Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.

Parameters of Assessment

• Preadmission: Comprehensive assessment of a critically ill older adult's preadmission health status, cognitive and functional ability, and social support systems helps identify risk factors for cascade iatrogenesis, the development of life-threatening conditions, and frequently encountered geriatric syndromes. Factors that nurses need to consider when performing the admission assessment include the following:
  • Pre-existing cognitive impairment: Many older adults admitted to intensive care units (ICUs) suffer from high rates of unrecognized, pre-existing cognitive impairment (Pisani et al. "Screening," 2003 [Level IV]; Pisani et al. "Under-recognition," 2003 [Level IV]).
    • Knowledge of preadmission cognitive ability could aid practitioners in:
      • Assessing decision making capacity, informed consent issues, and evaluation of mental status changes throughout hospitalization (Pisani et al. "Screening," 2003 [Level IV]).
      • Making anesthetic and analgesic choices
      • Considering one-to-one care options
      • Weaning from mechanical ventilation
      • Assessing fall risk
      • Planning for discharge from the ICU
    • Upon admission of an older adult to the ICU, nurses should ask relatives or other caregivers for baseline information about the older adult's:
      • Memory, executive function (e.g., fine motor coordination, planning, organization of information), and overall cognitive ability (Kane, Ouslander, & Abrass, 2004 [Level VI]).
      • Behavior on a typical day, how the patient interacts with others, their responsiveness to stimuli, how able they are to communicate (reading level, writing, and speech), and their memory, orientation, and perceptual patterns prior to their illness (Milisen et al., 2001 [Level VI]).
      • Medication history to assess for potential withdrawal syndromes (Broyles et al., 2005 [Level IV])
    • Developmental and psychosocial factors: Critical illness can render older adults unable to effectively communicate with the health care team, often related to physiologic instability, technology that leaves them voiceless, and sedative and narcotic use. Family members are therefore often a crucial source for obtaining important preadmission information. Upon ICU admission, nurses need to determine:
      • What is the elder's past medical, surgical, and psychiatric history? What medications was the older adult taking before coming to the ICU? Does the elder regularly use illicit drugs, tobacco, or alcohol? Do they have a history of falls, physical abuse, or confusion?
      • What is the older adult's marital status? Who is the patient's significant other? Will this person be the one responsible to make decisions for the elder if they are unable to do so? Does the elder have an advanced directive for health care? Is the elder a primary caregiver to an aging spouse, child, grandchild, or other person?
      • How would the elder describe his/her ethnicity? Do they practice a particular religion or have spiritual needs that should be addressed? What was their quality of life like before becoming ill?
    • Preadmission functional ability/nutritional status: Limited preadmission functional ability and poor nutritional status are associated with many negative outcomes for critically ill older adults (Mick & Ackerman, 2004 [Level VI]; Roche et al., 1999 [Level IV]; Rosenthal & Kavic, 2004 [Level VI]; Tullmann & Dracup, 2000 [Level VI]). Therefore, nurses should assess the following:
      • Did the elder suffer any limitations in the ability to perform their activities of daily live (ADLs) preadmission? If so, what were these limitations?
      • Does the elder use any assistive devices to perform their ADLs? If so, what type?
      • Where did the patient live prior to admission? Did they live alone or with others? What was the elder's physical environment like (e.g., house, apartment, stairs, multiple levels)?
      • What was the older adult's nutritional status like preadmission? Do they have enough money to buy food? Do they need assistance with making meals/obtaining food? Do they have any particular food restrictions/preferences? Were they using supplements/vitamins on a regular basis? Do they have any signs of malnutrition, including recent weight loss/gain, muscle wasting, hair loss, skin breakdown?
• During ICU stay: There are many anatomic/physiologic changes that occur with aging (see Table 25.1 in original guideline document). The interaction of these changes with the acute pathology of a critical illness, co-morbidities, and the ICU environment leads not only to atypical presentation of some of the most commonly encountered ICU diagnoses but may also elevate the older adult's risk for complications. The older adult must be systematically assessed for the following:
  • Co-morbidities/common ICU diagnoses
    • Respiratory: chronic obstructive pulmonary disease, pneumonia, acute respiratory failure, adult respiratory distress syndrome, rib fractures/flail chest
    • Cardiovascular: acute myocardial infarction, coronary artery disease, peripheral vascular disease, hypertension, coronary artery bypass grafting, valve replacements, abdominal aortic aneurysm, dysrhythmias
    • Neurologic: cerebral vascular accident, dementia, aneurysms, Alzheimer's disease, Parkinson's disease, closed head injury, transient ischemic attacks
    • Gastrointestinal: biliary tract disease, peptic ulcer disease, gastrointestinal cancers, liver failure, inflammatory bowel disease, pancreatitis, diarrhea, constipation, and aspiration
    • Genitourinary: renal cell cancer, chronic renal failure, acute renal failure, urosepsis, and incontinence
    • Immune/Hematopoietic: sepsis, anemia, neutropenia, and thrombocytopenia
    • Skin: necrotizing fasciitis, pressure ulcers
  • Acute pathology: Thoracic or abdominal surgery, hypovolemia, hypervolemia, hypo/hyperthermia, electrolyte abnormalities, hypoxia, arrhythmias, infection, hypo/hypertension, delirium, ischemia, bowel obstruction, ileus, blood loss, sepsis, disrupted skin integrity, multisystem organ failure.
  • ICU/Environmental factors: deconditioning, poor oral hygiene, sleep deprivation, pain, immobility, nutritional status, mechanical ventilation, hemodynamic monitoring devices, polypharmacy, high-risk medications (e.g., narcotics, sedatives, hypnotics, nephrotoxins, vasopressors), lack of assistive devices (e.g., glasses, hearing aids, dentures), noise, tubes that bypass the oropharyngeal airway, poorly regulated glucose control, Foley catheter use, stress, invasive procedures, shear/friction, intravenous catheters.
  • Atypical presentation: Commonly seen in older adults experiencing the following: myocardial infarction, acute abdomen, infection, and hypoxia.

Nursing Care Strategies

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