Dizziness can be a symptom of anemia, arrhythmia, depression, infection, ear disease, acute myocardial infarction, eye problems, stroke, cerebral tumors, vasovagal response, or cerumen impaction in the ear. It can also be a sign of drug toxicity. 17 Nursing assessments include checking for irregular pulses, measuring orthostatic blood pressure, reviewing the patient’s most recent electrocardiogram, and asking about hearing loss or ringing in the ears. Neurologic assessments are also required. Note balance as the patient walks heel to toe, observing if he begins to fall to one side or grabs on to objects for stability. Note his ability to perceive position (for example, can he close his eyes and still correctly detect direction as the nurse moves his big toe up and down?). Watch for swaying when the patient is standing with his eyes closed. Finally, measure extraocular movements by asking the patient to watch as you slowly outline the letter “H,” noting any rapid back-and-forth eye movements as he follows your hand.
Incontinence isn’t unique to older adults, but new-onset urinary incontinence should always be investigated. In older adults incontinence often occurs as a result of a urinary tract infection, limited mobility, or metabolic problems such as hyperglycemia or hypercalcemia. Other causes include the use of medications such as diuretics or sedatives, the latter of which can inhibit the person’s ability to recognize the need to use the toilet and slow his movement toward the bathroom. While many techniques can be used to rehabilitate people with urge or stress urinary incontinence or urinary retention, these reversible causes must be investigated first. 18 A dip stick urine test to look for the presence of the nitrites and blood usually found during infection can provide excellent clues for further workup. 19
PRESENTATION OF DISEASE
It is believed that immunity deteriorates with age as a result of decreasing T lymphocyte function. 20 With age, the thymus gland decreases in size and function. As a result, the effectiveness of the T lymphocyte response to antigens decreases. Rates of infection rise steadily with age, and mortality rates are sometimes two to three times higher for the same diseases seen in younger people. There is also an increase in certain cancers and autoimmune diseases with aging. Because of lower basal metabolic rates, older adults have lower core temperatures. Thus, a patient with a normal temperature or a low-grade fever may actually be experiencing a significant temperature hike. Additionally, with age, the body’s ability to trigger an inflammatory response to pathogens slows, making temperature an imprecise measure of the severity of infection. When assessing for infection, it’s critical to have an accurate baseline temperature and to note any recent changes such as confusion or decreased activity.
Because the symptoms of infections change with age—for example, fever and chills are replaced with confusion or decreased functional ability—they often go undetected in older adults until the infection has reached an acute stage. Additionally, many older adults who use non-steroidal antiinflammatory drugs for painful musculoskeletal conditions have their inflammatory response altered, so at intake nurses should always question patients about recent use of antipyretic medications. The following list describes possible presentations of the infections most commonly occurring in older adults:
- pneumonia—increased respiratory rate with decreased appetite and functioning
- urinary tract infections—incontinence, increased confusion and falls
Skin infections are often missed in older adults, who may be difficult to undress or move from a wheelchair. Cellulitis can occur in people with vascular disease; early signs may be missed in people with chronic dependent edema.
Alterations in gastrointestinal status have many causes, including low-level dehydration, slower peristalsis, chronic neuromuscular disease, or even lack of mobility related to osteoarthritis (which can make the older adult prone to constipation). Other causes of gastrointestinal distress may present in the older adult as follows:
- Upper or lower GI bleeding may present insidiously with signs of dehydration and crampy abdominal pain that’s difficult to localize.
- GI obstruction can present without the usual boardlike abdomen, but instead with cramps, dehydration, stringy stool or diarrhea, and vague complaints of feeling unwell.
- Diverticulosis may present with diffuse pain and a low-grade temperature that signal inflammation, infection, or even perforation.
When assessing for alterations in gastrointestinal status, first observe the contour of the abdomen, looking for old scars that might indicate adhesions. Then, using the stethoscope, listen in all four abdominal quadrants for the presence of bowel sounds. Percussion of the abdomen helps nurses determine whether the bowel is filled with feces or air. Special attention should be paid to any bruits or masses in older adults with poorly controlled hypertension; these may signal an abdominal aortic aneurysm and should be confirmed with an ultrasound or computed tomographic (CT) scan. Finally, light followed by deep palpation will help isolate painful areas, determine the existence of masses, and identify distention of the bladder. A patient’s report of blood in the stool or changes in stool color may be unreliable since the patient may be unable to clearly see the toilet contents.
