Older Patient Assessment

Published on 12/06/2015 by admin

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Older Patient Assessment

David Gourley

The purpose of this chapter is to introduce the respiratory therapist (RT) to many age-related changes in older adult patients. Gradual decline and chronic illness characterize aging. Many health care professionals are focused on treatment of acute illnesses and conditions. Clinicians may need to gain a different perspective when assessing and managing elderly patients and the chronic conditions associated with old age.

Communicating with older adults in the health care environment can be challenging owing to hearing loss, more frequent health issues, and age differences between them and members of their patient care team, including RTs. However, effective communication is a necessary component of patient care.Chapters 1 and 2 of this text describe various strategies that can be used to help optimize communication and overall outcomes with all patient populations, including older adults. Several of these strategies focus on encouraging them to participate in a dialogue about the design and implementation of their care plan. It has been shown that health outcomes can be enhanced by having patients, including older adults, take a share of the responsibility in their plan of care.

It is also important for the RTs and other members of the patient care team to understand age-specific physiologic and structural changes in organ systems that pertain to older adults. Such changes may be apparent in general appearance, vital signs, and diagnostic tests, including pulmonary function test results (see Chapter 9). In addition, realizing that older adults have depressed immune systems and may present with unusual signs and symptoms is especially important to their disease management.

Assessment of the functional performance of an older adult patient may uncover a potential source of disability or impairment or a special need. A systematic inventory of functional abilities can lead to improved diagnostic evaluation and choice of interventions. Functional ability can be directly correlated with the index of health.

The “graying of America” will increase the number of older adults seeking medical attention. Over the next 30 years, the population of older adults will dramatically increase. In 2008, there were about 39 million adults aged 65 years and older. By 2030, this number will likely increase to over 72 million.1 The average expenditure for consumer health care in the 64- to 74-year-old age group increased 21% from 1999 to 2006 and increased 26% in the 75 years and older age group in that same time span.2 Additionally, the rate of visits to emergency departments by senior citizens in the United States is growing faster than in any other age group.1 This translates to an increase in the need for clinicians, including RTs, who are knowledgeable about aging and older adults.

Patient-Clinician Interaction

The importance of patient-clinician interaction cannot be overstated. Chapter 1 discusses the stages of patient-clinician interaction. The same general techniques for establishing rapport with patients holds true for older adults, but one important difference that must not be overlooked with older patients is time. Gathering data from older patients takes more time. Wise and efficient use of time can make a difference between just recording vital signs and really assessing the patient. Having a plan before making contact with the patient allows the clinician to gather better history and physical data, in the most efficient manner. Keep in mind that older adults who are institutionalized may be weakened by chronic or acute conditions. Asking an older patient to do unnecessary repeated maneuvers, performing unnecessary manipulations, and exposing his or her skin for long periods of time may exacerbate these conditions. Performing a structured assessment in a calm, unhurried, and respectful manner is fundamental to good geriatric patient assessment.

Reducing Communication Barriers

Communication implies two things: the message has been delivered, and the message has been understood. When older patients know what clinicians are asking and why, they are usually more compliant.

There are many potential barriers that hinder patient-caregiver communication. Sensory deficit, such as hearing or visual impairment, are obvious barriers. Physical barriers related to poorly fitted dentures, nonfunctional hearing aids, or surgical removal of vocal chords may make it impossible for patients to talk. Aphasia, related to stroke, head trauma, or Alzheimer disease, might affect both speech and processing of language, as can the adverse effects of many medications. Emotional barriers often manifested as depression can block communication efforts. Other emotional events, such as the loss of a loved one, the death of a spouse, or even being relocated to a health care institution against the patient’s wishes, may be obstacles to effective communication.

Although determining the exact cause of the communication barrier is beyond the scope of therapists, there are a few interventions that may help bridge the gap. It is always important to approach older adults in a caring manner. A smile, a pat on the hand, and a kind word while making eye contact are usually successful forms of nonverbal communication. When addressing the patient, use his or her last name preceded by the appropriate title (e.g., Ms., Mr., Dr., Father). Using the patient’s last name shows respect and promotes an atmosphere of equality. Call the patient by his or her first name only if you are given permission. Calling patients “sweetie” or “dear” is too familiar, may be interpreted as condescending, and should be avoided.

