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This column looks at older adults in the ICU. Improving ICU clinicians' awareness of the symptoms of critically ill older adults is crucial to managing symptoms effectively. And communication with mechanically ventilated older adults is essential to accurate assessment of symptoms and choice of treatments.
Communication will require special strategies.
Use of an endotracheal tube or a tracheostomy creates communication challenges for critically ill older adults. Patients in the ICU they often experience obstructed speech, physiologic imbalances, weakness, pain, fatigue, and sedation, all of which may cloud thinking and hinder ability to respond. Nurses can communicate with nonspeaking ICU patients using a variety of techniques. But such methods may not work with older adults who have sensory or cognitive impairment. The aging process can result in a slowing of responses in interactions, as well as impairments in vision and hearing that may affect the ability to read and spell using an alphabet board or to understand spoken questions, explanations, and instructions. How should ICU nurses respond?
As part of an ongoing study (Improving Communication with Nonspeaking ICU Patients), we recently obtained data describing the cognitive characteristics and communication abilities of 42 adult ICU patients who were unable to speak because of laryngeal intubation. Subjects had Glasgow Coma Scale scores of 13 or higher. Ages ranged from 29 years to 82 years; 18 (43%) were 60 years old or older. All older adults in the sample had impaired vision or wore glasses, but more than half (10 of the 18) did not have their corrective lenses in the ICU. None of the three older adults who reported wearing hearing aids had the devices in the ICU.
Communication impairment prior to hospitalization, as evidenced by difficulties with speech, word recall, and writing, were reported more frequently in older (28%; five of 18) than in younger (8%; two of 24) subjects. Eight out of 18 (44%) older adults had delirium on enrollment screening using the Confusion Assessment Method-ICU 1; only four of the 24 (17%) younger subjects did. Additionally, a larger proportion of older subjects (33%; six of 18) than younger ones (21%; five of 24) were sedated when assessed on enrollment using the Richmond Agitation-Sedation Scale. 2 We are currently testing various strategies with non-speaking adults in the ICU (see Table 1, below). -Mary Beth Happ, PhD, RN, Judy Tate, MSN, RN, and Kathryn Garrett, PhD, CCC-SLP
1. Ely EW, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001;286(21):2703-10. [Context Link]
2. Sessler CN, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166(10):1338-44. [Context Link]
This vulnerable population requires specific assessment.
Adults age 65 and older account for more than 50% of all ICU patient days. 1 As the older adult population continues to grow, most critical care nurses will care for many patients in that age group. To adequately manage older ICU patients, ICU nurses need to recognize and accurately assess common symptoms.
Older adults challenge critical care clinicians because their symptoms often present quite differently from those of younger adults. 2 Symptoms tend to be nonspecific, poorly described, and difficult to assess in older adults, and the patients may have at least one chronic illness that complicates their management in the ICU and affects comfort and outcomes. 3 An ICU stay leaves an older adult at increased risk for infection, sepsis, sleep disturbances, pain, anxiety, nutritional deficiencies, adverse drug reactions, and delirium. 2, 3 Most existing studies of older adults in ICUs focus on mortality and quality outcomes. 4 Very few studies address common symptoms older adults experience in the ICU. Nelson and colleagues have shed some light (see Research Brief, above).
When an older patient cannot report symptoms, they may go unrecognized or be assessed inaccurately and lead to longer ICU stays. Recommendations for assessing signs and symptoms in nonspeaking older adults in the ICU include evaluating nonverbal cues such as grimacing, moaning, restlessness, rigidity, or bracing; using physiologic indicators such as heart and respiratory rates and blood pressure; consulting family members or caregivers; looking for cognitive and functional changes; anticipating procedures that can cause pain or distress such as turning or suctioning; and using alternative methods of communication. -Jennifer L. McAdam, MS, RN, and Kathleen A. Puntillo, DNSc, RN
More than 80% of mechanically ventilated patients developed delirium in the ICU.
For people under age 65 between 1996 and 1999, the number of ICU days per 1,000 was 37 days; for those ages 65 to 74, 178 days; for those ages 75 to 84, 245 days; and for those age 85 and older, 231 days.
Ely EW, et al. JAMA 2001;286(21):2703-10;Angus DC, et al. JAMA 2000; 284(21):2762-70.
A study finds that older adults have many.
A 2004 descriptive study conducted by Nelson and colleagues explored the common symptoms reported by critical care patients who have tracheostomies (N = 50; median age, 73). They found that 90% of patients had symptoms during their ICU stays; more than three-fourths had 10 or more symptoms. The most common were thirst, dry mouth, psychological symptoms such as sadness and worry, hunger, lack of energy, insomnia, shortness of breath, and pain. Ninety percent of the sample rated difficulty in communicating as the most distressful aspect of the ICU stay. This study, using data gathered as symptoms emerged, underscores the need for better assessment and treatment of older adults in the ICU-even those receiving analgesia and sedation. -Jennifer L. McAdam, MS, RN, and Kathleen A. Puntillo, DNSc, RN
Nelson JE, et al. Crit Care Med 2004;32(7):1527-34.
1. Angus DC, et al. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?JAMA 2000;284(21):2762-70. [Context Link]
2. Rosenthal RA, Kavic SM. Assessment and management of the geriatric patient. Crit Care Med 2004;32(4 Suppl):S92-105. [Context Link]
3. Mick DJ, Ackerman MH. Critical care nursing for older adults: pathophysiological and functional considerations. Nurs Clin North Am 2004;39(3):473-93. [Context Link]
4. Udekwu P, et al. Quality of life and functional level in elderly patients surviving surgical intensive care. J Am Coll Surg 2001;193(3):245-9. [Context Link]
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