GERIATRIC COMMON DISEASE AND TREATMENT PLANS
INTRODUCTION
Scientific and social changes of the 21st century have brought as radical change in the Health care delivery system. Nursing is an important component of the health care delivery system and the role of a nurse in patient welfare has no boundaries for praise. The Nursing profession has evolved through time to establish a firm role in the medical domain based on strong ethical, moral and professional principles. The nursing practice has undergone a positive shift from that of a vocation to a professional status today. That is to say, nursing has a more active role to play in the health care delivery system than the past and nursing, as a profession is ‘accountable’ today.
EFFECT OF AGING ON THE RESPIRATORY TRACT AND OTHER ORGANS
Geriatric nursing is a complex practice with its own typical situations and interventions. A geriatric nurse always cares for patients who have the complications of their old age along with the disease for which they are treated. Cognitive impairments pose a serious barrier on the reliability of geriatric assessments. Geriatric nursing practice demands commitment, knowledge and understanding of the complexity of the care under complex situations like ICU. Older patients suffer from diseases such as osteoporosis, dementia, cardiovascular disease, arthritis, diseases of the respiratory tract, psychosocial problems such as isolation and depression. Although Dyspnoea might be the best-recognized clinical manifestation of aging, the effects of ageing on the vital capacity of the lungs and the lung / thoracic cage structure have been explored. The prevalence of dyspnoea and the prevalence of cough is strongly associated with ageing. Barrel chest and crepitations heard over the dependent lung zones do not have pathological significance but is again closely associated with aging process (Yernault JC, 2002). The increased susceptibility of the elderly to lower respiratory tract infection has not been fully explained. Although mucociliary clearance affected by ciliary beating and it’s ultra structure, plays a crucial role in the defense of the airways against inhaled microbes, little has been known of the effects of aging on these parameters (Ho JC et.al, 2001).
Transmission electron microscopy studies have revealed an increase in the microtubular disarrangement and single central microtubules with aging. Older patients have been shown to have significantly slower ciliary beat frequency, higher percent of ciliary cross-sections displaying single tubules which can be attributed to the frequent occurrence of respiratory infection in the elderly (Ho JC et.al, 2001). Although aging and asthma predispose individuals to more severe and protracted infections, the organisms and course of infections in elderly individuals seems to be more dependent upon associated comorbidities, overall physiologic health and associated immune deficiencies. Except Chlamydia pneumoniae infections the causes of pneumonia in the elderly are similar. Thus, the host immune system, medications, pathogenesis and exacerbations have to be taken into account during preventive and therapeutic strategies for the elderly patient with pneumonia (Hunter, 1997). Bacterial pneumonia has long been recognized as a common and highly lethal infection in the aged. colonization of the oropharynx with potentially pathogenic bacteria is the first step in the evolution of most bacterial pneumonias.The oropharyngeal carriage rate of Staphylococcus aureus and aerobic gram-negative bacilli, such as Klebsiella pneumoniae, tends to be greater in the elderly.
The risk of colonization has been found to be increased in elderly persons who were substantially incapacitated by chronic cardiac or respiratory tract diseases. Age-related alterations in the mechanics and patterns of respiration suggest that the elderly are at increased risk for nocturnal aspiration. Senescence associated with a loss of elastic tissue within the lungs and a weakening of the muscles of respiration that impair cough effectiveness and disturbances in the patterns of respiration during sleep have been found to cause insomnia. Elderly patients with altered states of consciousness due to medications or central nervous system disease, such as stroke, are high risk patients. Other conditions recognized as predisposing to aspiration include mechanical devices, such as nasogastric tubes, and dysphagia, which can be due to carcinoma, stricture of the esophagus or central nervous system disease, such as a bulbar palsy (Anthony L. Esposito ,1989).Medications should be administered with caution in aged patients due to other factors like reduced or retarded liver and kidney function which metabolize antibiotics and other drugs.
DISESES OF THE RESPIRATORY TRACT IN GERIATRIC PATIENTS
The older patient suffers from a range of diseases of the Respiratory Tract .The diseases could be due to various internal factors in terms of a poor immune system due to old age or external factors like an allergic environment or a bacterial infection. The diseases of the respiratory tract are numerous and include Asthma, Chronic obstructive pulmonary disease (COPD) and Pneumonia. Aspiration pneumonia is a common type of pneumonia in older patients.
