The global population is aging, and with that comes new challenges. Optimal care must be delivered to minimize the time spent in the acute care setting. Avoiding costly complications and focusing on health promotion rather than disease management will be key. Geriatrics is a complex patient population and basic nursing care is essential to prevent unnecessary complications if our health care system is to survive. Our profession is ill prepared to optimally care for this patient population.

Keywords

Geriatrics

Health care

Complexity

Chronic conditions

Nursing

Key points

The world’s population is aging, and global predictions estimate that the largest growth sector from 2013 to 2050 will be persons over 60 years of age. By year 2030, 1 in every 8 persons on the planet will be over the age of 65.1 The United Nations predicts that this sector of the world’s population will triple by the year 2100, reaching 27% of the total global population.2 The reasons for this are 3-fold: People are living longer healthier lives, there are global declines in fertility, and baby boomers are reaching retirement.3,4 The situation is similar in the United States, with population increases of persons over 65 years expected to more than double from 2010 to 2050 (Fig. 1).5 As population demographics shift, in future decades we will also see a rise in noncommunicable disease that has the potential to stretch our already burdened health care system beyond its limits.3 Persons with chronic conditions such as heart failure, obesity, chronic obstructive pulmonary disease (COPD), hypertension, and more, consume vast amounts of our health care resources.6,7 Alzheimer disease is the sixth leading cause of death in the United States.8 Today, an American is diagnosed with Alzheimer disease every 68 seconds, and by 2050 this diagnosis will occur every 33 seconds.8

The workforce is ill prepared to care for an aging demographic: Health care professionals traditionally have little or no curricular content dedicated to geriatric care.9 Over half the patients hospitalized in the United States are over 65 years old, but less than 1% of the current nursing workforce is certified in geriatrics.10

Most of us who have been in practice for many years have traditionally “clumped” the geriatric patient population with young and middle-aged adults. As critical care nurses, we know that our practice is a specialized area, and that specific skills, critical thinking, and prioritization are vital to provide the best care possible for our patients. Most of us would not hesitate to admit our lack of expertise in, for example, pediatrics. If we were in a position where we were outside of our area of expertise we would seek help, information, and perhaps pursue educational offerings to build a sound knowledge base.

Many nursing professionals may not realize the extent to which the geriatric population consumes health care resources, or the complexity in care that older adults bring to the table. From a cost perspective, in 2013 the annual cost of Alzheimer disease to the United States was $203 billion, and by 2050 this cost is projected to reach $1.2 trillion annually.8 Cardiovascular disease and diabetes alone cost the United States over $750 billion every year.11 One in 5 elderly adults are readmitted to the hospital within 30 days of discharge.12 Not only are hospital readmissions costly in terms of finance, but also in terms of morbidity, mortality, and reduced quality of life. Most hospital readmissions are unplanned and have been associated with poor discharge planning, poor coordination of care, and ineffective communication of health care workers with each other, patients, and their families.12,13

So what do we need to do to provide patient-centered, quality care to our geriatric patient population? Five areas are addressed herein where astute critical care nurses can really make a difference in patient outcomes: The aging body, resiliency and vulnerability, functional status, polypharmacy, and chronic conditions. An overview of the complexity of older adult care in the intensive care unit (ICU) will follow a case study to help clarify and illustrate how nursing can make a difference in geriatric patient outcomes.

The aging body

The majority of older Americans consider themselves to be in good or excellent health (Fig. 2).14 Many remain active and independent well into their latter decades. Changes occur in our body systems as we age, and although daily functioning is maintained, the result of these age-related changes is that older adults have less reserve to bounce back from a health-related insult. Decreased reserve along with normal age-related changes makes us more vulnerable to complications or interactions with medications. What is important to note is that older adults often present to the acute care facility with atypical signs and symptoms of disease.15 Atypical presentation of disease in addition to increased vulnerability for complications is 1 reason why an understanding of normal, age-related changes is necessary. We must know what is normal to differentiate normal age-related changes from pathologic conditions.

Using a head-to-toe concise approach, some of the basics of age-related changes are presented herein. There is variability among individuals in the way we age, making individualized care more challenging for the astute critical care nurse.16

In the neurologic system, we have a decreasing number of functional neurons as we age, and transmission of information slows.17 This results in more time needed to learn and process new information, which has implications for meticulous and ongoing patient education. The hypothalamus does not regulate temperature as effectively, so atypical presentation of conditions, like pneumonia and sepsis, may occur. Proprioception decreases, as does our ability to adapt to changes in position, making falls more likely.17 The senses dull, and eyesight, hearing, touch, taste, and smell are less acute. A decreased ability to smell and taste can negatively affect appetite in an elderly individual who is ill. Decreased visual acuity may increase risk for falls in an unfamiliar environment.

The cardiopulmonary system is less efficient, resulting in decreased cardiac output, decreased ability to increase heart rate in response to stress, and overall decreased blood flow systemically.18 Older adults adapt to these changes quite well until increased or unusual demands are placed on the body: Perhaps they have to take the stairs when the elevator is broken or rush to cross a street before the traffic light changes to green. Increased peripheral resistance results in an increased systolic blood pressure. There are fewer alveoli in the lungs and decreased elasticity owing to calcification of the costal cartilage.18 The cough reflex is diminished, as is the ability to clear secretions.18 These and other changes lead to lower exercise tolerance and gas exchange, and increased susceptibility to pneumonia. Add to this the real possibility that the older patient you may see will most likely have comorbid conditions such as COPD or heart failure, taxing these body systems further.

The entire gastrointestinal system is affected by aging, and is often more bothersome than life threatening. Lesser saliva production, decreased number of taste buds, and decreased ability to digest starch and tolerate fats, make indigestion and constipation more likely.17 Absorption of nutrients,...