GERIATRIC UPDATE

CONTAGIOUS

OR

NOT? THAT IS

THE

QUESTION

Authors: Nancy Stephens Donatelli, MS, RN, CEN, NE-BC, FAEN, and Joan Somes, PhD, RNC, CEN, CPEN, FAEN, NREMT-P, New Wilmington, PA, and St. Paul, MN Section Editors: Nancy Stephens Donatelli, MS, RN, CEN, NE-BC, FAEN, and Joan Somes, PhD, RNC, CEN, CPEN, FAEN, NREMT-P

Earn Up to 8.5 CE Hours. See page 174. s 3 names pop up on the electronic tracking board, you note all are older adults. One is listed as having rib pain, the next has diarrhea, and the third has a cough. All have been triaged as level 3. When you go to the lobby, you see the 3 seated together chatting. You room them in the order they arrived and do a more thorough assessment of each. As you talk with them, you realize these 3 patients are not presenting with just simple complaints and in fact probably should have been isolated on arrival. Anna, aged 72 years, presents with complaints of body aches, fever, headache, and diarrhea. She is concerned because she volunteers at a free clinic that provides care for several immigrant populations. She wonders if she was exposed to something at the clinic. Her temperature is 38.9°C (102°F); pulse rate, 120 beats/min; respiratory rate, 22 breaths/min; and systolic/diastolic blood pressure, 110 mm Hg/72 mm Hg. She has had no vomiting, just watery diarrhea and cramps for 3 days. She takes no medications and has no allergies. She is currently pain free. Bob, aged 76 years, complains of left lower rib pain rated as 7 on a 0 to 10 scale. The pain started last night. He denies cough, fever, or trauma. He is concerned these symptoms could be heart-related but denies shortness of breath, sweating, or nausea. The pain seems to be located along the base of the rib cage and radiates from his back around to the chest. You see no sign of trauma or rash. The pain does not increase with a deep breath. His heart rate is 56 beats/min; systolic/diastolic blood pressure, 138 mm Hg/68 mm Hg; respirations, 22 breaths/ min; and temperature, 37°C (98.6°F). He takes no medications and has no allergies. Helen, aged 74 years, has had a very harsh, nonproductive, frequent cough for 3 weeks. Sometimes

A

Nancy Stephens Donatelli, Member, CODE Chapter, is Project Coordinator, Shenango Presbyterian SeniorCare, New Wilmington, PA. Joan Somes, Member, Greater Twin Cities Chapter, is Educator, Regions Hospital EMS, St. Paul, MN. For correspondence, write: Nancy Stephens Donatelli, MS, RN, CEN, NE-BC, FAEN; E-mail: [email protected]. J Emerg Nurs 2015;41:148-53. Available online 23 January 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.12.013

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she coughs so hard and long she thinks she is going to pass out. She has been using cough syrup with no relief. When she first started coughing, her physician did not believe an antibiotic was needed. She has not been back to see him. Her respiratory rate is 24 breaths/min; systolic/diastolic blood pressure, 156 mm Hg/72 mm Hg; heart rate, 88 beats/min; and temperature, 37.3°C (99.2°F). Oxygen saturation is 96%. Her lungs are clear; she takes no medications and has no allergies. Should the Patients Be Isolated?

Three additional questions asked during triage should wave red flags, provide clues that raise concern, and lead to thoughts of isolating the patients. Have you been out of the country? Have you been exposed to a sick person? (This is especially important if the patient was exposed to a sick visitor from outside the United States. However, a sick child or adult from within the United States could also expose the older adult to a devastating illness.) 3. Are your immunizations up to date? These questions plus a thorough history will provide significant information helping to determine whether the patient could be contagious to the staff and others in the emergency department, including other patients. 1. 2.

Why Does This Matter for the Older Adult?

As the geriatric patient ages, immunity lessens and the ability to fight off infection diminishes. In addition, vaccinations may become less effective, assuming the older adult received them at all. 1 The geriatric patient has fewer physiological reserves, and if an infection develops, he or she may not be able to tolerate the stresses placed on the body. Fever and/or dehydration can lead to tachycardia, which stresses the geriatric patient’s heart and places him or her at risk of atrial fibrillation. Hypotension, which places stress on all the organs, can occur as the result of dehydration or tachycardia, which may occur as part of the infection. In addition, hypoxia from increased work by the body, as well as poor oxygenation due to excessive coughing or poor oxygen transfer in the lungs, will further stress the older

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adult’s vital organs. The risk of injury and falls related to orthostatic hypotension, generalized weakness, electrolyte imbalance, or dysrhythmias is higher in the older adult with an infection. Sepsis and death are the ultimate poor outcomes and higher risks for the older adult because of the inability to mobilize the immune system or compensate when the body is stressed by the infection. 1 Thus the older adult is at higher risk and needs to be kept safe. Asking the 3 aforementioned questions and completing a more thorough history provide useful insight into the older adult’s illness and the decision of whether there is a need to isolate him or her.