ASPIRATION PNEUMONIA
Aspiration can be defined as an entry of a foreign substance in solid, liquid or gaseous state into the human respiratory tract. Aspiration pneumonia is a condition caused by such a direct impact of the aspirated material or by a primary or secondary bacterial infection of the lungs. The predisposing factors for aspiration in adults include alcoholism, stroke and other neuromuscular disorders and seizures (http://www.emedicine.com/Radio/topic57.htm). Conditions associated with aspiration pneumonia in older adults include decreased level of consciousness due to acute and chronic alcoholic abuse, drug overdose, stroke, seizure, head trauma, anesthesia, dysphagia, gastroesophageal reflux, neurologic disease like stroke, amyotrophic lateral sclerosis, myasthenia gravis, multiple sclerosis, Parkinson’s disease, Mechanical and device-related impairment of upper aerodigestive tract like nasogastric and percutaneous feeding tubes, endotracheal tubes, tracheostomy, Vomiting ,Bronchial obstruction due to neoplasm or foreign body ,Bronchiectasis and Pulmonary infarction . Individuals older than 70 years are at greater risk for complications of aspiration in the ICU setting, especially during intubation. (John L. Johnson, 2003).
Thus, Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused due to inhalation of the foreign material into the lungs, which may progress to form a collection of pus in the lungs called the lung abscess. The injured lungs subsequently become infected with multiple species of pathogens. Symptoms of aspiration pneumonia includes fever, fatigue, cough with foul-smelling sputum, greenish sputum containing pus or blood, Chest pain, shortness of breath, cyanosis due to lack of oxygen, tachycardia, wheezing, excessive sweating, difficulty in swallwing and a bad breath. Aspiration pneumonia occurs most commonly in hospitalized and chronically institutionalized older adults and aspiration pneumonia has been estimated to account for 6% to 9% of all cases of community-acquired pneumonia in USA (http://www.emedicine.com/Radio/topic57.htm ). The development of aspiration pneumonia after an aspiration is determined by the volume of material aspirated, its properties such as acidity, particulate nature, the frequency of aspiration and the status of host defense mechanism. Bacterial pneumonia results when aspirated bacteria are not effectively cleared from the lung. Pneumonia usually results from an aspiration of large volumes of material with a low pH or high bacterial density. Thus, Aspiration pneumonia can be classified as
CHEMICAL PNEUMONITIS
Acute chemical pneumonitis is a condition caused by acute inflammation of the major airways and lung parenchyma due to the aspirated materials such as mineral oil, hydrocarbons, and gastric acid. Aspiration of gastric contents is common cause of aspiration pnueumonia. Aspiration of low pH gastric secretions cause injury to the tracheobronchial tree and lung parenchyma. with diffuse bronchial erythema. (John L. Johnson, 2003). The severity of lung injury depends very much on the pH of the aspirated material and is greatest when the pH is less than 2.5. This injury results in complement activation and release of tumor necrosis factor alpha and IL-8 and other cytokines that enhance inflammation. Immediate and life-threatening Hypoxemia is typical of aspiration. Factors that contribute to hypoxemia, include reflex bronchospasm due to tracheal irritation, decreased surfactant activity accompanied by atelectasis and resultant ventilation-perfusion mismatching with intrapulmonary shunting and direct alveolar damage (John L. Johnson, 2003). Fever, leukocytosis and pulmonary infiltrates are common in acute chemical pneumonitis. Diffuse pulmonary infiltrates, refractory hypoxemia, and the adult respiratory distress syndrome are common in aspiration pneumonia. Recurrent fever, cough, and sputum production over 5 days period is indicative of secondary bacterial pneumonia.
BACTERIAL ASPIRATION PNEUMONIA
Bacterial aspiration pneumonia is like “Typical” pneumonia except for recurrent chills, pneumonia in lung segments, and growth of normal flora on routine sputum culture. Patients produce foul smelling sputum, show a more indolent disease with fever, malaise, weight loss, Leukocytosis and cough for 1 to 2 weeks (John L. Johnson, 2003). Most patients with aspiration pneumonia have infection due to multiple organisms as a result of aspiration of predominantly anaerobic flora originating in the oropharynx. The patient’s dental hygiene and of cough reflex are factors that influence the condition. The role of anaerobes in nosocomial pneumonia have been shown in a recent studies using appropriate sampling techniques and anaerobic culture methods. Anaerobic bacterial lung infections cause necrosis of lung tissues leading to cavitations and abscess formation or bronchopleural fistulae and empyema. Bacteroides, Peptostreptococcus and Fusobacterium species are the anaerobic pathogens most frequently isolated in patients with aspiration pneumonia.
