Aging and Critical Care
Preface Caring for Older Adults in Critical Care
Sonya R. Hardin, PhD, RN, CCRN, NP-C Editor
This issue of Critical Care Nursing Clinics of North America has been designed to focus on the care of the older adult. The proportion of older adults from the total intensive care unit (ICU) population is high. The number of older adults is expected to exceed that of the young by the year 2050; therefore, critical care nurses can expect to see increasing numbers in their units. With advancing age, older adults present with preexisting comorbidities and are at greater risk for mortality, especially if the ICU patient is older than 75. Fourteen articles have been compiled on the care of older adults in critical care. While not all issues seen in older adults are addressed, major areas of subject matter are presented that will be useful as a review for some and may be new information for others. The first article is by Linda Bell and discusses the epidemiology of acute and critical illness in older adults. She points out that with an extended lifespan, disability rates in older adults have not changed; they are living longer with disabilities that affect their quality of life and complicate acute and critical illness. Individuals admitted to our units often face physiological changes, associated with aging, that increase their risk of mortality. Therefore, the second article in this issue is written by Mandi Walker, Mark Spivak, and Mary Sebastian. A key message in this article is that consideration should be given when addressing the patients’ specific needs regarding the systemic changes experienced in aging. Each major body system presents its own unique challenges; therefore, information on changes that occur with aging is presented. The third article is written by Bethany Gentleman. She provides an overview of the focused subjective and objective assessment of the older adult for critical care nurses. Emphasis is placed on the use of relevant evidence-based screening tools, which may be useful in the care of a critically ill older adult. The fourth article is on ethnogeriatrics and was written after the author, Sonya R. Hardin, completed the Ethnogeriatric Faculty Development Program held yearly at Stanford University in Palo Alto, California. An increase in diversity of older adults is expected to emerge over the next ten years. Crit Care Nurs Clin N Am 26 (2014) xi–xiii http://dx.doi.org/10.1016/j.ccell.2013.10.010 ccnursing.theclinics.com 0899-5885/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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An ethnogeriatric assessment should be included on all admissions to the ICU. This assessment would include information on ethnicity, level of acculturation, religion/ spirituality, preferred interaction pattern, facilitation of communication, and any physical examination constraints due to ethnicity. The fifth article is by Rose Ann DiMaria-Ghalili and Michele Nicolo. It is known that nutrition and hydration are vital components of critical care nursing. However, meeting the nutrition and hydration needs of the critically ill older adult is often complex due to preexisting risk factors (malnutrition, unintentional weight loss, frailty, and dehydration), as well as ICU-related challenges (catabolism, eating and feeding, end-of-life care). This article highlights the challenges of managing nutrition and hydration, reviews assessment principles, and offers strategies for optimizing nutrition and hydration for the critically ill older adult. The sixth article is on infection, sepsis, and immune function in the critically ill older adult. Written by Camille Lineberry and Deborah E. Stein, the article discusses the vulnerability of older adults and the associated risk of developing sepsis due to functional and immune changes, as well as frequent instrumentation and contact with the health care system. The challenge of recognizing the early signs of sepsis is complicated often by nonspecific complaints. This article addresses how advanced age is an independent predictor of mortality in the septic population of elderly. The seventh article is focused on cardiovascular issues seen among older adults. Leslie L. Davis discusses select cardiovascular conditions and physiological changes that predispose elders to these conditions; typical signs and symptoms, common diagnostic tests, and evidence-based treatment for this population are included. The implications for nursing care of critically ill elders who have these conditions are also discussed. The eighth article is written by Delia E. Fredrick on the subject of pulmonary issues in critically ill older adults. Older adults have anatomic and physiologic changes of the protective mechanisms of the pulmonary system that can impact outcomes. She reviews many of the pulmonary changes, such as altered rate and effort of breathing, decreased expiratory strength effort, and impaired oxygenation, that can result in a cognitive change. A number of bedside nursing interventions are discussed, which help to improve patient outcomes. The ninth article is on renal issues in older adults. Bryan Boling reviews the most commonly encountered complications in the ICU associated with an alteration in kidney function. This article describes the classification of renal dysfunction, the effects of aging on kidney function, as well as additional risk factors, management strategies, and outcomes in the older adult population. One of the most important systems to ensure a quicker recovery when admitted to an ICU is in the area of mobility. Helen W. Lach, Rebecca A. Lorenz, and Kristine M. L’Ecuyer wrote the tenth article on aging muscles and joints. Critical illness can impose immobility, resulting in loss of strength and functional ability in older patients. The authors discuss how early mobilization programs reduce the impact of immobility and improve outcomes for older patients. The components of a successful mobility program include a good patient assessment, a core set of interventions, and use of the whole health care team. The eleventh article, on psychiatric disorders, was written by Laura M. Struble, Barbara J. Sullivan, and Laurie S. Hartman. Approximately 30% to 50% of older patients who are hospitalized for a medical condition also have a psychiatric disorder. The intent of this article is to prepare acute care nurses to meet the mental health needs of older adults with critical illness and prevent untoward sequelae of medical