Although often considered a disease of young adulthood, appendicitis also occurs in older adults. The rate of morbidity and mortality with appendicitis increases with age from 1% in the general population to 70% in older adults. 21 Among older adults, appendicitis is often misdiagnosed as bowel obstruction and surgical treatment is delayed, resulting in a higher rate of perforation. The four classic symptoms—right lower-quadrant pain, elevated white blood counts, fever, and anorexia—are still present and quite predictive but are often missed because health care providers may not suspect appendicitis in older patients. Thorough abdominal examination, blood work, careful evaluation of reports of pain and decline in appetite, and evaluation using abdominal and pelvic CT scans can reduce the potentially devastating effects.
In the most acute insult, myocardial infarction, the classic symptom is not crushing chest pain and diaphoresis, but sudden onset of dyspnea often accompanied by anxiety and confusion. Recognition of these signs and symptoms can result in early detection and treatment. The damaged heart muscle is unable to adequately perfuse, which causes associated symptoms such as confusion (caused by decreased cerebral profusion) or a drop in urine output (caused by decreased renal perfusion). The absence of ischemic pain is particularly evident among persons with long-standing angina and those with poorly controlled diabetes.
The beginning signs of worsening heart failure may be hard to detect in an inactive older adult with dependent edema. Often, the only changes noted may be a decreased appetite, weight gain of 2 to 3 lbs., and complaints of poor sleep. Teaching patients and caregivers these simple signs could ensure appropriate treatment and help patients to avoid future hospitalizations.
Nurses need to be cautious about the aggressive administration of IV fluids delivered to people with heart disease and long-standing, poorly controlled hypertension; they may be at high risk for heart failure. Aggressive treatment is required for those identified as high risk. Critical observations include sudden onset of confusion or increased anxiety, increase in respiratory rate, widening pulse pressure, weight change from baseline, overwhelming fatigue, and anorexia.
Type 2 diabetes.
As blood glucose rises, the older adult may not experience the three P s: polyuria, polydipsia, and polyphagia. Instead, the patient is more likely to become dehydrated, confused, develop incontinence related to glycosuria, and later develop a wasting disorder with weight loss instead of gain. Confusion is an early symptom of hypoglycemia. If older adults are treated with certain oral hypoglycemic agents that stimulate insulin production (such as sustained-release glipizide [Glucotrol XL and others]), their risk for acute hypoglycemia increases because they are less able to create and store glycogen for transformation to blood glucose when blood levels drop. This is especially problematic if the person lives alone and has no one to remind him to eat during illness or other times of stress. The American Diabetes Association recommends that people in the following categories be screened for diabetes: those with a family history of the disease; those with a body mass index greater than 25; those with hypertension or elevated lipids; members of high-risk racial or ethnic groups such as African Americans, Latinos, Native Americans, Asian Americans, or Pacific Islanders; and those with a history of vascular disease with a fasting plasma glucose level of greater than 126 mg/dL. 22
Fatigue and tremor, two of the most common symptoms of thyroid problems, may be missed or absent in old age. The gland itself may be hard to palpate as it slips lower and deeper into the neck. Instead, hyperthyroidism presenting in old age is often seen with new onset atrial fibrillation, weight loss, proximal muscle weakness, and confusion, while hypothyroidism may have few, if any, symptoms. 23 Many older adults have subclinical thyroid disease and may suffer cardiac disease and osteoporosis before treatment is initiated; nurses should carefully assess complaints of fatigue in all older adults.
To assess endocrine problems, the thyroid can be palpated in the neck as the trachea is stabilized and the person is asked to turn his head. Thyroid stimulating hormone remains the preferred indicator of thyroid disease (the normal range for adults is 0.4 to 4 μIU/mL) and needs to be closely monitored in older adults taking amiodarone (Cardarone and others) for heart disease. 24
Depression is the most commonly occurring mental health problem for older adults, especially in those with chronic illness and those living in institutions. 25 As the rate of suicides is highest in older white men, early assessment and treatment of depression is paramount. 26 However, many older adults avoid complaining of feeling sad or depressed, which can make it difficult for health care practitioners to recognize this problem in their patients. 27 Additionally, the societal expectation that older adults are tired, complain, and have little interest in life may disguise the most common symptoms of depression: fatigue, somatic symptoms that don’t seem to have an origin in pathology, and a decrease in activities the person formerly enjoyed. Failure to recognize that most older adults find satisfaction and joy in life can deprive patients of treatment that could vastly improve the quality of their lives.
