Critical care nursing for older adults: pathophysiological and functional considerations

The psychosocial health, experiences and needs of older adults and care partners during the first surge of the COVID-19 pandemic: a mixed-methods study

Background

Minimal research has leveraged qualitative data methods to gain a better understanding of the experiences and needs of older adults (OAs) and care partners of OAs with and without Alzheimer’s Disease (AD) and AD-related dementias (AD/ADRD) during the first surge of the COVID-19 pandemic. In this study, we: 1) quantitatively evaluated the psychosocial health of community-dwelling OAs; 2) quantitatively evaluated the perceived stress of care partners for OAs; 3) qualitatively characterized the experiences and needs of community-dwelling OAs and their care partners; and 4) explored differences in the experiences of care partners of OAs with and without AD/ADRD during the first surge of the COVID-19 pandemic in the New York metropolitan area.

Methods

In this mixed-methods study, telephone interviews were conducted with 26 OAs and 29 care partners (16 of whom cared for OAs with AD/ADRD) from April to July 2020. Quantitative data included: demographics; clinical characteristics (Katz Index of independence in activities of daily living (Katz ADL) and the Lawton-Brody instrumental activities of daily living scale (Lawton-Brody)); and psychosocial health: stress was assessed via the Perceived Stress Scale (PSS), social isolation via the Lubben Social Network Scale (LSNS), loneliness via the DeJong Loneliness Scale (DeJong), and depression and anxiety via the Patient Health Questionnaire-Anxiety and Depression (PHQ). Qualitative questions focused on uncovering the experiences and needs of OAs and their care partners.

Results

OAs (N = 26) were mostly female (57.7%), and White (76.9%), average age of 81.42 years. While OAs were independent (M = 5.60, Katz ADL) and highly functional (M = 6.92, Lawton-Brody), and expressed low levels of loneliness, stress, depression and anxiety (M = 1.95 on DeJong; M = 12.67 on PSS; M = 1.05 on PHQ depression; and M = 1.09 on PHQ anxiety), open-ended questions elicited themes of fear and worry. Care partners (N = 29) were mostly female (75.9%), White (72.4%), and married (72.4%), and reported moderate stress (M = 16.52 on the PSS), as well as a psychological impact of the pandemic.

Conclusions

Early in the pandemic, OAs reported minimal stress and loneliness; this may have been related to their reports of frequent interaction with family, even if only virtually. By contrast, care partners were moderately stressed and worried, potentially more than usual due to the additional challenges they face when trying to meet their loved ones’ needs during a pandemic.

Preemptive light sedation in intensive care unit may reduce pulmonary complications in geriatrics receiving pancreaticoduodenectomy

BACKGROUND

Patients undergoing pancreaticoduodenectomy (PD) for periampullary lesions are usually elderly with a high risk of postoperative morbidity and mortality. This retrospective cohort study investigated whether postoperative preemptive light sedation aids in recovery of elderly patients following PD.

METHODS

Ninety-nine geriatric patients undergoing PD at one hospital were enrolled from 2009 to 2018. Patients in the sedation group received mechanical ventilation support and preemptively light sedation with fentanyl and propofol or dexmedetomidine in the first 5 days postoperatively in the intensive care unit (ICU). Patients in the control group underwent early extubation and received morphine for pain control but no postoperative sedatives in the ordinary ward. Patients in the two groups were matched 1:1 using propensity scoring. The postoperative complication rate, surgical mortality, and postoperative hospital length of stay (LOS) were recorded. We also tested inflammation in an immortal human bronchial epithelial cell line.

RESULTS

After 1:1 matching, 40 patients in the sedation group were compared with 40 patients in the control group. The sedation group had a significantly lower pulmonary complication rate and fewer patients with postoperative gastroparesis. Both groups had similar postoperative hospital LOS and identical surgical mortality rates. Patients in the sedation group had significantly better postoperative quality of life, including less pain and less heartbeat variation. In vitro cell experiments supported the above clinical observations, showing that adequate use of sedatives could significantly elevate the cell viability rate, protect cells from damage, decrease interleukin-6 production, and reduce inflammation.

