Sepsis and the Frail Elder

PATHOPHYSIOLOGY, TREATMENT, NURSING CARE AND LONG-TERM EFFECTS

Learning Objectives:

Define sepsis as it relates to the elderly population

Achieve an understanding of the etiology of sepsis in the elderly

Discuss treatment options

Be able to implement evidence-based nursing care of the elderly patient

who presents with sepsis

Gain insight into the long-term effects of surviving sepsis:

Quality of life (QOL) implications

What can we do to improve outcomes?

What is Sepsis?

Sepsis is defined as a life-threatening organ dysfunction caused by a

dysregulated host response to infection and/or super antigen [leading to]
profound circulatory, cellular and metabolic abnormalities [which]
unchecked cause multisystem organ failure and death

Chamberlain, (2016); Girard, Opal & Ely, (2005).

Sepsis in the elderly population is associated with a higher morbidity and

mortality rate peaking at 38.4 % in patients aged >/= 85 years old. Elderly
patients constitute 2/3 of the patients admitted to hospital with sepsis and
patients aged >/= 65 years old account for 40-50% of all bacteremia
cases with an overall fatality rate of 40-60%

Destarac & Ely, (2002).

Etiology of Sepsis in the Elderly

Population

Most commonly bacterial

Related to respiratory, urinary, abdominal and skin infections

Elders are more susceptible related to chronic conditions, comorbidities,

decreased immune response, malnutrition, dementia, medication
regimens, decreased mobility and functional status, residence in longterm care facilities and repeated hospitalizations, repeated exposure to
antibiotic therapy, prosthetic devices, and prior colonization by gramnegative multi-drug resistant organisms

Destarac & Ely, (2002); Girard et al., (2005); Lange, (2012); Nasa et al., (2012).

Bacterial causes of Sepsis

Gram-negative Bacteria

Gram-positive Bacteria

Escheria coli (urinary/peritoneal)

Klebsiella pneumoniae
(urinary/respiratory)

Streptococcus pneumonia
(pneumonia/meningitis)

Streptococcus pyogenes (skin/soft tissue)

Enterobactor (urinary)

Pseudomonas aeruginosa
(pneumonia/skin)

Staphylococcus aureus/ Methicillin

resistant staphylococcus aureus (skin/soft
tissue/pneumonia/urinary)

Proteus (urinary)

Enterococcus (urinary)

Bacteroides fragilis (peritoneal)

Chamberlain, (2016).

Treatment of Sepsis and Septic Shock

in the Elderly

Timely diagnosis is KEY. The threshold for immediate treatment should be

lowered in this susceptible and vulnerable population

Elders often present with infection atypically: hypothermia, CONFUSION,

delirium, falls, weakness, anorexia and urinary incontinence

Most likely sources of infection are PNEUMONIA and URINARY INFECTIONS

Obtain pan cultures, lactic acid level, CBCD, BMP, chest xray, start empiric
broad spectrum antibiotic coverage

Begin supportive care: cardiac and respiratory monitoring, fluid resuscitation,

vasoactive drug therapy, electrolyte repletion, pain control, supplemental
oxygen and/or intubation, invasive line placement and foley catheter as well
as renal replacement therapy may be necessary

Chamberlain, (2016); Destarac & Ely, (2002); Girard et al., (2005); Nasa et al., (2012).

Evidence-based Nursing Care of the

Septic Elder

Ideally, the goals of providing nursing care to the critically-ill older adult
include restoring physiologic stability, preventing complications, maintaining
comfort and safety, and preserving or preventing decline in pre-illness
functional ability and quality of life

The development of a patient-centered, multidisciplinary plan of care which

takes each body system and the implications of pre-existing conditions into
consideration is key in achieving best outcomes in this fragile population

The nurse must be familiar with age-related changes and their implications to
the patient: coordination of care with pharmacists, respiratory, physical and
occupational therapists, pharmacists, case management, social workers and
the patients family members and care-givers assure that best-practice care
interventions are implemented at each stage of sickness and recovery.

