Centre for Gerontological Nursing

SN402 Gerontological Nursing

Week 3:
Care for older people in acute care settings
Rick Kwan RN, PhD
Assistant Professor

Patrick KOR RN, MSc, PhD candidate

Clinical Instructor

(Acknowledgement: Thanks to Mr Patrick Kor for his contribution of

slides)
Pre-class survey
 Intended learning outcome
After the lecture, the students will be able to
1. Identify the common iatrogenesis of hospitalization (acute
setting) in older adults and the prevention strategies.
2. Understand the risk factors for developing atypical
presentation of illness in older adults.
3. Identify the three types of atypical presentation of illness
include: (1) Vague Presentation (2) Altered Presentation
and (3) Non presentation (under-reporting)
 Acute care setting
• Purpose: to improve health and whose effectiveness largely
depends on time-sensitive and, frequently, rapid
intervention.

WHO (2013)
Number of hospitalization
Hazards of hospitalization in older adults
• Hospitalization can be the beginning of a
downward trajectory for many elders with
decline in function and quality of life, nursing
home placement and death.
 Hazards of hospitalization in older
adults
• 1. Nosocomial infection (Hospital-acquired infection)
• Occurring within 48 hours of hospital admission, 3 days of discharge
• An infection that is contracted from the environment or staff of a
healthcare facility
• Found higher in older adults

Avci et al (2012)
Adverse clinical events of hospitalization

Adverse Clinical Events and

Mortality During
Hospitalization and 3
Months After Discharge in
Cognitively Impaired Elderly
Patients.

Marengoni et al. J of Gerontol April 2013 68(4)

 Hazards of hospitalization in older
adults
• 2. Immobility and falls
• Deconditioning with sustained bed rest (reduced aerobic capacity,
muscle strength, respiratory function, vasomotor instability)
• Medical and surgical therapies (feeding tubes, bladder catheters)
• Adverse drug events
• Hostile hospital environment (restraints, slippery appearing floors,
clutter, absent handrails)
• Psychosocial factors
 Functional decline after hospitalization

Covinsky et al (2003)
Functional decline after hospitalization

Covinsky et al (2003)
Consequences of older adult with Influenza
 Other hazards of hospitalization
• Functional decline
• Immobility and falls
• Delirium
• Pressure sores
• Nosocomial infections
• Depression
• Undernutrition
• Polypharmacy
• Deep vein thrombosis
Friedman et al (2008)
Age related changes and hospitalization

Creditor, 1993
Game Time
 Age related changes and hospitalization
Changes with Usual Aging Contribution of Potential Primary Effects Potential Secondary
Hospitalization Consequences
Reduced muscle strength Immobilization, high bed Deconditioning, fall Dependency
and aerobic capacity and rails
Vasomotor instability Reduced plasma volume Syncope, dizziness Fall, fracture

Baroreceptor insensitivity Inaccessibility of fluids

and reduced total body
water
Reduced bone density Accelerated bone loss, Increased facture risk Facture
Decrease Vit D.
Reduced sensory Isolation, lost glasses, lost Delirium False labeling, physical
continence hearing aid, sensory restraint, chemical restraint
deprivation
Altered thirst, taste, smell, Barriers, therapeutic diets Dehydration, malnutrition Reduced plasma volume,
and dentition tube feeding
Fragile skin Immobilization, shearing Pressure sore Infection

Tendency to urinary Barriers Functional incontinence Catheter,et

Friedman family rejection
al (2008)
incontinence
 Principle of nursing care
• Baseline and ongoing assessment of risk factors
• Protocols aimed at improving self-care, continence,
nutrition, mobility, sleep, skin care, and cognition
• Daily rounds with a multidisciplinary team
• Protocols to minimize adverse effects of selected
procedures (e.g., urinary catherization) and medications
(e.g., sedative-hypnotic agents) and limit the use of mobility
restrictors (lines, tubes, and restraints)
• Environmental enhancements, including handrails,
uncluttered hallways, large clocks and calendars, elevated
toilet seats, and door levers
• Encouraging mobilization during hospitalization
Hughes (2008)
Encouraging mobilization during
hospitalization
 Acute Care for Elders(ACE) Unit
• Firstly developed at the University Hospitals of Cleveland (US)
in 1990.
• A prepared environment to promote mobility and orientation
• Patient-centered care with nursing initiated protocols for
independent self-care, sleep hygiene, mood, and cognition
• Comprehensive plans for returning home, facilitated by social
service intervention early in the course of care to mobilize the
family and other community resources
• A review of the medical care to promote optimal prescribing
for older patients

Pierluissi et al (2014)
A video
General acute care setting

Pierluissi et al (2014)
ACE Unit

Pierluissi et al (2014)
 Effectiveness of ACE
• https://www.youtube.com/watch?v=c-IqG8l4a-A
Atypical presentation of illness in older
people

• What is the meaning of decrease GC?