CONCLUSION

Postoperative preemptive light sedation in the ICU in geriatric patients following PD may not only reduce the rates of postoperative pulmonary complications and gastroparesis but also improve postoperative quality of life without prolonging the postoperative hospital LOS.

Challenges and Barriers to Providing Care to Older Adult Patients in the Intensive Care Unit: A Qualitative Research

BACKGROUND:

Enhancing the quality of care for elderly patients needs an understanding of the challenges and obstacles experienced by the intensive care unit (ICU) staff in providing care.

AIM:

To explore the most challenging issues experienced by ICU staff, in particular, nurses, in the care of elderly patients in the general adult ICU.

DESIGN:

A qualitative research design was employed. The Standards for Reporting Qualitative Research (SRQR) were followed.

METHODS:

Based on theoretical sampling, we carried out 34 in-depth semi-structured interviews from two medical adult ICUs. Data analysis was carried out using qualitative conventional content analysis.

RESULTS:

Data analysis led to the identification of three interrelated categories and 12 subcategories. Three main categories were factors related to nurses’ attitude in elderly care, factors related to the system of care, and factors related to the models of patient care delivery. These categories came under the main theme of “Inappropriate and unfair system for elderly care”.

CONCLUSION:

The findings of this study increase scholarly understanding of challenges and barriers to providing care to elderly patients in the general adult ICU. We found that the provision of care to elderly patients is inappropriate and unfair. Various obstacles must be overcome to improve the care of these patients. For example, negative attitudes toward elder care, inappropriate environments, lack of resources, lack of knowledge and skills, a specialized model of care delivery, respect for humanity, care without considering patient age, and separating professional conflicts from patient care. These findings may be used by ICU’s caregivers and managers to improve the quality of care.

IMPLICATIONS FOR PRACTICE:

Various obstacles were documented that need to be overcome by hospital administrators, nursing managers, clinical nurses, nursing educators, nursing researchers to improve the care of elderly patients admitted to ICU.

Prevalence and Determinants of Overweight, Obesity, and Type 2 Diabetes Mellitus in Adults in Malaysia

This systematic review aimed to examine trends in overweight, obesity, and type 2 diabetes mellitus (T2DM) among Malaysian adults, and to identify its underlying determinants. A review of studies published between 2000 and 2012 on overweight, obesity, and T2DM was conducted. The Cochrane library of systematic reviews, MEDLINE, EMBASE, Biosis, Scopus, and MyJurnal digital database were searched. According to national studies, the prevalence of overweight increased from 26.7% in 2003 to 29.4% in 2011; obesity prevalence increased from 12.2% in 2003 to 15.1% in 2011, and T2DM prevalence was reported as 11.6% in 2006 and 15.2% in 2011. Distal determinants of increased risk of overweight, obesity, and T2DM were as follows: female, Malay/Indian ethnicity, and low educational level. The limited number of studies on proximal determinants of these noncommunicable diseases (NCDs) indicated that an unhealthy diet was associated with increased risk, whereas smoking was associated with decreased risk. However, more studies on the proximal determinants of overweight, obesity, and T2DM within the Malaysian context are needed. Overall, our findings provide insights for designing both future investigative studies and strategies to control and prevent these NCDs in Malaysia.

Impact of critical care nursing on 30-day mortality of mechanically ventilated older adults

OBJECTIVES

The mortality rate for mechanically ventilated older adults in ICUs is high. A robust research literature shows a significant association between nurse staffing, nurses' education, and the quality of nurse work environments and mortality following common surgical procedures. A distinguishing feature of ICUs is greater investment in nursing care. The objective of this study is to determine the extent to which variation in ICU nursing characteristics-staffing, work environment, education, and experience-is associated with mortality, thus potentially illuminating strategies for improving patient outcomes.