Preface
events. They discuss the importance of baseline assessment data and manifestations of common psychiatric disorders. “Delirium in the Older Adult in Critical Care,” written by Katheryne Tifuh Amba, is the twelfth article in this issue. The article focuses on the common neurological condition of delirium and how often the challenge exists in diagnosis. The thirteenth article is written by Roberta Kaplow on the topic of oncologic issues in the older adult. This article describes the pathophysiologic changes that occur with aging as they relate to cancer and cytotoxic therapies, implications for drug therapy, and complications of treatment modalities as they relate to the older person with cancer who may potentially be admitted to the ICU. Knowledge of these issues is essential for health care providers so they can face the complexities that may occur and optimize the outcomes of critically ill older persons diagnosed with cancer. The fourteenth, and last article in this issue, is on palliative care in the critical care unit. Author Joan E. Dacher discusses the need for palliation, the leadership roles nurses must assume, and barriers to palliative care programs. Her key message is that unless patients and families are offered a choice in care trajectory, many will continue to expect the traditional practice of care. End-of-life discussions are ethically necessary to ensure comfort is provided versus futile care. I want to personally thank all of the authors of this issue who worked tirelessly to produce information that is important to the care of older adults and critical to the optimal outcomes. Critical care nurses strive to provide safe care and to continually enhance knowledge in the care of patients. I appreciate all the caring moments nurses provide to help the families of older adults at the end of life. Sonya R. Hardin, PhD, RN, CCRN, NP-C College of Nursing East Carolina University 600 Moye Boulevard Greenville, NC 27858, USA E-mail address: [email protected]
xiii
Preface Caring for Older Adults in Critical Care
Sonya R. Hardin, PhD, RN, CCRN, NP-C Editor
This issue of Critical Care Nursing Clinics of North America has been designed to focus on the care of the older adult. The proportion of older adults from the total intensive care unit (ICU) population is high. The number of older adults is expected to exceed that of the young by the year 2050; therefore, critical care nurses can expect to see increasing numbers in their units. With advancing age, older adults present with preexisting comorbidities and are at greater risk for mortality, especially if the ICU patient is older than 75. Fourteen articles have been compiled on the care of older adults in critical care. While not all issues seen in older adults are addressed, major areas of subject matter are presented that will be useful as a review for some and may be new information for others. The first article is by Linda Bell and discusses the epidemiology of acute and critical illness in older adults. She points out that with an extended lifespan, disability rates in older adults have not changed; they are living longer with disabilities that affect their quality of life and complicate acute and critical illness. Individuals admitted to our units often face physiological changes, associated with aging, that increase their risk of mortality. Therefore, the second article in this issue is written by Mandi Walker, Mark Spivak, and Mary Sebastian. A key message in this article is that consideration should be given when addressing the patients’ specific needs regarding the systemic changes experienced in aging. Each major body system presents its own unique challenges; therefore, information on changes that occur with aging is presented. The third article is written by Bethany Gentleman. She provides an overview of the focused subjective and objective assessment of the older adult for critical care nurses. Emphasis is placed on the use of relevant evidence-based screening tools, which may be useful in the care of a critically ill older adult. The fourth article is on ethnogeriatrics and was written after the author, Sonya R. Hardin, completed the Ethnogeriatric Faculty Development Program held yearly at Stanford University in Palo Alto, California. An increase in diversity of older adults is expected to emerge over the next ten years. Crit Care Nurs Clin N Am 26 (2014) xi–xiii http://dx.doi.org/10.1016/j.ccell.2013.10.010 ccnursing.theclinics.com 0899-5885/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
xii
Preface