These pathogenic bacteria enter the respiratory tract and cause infection due the weak cell mediated immunity in the respiratory tract on account of the aging process.The gastroenteric secreations though sterile often become colonized by enteric bacilli in patients treated with antacids, histamine2 blockers, or proton pump inhibitors. Gram-negative enteric bacilli and Staphylococcus aureus infections are common in such patients. Peptostreptococcus, Fusobacterium, Porphyromonas, Prevotella are obligate anaerobes acquired in community (John L. Johnson, 2003). These older patients run the risk of multiple infections due to secondary infections and cross infections. The older patients are prone to nosocomial infections even during their stay in the hospital treatment. Ventilator-Associated Pneumonia is a common nosocomial infection in the ICU accounting for 13% to 18% of all nosocomial infections. Gastroesophageal reflux of stomach contents into the oropharynx followed by aspiration into the lungs seems to be an important cause of nosocomial pneumonia because of the fact that nasogastric tubes impairs lower esophageal sphincter function and predisposes patients to aspiration pneumonia. Hence, feeding tubes that have a small-bore of about 3 mm have been advocated in lieu of traditional large-bore nasogastric tubes (John L. Johnson, 2003).
Critically ill older patients supported by mechanical ventilation are especially vulnerable to ventilator-associated pneumonia, leading to increased mortality and morbidity and prolonged hospital stay. Because of intubations, bacteria have direct access to the lower airways and the endotracheal tube, bypasses normal filtration mechanisms and the epiglottis (Ferrer M, 1999). The endotracheal tube serves as a route for inoculation of the bacteria such as Pseudomonas aeruginosa. Infections may occur even due to improper hand washing, not changing the gloves from patient to patient, and contamination of respiratory devices like nebulizers, spirometers, oxygen sensors, bag-valve mask devices, and suction catheters (Shelby Hixson, 1998). Staphylococcal infections are common in post operative hospital care. Streptococcus pneumoniae, Bacillus anthracis, Mycobacterium tuberculosis and Mycoplasma are commonly encountered bacterial pathogens that can cause pneumonia in such older patients as secondary infections and cross infections. The risk of aggressive pathogens, such as Pseudomonas aeruginosa and Acinetobacter species, is highest in patients in intensive care units and those in whom pneumonia develops after hospitalization for 5 or more days. Most of the older patients are the immunocompromised patients (John L. Johnson, 2003).
DIAGNOSIS
Physical examination with a stethoscope reveals crackling sounds in the lungs. This is followed by a chest X- ray, CT scan, Sputum examination / Culture, Blood examination, bronchoscopy and endoscopic studies. Traditionally, poster anterior (PA) and lateral chest radiographs have been used to diagnose aspiration pneumonia. X- ray examination shows infiltrates typically occurring in gravity-dependent lung regions. If a person aspirates in the supine position, then the posterior segments of the upper lobes and the superior segments of the lower lobes are most often affected. Infiltrates can be observed in the basilar segments of the lower lobes if patients aspirate while in sitting or standing position. These early findings indicate inflammation and not necessarily bacterial infection. Bacterial infections can be detected in chest films that show infiltrates in lung regions with abscess and empyema. In contrast to the atypical pneumonias that present on chest X-ray as a patchy ill defined infiltrate giving a cobweb appearance, Typical pneumonias show well defined consolidated densities. A CT precisely determines the location of the lobar or segmental opacity. A foreign body in the tracheobronchial tree (http://www.nlm.nih.gov/medlineplus/ency/article/000121.htm ) and associated atelectasis or consolidation can be easily diagnosed with CT scans. Aspiration of materials can also be determined by measuring the tissue attenuation on CT scans.