The “Healthy” Older Adult Is at Higher Risk

You may have noticed that these 3 older adults are considered “healthy.” They take no medications and have no comorbid conditions. As the baby-boomer generation ages, we are going to see more individuals who are active and healthy. As a result, older adults are also traveling and volunteering more than ever. Statistics show that “Peace Corp volunteers 60 and older have more than doubled in the past three years.” 2 Global Volunteers, a nonprofit, international development organization that sends small teams to work as English teachers, assist with health care, and build schools and community facilities, states that “about 67 percent of the volunteers are older adults drawn from the United States and Canada.” 3 Both of these agencies place volunteers within the United States and internationally. A report released by the Families and Work Institute, reported that “one in five workers aged 50 and older has a retirement job today.” 4 These persons are officially retired but are working a job for a variety of reasons. Seventy-five percent reported they would continue to work in the future. Because of this, it is important to ask older adults about recent travel, as well as volunteer work. Just because they are “old” does not mean they are homebound, confined in a chair or bed, watching daytime TV.

Resources Related to Infectious Diseases

The Centers for Disease Control and Prevention provides an excellent resource titled “CDC Health Information for International Travel 2014,” 5 also known as the Yellow Book. Available online, as a hard copy, or as an app for mobile devices, this resource is published every 2 years for health care providers who deal with travelers. The authors recommend asking the recently returned traveler about travel itinerary and duration, timing and severity of illness,

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accessing and complying with pre-travel consultants’ recommendations and pre-travel immunizations (if either were even obtained), medical history and medications, current symptoms, accommodations while traveling, precautions (eg, repellants or bed netting), sources of drinking water, types of foods ingested, bites or scratches, freshwater exposure (eg, swimming or rafting), or need for medical care while abroad. They note that the most common syndromes are febrile illness, acute diarrhea, and dermatologic conditions, but the patient may also present with respiratory symptoms. The most frequent respiratory symptoms are associated with influenza, but there are multiple other respiratory diseases that the traveler may have been exposed to and that should be considered. 6 The Table reviews several diseases having the potential to affect the older adult as he or she travels and/or volunteers. A baby boomer’s immunity should also be verified. When baby boomers were children, vaccinations against many diseases were just starting to be administered widely. Older baby boomers actually had the diseases (measles, mumps, rubella, and chicken pox). Many older adults did not receive the classic “baby shots” that immunized against diphtheria, pertussis, or tetanus. Some of baby boomers were immunized for small pox. If they are nurses, they may have been re-immunized for a variety of diseases in nursing school. An immunization/immunity history is important, especially to determine whether the patient had the actual disease, received only 1 set of immunizations, or received “boosted” immunizations. The recent outbreak of pertussis has led the CDC to recommend that older adults receive the adult diphtheria, pertussis, and tetanus (Tdap) booster if they have not received one in the past 10 years. 8 The CDC also recommends that adults 60 years or older be vaccinated for the seasonal flu (influenza), pneumococcal disease (protecting against lung and blood infection), and zoster (protecting against shingles). In addition, older adults who deal with patients or students should also ensure they have had a complete hepatitis B series (which protects against hepatitis B). Baby boomers born after 1957 should also consider a measles-mumps-rubella vaccination, especially if they are unsure whether they had the diseases or received the vaccinations or if they do not have serologic evidence of immunity. If a baby boomer has not had chicken pox (varicella), a documented vaccination, or a serum titer showing immunity, he or she should consider being vaccinated for this disease. If an older adult interacts with students who may have Neisseria meningitidis, the older adult should consider receiving the meningococcal vaccine. 8 The risk of exposure to many of these preventable diseases has increased because of parents not having children immunized for a variety of reasons. “Herd protection” is becoming less

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TABLE

Infectious diseases with potential to affect older adults who travel or volunteer 7 Disease

Cause

Symptoms

Geographic areas of travel

Chikungunya (pronounced “chik-en-gun-ye”)

Incubation period of approximately 28 d (range, 15–50 d); caused by a virus that spreads through mosquito bites