Be aware of the environment. If the room is too hot, too cold, or too dark or if sunlight from a window is blinding your patient, his or her discomfort may affect your assessment efforts and thus assessment results. Introduce yourself clearly, both by name and by department. Give the patient your full attention. Let him or her know that you are performing an important job. Tell the patient you look forward to working with them and encourage them to ask questions as they arise. If the patient seems confused, a gentle reminder of your role and goal may reassure him or her. Eliminate or reduce background noise and interruptions when possible. Taking a few seconds to do this up front will save time later.

Approach the patient and position yourself at eye level (Fig. 13-1). Maintain an unhurried pace, but keep the assessment structured in a logical manner so that all subjective and objective data can be recorded. An unorganized, unstructured, and hurried approach to assessment can be counterproductive. When asking your patient a question, wait for his or her answer. Try not to put words in the patient’s mouth. Older adults function better when they do not feel rushed.

Age-Related Sensory Deficit

Although research confirms the presence of age-related decremental changes in vision and hearing, it is important to remember that all older adults are neither hard of hearing nor visually impaired.

Hearing Impairment

Mild hearing loss begins in the 40s and slowly worsens as we get older. It is estimated that 40% to 50% of people over 75 years old have some level of hearing loss.

Presbycusis, an age-related, progressive, bilateral hearing loss, is the most common cause of auditory impairment in the United States. This condition affects about 23% of adults between the ages of 65 and 75 years.3,4 In the 70- to 80-year-old group, as many as 50% of older adults have hearing impairment that actually affects their communication skills.5 Statistics on the exact number of older adults with impaired hearing varies, depending on the source of information. A prospective patient evaluation and retrospective analysis from 576 consecutive frail elders found hearing impairment in 64% of those tested.4 The burden of hearing loss in older adults is considerable and is often associated with diminished functional independence.

Tinnitus, defined as a symptom rather than a disease, is also more prevalent in elderly people.5 Tinnitus is an auditory perception not caused by external sounds. It may be described as ringing, buzzing, roaring, or chirping in the ears. Depending on the severity of symptoms, tinnitus can result in mental status changes ranging from mild irritation to depression and suicidal thoughts. Tinnitus can be a result of ototoxicity, so drug-induced hearing impairment should always be considered in older adults. Ototoxicity is defined as a damaging effect on the eighth cranial nerve or in the organs of hearing or balance. The diminished hearing capacity that clinicians observe in institutionalized patients may be inflated by ototoxicity. Commonly prescribed pharmacologic agents, including aminoglycoside antibiotics (streptomycin, kanamycin, neomycin, gentamicin, and viomycin), salicylates, diuretics (ethacrynic acid and furosemide), and quinine or chloroquine, are particularly notorious for causing ototoxicity.6

Assessing for Hearing Impairment

Simple and accurate methods assess the presence or absence of hearing loss. Some that are commonly used are the whispered voice, a tuning fork, finger rub, a portable audioscope, and the Hearing Handicapped Inventory for the Elderly-Screening (HHIE-S) questionnaire.7 If the RT suspects that a patient may have significant hearing loss, he or she should inform the nurse and other appropriate members of the patient care team to collectively determine whether further action is appropriate.

Compensating for Hearing Impairment

If a hearing loss is suspected, ask clearly, “Can you hear me?” while facing the patient. If no documented hearing loss exists on the chart, discuss with the nurse the possibility of accumulated earwax or ototoxicity. If the patient has a hearing aid, make sure that it works and that it is in place. If there is no hearing aid, consider using an amplification device if available. Face the patient and speak slowly and clearly, keeping the entire mouth visible. (If you need to wear an isolation mask or have a mustache, the patient may be at a disadvantage.) Lower the pitch of your voice and do not shout.

If you are comfortable with the patient and the situation, you may use your stethoscope as an amplification device by placing the earpieces in the patient’s ears and speaking through the bell.