Necrosis, cavity formation, and empyema are all complications of aspiration pneumonia, which can be examined with CT than with plain radiography. A sputum Gram stain examination shows numerous neutrophils and mixed flora of gram-positive bacilli and cocci and gram-negative rods which can be suggestive of multiple microbial infection typically seen in aspiration pneumonia and can be an important diagnostic marker. A sputum culture in nonintubated patients with aspiration pneumonia can be done to identify serious pathogens including gram-negative enteric bacilli. Blood, pleural fluid, transthoracic needle aspirates, and bronchoscopic-protected specimen brush samples can be utilized for anaerobic as well as aerobic bacterial culture. Blood examination reveals leukocytosis. Other tests include swallowing studies such as a barium swallow test and endoscopy (http://www.nlm.nih.gov/medlineplus/ency/article/000121.htm). The patient’s swallowing mechanism can be studied by using fluoroscopy with a contrast agent. To get a definitive diagnosis a translaryngeal aspiration must be performed. This is a dangerous procedure and hence, the patients are treated empirically on the basis of predicted bacteriology (John L. Johnson, 2003).
TREATMENT
Initial therapy for acute aspiration depends on the correct recognition of the aspiration, treatment of acute hypoxemia and bronchospasm and discontinuation of nasogastric tube feeding. The next step involves the suctioning of upper airway if tube feeding, foreign material, or secretions are still present in the oropharynx without inducing gagging and emesis. Supplemental oxygen by mask or nasal cannula is administered during the initial assessment. A Venturi mask (John L. Johnson, 2003). is recommended to ensure a consistent, high inspired-oxygen concentration. Intubation and positive pressure mechanical ventilatory support is required in older patients. Chemical pneumonitis does not require antibiotic therapy. Since patients who aspirate pathogens are debilitated and immuno-compromised and are at increased risk for infectious pneumonia, it is better to begin the treatment with a broad-spectrum antibiotic. Antibiotics used for community-acquired aspiration pneumonia include clindamycin , beta-lactam and beta-lactamase inhibitor combinations such as ampicillin and penicillin with metronidazole. Metronidazole should not be given as monotherapy for aspiration pneumonia. The newer fluoroquinolones, gatifloxacin, moxifloxacin hydrochloride have been found to have reasonable anaerobic activity and achieve high concentrations in lung tissue and endobronchial secretions. Trimethoprim-sulfamethoxazole and aminoglycosides ineffective against anaerobes.
Treating gram-negative enteric bacilli and staphylococcal infections is important in nosocomial aspiration pneumonia. Hospital-acquired aspiration pneumonia can be treated with cefepime hydrochloride or ceftazidime with clindamycin or metronidazole. Beta-lactam and beta-lactamase inhibitor combination such as ampicillin and sulbactam, piperacillin sodium and tazobactam sodium, ticarcillin, clavulanate potassium and fluoroquinolones have been found effective. For patients with nasopharyngeal colonization of staphylococci and for patients with other active staphylococcal infections Antistaphylococcal coverage is recommended. Vancomycin is the drug of choice for antistaphylococcal coverage if methicillin-resistant S. aureus is a problem (John L. Johnson, 2003). Careful monitoring of the patient is important to distinguish chemical pneumonitis from bacterial pneumonia. A clinical response within 48 hours with rapid clearing of pulmonary infiltrates, suggests chemical pneumonitis rather than bacterial pneumonia and antibiotic therapy should be stopped. Prolonged fever is common in patients with lung abscess or with infections due to aggressive pathogens, such as P aeruginosa. Treatment for a period of 7 to 10 days is recommended and should be extended for a minimum of 14 to 21 days in case of isolation of highly resistant pathogens, such as P aeruginosa or Acinetobacter species (John L. Johnson, 2003). Complications of aspiration pneumonia include lung abscess, empyema, and bronchopleural fistula. Cavitary pneumonia or lung abscess requires longer treatment for 4 to 8 weeks. Lung abscesses respond to prolonged antibiotic treatment and adequate pleural drainage is important in patients with empyema.
CONCLUSION
The lack of specific and sensitive markers of aspiration complicates the epidemiological study of aspiration syndromes it is clinically difficult to distinguish between aspiration pneumonitis and aspiration pneumonia. Studies indicate that 5 to 15 percent of cases of community-acquired pneumonia are aspiration pneumonia and aspiration pneumonia is the most common cause of death in patients with dysphagia due to neurologic disorders, a condition that affects approximately 300,000 to 600,000 people each year in the United States (John L. Johnson, 2003). Thus, a nurse needs insight, sensitivity, effective communication skills and strategies to give what the patient needs and uphold the values of nursing care. A nurse should look for ways to improve the relationship between the family and the supporting health care of such critically ill old patients .The entire concept of care is based on communication, adaptation and recognition of the patient’s needs. The geriatric nursing demands maximum nursing interventions and constant monitoring of the patients especially with conditions like pneumonia. Thus, there is also a need for specialist nurses who are experts in not only medical care but also patient care.
