 38.3° C (100.94° F) are very serious in older people and are more likely to be associated with serious bacterial or viral infections (Norman, 2000).

Safety Alert

A temperature of 98.6° F may indicate fever in frail older people. Because of thermoregulatory changes, up to one-third of older people with acute infections may present without a febrile response. Additionally, baseline temperatures in frail older people may be lower than the expected 98.6° F. If the baseline temperature is 97° F, a temperature of 98° F is a one-degree elevation and may be significant. Temperatures reaching or exceeding 100.94° F are very serious in older people and are more likely to be associated with serious bacterial or viral infections. Careful attention to temperature monitoring in older adults is very important and can prevent morbidity and mortality. Accurate measurement and reporting of body temperature requires professional nursing supervision.

More older people die from excessive heat than from hurricanes, lightening, tornadoes, floods, and earthquakes combined (Centers for Disease Control and Prevention, 2006). When body temperature increases above normal ranges because of environmental or metabolic heat loads, a clinical condition called heat illness, or hyperthermia, develops. Heat illnesses tend to follow a continuum (Table 13-2), beginning with mild heat fatigue and ending with the potentially fatal heat stroke, so it is imperative to assess hyperthermia quickly and appropriately. Heat fatigue is usually caused by exposure to high outside temperatures or overexertion in a hot environment. It is characterized by pale or sweaty skin that is still moist and cool to touch, elevated heart rate, and feelings of exhaustion and weakness. Core body temperature remains normal (Ham et al., 2007). Diuretics and low intake of fluids exacerbate fluid loss and can precipitate the onset of hyperthermia in hot weather.

TABLE 13-2

HEAT SYNDROMES

ILLNESS	SYMPTOMS	TREATMENT
Heat fatigue/heat syncope	Pale, sweaty skin that is still cool and moist to the touch Elevated heart rate and patient feels exhausted and weak Body temperature remains normal Some loss of vascular volume and electrolytes from sweating Sudden syncopal spell or dizziness after exercising in the heat	Oral hydration with electrolyte replacement Cooler, less humid environment Rest
Heat cramps and heat exhaustion	Muscle cramping of legs, arms, or abdominal wall. Skin remains moist or cool and clammy, tachycardia, decreased pulse pressure, and thirst usually present. Altered mental status (giddy, confused, weak), nausea. Core temperature normal or mildly elevated.	Cool environment, hydration, IV normal saline, rest
Heat stroke	Mechanisms to control heat are lost, core temperature rises quickly (>104° F) and causes cellular and end organ damage, skin flushed and hot and dry. Mental status changes, tachycardia, hypotension, hyperventilation.	Complex medical emergency; if untreated will cause death. Cool person as rapidly as possible, IV infusions. Complications during treatment include hypoglycemia, shivering, seizures, renal failure, and hypotension.

Modified from: Ham R, et al: Primary care geriatrics: A case-based approach, ed 5, St. Louis, 2007, Mosby; Ebersole P, et al: Toward Healthy Aging: Human needs and nursing response, ed 7, St. Louis, 2008, Mosby.

Heat stroke, the most serious form of heat illness, is a medical emergency that usually arises from failure of normal body-cooling mechanisms to cope with extremely high environmental heat or humidity. Heat stroke affects the hypothalamic thermoregulatory center and impairs the ability to sweat or lose heat by vasodilation. This condition can quickly lead to death unless treated, and rising core temperatures above 40° C (104° F) increase the likelihood of irreversible brain damage. Hyperthermia requires active cooling and fluid replacement. Because hyperthermia induces loss of thermoregulatory control, temperature must be closely monitored to avoid inducing hypothermia.

Box 13-1 presents interventions to prevent hyperthermia when the ambient temperature exceeds 90° F (32.2° C). Local governments and communities must coordinate response strategies to protect the older person when environmental temperatures rise. Strategies may include providing fans, opportunities to spend part of the day in air-conditioned buildings, and identification of high-risk older people.

BOX 13-1 Interventions to Prevent Hyperthermia

• Drink 2 to 3 L of cool fluid daily.

• Minimize exertion, especially during the heat of the day.

• Stay in air-conditioned places, or use fans when possible.

• Wear hats and loose clothing of natural fibers when outside; remove most clothing when indoors.

• Take tepid baths or showers.

• Apply cold wet compresses, or immerse the hands and feet in cool water.

• Evaluate medications for risk of hyperthermia.

• Avoid alcohol.

Hypothermia

Nearly 50% of all deaths from hypothermia occur in older adults (Ham et al., 2007). Hypothermia is produced by exposure to cold environmental temperatures and is defined as a core temperature of less than 35° C (95° F). Hypothermia is categorized into mild, moderate, and severe, depending on the core temperature taken with a rectal probe thermometer. Hypothermia is a medical emergency requiring comprehensive assessment of neurological activity, oxygenation, renal function, and fluid and electrolyte balance.

During cold weather, two situations tend to produce hypothermia: (1) exposure involving a healthy individual in severely cold environmental conditions for a prolonged period; or (2) exposure involving a person with impaired thermoregulatory ability in room temperature without protection. The more severe the impairment or prolonged the exposure, the less able are thermoregulatory responses to defend against heat loss. Older adults are particularly predisposed to hypothermia because the opportunity for heat loss frequently coexists with the decline in heat generation and conservation responses. Such coexistence occurs frequently among persons who are homeless or cognitively impaired; persons who are injured in falls or from trauma; and persons with cardiovascular, adrenal, or thyroid dysfunction, and diabetes. Other risk factors include excessive alcohol use, exhaustion, poor nutrition, inadequate housing, as well as the use of sedatives, anxiolytics, phenothiazines, and tricyclic antidepressants.

Unfortunately, a dulling of awareness accompanies hypothermia, and persons experiencing the condition rarely recognize the problem or seek assistance. For the very old and frail, environmental temperatures below 65° F (18° C) may cause a serious drop in core body temperature to 95° F (35° C). Factors that increase the risk of hypothermia are numerous, as shown in Box 13-2.

BOX 13-2 Factors that Increase the Risk of Hypothermia in Older Adults

Thermoregulatory Impairment