Vision Impairment

Visual impairment is one of the most significant changes associated with aging. Vision is an important part of performing activities of daily living and interaction with society. The patient care team must consider the effect visual impairment has on the geriatric population, including ability to drive a car, read newspapers and books, and identify common objects or people. Given the importance of vision and the impact of vision loss on the patient’s well-being, it is important for the clinician to understand the most common causes of vision impairment.

Presbyopia, a normal age-related change in the lens of the eye, usually results in correctable farsightedness. Although presbyopia can occur in adults as early as age 40 years, it is much more common in older adults. More serious disorders of the eye that frequently affect older patients include cataracts, glaucoma, diabetic retinopathy, and macular degeneration. Age is the major risk factor for developing a cataract, an opacity of the lens, that reduces visual acuity. Patients who live to an advanced age are likely to develop cataracts.

Visual impairment has been identified as the second most prevalent disability in adults older than age 65 years.8 Studies also reveal that sensory impairment diminishes functional status.4 Thus, RTs need to be aware of assessment techniques and compensatory strategies when caring for patients with vision loss.

Compensating for Vision Loss or Impairment

Consistency and safety are of primary importance for hospitalized patients with low vision. The old adage “a place for everything and everything in its place” is critical for those with visual impairment.9 Waste baskets, chairs, and bedside tables that are moved around the room for the convenience of the caregivers may pose a hazard. Knowing on which side the patient is used to getting out of bed will help in properly organizing the hospital room. Paper handkerchiefs, a hairbrush, or a telephone moved from where the patient has placed them will be missed. If the patient wears eyeglasses, make sure they are clean and properly positioned. Older adults with low vision may be able to read words that are enlarged and in bold print. Medicine bottle lids can be marked with a single large letter indicating the name of the medication for when the patient is discharged from the hospital. Words written with puff paint, which is available at craft stores, can help patients distinguish between different metered-dose inhalers (MDIs). Older patients with low vision will require increased illumination. Halogen lighting, if available, provides more illumination than incandescent bulbs. Enhancing contrast also enables elders with low vision to locate and identify objects. The use of coping strategies by older adults with age-related vision loss is associated with better adaptive outcomes.8

When patients are blind, verbal communication is extremely important. Speak clearly, and thoroughly explain the procedures you are going to perform until comprehension is evident. If it becomes necessary to move a patient with vision loss, tell him or her what you are going to do, offer an arm as a support and guide, and let the patient initiate the movement.10

Aging of the Organ Systems

The effect of aging on specific organ systems varies widely from one person to another. We spend about one fourth of our lives growing up and another three fourths growing old. Simple observation will attest to the fact that we do not all age at the same rate. Organ systems also age independent of one another. Lifestyle choices and environmental factors influence organ system functioning.11,12 The combination of these external factors, along with aging and disease processes, alters the body’s organ systems in both structure and function.

Age-Related Changes

A brief review of age-related changes in the cardiovascular and pulmonary systems may be helpful before the assessment of an older adult patient. Keep in mind that the following information reflects average changes with age. In older adults, deviation from average is not uncommon. Aging and disease processes also tend to overlap in producing similar signs and symptoms. When evaluating older patients, it is important to understand and recognize the differences.


Cardiovascular System

Diseases of the heart and blood vessels are common in elderly patients. The widespread prevalence of coronary artery disease has presented a challenge for researchers engaged in studying the effect of normal aging on the heart. Evidence regarding aging and human cardiovascular function is generally limited by the need to measure serial cardiac anatomy and physiology noninvasively.11 Cardiovascular changes have been studied in aging animals; however, translation of animal data to humans cannot be presumed. Many older adults do have some measure of cardiac hypertrophy, but it is generally accepted that in the absence of disease, there is minimal alteration in the size of the heart. As a result of decreased contractile properties in the heart and blood vessels, there is an age-related increase in systolic blood pressure and an elevated left ventricular afterload, which results in left ventricular wall thickening. Arterial walls stiffen with age. Blood vessels lose elastin and smooth muscle fibers and gain collagen and calcium deposits. Left ventricular systolic function remains relatively stable with no significant changes in resting left ventricular ejection fraction, cardiac output, or stroke volume.11 Left ventricular diastolic function, however, is reduced; this is most likely a result of structural changes in the left ventricular myocardium. The early left ventricular diastolic filling rate progressively slows after the age of 20 years. By the age of 80 years, the filling rate may be reduced by up to 50%.6