REFERENCE
American Thoracic Society, “Research Priorities in Respiratory Nursing”, Am. J. Respir. Crit. Care Med., Volume 158, Number 6, December 1998, 2006-2015.
American Thoracic Society. 1995. Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventive strategies: a consensus statement. Am. J. Respir. Crit. Care Med. 153: 1711-1725.
Anthony L. Esposito, Pneumonia in the elderly,American Family Physician, Nov 15, 1989
Bassin, A. S., and M. S. Niederman. 1995. Prevention of ventilator-associated pneumonia: an attainable goal? Clin. Chest Med. 16: 195-208 .
BeckSague C, Sinkowitz RL, Chinn R, Vargo J, Kaler W, Jarvis WR. Risk factors for ventilator-associated pneumonia in surgical intensive-care-unit patients. Infect Control Hosp Epidemiol 1996;17;374376.ilated patients and its role in the pathogenesis of nosocomial pneumonia. Eur J Clin Microbiol Infect Dis 1996;15: 533544.
Ferrer M, Bauer TT, Torres A, et al. Effect of nasogastric tube size on gastroesophageal reflux and microaspiration in intubated patients. Ann Intern Med 1999;130(12):991-4
Huxley EJ, Viroslav J, Gray WR, et al. Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med 1978;64(4):564-8 .
Ho JC.et.al, The effect of aging on nasal mucociliary clearance, beat frequency, and ultrastructure of respiratory cilia Am J Respir Crit Care Med. 2001 Mar;163(4):983-8.
Hunter a. j. Bryant r. e. Treatment of asthma and allergic disease in the elderly
1997, vol. 17, 671-700 .
Jane Richardson, “Health promotion in Palliative care: the patients perception of therapeutic interaction with the Palliative nurse in the primary care setting”, Journal of Adv. Nurs. Vol 40 (4); 432, Nov 2002.
John L. Johnson, MD; Christina S. Hirsch, Aspiration pneumonia-Recognizing and managing a potentially growing disorder, Postgraduate Medicine, Vol 113 No 3 March 2003.
McCann Kathleen et, al, ’An examination of touch between nurses and elderly patients in a continuing care setting in Northern Ireland ,’Journal of Advanced Nursing, Vol 18’ 838, May 1993.
Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001;344(9):665-71 .
Marrie TJ, Durant H, Yates L. Community-acquired pneumonia requiring hospitalization: 5-year prospective study. Rev Infect Dis 1989;11(4):586-99 .
Mundy LM, Auwaerter PG, Oldach D, et al. Community-acquired pneumonia: impact of immune status. Am J Respir Crit Care Med 1995;152(4 Pt 1):1309-15
Phillips CD et, al, ‘Effects of cognitive impairment on the reliability of geriatric assessments in nursing homes’, J Am Geriatr Soc, Vol 41(2); 136-42, Feb 1993.
Shelby Hixson, Tracey King, Nursing Strategies to Prevent Ventilator-Associated Pneumonia, “AACN Clinical Issues: Advanced Practice in Acute and Critical Care, Vol 9, No 1.Feb 1998.
Shirai T, ‘Correlation between peripheral blood T-cell profiles and airway inflammation in atopic asthma.’ J Allergy Clin Immunol. 2006 Sep;118(3):622-6.
Wilma M.C.M et.al, ‘Non Verbal behaviour in nurse elderly patient communication’, Journal of Advanced Nursing Vol 29 : 808, Apr 1999.
Wust SK, Complement in asthma: sensitivity to activation and generation of C3a and C5a via the different complement pathways.’ Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, 110 Irving Street, NW, Washington, DC 20010, USA.
Yernault JC, Scillia P. Clinical and radiological aspects of ageing of the respiratory tract, Rev Mal Respir. 2002 Sep; 19(4): 481-9.
http://www.nlm.nih.gov/medlineplus/ency/article/000121.htm
http://www.emedicine.com/Radio/topic57.htm.