Botlz, et al., (2012)

Evidence-based Nursing Care of the

Septic Elder, Body Systems

Neurological

Cardiac

Assess pain and sedation needs

Monitor electrocardiogram for changes

Review medications and side effects

Check cardiac enzymes every 8 hours x2

to assess for cardiac damage

Monitor for delirium/change in mental status

Provide for assistive-communication devices

Provide vasoactive support as needed

Advocate for family presence

Assess central venous pressure to ensure

for adequate hydration/avoid fluid
overload

Encourage early mobilization and line/tube removal

Respiratory
Place continuous pulse oximetry
Check arterial blood gas to assess
acidosis/oxygenation requirements
Elevate HOB to 30 degrees to decrease risk of
aspiration
Utilize ICU pulmonary bed settings

If ventilated, initiate VAP prevention bundle and

advocate for spontaneous awakening/weaning
trials.
Mobilize ASAP!

Evidence-based Nursing Care of the

Septic Elder, Body Systems, cont.

Gastrointestinal

Genitourinary

Assess nutritional and electrolyte status

Assess urinary output every hour

Initiate supplemental feedings and electrolyte

replacement if indicated

Assess renal function and

creatinine clearance both at
baseline and as effected by illness
and medications in hospital

Initiate stress ulcer prophylaxis

Implement bowel regimen

Skin

Perform comprehensive initial and

every 2-4 hours assessments of
preexisting and developing issues

Implement continuous rotation

modules, repositioning every 2 hours

Monitor for gastrointestinal bleeding

Ensure patency and cleanliness of

urinary catheters

Monitor invasive lines/IVs for

infiltration/infection/skin breakdown

Achieve glycemic control

Discontinue foley catheter ASAP

Encourage early mobilization

Initiate aspiration precautions

Use Braden Scale

Evidence-based Nursing Care of the

Septic Elder, Body Systems, cont.

Immune:

Assess efficacy of antibiotic therapy

Monitor for anemia, transfuse if patients hemoglobin is <7, or is

actively bleeing or shows cardiac demand ischemia

Monitor and support thermoregulation

Maintain infection control and preventative measures

Re-panculture for temperatures >101.5 or decline in status

Consider infectious disease MD consult in conjunction with ICU

team management

Boltz et al., (2012); Lange, (2012).

Long-Term Effects of
Sepsis in the Elderly

Prior focus has been on decreasing short-term

mortality during hospitalizationlittle attention has

been given to the post-ICU course and the
chronic issues that confront patients in the months
to years following an ICU stay
Volk & Grassi, (2009).

Quality of Life (QOL) issues abound following

survival of a sepsis-related admission, most are
related to cognitive decline and substantial
worsening in trajectoryin those patients with
better baseline functioning
Iwashyana et al., (2010).

The odds of acquiring moderate to severe

cognitive impairment were 3.3 times higher
following an episode of sepsis, with an additional
mean increase of 1.5 new functional limitations
per person among those with no or mild
preexisting functional limitations
Iwashyana et al., (2012).

What can we DO to Help?

Sepsis-specific
plans of care
Better sedation practices

Earlier cognitive/physical therapy

practices
More aggressive vaccination practices

Management of
Chronic Disease
Outpatient care must improve
management of chronic
conditions: Patient-centered
models of care which are
community-based

Recognition of atypical sepsis

presentation in elderly patients

This will lead to less

hospitalizations, community and
nosocomial-acquired infections

FOCUS ON LIMITING DEFICITS

ASSOCIATED WITH SEPSIS

Improve baseline wellness and

QOL
Involve palliative care practices
for those with severe illness

End-of-Life
Discussions
Initiate discussion of QOL and patient
preferences EARLY

Elderly patients are open to these

discussions.. Often it is the family and
medical team who limit accessibility
of openness in discussing QOL as
related to end-of-life care options
This is a 2020 Health Care Iniiative- as
it relates to palliative and hospice
care initiatives
Gerard et al., (2005); Iwashyana et al.,
(2012); Volk & Grassi, (2009).

Sepsis 2016

Develop and Initiate bundle: hard order sets and associated protocols will
improve timely treatment and therefore improve outcomes!

Multidisciplinary approach: promotes compliance through a team approach

Education: Physician, Nurse and Pharmacy Leaders can enact change in

practice!

Eliminate barriers to change through unit-based champions- Mentoring is

key!