Kurlowicz recommends screening for depression in the following high-risk groups: alcohol or substance abusers; people with dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic lung disease, or Parkinson disease; those suffering from functional disability, especially new onset; widows or widowers; caregivers; and those who are isolated or lacking social support. 28 Furthermore, certain medications, especially digitalis (Digoxin and others), propranolol (Inderal and others), and benzodiazepines, are associated with depression. 29
Because the complaints of younger and older adults may be different, it’s important to use an instrument specific to assessing depression in older adults. One such instrument is the Geriatric Depression Scale, which is available at www.hartfordign.org/resources/education/tryThis.html. Depression scales developed specifically for older adults don’t focus on somatic complaints or fatigue, as these may be manifestations of chronic illness. Older adults often present with confusion, lack of interest in life, or unwillingness to participate in the examination (providing answers such as “Why are you bothering me?”). Asking the questions, “Are you sad or blue?” and “Have you stopped doing things that once gave you pleasure?” are simple screening questions to detect depression. Nurses must ask specifically about plans for self-harm when self-destructive thoughts are stated.
Complete the CE test for this article by using the mail-in form available in this issue or visit NursingCenter.com ’s “CE Connection” to take the test and find other CE activities and “My CE Planner.”
The 8TH Annual Nurses Improving Care for Healthsystem Elders Leadership Conference
January 31 to February 1, 2005
Marriot Financial Center Hotel, New York City
For more information, visit www.nicheprogram.org.
Case Study What’s causing this patient’s confusion?
Three days after undergoing an open reduction and internal fixation of a fractured hip, 82-year-old Carol Thompson is admitted to the hospital after her daughter found her bruised body crumpled at the bottom of a flight of stairs. Although once very independent, Ms. Thompson is now confused and uncooperative. She is pulling at her dressing and unwilling to keep her hip-abduction pillow in place. The social worker recommends placement in a nursing home.
You suspect that something else could be causing Ms. Thompson’s decline. From the chart you learn she fell down poorly lighted stairs and lay there for more than 18 hours before being found. Suspecting a slow bleed into her brain from a subdural hematoma, you wonder if anyone has determined if Ms. Thompson hit her head when she fell. You check her pupils and her major cranial nerves. Because she was dehydrated on admission, she received a large amount of IV fluids. Wondering if she received too much too quickly—perhaps worsening undetected heart disease—you check her pulses and blood pressure and note any edema or neck-vein distention. You ask her daughter to bring in her medicine vials, and note that her daily levothyroxine (Synthyroid) was not ordered since admission.
Ms. Thompson’s surgery was complicated and lasted longer than expected; she did not receive a transfusion. You wonder if she might still be recovering from the anesthesia and check to see if hemoglobin and hematocrit levels were checked postoperatively; they were tested only on day one. Despite pressurized devices and the use of anticoagulant, you consider that she might have had a small stroke or other vascular insult. Finally, you wonder about pain management. Not only is Ms. Thompson recovering from major surgery, but she also has significant arthritis. Could her pain be adequately treated with the opioid analgesic ordered? You check her vital signs, perform a neurologic examination, assess for delirium using the Confusion Assessment Method, note her comfort level using the Checklist of Nonverbal Pain Indicators, examine her oral mucosa and conjunctiva for paleness, and review her medication record using the Beers Criteria for Potentially Inappropriate Medication Use in the Elderly.
In consultation with the orthopedic surgeon and the nurse practitioner managing her care, you arrange for the levothyroxine to be restarted, blood work to be drawn, and a change in pain medication to a sustained-release and breakthrough morphine agent. You also ask her daughter to meet with health care providers to discuss a longer hospital stay—until the medical issues causing this possible delirium can be addressed. You arrange for her daughter to visit outside of visiting hours and you remind her to bring in her mother’s eyeglasses.
Ms. Thompson’s delirium begins to lift in about 24 hours. Within 48 hours, she is participating with her treatment plan and looking forward to returning home.
Med Surge With age, the body’s reaction to medication changes
For Groucho Marx, old age was not a subject of reverence. “Anyone can get old,” he said. “All you have to do is live long enough.” Of course, a clinician knows what a comedian doesn’t: living “long enough” these days usually entails a medication regimen—and with this comes a high risk of adverse drug events and drug–drug interactions. The fact is, even in otherwise healthy older adults, changes in body composition influence the absorption, distribution, and clearance of medications.30
According to Williams, “In older persons, absorption is generally complete, just slower. In addition to age-related changes, common medical conditions such as heart failure may reduce the rate and extent of absorption.”30
As people age, they lose lean body mass gain and adipose tissue gain. Because there is less fluid available, water-soluble medications can reach toxic levels more quickly. Furthermore, the increase in adipose tissue means that fat-soluble drugs (predominantly the psychotropics) are absorbed into these less well-vascularized fat stores, and it takes longer for the drug to reach a therapeutic level (as well as longer for them to be excreted from the system). Vigilant monitoring is required with potentially nephrotoxic medications, including antimicrobials, cardiovascular agents, H2-antagonists, oral hypoglycemics (especially the sulfonylureas), and nonsteroidal antiinflammatory agents.