 Decrease general condition

Sin (2004)
 Atypical presentation illness
• Does NOT like the traditional symptoms that we
normally see associated with the disease.
• Physiological changes due to aging result in different
pathophysiological responses to foreign stimuli.
• The elderly may not be able to verbalize the symptoms
• The presentation include symptoms, physical findings,
and laboratory values

Habib & Sidra (2013)

 Risk factor of the atypical presentation
1. Age related changes

Habib & Sidra (2013)

 Age related changes behind the
symptoms
A) Thermoregulation
Age related changes behind the symptoms
B. Cardiac - Autonomic Nervous system
• Decrease beta receptor responsiveness
• Decrease heart rate and cardiac output
C. Volume regulatory
• decreased body water reserves due to decrease percent
body water.
• decreased thirst drive
D. Immune dysregulation
• decrease number of T cell
• decreased responsiveness
• decreased production & response to IL-2
E. Central nervous system
 Risk factor of the atypical presentation
1. Multiple co-morbidities
Nocturia  Masked by BPH
2. Medications: eg. Opioid use, Beta blocker

3. Cognitive impairment
Cannot recall the symptoms
Consequence of the atypical presentation
1. Inevitable alterations that occur within the various body
systems that represent normal physiological changes of
aging.
Eg, Absence of fever in elderly with infection
2. Pathophysiological changes associated with aging, or the
accumulation of disease.
The likelihood of developing major diseases such as heart disease,
diabetes, osteoporosis, stroke, and dementia all increase with age.
 Atypical Presentation of Illness in
Older Adults
• Acute confusion (for example, “delirium”)
• Failure to eat or drink (for example, anorexia)
• Lack of pain with a disease known to cause pain (such as
gastric ulcer disease)
• Functional decline
• Reduced mobility
• Generalized weakness
• Falling
• Fatigue
• Urinary Incontinence
• Agitation Petere (2010)
 Presentation of illness in elderly
1. Vague (Non-Specific) Presentation of Illness

2. Altered Presentation

3. Non-presentation
 Vague (non-specific) presentation
• Acute illness (e.g. pneumonia/stroke) can present as
Vague (Non-Specific) Presentation of
Illness
• Giants of Geriatrics:
• coined by Prof. Bernard Isaacs (1991)
• functional and/or cognitive impairment secondary to a disease
• the major symptoms associated with ageing

Isaaca (1992)
Vague (Non-Specific) Presentation of
Illness
• Possible cause of confusion in elderly

Miller (2014)
 Altered presentation
• Emergence of classic symptoms may present a confusing picture
 Altered presentation
• The presentation of a symptom or a group of symptoms in
older adults may present a confusing picture to health care
provides.
 Altered presentation of pneumonia
General population Presentation in elderly/atypical symptoms
Productive cough of purulent sputum The onset of disease may be insidious

The temperature may rise to 38.9°–39.4°C Minimal cough, no sputum production, no

fever

In a few: a single episode of shaking chills May appear tired or confused

followed by sustained fever and a cough
productive of blood-tinged sputum
Nausea and vomiting or diarrhea – (20%)

Symptoms of a new cardiac arrhythmia,

myocardial ischemia, or an actual infarction
(10%)
No fever in (39%)

No Leucocytosis in (31%)
Habib & Sidra (2013)
Altered presentation of pneumonia
 Altered presentation of UTI
General adult Elderly/atypical symptoms
Cystitis: dysuria, frequency, urgency, Acute lower tract irritative symptoms
suprapubic pain (frequency, dysuria, urgency, in-creased
incontinence)
Symptoms of acute pyelonephritis Fever with urinary retention or
develop rapidly over a few hours or a day: obstruction of the urinary tract
fever, shaking chills, nausea, vomiting,
abdominal pain, diarrhea + symptoms of
cystitis
Tachycardia, generalized muscle Urinalysis may not show
tenderness a large number of white cells.
Marked tenderness on deep pressure in Gross hematuria
costovertebral angle/s or on deep
abdominal palpation
Asymptomatic bacteriuria in 20%-50% of
SouthernCare University (2015) women, and in 20% of men over 80
years
Altered presentation of acute abdomen
General adult Elderly/atypical symptoms
Pain The diagnosis may be difficult
because of unique factors.

