Age-Related Changes Affecting Vulnerability

Older patients discharged home from the ED are at significant risk for adverse outcomes such as functional decline, return to the ED, hospitalization, and death.^1,² Age-related physiologic changes affect all organ systems (Fig. 53-1), which potentially has important implications in clinical management of patients in the ED.

Fig. 53-1 Summary of the physiologic changes that occur in all systems and that the critical care nurse must consider in caring for the elderly patient in the critical care unit. GFR, glomerular filtration rate; GI, gastrointestinal; MEOS, microsomal enzyme oxidative system; SQ, subcutaneous.

From Urden, L. D., Stacy, K. M., & Lough, M. E. (Eds.). [2010]. Critical care nursing: Diagnosis and management [6th ed.]. St. Louis, MO: Elsevier.

Knowledge of these physiologic changes is important in caring for this vulnerable population in the ED ³ (Table 53-1).

TABLE 53-1 AGE-RELATED PHYSIOLOGIC CHANGES

AGE-RELATED CHANGES	CLINICAL CONSIDERATIONS	NURSING INTERVENTIONS
Cardiovascular system
• ↓ Inotropic and chronotropic myocardial response to catecholamine stimulation • ↓ Baroreceptor sensitivity • ↓ Blood vessel compliance	• Stress- and exercise-induced increases in cardiac output rely on diastolic filling • Increased tendency for orthostatic hypotension with position change, particularly if on antihypertensive medications • ↑ Peripheral vascular resistance and BP	• Closely monitor vital signs (be alert for tachyarrhythmias), oxygen saturation, and cognitive function when administering vasoactive drugs and in patients presenting with heart failure • Evaluate each patient’s response to BP reductions, as some may not tolerate a “normal” BP
Respiratory system
• ↓ PaO₂ level	• ↓ Ventilatory response to hypoxia and hypercapnia • ↑ Sensitivity to opioids and benzodiazepines	• Monitor oxygen saturation, including exhaled CO₂ if available, when administering opioids and benzodiazepines • “Start low and go slow” when administering high-risk drugs, especially in patients with cardiovascular, pulmonary, and cognitive disorders
Renal system
• ↑ Glomerular filtration rate • ↓ Ability to concentrate and conserve H₂O • ↓ Ability to excrete salt and H₂O loads, urea, NH₃, and drugs	• ↑ Sensitivity to drugs cleared by kidneys (i.e., antibiotics, contrast agents) • ↑ Risk for dehydration and hypernatremia • ↑ Risk for fluid overload and drug reactions	• Certain antibiotics administered in the ED may require renal dosing. Estimate creatinine clearance as a measurement of renal function rather than serum creatinine (normal value does not mean normal renal function because age-related loss of muscle mass affects serum creatinine) • Monitor oxygen saturation, cardiac rhythm, vital signs, and cognition for mental status changes in patients being treated for dehydration or fluid overload • Fluid resuscitation should be slower than for younger patients
Liver
• ↓ Total hepatic blood flow	• ↑ Adverse drug interactions	• Observe for any changes in vital signs, cardiac rhythm, and cognitive function following administration of medications
Neurologic system
• ↑ Cranial dead space • Changes in neurotransmitter function	• Symptoms associated with hemorrhage take a long time to manifest • Delayed or impaired processing of sensory and motor information	• Be aware that normal mental status–neurologic examinations do not confirm the absence of serious injury • Quiet the environment and limit distractions while completing mental status–neurologic examinations
Musculoskeletal
• ↓ Lean body mass • Thinning of intervertebral cartilage with compression of the spinal column • ↓ Joint mobility	• ↑ Risk for deconditioning and functional decline with acute and chronic illness • ↑ Risk for fractures	• Encourage independence with assistance as needed while in the ED rather than “doing it for them” • Educate patient and families about importance of home safety and preventing functional decline associated with acute illness and injury

BP, Blood pressure; CO₂, carbon dioxide; ED, emergency department; H₂O, water; NH₃, ammonia; PaO₂, partial pressure of oxygen in arterial blood.