There is an age-related increase in elastic and collagen tissue in the cardiac conducting system, heart, and arteries, causing the vessels to become more rigid and thick. Researchers have noted a pronounced reduction in the number of pacemaker cells in the sinoatrial (SA) node, estimated by one author to be as high as a 90% decline in SA node cell numbers.11 The consequence of these age-related losses is an increase in cardiac arrhythmias. Atrial fibrillation is the most common cardiac arrhythmia, occurring in up to 5% of adults older than 80 years of age.13 Pressure receptor sensitivity declines with age. As a result, older adults have a blunted compensatory response to both hypertensive and hypotensive stimuli.

Calcification of heart valves is more prevalent in elderly people. In elderly patients, the predominant causes of valvular heart disease are degenerative calcification, myxomatous degeneration, papillary muscle dysfunction, and infective endocarditis. One third of patients older than 70 years of age have calcium deposits in the aortic or mitral valves.6

Congestive heart failure (CHF) may result from valvular disease, hypertension, cardiomyopathy, or ischemic heart disease. The incidence of CHF doubles for each decade of life between 45 and 75 years.11 The pressure the ventricles must overcome to pump blood out of the heart can lead to left ventricular failure, right ventricular failure, or biventricular failure. Left- and right-sided failures will both result in reduced cardiac output and an increased heart rate. CHF usually develops gradually and progresses over time. It may not be detected in the early stages, and it has a high morbidity and mortality rate. Some other CHF symptoms are more typically associated with the damaged ventricle, either left or right (Box 13-1).

Pulmonary System

There are a number of age-related physiologic changes in the pulmonary system. Structurally, the trachea and bronchi become more rigid with age. Smooth muscle fibers in the lungs are progressively replaced with fibrous connective tissue. Alveolar septa gradually deteriorate. Although the number of alveoli does not change, loss of alveolar walls increases the size of the alveoli and reduces surface area for gas exchange. The alveolar-capillary membrane thickens, causing a reduction in diffusion of pulmonary gases. Aging lungs have less elastic recoil. The chest wall becomes stiffer, probably as a result of ossification of the cartilage-rib juncture and progressive dorsal kyphosis. Although loss of elasticity of lung tissue actually increases lung compliance, the rigidity of the thoracic cage reduces compliance enough to result in an overall decrease in lung compliance. The stiffer chest wall and reduction in elastic recoil are factors in an age-related increase in functional residual capacity (FRC) and residual volume (RV).

Physiologically, aging alters both ventilation and gas exchange. Changes in ventilation and gas distribution are primarily related to the altered lung and chest wall compliance. The balance of inward forces (elastic recoil) and outward forces (chest wall and muscles of ventilation) determines lung volumes at rest. At about 55 years of age, respiratory muscle strength begins to weaken.6 The strength of the diaphragm for a 55-year-old is only about 75% of that for a healthy young adults. The important functional changes that take place with aging of the pulmonary system are reductions in elastic recoil and ventilatory muscle strength. The central control of these activities also changes with increasing years. Cardiac and pulmonary responses to decreased oxygen and elevated carbon dioxide levels diminish with age. Thus, the changes in ventilation and respiration with aging emerge as a complex picture.14 In the absence of disease, age-related changes in the lungs are inconsequential. However, the combination of age-related and disease-related pulmonary changes puts the patient at risk for increased morbidity and mortality.

Pulmonary Defense Mechanisms

Aging not only alters physiologic functioning of the lung (ventilation and respiration) but also affects the protective function of the lungs. With increasing age, the epithelial cells of the mucous membranes that line the tracheobronchial tree show degenerative changes. The number of cilia is reduced, and ciliary activity slows down. There is a decrease in the phagocytic activity of the macrophages in the mucous membrane. Combined, these changes lead to a reduction in mucociliary clearance. In addition, the loss of an effective cough reflex contributes to the increased susceptibility of older patients to lung infections.