Diminished or absent Less abdominal inflammatory

bowel sounds response; less guarding/spasm,
Fever (3) Lower leucocytes count and Lower
and delayed temperature.

"Silent" acute abdomen

Mild discomfort and constipation
SouthernCare University (2015)
All of them complain abdominal pain!

van Geloven et al (2000)

Myocardial Infarction in the Elderly

Freisinger et al 2014
 Altered presentation of acute MI
Symptom Proposed Mechanisms

Dyspnea  Transient rise in LV pressure during ischemic event

 Acute left ventricular systolic dysfunction
 Age-dependent pulmonary changes
 Associated lung disease
Absent/Atypical  Altered pain perception:
Chest Pain  -Increased level of endogenous opioids
 -Increased opiod receptor sensitivity
 -Impaired autonomic peripheral nerve and central mechanisms
 -Sensory neuropathy
 Ischemic preconditioning:
 -Higher prevalence of repetitive episodes of ischemia
 -Higher prevalence of DM
 -Higher prevalence of multivessel disease
 -Higher prevalence of collateral flow
 Impaired ability to recall/report symptoms Carro & Kaski (2012)
 Etiology of elevated troponin levels
in the absence of MI
• Congestive heart failure

• Sepsis/critically ill patients

• Arrhythmias (tachycardias, bradycardias)

• Chronic renal failure

 Non-presentation of Illness
• A host of illnesses in older adults may go unrecognized for
many years and significantly impact quality of life
 Cause of non-presentation of illness
• The insidious nature of the onset of the illnesses and the
vague symptoms associated with these problems
• A tendency on the part of patients and families to regard
many of these symptoms as a "normal" part of aging
• Reluctance of older people to complain about problems
because of concerns as to being ignored or generating
burdensome tests
• Communication deficits including hearing impairments,
poor vision, and speech problems

(Ham, 2014)
 Cause of non-presentation of illness
• The perception of unresponsive system of care,
disinterested personnel or lack of facilities for elderly.
• Depression: reduces the desire for improvement.
• Dementia: diminishes the capacity to accurately describe
symptoms.
• Denial: fear of economic, social and functional
consequences.

(Ham, 2014)
Atypical presentation
 Nursing assessment
• Comprehensive Geriatric Assessment
• Past social and family histories
• Full medical history & focused physical examination
• Weight pattern
• Lab value review
• Medication reconciliation
• Communication skills
• Baseline function  ADLs
• Cognitive function

(Ham, 2014)
 Case scenario one
• Patient 1 is a 78-year-old man who has come to the emergency
department with a 3-day history of weakness, falls, and
confusion. His vital signs are as follows: 160/80 mm Hg; pulse 78
beats/min; respiratory rate, 22 breaths/min; and temperature
36.2°C.
• PMH: hypertension MI, and benign prostatic hypertrophy.
• Medications include Lasix, 40 mg once per day; terazosin, 10 mg
once per day; and aspirin, 80 mg once per day.
• Regarding the patient’s present illness, he has had a 3- to 4-day
history of periods of confusion, forgetfulness, frequent repetition,
agitation, and trouble walking.
• He fell 2 days ago while getting out of bed and again this morning
while getting out of the shower.
• He has bruising to his left knee and left hip.
• He was not able to get up after falling this morning and needed
help from his wife. He has been feeling weak and lethargic over
the past few days.
 What is your concern of the case?
• Neurologic event TIA?
• Cardiac event, such as congestive heart failure (CHF) or angina?
• Side effect of medication? Eg. Hypokalemia due to Lasix
• In the AED the doctor ordered:
• Blood x Troponin I, CBC, LRFT,
• Urine analysis and C/ST;
• ECG; Hip x-ray and CT brain
• Result:
• The patient’s CBC is within normal limits.
• His sodium level is a bit low, at 130 mmol/L, but all other electrolyte levels
are within normal ranges.
• The result of his troponin test is negative.
• His ECG shows his old MI but no new changes.
• The CT scan of his head is negative. Imaging of his left hip shows no
fracture
 Confirmed diagnosis
• His routine and microscopic urine test shows a urinary tract
infection.
• Diagnosis: UTI
• Risk factors:
• History of benign prostatic hypertrophy
• Age related changes in bladder muscle
• Decrease fluid intake