Creatinine Clearance

The Cockcroft-Gault formula is used to measure creatinine clearance in older adults with stable kidney function.

Normal range of creatinine clearance is 97 to 137 mL/min in men and 88 to 128 mL/min in women.

TABLE 53-2 AGE-RELATED PHARMACOKINETIC CHANGES

PHARMACOKINETIC PARAMETER	Age-related change	OTHER FACTORS EXERTING EFFECT
Absorption—impacts uptake of the drug into tissue	↓ Absorptive surface of small intestine ↓ Splanchnic blood flow ↑ Gastric acid pH ↓ GI motility	• Achlorhydria (primary disorder or resulting from prolonged histamine [H₂] blockers or proton-pump inhibitors) • Administering multiple medications together • Tube feedings
Distribution—tissue into which the free form of the drug is distributed	↓ Lean body mass and total H₂O ↑ Total body fat ↓ Serum albumin ↑ α₁-acid glycoprotein	• Heart failure • Ascites
Metabolism—chemical change that renders the drug active or inactive	↓ Liver mass and blood flow ↓ Microsomal drug-metabolizing enzyme system that affect CYP 450 enzymes	• Tobacco abuse • Alcohol and caffeine • Drugs that inhibit or induce CYP 450 enzyme activity
Excretion—removal of drug by elimination	↓ Renal blood flow and glomerular filtration rate (GFR) ↓ Distal renal tubular secretory function	• Acute and chronic renal disease
Pharmacodynamics—physiologic response to a drug	↓ Predictability in drug response at usual or lower concentrations of many drugs	• Drug-drug interactions • Drug-disease interactions

CYP 450, cytochrome P450; GI, Gastrointestinal; H₂O, water.

Adapted from Rice, K. L., & Winterbottom, F. (2010). Gerontological alterations and management. In L. D. Urden, K. Stacy, & M. E. Lough (Eds.), Critical care nursing (6th ed.). St. Louis, MO, Mosby.

Cross-Cultural Issues in the Elderly

Emergency departments generally provide care to a variety of culturally diverse groups that represent the community they serve. However, the urgency of rapid assessment and intervention associated with emergency services may prevent individualization of care from a cross-cultural perspective. Irrespective of the elderly patient’s ethnic background, verify individual preferences and beliefs. Remember the following tips:

• Elderly persons within every ethnic group can differ greatly.

• Individual preferences may differ from those of persons of shared cultural heritage.

• Differences between ethnic groups differ widely regarding:

• Involvement of family and friends in decision making

• Disclosing medical information about condition and prognosis

• End-of-life decision making and preferences about care

Table 53-3 describes cross-cultural issues for 15 ethnic groups⁴; however, never make assumptions about a patient based on a cultural or ethnic label.

TABLE 53-3 A GUIDE TO CROSS-CULTURAL HEALTH CARE FOR OLDER ADULTS

Quality Indicators for Older Adult Emergency Care

In 2009 the Society for Academic Emergency Medicine and the American College of Emergency Physicians identified three conditions as having quality gaps in the care that older adults receive in the ED.⁵ These conditions include cognitive impairment, pain management, and transitional care.

Table 53-4 describes quality indicators associated with cognitive impairment, pain management, and transitional care.