An ethnogeriatric assessment should be included on all admissions to the ICU. This assessment would include information on ethnicity, level of acculturation, religion/ spirituality, preferred interaction pattern, facilitation of communication, and any physical examination constraints due to ethnicity. The fifth article is by Rose Ann DiMaria-Ghalili and Michele Nicolo. It is known that nutrition and hydration are vital components of critical care nursing. However, meeting the nutrition and hydration needs of the critically ill older adult is often complex due to preexisting risk factors (malnutrition, unintentional weight loss, frailty, and dehydration), as well as ICU-related challenges (catabolism, eating and feeding, end-of-life care). This article highlights the challenges of managing nutrition and hydration, reviews assessment principles, and offers strategies for optimizing nutrition and hydration for the critically ill older adult. The sixth article is on infection, sepsis, and immune function in the critically ill older adult. Written by Camille Lineberry and Deborah E. Stein, the article discusses the vulnerability of older adults and the associated risk of developing sepsis due to functional and immune changes, as well as frequent instrumentation and contact with the health care system. The challenge of recognizing the early signs of sepsis is complicated often by nonspecific complaints. This article addresses how advanced age is an independent predictor of mortality in the septic population of elderly. The seventh article is focused on cardiovascular issues seen among older adults. Leslie L. Davis discusses select cardiovascular conditions and physiological changes that predispose elders to these conditions; typical signs and symptoms, common diagnostic tests, and evidence-based treatment for this population are included. The implications for nursing care of critically ill elders who have these conditions are also discussed. The eighth article is written by Delia E. Fredrick on the subject of pulmonary issues in critically ill older adults. Older adults have anatomic and physiologic changes of the protective mechanisms of the pulmonary system that can impact outcomes. She reviews many of the pulmonary changes, such as altered rate and effort of breathing, decreased expiratory strength effort, and impaired oxygenation, that can result in a cognitive change. A number of bedside nursing interventions are discussed, which help to improve patient outcomes. The ninth article is on renal issues in older adults. Bryan Boling reviews the most commonly encountered complications in the ICU associated with an alteration in kidney function. This article describes the classification of renal dysfunction, the effects of aging on kidney function, as well as additional risk factors, management strategies, and outcomes in the older adult population. One of the most important systems to ensure a quicker recovery when admitted to an ICU is in the area of mobility. Helen W. Lach, Rebecca A. Lorenz, and Kristine M. L’Ecuyer wrote the tenth article on aging muscles and joints. Critical illness can impose immobility, resulting in loss of strength and functional ability in older patients. The authors discuss how early mobilization programs reduce the impact of immobility and improve outcomes for older patients. The components of a successful mobility program include a good patient assessment, a core set of interventions, and use of the whole health care team. The eleventh article, on psychiatric disorders, was written by Laura M. Struble, Barbara J. Sullivan, and Laurie S. Hartman. Approximately 30% to 50% of older patients who are hospitalized for a medical condition also have a psychiatric disorder. The intent of this article is to prepare acute care nurses to meet the mental health needs of older adults with critical illness and prevent untoward sequelae of medical
Preface
events. They discuss the importance of baseline assessment data and manifestations of common psychiatric disorders. “Delirium in the Older Adult in Critical Care,” written by Katheryne Tifuh Amba, is the twelfth article in this issue. The article focuses on the common neurological condition of delirium and how often the challenge exists in diagnosis. The thirteenth article is written by Roberta Kaplow on the topic of oncologic issues in the older adult. This article describes the pathophysiologic changes that occur with aging as they relate to cancer and cytotoxic therapies, implications for drug therapy, and complications of treatment modalities as they relate to the older person with cancer who may potentially be admitted to the ICU. Knowledge of these issues is essential for health care providers so they can face the complexities that may occur and optimize the outcomes of critically ill older persons diagnosed with cancer. The fourteenth, and last article in this issue, is on palliative care in the critical care unit. Author Joan E. Dacher discusses the need for palliation, the leadership roles nurses must assume, and barriers to palliative care programs. Her key message is that unless patients and families are offered a choice in care trajectory, many will continue to expect the traditional practice of care. End-of-life discussions are ethically necessary to ensure comfort is provided versus futile care. I want to personally thank all of the authors of this issue who worked tirelessly to produce information that is important to the care of older adults and critical to the optimal outcomes. Critical care nurses strive to provide safe care and to continually enhance knowledge in the care of patients. I appreciate all the caring moments nurses provide to help the families of older adults at the end of life. Sonya R. Hardin, PhD, RN, CCRN, NP-C College of Nursing East Carolina University 600 Moye Boulevard Greenville, NC 27858, USA E-mail address: [email protected]
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