Institutionalized older adults are subject to some conditions that may result in a reduced level of consciousness. Neurologic disorders and pharmacologic agents, such as narcotics or sedatives, can effectively blunt the cough reflex. Aspiration is always a concern. Patients with dysphasia, impaired esophageal motility, or reflux disease are at added risk when the cough mechanism is not working properly.

Immunity

Humoral immunity, which takes place in bodily fluids, is associated with antibody production and B lymphocytes. T cells are primarily related to cell-mediated immunity and constitute about 70% of the lymphoid pool in the blood. Cell-mediated immunity involves a variety of activities designed to restrain or destroy cells that the body recognizes as harmful. With age comes a decrease in cell-mediated immunity. This age-related decline in cellular immunity correlates with an increased frequency of secondary (reactivation) tuberculosis in elderly patients. The acute antibody response to extrinsic antigens, such as pneumococcal and influenza vaccines, is also reduced in old age. Immunizations, although not as effective in older adults, are still strongly recommended.

Research regarding the clinical implications of immunosenescence, which is aging of the immune system, is confounded by a number of factors. Within subpopulations of older adults, there is considerable heterogeneity of the immune response. Genetic factors may play a role, as may environmental pollutants, socioeconomic status, and nutrition. Even efforts to increase immune function (nutritional supplements or booster vaccines) may not be equally effective in older adults. Although increased rates of infection and malignancy are associated with the dysregulated immune response common in older adults, these changes have not been causally related to the increased incidence of disease.15 What does seem reasonable to presume, however, is that the age-related changes in the immune system may impair the older patient’s ability to effectively repel bacterial infections and may make them more susceptible to increased morbidity and mortality from pneumonia, sepsis, or other bacterial growths.

Unusual Presentations of Illness

What you see in a 40-year-old patient presenting with an acute condition or exacerbation of a chronic disease may differ from the presenting symptoms of an 80-year-old patient with the same disease. The variations in signs and symptoms can make it difficult to diagnose such common occurrences as pneumonia or a heart attack.

Some older adults will downplay their symptoms, assuming the aches and pains are simply due to old age. However, research indicates that in some cases aging neurons may decrease peripheral sensitivity, causing a reduced sense of pain.16

Immune system changes, as previously discussed, put older adults at a higher risk for harboring infectious agents. Changes in the cardiac system may result in blunting of the tachycardiac response to hypoxia or sepsis. Some aging organ systems lose the ability to compensate for injury to other organ systems.

Inflammation is one of the body’s first responses to infection or injury. It was once believed that in older adults the diminished febrile response, mild leukocytosis, and weakened local inflammatory response were related to the aging process. New evidence has shown that the same lack of immune response occurs in younger adults with multiple illnesses. Recent data support the theory that it is the accumulation of diseases not the age of the patient that impairs immunity.6

Pneumonia

In a patient with pneumonia, typical presentations are cough, fever, and purulent sputum production. These signs can be deceptively subtle in older adults, particularly a lack of an elevated temperature. With a lower base temperature and a reduced ability to mount a febrile response, older adults with pneumonia may be quite ill before the cause is detected. Some older patients with an infection may simply complain of a poor appetite, fatigue, lack of ability to perform daily activities, a generalized weakness, altered mental status, and lethargy. Extrapulmonary symptoms, such as nausea, vomiting, diarrhea, myalgia, and arthralgia, are common. The most sensitive sign of pneumonia in an elderly adult is an increased respiratory rate (>28 breaths/minute).14

Chest radiographs may be helpful in diagnosing pneumonia, but this is not the case if the patient is dehydrated. The pneumonic infiltrate may be obscured by pulmonary edema or may not be detectable on the chest film until 24 to 48 hours after the patient has been rehydrated.17

Sputum specimens collected for culture and sensitivity are recommended to avoid empirical therapy with a broad-spectrum antibiotic. Unfortunately, obtaining a good sputum specimen from an older debilitated patient is the exception, not the rule. For patients who do not respond to therapy or who relapse after an initial response to therapy, collecting sputum by transtracheal aspiration or a bronchoscopy may be considered. Depending on the pathogenic organism, blood cultures have a diagnostic yield of only about 10% to 20%.17