The aging of the population is no longer a “portent of things to come,” it is a reality. The absolute number of adults older than 65 years of age worldwide increases by approximately 870,000 people each month.1 Population projection tables estimate that the number of adults who are older than 65 will increase for decades. Currently, in the United States, adults older than 85 are the fastest-growing segment of the population.2
How will this affect health care institutions?
What effect will this have on health care delivery?
Who will be trained to provide competent geriatric patient care?
Conservatively speaking, it has been estimated that 60% to 70% of patients seen and treated by respiratory therapists who care for adults are older than 65. In 2000, it was also determined that more than half (55.8%) of all ICU days were incurred by patients older than 65.3 Understanding that chronic pulmonary and cardiac diseases take decades to develop, it is not surprising that our patients are older. Although COPD is the fourth leading cause of death in the United States, circulatory disorders are the leading killer of older adults in North America and Europe.4 Due to the aging of the population, the proportion of deaths caused by noncommunicable diseases will rise. Globally, it is estimated that deaths caused by cancer will increase 59% between 2004 and 2030 and deaths caused by cardiovascular disease will increase 37% during that same time span.5 Who cares for these patients? We do.
The Aging Cardiopulmonary System
Age changes things. Aging is associated with changes in cardiopulmonary structure and function. Loss of elasticity in muscles and blood vessels as we age is a major factor in many age-related alterations in structure and function. Age-associated cardiac changes that are clinically relevant are increased vascular stiffness resulting in decreased distensibility of large and medium sized arteries and impaired left ventricular diastolic function, which impedes relaxation of the heart. The left ventricular wall thickens as we age, reducing the size of the interior of the left ventricle. With advanced age, there is a decrease in the force and speed of myocardial contraction. The cardiac conduction system is less effective in the elderly. In fact, when an individual reaches the age of 75, the number of pacemaker cells in the sino-atrial (SA) node may be decreased by as much as 90%.2 Valvular fibrosis and sclerosis are not uncommon in the elderly, as evidenced by the numbers of aortic and mitral valve replacement surgeries that are routinely performed on older patients. Older hearts are also less responsive to beta-agonist stimulation.
How do these changes affect the pulmonary system? Left ventricular failure often leads to pulmonary congestion, resulting in increased ventilation/perfusion (V/Q) mismatching, and a decline in Pao2. Aortic and mitral valve pathologies will also increase fluid backup into the lungs. Typical symptoms that patients may present with are dyspnea, orthopnea, and, on occasion, cyanosis. A study published in 2004 indicates a 10-fold increase in death, clinical heart failure, and cardiogenic shock as age increases from <60 to >85 years.5
Doing an assessment on an older adult can be challenging. Getting an accurate heart rate, blood pressure, and oxygen saturation may be more difficult simply as a result of the effects of aging.
The elastic properties of the pulmonary system are also affected by advanced years. The lungs lose elasticity and become more compliant, while the thoracic cage, due to increased calcification of the ribs and vertebral joints, becomes less compliant. The anterior-posterior (A-P) chest-wall diameter is enlarged due to the reduction in elasticity and air trapping. Overall, the compliance is reduced, which will result in smaller tidal volumes and a slight age-associated increase in the respiratory rate. With age, all muscles lose strength, including the diaphragm (10% to 20% decline).6 There is a progressive decrease in alveolar surface area by about 30% in individuals between 20 and 70 years of age.6 All of these age-related changes will affect oxygenation. The most significant decrease in Pao2 happens between 40 and 70 years of age. For many years, it was presumed that a simple formula called the “70-70 Rule” was accurate, meaning that by age 70 the Pao2 would be 70 mm Hg and would decline thereafter with each consecutive year. Research, however, has demonstrated that this is not true. We now know that in older adults, a supine Pao2 is approximately 5 mm Hg lower than a seated Pao2, and that a seated Pao2 remains relatively stable throughout old age at about 83 mm Hg.7 Of interest is that pH and Paco2 remain relatively constant in healthy elders regardless of their advanced age.
What you will notice in your assessment: a slower heart rate, an increased pulse pressure (pressure gradient between systemic systolic and diastolic blood pressure), softer breath sounds, smaller tidal volumes, and possible crackles in the bases (atelectasis associated with smaller tidal volumes), which may increase respirations slightly. Respirations over 24 to 26, however, with no apparent reason may be pathology. Geriatric patients have complex medical needs. Whatever affects the heart ultimately affects the lungs. As respiratory therapists, however, our concern must be for more than just cardiopulmonary pathology.
Appropriate/Inappropriate Drug Use
There are a number of potential problems with the use of medications in the elderly. The quote, “For the elderly, this may be the age of safe surgery and dangerous medicine,” was published in 1984.8 More than 25 years ago, the dangers of inappropriate drug use in older adults were already apparent. In 2000, elderly people constituted about 13% of the US population, yet consumed 32% of all prescription drugs.9 As our older population grows, so will medication use. Preventable adverse drug events (ADEs) in this country carry a huge financial burden. In 2000, the calculated cost of each ADE among Medicare patients older than 65 was $1,983, with a national annual cost estimated to be over $8 million.2 The use of drugs to treat medical conditions is very appropriate, regardless of age, but the benefits can be achieved only if and when the prescribing is appropriate. With the elderly, however, there are special concerns, and one of them is polypharmacy, the concurrent use of many drugs. Adults over the age of 65 take, on average, five different prescription medications per day. Older adults are also likely to combine over-the-counter (OTC) medications with their prescription drugs, often putting themselves at risk for adverse drug reactions. Combining prescription drugs while consuming alcohol is an added danger, but unfortunately not uncommon. Compliance can be a huge issue. Older adults have been independent most of their lives and do not always want to relinquish control. Having someone tell them what to do and when to do it is not always welcome advice.