DESIGN

Multistate, cross-sectional study of hospitals linking nurse survey data from 2006 to 2008 with hospital administrative data and Medicare claims data from the same period. Logistic regression models with robust estimation procedures to account for clustering were used to assess the effect of critical care nursing on 30-day mortality before and after adjusting for patient, hospital, and physician characteristics.

SETTING

Three hundred and three adult acute care hospitals in California, Florida, New Jersey, and Pennsylvania.

PATIENTS

The patient sample included 55,159 older adults on mechanical ventilation admitted to a study hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients in critical care units with better nurse work environments experienced 11% lower odds of 30-day mortality than those in worse nurse work environments. Additionally, each 10% point increase in the proportion of ICU nurses with a bachelor's degree in nursing was associated with a 2% reduction in the odds of 30-day mortality, which implies that the odds on patient deaths in hospitals with 75% nurses with a bachelor's degree in nursing would be 10% lower than in hospitals with 25% nurses with a bachelor's degree in nursing. Critical care nurse staffing did not vary substantially across hospitals. Staffing and nurse experience were not associated with mortality after accounting for these other nurse characteristics.

CONCLUSIONS

Patients in hospitals with better critical care nurse work environments and higher proportions of critical care nurses with a bachelor's degree in nursing experienced significantly lower odds of death.

The impact of aging physiology in critical care

Aging physiology greatly impacts care delivery in the geriatric patient population. Consideration should be given to addressing the patient-specific needs regarding the systemic changes seen in the aging patient. Each major body system presents its own unique challenges to the critical care practitioner, and a comprehensive understanding of these changes is necessary to effectively care for this patient population. This article summarizes these changes and provides key points for the practitioner to consider when caring for the aging patient in the critical care arena.

Assessing and managing critically ill older adults: Resources for educators and clinicians

Facilitating students' knowledge and ability to care for critically ill older adults is a daunting task for even the most experienced teacher. Faculty, preceptors, and mentors must address the seemingly dichotomous objectives of training practitioners capable of providing safe, technologically advanced care intended to restore hemodynamic stability tempered by the simultaneous goal of providing person-centered, culturally competent, age-appropriate interventions. This article provides specific approaches to prepare baccalaureate nursing students for some of the challenges experienced when caring for critically ill older adults, including teaching strategies, clinical competency behaviors/activities, and postconference topics. By creating a safe environment for asking questions, sharing their expertise and experiences, and adequately addressing individual learning styles, teachers can begin to instill the passion, commitment, and knowledge needed to care for this vulnerable population.

Geropharmacology: a primer for advanced practice. Acute care and critical care nurses, part II

In the first part of this 2-part continuing education series, sources of medication errors were discussed. A predominant source of errors was the prescribing of potentially inappropriate medications for older adults. In this second part, drug classifications and drugs posing problems for older adults and cautions for advanced practice acute care and critical care nurses in their medication therapy management are highlighted. Cautions are advanced for anticholinergics, antihypertensives, analgesics, and psychotropics because of the severity of adverse reactions, including anticholinergic symptoms; mental status changes (especially confusion, sedation, delirium, and cognitive impairment); orthostatic hypotension; gastrointestinal tract problems (especially hemorrhage); depression; and neurobehavioral disturbances (agitation and aggressiveness). Risks of life-threatening outcomes associated with medications and adverse reactions are highlighted.

Geropharmacology: a primer for advanced practice acute care and critical care nurses, part I

Advanced practice nurses' challenge in managing older adults' medication regimens from an evidence base is difficult because older adults are vulnerable to medication errors and adverse drug reactions related to a number of factors. Predicting patients' responses to drugs is compounded during critical illness, adding to the heterogeneity and unpredictability of drug effects that are prevalent premorbidly. In the first part of this 2-part continuing education series, sources of medication errors and older adults' vulnerability are discussed, including normal changes of aging affecting pharmacokinetics and pharmacodynamics, polypharmacy, self-medicating, patient-family noncompliance, and inappropriately prescribed medications. In the second part, drug classes and drugs posing particular problems for older adults and cautions for acute care and critical care nurses who manage the medications of older adults are highlighted.