Page 42 Complete Your CE Test Online - Click Here 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. Nursing consideration: Older adults often present atypically with infection and sepsis. The nurse must be astute in evaluating changes in the patient and take into consideration changes from the patient’s baseline presentation whenever possible. Involving a family member or caregiver in the evaluation of the elderly may help to achieve a comprehensive evaluation. Bacteremia in the older adult Older patients are more likely to develop bacteremia from gastrointestinal and genitourinary sources than younger patients, with gram-negative bacteria the infectious agent (Mody, 2017). Mortality rates increase with age for nosocomial gram-negative bacteremia (Mody, 2017). Mortality rates for older adults were found to be 37% to 50%, compared to a mortality rate of 5% to 35% in younger adults (Pien et al., 2010). Reasons for the increased risk of mortality for older adults include higher frequency of invasive catheters, depressed immune response, comorbidities, and a higher incidence of end organ damage, such as renal insufficiency or acute respiratory distress syndrome (Mody, 2017). Infective endocarditis in the older adult Infective endocarditis is an infection in the endocardium of the heart that affects older adults 4.6 times more than it affects younger populations (Hoen et al., 2002). In older adults, streptococci and staphylococci are the main causative organisms. Infective endocarditis is also more difficult to diagnose in older patients, leaving them at a higher risk for undetected infection that may lead to sepsis. Pneumonia in the older adult Pneumonia is a cause for concern with the aging population. Adults older than age 65 comprise more than 50% of all cases of reported pneumonia (Fry, Shay, Holman, Curns, & Anderson, 2005; Hoen et al., 2002; Jackson et al., 2004). Streptococcus pneumoniae is the most frequent causative organism in older populations, but gram-negative organisms – such as Haemophilus influenzae, Legionella pneumophila, Moraxella catarrhalis, and Klebsiella spp – are more frequently seen in older adults with chronic obstructive pulmonary disease (COPD) who reside in long-term care facilities than those who reside elsewhere (Mody, 2017). Lack of vaccinations, immobility, immunosuppression, and chronic respiratory illnesses increase the risk of developing pneumonia and subsequent sepsis. Prosthetic device infections Many older adults are likely to have prosthetic devices as they age, including joint replacements, pacemakers, heart valves, and vascular grafts (Mody, 2017). Prosthetic joint replacements offer a particular challenge for treatment, as they are found to have microbial biofilms that reduce the effectiveness of antibiotics and may also have reduced blood flow secondary to scarring from surgery (Mody, 2017). Typically, removal of the prosthesis and reimplantation is recommended, which could be difficult to withstand for the older patient with existing comorbidities (Mody, 2017). Urinary tract infections in the older adult Older adults are particularly prone to the development of urinary tract infections (UTIs). UTIs are the most frequent cause of infection in adults older than age 65, with the incidence in men over age 80 of 5.3% and 10% in women over age 80 (Foxman & Brown, 2003). Gram- negative bacilli – such as Escherichia coli, Enterobacter, Klebsiella, and Proteus – are the most common causative organisms. But there is increased incidence of more resistant organisms also being isolated, such as Pseudomonas aeruginosa and gram-positive organisms, such as Enterococci, Staphylococci, and Streptococcus (Mody, 2017). Elderly patients with catheters are at the greatest risk for sepsis. The use of chronic indwelling catheters in nursing homes leading to cases of asymptomatic UTI is seen in 25% to 54% of women (Juthani-Mehta, 2007). In these cases, there is no benefit to treating with antibiotics, and treatment can lead to the problem of antibiotic-resistant organisms (Mody, 2017). Key points ● ● Older adults are at risk for developing sepsis for many reasons, including immune system changes, nutritional deficiencies, increased risk for HAIs and CAIs, comorbidities, and chronic health issues. ● ● Older adults may present atypically with infection, allowing the infection to go undiagnosed and, therefore, untreated, potentially leading to sepsis. ● ● Older adults are more likely to have prosthetic devices and subsequent infections of devices, infective endocarditis, pneumonia, and urinary tract infections than younger populations. SEPSIS AND PREGNANCY Pregnant women and those in the postpartum or puerperal phase (6 weeks after delivery) can develop sepsis and septic shock. In this population, sepsis can develop quickly in an otherwise healthy- appearing patient and have serious and life-threatening consequences, such as preterm labor and delivery, fetal infection, septic shock, multiple organ dysfunction syndrome multiple organ dysfunction syndrome (MODS), and death (Barton & Sibai, 2012).