nursing.elitecme.com Page 139 Complete Your CE Test Online - Click Here prepare those foods for themselves because of physical or cognitive limitations. Many older adults live and eat by themselves, resulting in reduced caloric intake (Ritchie & Yukawa, 2017). Appetite tends to decrease with age, and elderly adults may simply not feel hungry. Problems with teeth, gums, or dentures and swallowing difficulties may also impair a person’s nutrition. Physical limitations, such as dysphagia (difficulty or discomfort swallowing), may affect those who have suffered a stroke or have such diseases as Parkinson’s, Zenker’s diverticula, and amyotrophic lateral sclerosis (ALS), thus reducing nutritional intake (Ritchie & Yukawa, 2017). Older adults may have difficulty or pain with chewing because of poor dentition. Or they may have tremors or other conditions, such as arthritis, that may make it difficult to feed themselves. Other conditions that may affect the intake of adequate nutrition include the following (Ritchie & Yukawa, 2017): ● ● Malignancy. ● ● Depression. ● ● Alzheimer’s disease. ● ● Gastrointestinal disorders (gastroesophageal reflux, celiac disease, inflammatory bowel, peptic ulcer disease, ischemic bowel, pancreatic insufficiency). ● ● Drug or alcohol dependence. ● ● Medication side effects. Vitamin deficiency Older adults are highly susceptible to vitamin deficiencies from either poor nutritional intake or poor absorption of vitamins that is a consequence of aging. Vitamin B12 deficiency is rather common in adults > 65 years of age, possibly affecting the nervous system (Ritchie & Yukawa, 2017). Nursing consideration: Nurses should identify anyone at risk for falls and should ensure proper fall precautions are in place. This can protect the patient from being injured and developing a subsequent infection that may progress to sepsis. Vitamin D is often deficient in older adults as well, resulting from such causes as poor intake and lack of sun exposure (Ritchie & Yukawa, 2017). Vitamin D is necessary for the absorption of calcium. A deficiency in vitamin D can lead to muscle weakness, increased risk of falls and fractures, and functional impairment (Bischoff-Ferrari, Dawson-Hughes, & Willett, 2004; Gerdhem, Ringsberg, Obrant, & Akesson, 2005; Milaneschi et al., 2010). If an adult is functionally impaired or at risk for falls and fractures, it stands to reason she is also at an increased risk for infection and development of sepsis. Calcium deficiency is also prevalent in older populations as a result of malabsorption by the gastrointestinal tract as a person ages (Ritchie & Yukawa, 2017). Adults between the ages of 70 and 90 absorb one-third the amount of calcium that younger adults absorb (Ritchie & Yukawa, 2017). Calcium deficiency is associated with reduced bone mass and osteoporosis, which can lead to osteoporotic fractures (Gennari, 2001). EBP alert! Osteoporosis affects more than 10 million people in the United States. Within that population, there are nearly 2 million fractures each year (National Osteoporosis Foundation, 2015). Comorbidities Older adults are more likely to suffer comorbidities than are younger adults. They may have preexisting conditions that put them at risk for infection, such as diabetes, cancer, kidney dysfunction, liver disease, and lung disease—among others. Older people are also more likely than younger adults to need invasive devices that have the potential of becoming infected, such as indwelling catheters, peripheral catheters, joint replacements, and pacemakers. These comorbidities may lead directly or indirectly to infection and increase the risk of morbidity and mortality of sepsis. In fact, chronic diseases—such as heart disease, lung disease, and diabetes—affect a person’s immune system more than their chronological age does (Mody, 2017). HAIs and CAIs Older adults are also more likely than younger adults to be hospitalized, live in long-term care centers, or participate in senior day care programs where they are highly susceptible to infection. They are also more likely to develop antibiotic-resistant infections in these care centers than in other sites. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), fluoroquinolone- resistant Streptococcus pneumoniae, and resistant gram-negative bacilli are more apt to affect this patient population than a younger population (Kupronis, Richards, & Whitney, 2003; O’Fallon, Schreiber, Kandel, & D’Agata, 2009). Older adults are susceptible to immune suppression and malnutrition related to immobility, social isolation, and depression. Emotional states of agitated depression, confusion, Alzheimer’s, dementia, or hopelessness can contribute to a lack of appetite or dehydration from a diminished sense of thirst. Concomitant factors that contribute to the risk of injuries and infections can also increase their risk of developing sepsis. Self-evaluation: Question 7 Which of the following statements about the older patient is false? a. Older patients are more likely to have nutritional deficiencies, such as low calcium and vitamin D, than younger patients that may lead to increased risk of falls and fractures, thereby increasing the risk for infection. b. The patient over age 65 is twice as likely to develop sepsis than those in a younger demographic. c. The older patient is more at risk than the younger patient for developing sepsis as a result of comorbidities. d. Normal changes in immune function can leave the older patient more susceptible to infection than the younger patient. Altered clinical presentation of symptoms of infection Older adults may present atypically for infection allowing the practitioner to potentially miss diagnosing an infection early and treating it promptly, thus leading to a greater potential to develop sepsis. Older adults may have confusion or alterations in mental status as their baseline, making it difficult to identify mental status changes associated with infection or sepsis. Changes in the sensorium or memory of older persons may affect their ability to report a reliable history of previous infections or antibiotic use. In older adults, fever, sweating, and chills may be absent or not as pronounced as they would be in the younger patient (Mody, 2017). Older adults often have a lower baseline core temperature, in general, than younger adults. More specifically, those adults with dementia, women who are postmenopausal, and those who have a low body mass index may have a lower core temperature than others have. (Gomolin, Aung, Wolf- Klein, & Auerbach, 2005; Norman, 2000). In frail older patients, fever may be considered as one or more of the following readings (Mody, 2017): ● ● Single oral temperature > 37.8˚C (> 100˚F). ● ● Persistent oral or tympanic membrane temperature ≥ 37.2˚C (99.0˚F). ● ● Rectal temperature ≥ 37.5˚C (99.5˚F). ● ● Rise in temperature of ≥ 1.1˚C (≥ 2˚F) above baseline temperature. It is important for the clinician to get a thorough clinical picture of the patient’s baseline status to notice a change that may be subtle and easily overlooked.