Inappropriate drug prescribing has been a special concern in frail elderly patients, and it is often related to the class of drugs ordered. One study revealed that the most common drug classes with appropriateness problems were medications used to treat gastric problems (50.6%); cardiovascular medications (47.6%); and central nervous system drugs (23.9%).10 Inappropriate prescribing is likely to have the greatest impact on older adults who are acutely ill, so these are the patients we must watch carefully. Symptoms of accidental drug overdose can range from difficult arousal to bradycardia or nausea/vomiting. Consequences of adverse drug reactions may include delirium, falls, deconditioning, and functional decline. One way of improving drug adherence in the elderly is through an open avenue of communication between the patient, the pharmacist, and the physician. Both oral and written instructions must be provided: large print (14 font), double spaced, with black print on white paper. Comprehension of the drug regimen should be assessed on a regular basis. If patients do not demonstrate understanding, family members or friends should be recruited to provide oversight. There are devices available to help adults remember to take their medications, including metered dose inhaler adherence measuring devices, weekly pill boxes, or automated refill reminders. While no one way of evaluating adherence seems superior, any system that works will reduce noncompliance and the incidence of ADEs.
Communicating with Older Adults
Communication implies two things: message delivered and message understood. With older adult patients, and older adults in general, there may be disconnects that interfere with adequate communication. Sensory deficits in hearing or vision can affect communication. In the hospital setting, extraneous noise such as loud televisions, monitors, alarms; housekeeping personnel running vacuum/floor cleaners; and even health care professionals’ conversations can make it difficult for patients to understand us and for us to comprehend what they are trying to tell us. Weaker muscles and/or stroke can also affect patients’ speech, making it very hard to understand. Fear and anxiety may be barriers to patients communicating with any of their health care providers. Unfortunately, poor communication can result in missed diagnoses, noncompliance, frustration, and anger on the part of both the patient and the physician. Communication, or lack thereof, may be a cultural issue. Some older adults have been taught not to question authority, and physicians are seen as authority figures. Asking “yes or no” questions will almost always elicit a response of “yes” so as not to offend, even though the patient may not have understood the question. Language barriers are becoming more and more common, regardless of where you live and practice. The globalization of the world brings us patients from many different countries. Hospitals are required to have lists of volunteers who speak many languages; these interpreters are not always available 24 hours a day, however. Health care literacy has been noted to decline with advanced age. It is also now more likely that patients/family members will show up with pages of health information that they have downloaded from the Internet. Not really understanding the disease process or pathology, they may not realize that what they have found has little relevance to the existing condition. There are ways to approach patients who do not seem to be getting our message. The first rule is—no shouting. Check to see if a hearing amplification device is needed and available. Make eye contact with the patient, and position yourself so they can see your lips move. If health literacy is questionable, explain procedures/therapy in terms that they can understand. If a language barrier exists, find an interpreter or demonstrate what you want them to do in a nonthreatening manner. The message does not have to be delivered in a patient’s native language for the message to be understood.
Regardless of a patient’s age, ethnicity, or religious beliefs, they all deserve the best care we can provide. Understanding that there are age-associated changes in their bodies that alter our assessments and necessitate subtle changes in our approach to therapy is going to become more important over the next decades. As respiratory therapists, we have always had to adapt to change. These times and these patients require us to “get to the heart of aging.” Are we up to the challenge?
Helen M. Sorenson, MA, RRT, CPFT, FAARC, is an associate professor, Department of Respiratory Care, UT Health Science Center at San Antonio. For further information, contact [email protected]
- Kinsella K, He W. US Census Bureau. International Population Reports, P95/09-1, An Aging World: 2008. Available at: www.census.gov/prod/2009pubs/p95-09-1.pdf. Accessed September 28, 2010.
- Arenson C, Busky-Whitehead J, Brummel-Smith K, O’Brien JG, eds. Reichel’s Care of the Elderly: Clinical Aspects of Aging. 6th ed. New York: Cambridge University Press; 2009.
- Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr. Committee on Manpower for Pulmonary and Critical Care Societies. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762–70.
- World Health Organization. World Health Statistics 2008. Available at: www.who.int/whosis/whostat/EN_WHS08_TOCintro.pdf. Accessed September 28, 2010.
- Lakatta EG, Schulman S. Editorial Comment: Age-associated cardiovascular changes are the substrate for poor prognosis with myocardial infarction. J Am Coll Cardiol. 2004;44:35-7.
- Zaugg M, Lucchinetti E. Respiratory function in the elderly. Anesthesiol Clin North Am. 2000;18:47-58.
- Cerveri I, Zola MC, Fanfulla F, et al. Reference values of arterial oxygen tension in the middle-aged and elderly. Am J Respir Crit Care Med. 1995;152:934-41.
- Cohen SH, Lamy PP, Fedder DO. The Medicated Generation (videotape). MedSchool Maryland Productions and Video Press, University of Maryland School of Medicine. 9. Hanlon JT, Fillenbaum GG, Schader KE, Kuchibhatia M, Homer RD. Inappropriate drug use among community-dwelling elderly. Pharmacotherapy. 2000;20:575-82.
- Hanlon JT, Artz MB, Pieper CF, et al. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother. 2004;38:9-14.