Change the culture throughout the organization to recognize sepsis as an

emergency and mobilize resourcescreate an environment to allow for
efficient care and eliminate delays in treatment

Health Research & Educational Trust, (2016).

Sepsis 2016, continued

New criteria:

Temperature <36 or >38 degrees Celsius

Heart rate >90 beats per minute

Respiratory rate >20 per minute

PaC02 32mmHg

White blood cell count <4,000 or >12,000 and/or >10%bandemia

If Lactic Acid level is >4 this is now defined as severe sepsis

If persistent hypotension along with signs of end-organ damage this is now

septic shock

Health Research & Educational Trust, (2016).

Sepsis is diagnosed in over one million patients

each year in the United Statestreatment costs
resulted in an estimated $20.3 billion making it
the most expensive condition treated in 2011,
with a mortality rate of 28 to 50%
HEALTH RESEARCH AND EDUCATIONAL TRUST, (2016).

An aggressive and multidisciplinary approach must be implemented upon

presentation and reevaluated daily in order to achieve best-care practice as
well as the provision of patient-centered, evidence-based care; we can
improve on current practices in order to ensure for better future outcomes.

In Conclusion..

Sepsis and Septic Shock are multifactorial in etiology, treatment options

and long-term effects.

Quality of life both during and post-hospitalization needs to be brought

into treatment discussions sooner rather than later in order to achieve
more patient-centered outcomes.

As practitioners, it is up to us to recognize sepsis and to incorporate

discussions of patient-centered care into health care discussions with
patients and family.

THANK YOU COLLEAGUES FOR SHARING YOUR KNOWLEDGE, THOUGHTS

AND YOURSELVES THESE LAST WEEKS, I HAVE LEARNED FROM YOU ALL.

REFERENCES
Boltz, M., Capezuti, E., Fulmer.,T. & Zwicker, D. (2012). Evidence-based geriatric nursing

protocols for best practice. A. OMeara (Ed.). New York, NY: Springer Publishing

Company.

Chamberlain,

N. R. (2016). Sepsis and septic shock. Retrieved from

https://www.atsu.edu/faculty/chamberlain/website/lectures/lecture/sepsis2007.htm

Destarac,

L. A. & Ely, E. W. (2002). Sepsis in older patients: An emerging concern in critical

care. Advances in Sepsis 2 (1). Retrieved from

http://advancesinsepsis.com/pdfs/934.pdf

Girard,

T. D., Opal, S. M. & Ely, E. W. (2005). Insights into severe sepsis in older patients:

From epidemiology to evidence-based management. Clinical Infectious Diseases 40 (5),

719-727. doi: 10.1086/427876

Health

Research and Educational Trust. (2016). Severe sepsis and septic shock change

package:2016. Retrieved from

http://www.hret-hen.org/topics/sepsis/HRETHEN_ChangePackage_Sepsis.pdf

Iwashyana,

T. J., Ely, E. W., Smith, D. M. & Langa, K. M. (2010). Long-term cognitive

impairment and functional disability among survivors of severe sepsis. Journal of

American Medicine 304 (16), 1787-1794. doi: 10.1001/jama.2010.1553.

References, continued
Lange, J. W. (2012). The nurses role in promoting optimal health of older adults: Thriving in
the wisdom years. Philadelphia, PA: F. A. Davis Company.

Martin, G. S., Mannino, D. M. & Moss, M. (2006). The effect of age on the development and
outcome of adult sepsis. American Journal of Critical Care Medicine 34 (1), 15-21.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16374151
Nasa, P., Juneja, D. & Singh, O. (2012). Severe sepsis and septic shock in the elderly: An
overview. World Journal of Critical Care Medicine 1 (1), 23-30.
doi: 10.5492/wjccm.v1.i1.23
Opal, S. M., Girard, T. D. & Ely, E. W. (2005). The immunopathogenesis of sepsis in elderly
patients. Clinical Infectious Diseases 41 (7), 504-512. Retrieved from
http://cid.oxfordjournals.org/content/41/Supplement_7/S504.full.pdf
Volk, B. & Grassi, F. (2009). Treatment of the post-ICU patient in an outpatient setting.
American Family Physician 79 (6), 459-464. Retrieved from
http://www.aafp.org/afp/2009/0315/p459.html