Africa; Asia; parts of Central and South America; and islands in Indian Ocean, Western and South Pacific, and the Caribbean

Ebola

The first patient becomes infected through contact with an infected animal, such as a fruit bat or primate. The Ebola virus is spread through direct contact, broken skin or mucous membranes, blood or body fluids, or contaminated objects. Caused by contaminated food and water or hand contact with person with hepatitis

Incubation period usually 3–7 d (range, 1–12 d); acute onset of fever and polyarthralgia; hands and feet most often affected; headache, myalgia, arthritis, conjunctivitis, nausea/vomiting, and maculopapular rash Symptoms may appear from 2 to 21 d after exposure; average is 8–10 d; fever, severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain, unexplained hemorrhage, bleeding, and bruising

Sudden onset of fever, tiredness, loss of appetite, nausea, vomiting, stomach pain, and jaundice

Common infection in developing countries, especially in rural areas; can happen in urban areas with “standard” tourist accommodations Seen worldwide; large outbreaks of have occurred in south and central Asia, tropical east Asia, Africa, and Central America. Pertussis is seen in all countries, with the highest rates in developing countries where very few people have received the vaccine.

Hepatitis A

Hepatitis E

Spread by contaminated water; can occur in developed countries by eating uncooked or undercooked animal products

Sudden onset of fever, tiredness, loss of appetite, nausea, vomiting, stomach pain, and jaundice

Pertussis (whooping cough)

Caused by bacteria; infection spreads when infected people cough and sneeze near others.

West Nile virus

Caused by a virus spread through mosquito bites

Early symptoms similar to a cold, including runny nose, low fevers, and mild cough; later symptoms include “fits” of many rapid coughs followed by a high-pitched “whoop,” vomiting, and exhaustion. Incubation period of 2–6 d, with ranges from 2 to 14 d; 80% of people do not feel sick. Symptoms can include fever; headache;

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West Africa, Guinea, Liberia, Sierra Leone, and Democratic Republic of the Congo

Africa, Europe, Middle East, west and central Asia, and North America

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Table (Continued) Disease

Cause

Tetanus (“lockjaw”)

Caused by bacteria found in soil, entering body through any skin break

Malaria

Malaria is a disease spread through mosquito bites. Symptoms usually appear within 7–30 d but can take up to 1 y to develop. Dengue is a viral illness spread through mosquito bites. Symptoms can take up to 2 wk to develop.

Dengue

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Symptoms

tiredness; nausea; vomiting; swollen lymph glands; and a rash on the chest, stomach, or back. Serious symptoms include high fever, headache, neck stiffness, lack of energy, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness, and paralysis. Jaw muscles tighten. The person cannot open his or her mouth. Other symptoms include headache, painful muscle stiffness, trouble swallowing, seizures, fever, and high blood pressure. Can cause difficulty breathing and paralysis Symptoms include high fevers, shaking chills, and flu-like illness.

Symptoms include fever; headache; nausea; vomiting; rash; and pain in the eyes, joints, and muscles. In severe cases, symptoms may include intense stomach pain, repeated vomiting, bleeding from the nose or gums, and death.

Geographic areas of travel

Occurs throughout the world; people who are doing humanitarian aid work, such as constructing or demolishing buildings, may be at higher risk.

Africa, Central and South America, parts of the Caribbean, Asia, Eastern Europe, and the South Pacific

The Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa

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reliable because of increases in travel and the intermingling of persons coming from locations where a disease still occurs to an area that is at risk because of the opinion that the disease has been wiped out in the area, so the population does not need or has not received vaccine protection. 9 You learn as you ask the 3 questions that Anna traveled in Mexico and ate local fruits and vegetables. Body aches, fever, headaches, and crampy diarrhea developed during her trip. Hepatitis A and hepatitis E caused by contaminated food and water are 2 diseases that cause fever and body aches. Anna could have just as easily been in a country that has other fever-generating complaints. In Mexico West Nile virus causes the same symptoms; however, the cause is from a virus spread through mosquito bites. Anna actually had not been exposed to any ill patients at the clinic within the past month, so it does not appear that such an exposure would have been the cause of her symptoms. She is not up to date on her immunizations. Bob has not been out of the country and he has not had close contact with any sick people that he is aware of, but he admits he is not up to date on his immunizations— specifically the shingles vaccine. Bob noted he did have chicken pox as a child. Even though the emergency physician carried out all the testing to rule out a cardiac event, he was pretty sure that Bob was in the pre-rash stage of shingles and the rash would be developing very soon. In fact, as Bob was dressing, blisters were starting to develop along the path of the pain. Helen has not been out of the country, but you learn she volunteers at a school, reading to first graders. She seems to remember that one of the children had a very bad cough several months ago and the child has not been back to school since. There was a rumor that the child might have had whooping cough, but Helen thought nothing of it. She remembers receiving “baby shots” and might have received a tetanus shot 15 to 20 years ago but has received nothing recently. The physician performs a battery of tests, including a swab for pertussis, which turns out positive. Helen is administered antibiotics, and an inventory is taken to identify people with whom she has been in contact. Each of our older adults at first glance could have been considered to have a “simple” illness, but careful questioning and awareness led to a more accurate diagnosis and treatment, as well as isolation. Awareness of symptoms associated with diseases such as pertussis, varicella, meningitis, Ebola, hepatitis, influenza, malaria, and other infectious diseases, as well as those that may have been prevented if the patient’s immunization status had been current, is critical to patient care. Remember that it is not necessary to travel out of the country to be exposed to many infectious diseases, but the risk is higher when traveling, especially when in areas where