Protein malnutrition is common in underweight and obese older adults. This means that there are fewer binding sites for protein-binding drugs such as warfarin (Coumadin and others) or phenytoin (Dilantin and others); causing more “free” drug to circulate and putting the patient at greater risk for adverse effects such as bleeding or confusion. Protein malnutrition is determined by using prealbumin level less than 15 mg/dL, serum albumin level less than 3.2 g/dL, total lymphocyte count less than 1500 × mm3, transferrin level less than 200 mg/dL, and serum cholesterol level less than160 mg/dL.31
With decrease in kidney and liver functioning, clearance and excretion of drugs also takes longer. The nurse needs to closely monitor serum protein level (normal range 5.5 to 9.0 g/dL) and albumin level (normal range 3.5 to 5.5 g/dL), as well as renal and liver functions to help the older patient avoid toxicity or undertreatment.32
Assessing kidney function and drug toxicity.
Measures of serum creatinine, used to assess excretion for many drugs, are related to muscle mass and thus aren’t a good measure of kidney functioning in a frail individual or one who has lost muscle mass due to immobility. Contact the physician or pharmacist if there’s any doubt regarding the nephrotoxicity of the drug, and use the Cockcroft–Gault formula to calculate the creatinine clearance (see Cockcroft–Gault Equation for Calculating Creatinine Clearance, page TK). Creatinine clearance, a measure of the glomerular filtration rate, is a valuable way to note decline in kidney function in older adults. Accepted clearances are published for each drug, but the nurse should be especially concerned in patients with a clearance of less than 50 mL/min, which is indicative of a prerenal state.33 The pharmacist should be consulted about the need for dose adjustment, and monitoring of renal function should continue.
Try This A resource for geriatric tools
Several types of assessments are needed to determine if changes in a patient’s health are due to a change in health status or to normal aging. Yet while numerous assessment tools exist, few have been either developed for or modified to meet the norms of aging. An excellent resource for nurses working with older adults is the “Try This” series, sponsored by the Hartford Institute for Geriatric Nursing. Available both in print and on the Internet (at www.geronurseonline.org, this series is focused on assessing common problems and symptoms in older adults. Through “Try This,” nurses can gain access to a wide variety of resources, including the Beers Criteria for Potentially Inappropriate Medication Use in the Elderly and tools used to assess mental status or confusion (the Mini Mental State Examination or the Confusion Assessment Method), pain or discomfort (Checklist of Nonverbal Pain Indicators), and falling (Fall Risk Assessment). In addition to providing the tool, “Try This” provides directions for administration and guidance on the interpretation of results.
Tips for Nurses By Health Care Setting
- Confusion is not inevitable. Look for neurologic events or new medication.
- Many hospitalized older adults suffer from chronic dehydration accelerated by acute illness.
- Not all older adults have high fevers with infection. Other symptoms can include increased respiratory rate, falls, incontinence, or confusion.
Nursing home nurses
- Pain is undertreated in older adults with dementia. Look for nonverbal cues such as grimacing or resistance to care.
- Decline in functional ability (even minor declines, such as the inability to sit upright in a chair) may be a signal of new illness.
- Residents with less muscle mass—both the frail and the obese—are at much higher risk for toxicity from protein-binding drugs such as phenytoin (Dilantin and others) and warfarin (Coumadin and others).
Ambulatory care nurses
- Complaints of fatigue or decreased ability to do usual activities may be signs of anemia, thyroid problems, depression, or neurologic and cardiac problems.
- Severe gastrointestinal problems in older adults don’t always present with the acute symptoms seen in younger patients. Ask about constipation, crampy sensations, and changes in bowel habits.
- Older adults reporting increased dyspnea and confusion, especially those with a cardiac history, should be sent to the ED; these are the most common presentation of myocardial infarction in this population.
- Depression is common among older adults with chronic illnesses. Watch for lack of interest in former activities, significant personal losses, or changes in role or home life.
Home care nurses
- Falls should be investigated further, focusing on balance, gait, and neurologic issues.
- Older adults being treated for late-stage heart disease should be monitored for loss of appetite as an early symptom of impending failure.
- Drug–drug interactions in older patients who are seeing more than one provider and taking multiple medications are common. Watch for signs.
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