Don't make dangerous mistakes with elder vital sign assessment

Assumptions might be wrong

A heart rate in the 60s might be the expected result of a patient on a beta blocker. "But, it may really be a masked tachycardia limited by the medication," says Barb Smith, RN, BSN, MSA, CEN, trauma program manager at Botsford Hospital in Farmington Hills, MI.

Likewise, a blood pressure of 120/80 is considered to be normal in a healthy adult, but it might be hypotensive in an elder whose "normal" is much higher due to their peripheral vascular disease.

If you don't take a patient's age into account, information you obtain at triage can be misleading. "Age-related changes, co-morbidities, and medications can limit the physiologic responses seen in this age group," says Smith. She suggests asking these questions of elders at triage:

  • Does the patient have any pre-existing medical conditions such as chronic obstructive pulmonary disorder, diabetes, or cardiac disease, which might put them at higher risk for complications?
  • What medications do they take? Are they taking warfarin, clopidogrel, or aspirin that might lead to bleeding or further injury? "Older adults are frequently on anticoagulant medications, which may result in coagulapathies and bleeding into the brain or fractures sites," says Smith.
  • What is their baseline neurologic status?
  • Does the patient have advanced directives?
  • If patient was injured, what is their mobility and functioning status prior to the injury? Do they use assistive devices such as a cane or a walker? How did the injury happen?
  • If a fall occurred, were there any signs or symptoms such as chest pain, palpations, dizziness, or weakness prior to the fall that might need further diagnostics?

"Medical disease symptoms can frequently lead to falls and injuries in the elderly population," says Smith. To improve your assessment of elders:

Perform frequent neurological assessments, including a Glasgow Coma Scale.

"This can help to identify subtle changes early," says Smith. "The aging process leads to a decreased cerebral blood flow and cerebral atrophy. This makes the brain more susceptible to injury."

Have a high index of suspicion for pulmonary complications.

The elderly have a loss of pulmonary reserves that predispose them to pulmonary complications, says Smith. They have a decreased cough reflex, and they have decreased diaphragm and respiratory muscle strength.

"Falls that result in rib fractures can be detrimental to the elderly patient," Smith says. "They increase the risk of mortality and pneumonias, due to limited pulmonary reserves."

Closely monitor pulse oximetry level, lung sounds, and respiratory status.

"This is important, as hypoxia can be very harmful," says Smith. She recommends giving supplemental oxygen to keep pulse oximetry above 90%, to improve the oxygen carrying capacity of the existing hemoglobin.

Keep in mind that some older patients have pre-existing anemia with a decreased oxygen transporting capacity. "This is further stressed by a trauma such as a fracture, which may lead to angina or myocardial infarction," says Smith. "Blood loss from a femur fracture can result in 1500 milliliter blood loss. A humerus or tibia may lose 750 milliliters. Pelvis fractures can be life-threatening, and large blood loss is possible."

Always look for a cause for change in mental status.

Slower speed of cognition is a normal change for elders, but an abrupt change in thinking, memory, motor skills, or confusion can certainly be from acute illness, infection, electrolyte abnormality, or medications, warns Karen Hayes, PhD, ARNP, assistant professor at the School of Nursing at Wichita (KS) State University.

"Changes in neurologic assessment need to be verified by family, primary care providers, or other caregivers," Hayes says.

Are vitals really "normal?"

"Physiologic aging leads to changes in what we might consider 'normal' vital signs," says Hayes. She gives these examples:

  • Increased peripheral vascular resistance raises blood pressure.
  • "Many older adults on anti-hypertensive medications may not respond to events which would normally elevate measured blood pressure," says Hayes.

  • A decrease in heart rate, or minimal increase in heart rate, might be an unrecognized response to stress.
  • "Therefore, using heart rate as an indicator of fever, sepsis, hypovolemia, hypervolemia, and pain may be unreliable in older adults," says Hayes.

  • Thermoregulatory responses to heat or cold are impaired.
  • "Ill elders may have lower core body temperatures because of the environment or the cold intravenous fluids we infuse," says Hayes.

  • Breathing tends to be more rapid and more shallow than younger adults because of less respiratory reserve.
  • "Elders are less likely to recognize the sensation of dyspnea and can mask impending respiratory failure," says Hayes. "There is a generalized decrease in arterial oxygen levels."

Sources

For more information on assessment of vital signs in elders, contact:

  • Karen Hayes, PhD, ARNP, Assistant Professor, School of Nursing, Wichita (KS) State University. Phone: (316) 978-5721. E-mail: Karen.Hayes@wichita.edu.
  • Barb Smith, RN, BSN, MSA, CEN, Trauma Program Manager, Botsford Hospital, Farmington Hills, MI. Phone: (248) 888-2575. E-mail: basmith@botsford.org.

Clinical Tip

Don't be fooled by 'normal' blood pressure

In your elder patient, changes in the aging myocardium cause the heart to be a less than effective pump.

"Cardiac output and stroke volume decrease," says Barb Smith, RN, BSN, MSA, CEN, trauma program manager at Botsford Hospital in Farmington Hills, MI. "There is a decrease in coronary blood flow related to atherosclerosis and a decrease in the conduction rates."

In addition, the compensatory mechanisms for shock, such as an increased heart rate, are frequently not seen. This situation is due to beta blockers, calcium channel blockers, or other cardiac medications that the elderly patient might be taking.

"A normal blood pressure may represent shock in a patient that is normally hypertensive," says Smith.


Current stats on elders in EDs

In 2006, 48 of every 100 patients visiting EDs were older than age 65, according to the latest available statistics from the Centers for Disease Control and Prevention. In 2006, 17% of ED visits were by elderly patients, according to the Nationwide Emergency Department Sample of the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Another study on the changing populations of ED patients reports that between 1996 and 2005, geriatric patients was one of the groups that increased significantly.1

"The best we can tell, these trends are going to continue," says Mary Pat McKay, MD, MPH, associate professor of emergency medicine and public health at the George Washington University Medical Center in Washington, DC. "Absolute numbers will compound, as both the visit rate and the number of persons over 65 increase. Since there is no plan to significantly increase the availability of ED beds, overcrowding will only increase."

Reference

  1. Xu KT, Nelson BK, Berk S. The changing profile of patients who used emergency department services in the U.S.: 1996-2005. Ann Emerg Med 2009; 54:805-810.