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sanitation is less than optimal. Moreover, remember that vaccine-preventable diseases are being seen more frequently because of older adults’ immunity wearing off, children not being vaccinated, and non-vaccinated people moving into an area. Always keep in mind symptoms associated with these diseases so that the diagnosis can be made earlier and treatment started sooner. A case in point was a patient who presented to one of our emergency departments with muscle stiffness and trouble swallowing that had progressed over several weeks. Eventually, after many “negative” tests and procedures, it was determined the patient had contracted lock jaw (tetanus) from a simple rose-thorn stick several months earlier. (There had never been any “rusty metal” involved.) She survived a long stay in the intensive care unit while receiving ventilator treatment. Oddly, a second patient presented that summer with similar symptoms. She was diagnosed much more quickly because of heightened awareness. The tetanus immunization status was not current in either patient, and who would have thought to ask? As this case study is written, Ebola is of major concern. Yet each of the diseases mentioned could have, and have had, deadly consequences. Nurses should recognize that by asking the questions about travel, exposure, and immunizations, it is possible to help prevent the spread. Ensuring you advocate to update immunizations for geriatric patients, as well as educate the patients and their families about the importance of immunizations, is critical. REFERENCES 1. Smith C, Cotter V. Age-related changes in health. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, (eds.), Evidence-Based Geriatric Nursing Protocols for Best Practice. 4th ed. New York, NY: Springer; 2013:23-47. 2. Ausland A. Too old to volunteer abroad? Think again! Huff Post Impact. www.huffingtonpost.com/aaron-ausland/too-old-to-volunteerabro_b_1578992.html. Accessed November 2, 2014. 3. Global Volunteers. Volunteer opportunities. www.globalvolunteers.org. Accessed November 2, 2014. 4. Brown M, Aumann K, Pitt-Catsouphes M, et al. Working in retirement: a 21st century phenomenon. http://familiesandwork.org/site/research/reports/ workinginretirement.pdf. Published July 2010. Accessed November 8, 2014. 5. Centers for Disease Control and Prevention. CDC health information for international travel 2014. http://wwwnc.cdc.gov/travel/page/yellowbookhome-2014. Accessed November 2, 2014. 6. Fairley JK. General approach to the returned traveler. CDC Health Information For International Travel. http://wwwnc.cdc.gov/travel/ yellowbook/2014/chapter-5-post-travel-evaluation/general-approach-tothe-returned-traveler. Updated May 2013. Accessed November 16, 2014. 7. Centers for Disease Control and Prevention, Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases. Travelers’ health. http://www.cdc.gov/travel/diseases. Updated December 5, 2013. Accessed November 11, 2014.

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8. Centers for Disease Control and Prevention. Vaccine information for adults. http://www.cdc.gov/vaccines/adults/rec-vac/. Reviewed August 2013. Accessed November 16, 2014. 9. Centers for Disease Control and Prevention. If you chose to not immunize your child [educational pamphlet. http://www.cdc.gov/ vaccines/hcp/patient-ed/conversations/downloads/not-vacc-risks-coloroffice.pdf. Reviewed March 2012. Accessed November 16, 2014.

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Submissions to this column are encouraged and may be sent to Joan Somes, PhD, RNC, CEN, CPEN, FAEN, NREMT-P [email protected] or Nancy Stephens Donatelli, MS, RN, CEN, NE-BC, FAEN [email protected]

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Contagious or not? That is the question.

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