• In older adults, infections often present with falls, confusion,

change in functional status, or weakness, rather than fever.
 Conclusion
• The major hazards of hospitalization in older adults include
the nosocomial infection , immobility, fall and functional
decline.
• The acute setting for elderly should also aim at promoting
their functional ability and emotional needs.
• Atypical presentation of illness results from 1. Age related
changes 2. Multiple co-morbidities 3. Medications 4. Cognitive
change
• They are divided into (1) Vague Presentation (2) Altered
Presentation and (3) Non presentation (under-reporting)
• Atypical presentation was commonly found in MI, infection,
DM, heart failure especially in elderly with cognitive
impairment.
 Clinical Implication
• Comprehensive assessment in older people is very
important, in order to
• Pick up atypical presentation
• Identify risk factors for hospitalization related hazards
• History taking (better to involve family) is important, in
order to pick up unrecognized conditions (e.g. dementia)
• Implementation of treatment for acute illnesses are not
enough, nurses should focus on prevention of
hospitalization hazards (e.g. fall, malnutrition, dehydration,
pressure ulcers)
• Ultimate goal for care of older people with acute illness:
• Return the client home with similar function
 Bibliography
• Brent, G. A. (2012). Mechanisms of thyroid hormone action. The Journal of Clinical Investigation, 122(9), 3035-
3043. doi:10.1172/JCI60047
• Carro, A., & Kaski, J. C. (2011). Myocardial Infarction in the Elderly. Aging and Disease, 2(2), 116-137.
• Covinsky, K. E., Palmer, R. M., Fortinsky, R. H., Counsell, S. R., Stewart, A. L., Kresevic, D., . . . Landefeld, C. S.
(2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses:
increased vulnerability with age. J Am Geriatr Soc, 51(4), 451-458.
• Freisinger, E., Fuerstenberg, T., Malyar, N. M., Wellmann, J., Keil, U., Breithardt, G., & Reinecke, H. (2014).
German nationwide data on current trends and management of acute myocardial infarction: discrepancies
between trials and real-life. Eur Heart J, 35(15), 979-988. doi:10.1093/eurheartj/ehu043
• Ham, R. J., Sloane, P. D., Warshaw, G. A., Potter, J. F., & Flaherty, E. (2014). Ham's Primary Care Geriatrics: A
Case-Based Approach: Elsevier Health Sciences.
• Hughes, R. (2008). Patient safety and quality: An evidence-based handbook for nurses (Vol. 3): Citeseer.
• Isaacs, B. (1992). The challenge of geriatric medicine: Oxford University Press, USA.
• Peters, M. L. (2010). The older adult in the emergency department: aging and atypical illness presentation. J
Emerg Nurs, 36(1), 29-34. doi:10.1016/j.jen.2009.06.014
• Pierluissi, E., Francis, D. C., & Covinsky, K. E. (2014). Patient and hospital factors that lead to adverse outcomes
in hospitalized elders Acute Care for Elders (pp. 21-47): Springer.
• Habib, R. & Sidra, Q. (2013). Atypical Manifestations of Medical Conditions in the Elderly. Canadian Geriatrics
Society Journal of CME, 3 (1), 17-24.
• van Randen, A., Lameris, W., Luitse, J. S., Gorzeman, M., Hesselink, E. J., Dolmans, D. E., . . . Boermeester, M. A.
(2011). The role of plain radiographs in patients with acute abdominal pain at the ED. Am J Emerg Med, 29(6),
582-589.e582. doi:10.1016/j.ajem.2009.12.020
• Creditor, M. C. (1993). Hazards of hospitalization of the elderly, Annals of Internal Medicine, 118, p. 219-213.
Learning experience
Post-class survey