TABLE 53-4 QUALITY INDICATORS FOR OLDER ADULT EMERGENCY CARE

CONDITION	QUALITY INDICATORS	RATIONALES
Cognitive impairment (includes acute mental status changes and memory impairment)	1. Include level of alertness and orientation in baseline cognitive assessment. 2. Assessment of patients with acute mental status changes: Focus on documenting the presence or absence of delirium-related symptoms (Table 53-6 and Table 53-7). 3. For patients with an acute mental status change who are discharged home: Document the name of the support person who is responsible for the plan of care and medical follow-up. 4. Determine whether cognitive impairment has been previously diagnosed by a health care provider, screen for dementia (see Table 53-7) if appropriate, or refer for follow-up.	1. Cognitive impairment is common in patients in the ED and screening for impairment is feasible. 2. An acute mental status change is a key feature of delirium. Although delirium is potentially life-limiting, it is frequently missed. 3. Delirious patients discharged home are at an increased risk for death in the months following discharge ^a without appropriate management. 4. Chronic mental status changes frequently play a role in why the patient presents to the ED (i.e., nonadherence to medical regimen, traumatic injury). However, many patients who present with a baseline cognitive impairment have no prior history of abnormal mental status changes.
Pain management	1. Formal assessment of acute pain within 1 hour of arrival at ED. 2. Pain assessment every 1 to 2 hours as appropriate but within 6 hours if still in ED. 3. Pain reassessment prior to discharge home. 4. Initiate pain treatment for moderate to severe pain (numeric pain score of 4 or higher) or document why treatment was not initiated. 5. Provide instructions about a bowel regimen to all patients discharged from the ED who receive a prescription for opioids or document why a bowel regimen was not provided.	1, 2, and 3 Appropriate assessment of pain fosters effective treatment. 4. Consider opioids (other than meperidine and propoxyphene) when nonopioid analgesia is ineffective. 5. Constipation is a side effect of opioid analgesia.
Transitional care	1. Critical information from nursing homes transferring patients to the ED includes: • Reason for transfer • Resuscitation (code) status • Medication allergies • Medication list • Contact information for nursing home • Primary care and on-call physician • Resident’s legal health care representative, family member 2. When patients are discharged back to the nursing home, critical information the ED should communicate includes: • Diagnosis • Test results and pending results • Recommendations regarding medication regimen • Any follow-up required by primary care	1. Individualized information is essential to make treatment decisions. 2. Communication between providers is critical to ensure continuity of care.

ED, Emergency department.

^a van Zyl, L. Y., & Davidson, P. R. (2003). Delirium in hospital. An underreported event at discharge. Canadian Journal of Psychiatry, 48, 555–560.

Cognitive Impairment

• Older adults frequently present to the ED with mental status changes.

• Approximately 25% of older patients in the ED have some type of cognitive impairment.⁶

• About 10% present with delirium.⁶

• About 20% present with some type of dementia or chronic memory impairment.⁶

Pain Management ⁵

• Pain is a common chief complaint in the ED, with approximately 75% reporting moderate or severe pain.

• Unrelieved acute pain is associated with poor clinical outcomes, including functional decline and an increased risk for developing delirium.

• Advanced age is the strongest independent predictor that a patient will not receive any analgesia in the ED.

• Thirty-three percent of patients presenting with hip or long-bone fracture do not receive analgesia in the ED and only 57% receive opioids.

Transitional Care from the Nursing Home ⁵

• More than 2.7 million nursing home residents visit an ED each year. Therefore it is critical that communication channels are open between the ED and nursing home to optimize clinical outcomes.

• Nursing home residents are frequently transported to and from the ED without essential information.

• Nursing home residents are frequently sent to the ED without adequate documentation, including the reason for the visit to the ED.

• Many nursing home residents are returned from the ED without any written information.

Primary Assessment of the Geriatric Patient

Although older adults seek emergency care for a variety of complaints, they frequently present with acute pain, psychiatric disorders, urosepsis, and dehydration. This section will describe tips for assessing each of these conditions, including therapeutic interventions, and diagnostic considerations that focus on the unique needs of older adults.

Pain

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”⁷ Acute pain has rapid onset with limited duration usually related to apparent pathology. Chronic pain persists for long periods of time and may not be related to disease process. Among older community dwellers, more than 50% report living with pain while at least 85% of nursing home residents experience some form of pain.⁸ The high prevalence of chronic and acute pain in older adults necessitates adequate pain assessment in the ED. Pain management is considered a quality indicator in managing older adults in the ED (Table 53-4).