Point for Practice

Consider the above skin changes associated with the ageing process and identify how nursing strategies can be modified to care for the skin of older adults.

Conditions affecting thermoregulation in older adults

In the next section, we will examine two conditions that may affect older adults in relation to the regulation of body temperature, namely hypothermia and heat stroke.

Hypothermia

According to Mallet (2002), hypothermia is recorded on 300 death certificates in the United Kingdom annually. Those are cited diagnoses only so it is possible that this represents the tip of the iceberg only. There may be many deaths related to, but not directly attributed, hypothermia that are not registered. Hypothermia has been described by Linton and Matteson (1997) as one of the most important causes of death in older people in the United Kingdom. In a developed country, there should be very few deaths relating to hypothermia, but older people are a susceptible group as they may not always be able to pay to heat their homes. Older people who live in milder climates are also susceptible to hypothermia during the cooler months of the year (Mallet, 2002).

Hypothermia occurs when there is excessive heat loss from the body, when the body is unable to continue to respond to heat loss or when the temperature regulatory centre in the hypothalamus malfunctions (Ramont and Niedringhaus, 2004). Environmental conditions such as extremely windy and wet weather can greatly accelerate the onset of hypothermia (Rosdahl and Kowalski, 2003). A common cause of hypothermia in older adults is due to prolonged lying times after a fall. This reason for developing hypothermia is a combination of changes due to the ageing process, decreased levels of mobility and the ambient temperature. A rapid response to falls in older adults will therefore reduce this risk. The development of hypothermia is usually unintentional or accidental (Black and Hawks, 2005).

Hypothermia is defined as having a core temperature of less than 35°C. It can be further divided into mild, moderate and severe where mild is 32–35°C; moderate is 28–32°C; severe is less than 28°C. Hypothermia has also been divided into different types described as primary and secondary. Primary hypothermia has been described as exposure hypothermia where it has developed after an older adult has been exposed to low temperatures in the environment or they have been exposed to an immersion injury. Secondary hypothermia has been described as urban hypothermia and is common in patients who are ill or infirm and patients who abuse alcohol and/or drugs.

Kare and Shneiderman (2001) use a different method of classifying hypothermia. They classify hypothermia as accidental, inadvertent and intentional. Accidental hypothermia is similar to primary hypothermia and is described as exposure to cold environments without adequate clothing. In the United Kingdom, up to 10% of community-dwelling older adults have body temperatures close to hypothermic levels. Inadvertent and intentional hypothermia are associated with the care of hospitalised patients. Inadvertent is most commonly seen in surgical patients resulting from exposure to cool environments, whereas intentional hypothermia is the use of bringing patients’ temperatures down to hypothermic levels for certain types of surgery.

Risk factors for hypothermia

For normal thermoregulation to occur, heat production needs to balance with the control of heat loss so that a constant core temperature is achieved (Mallet, 2002). There are a number of factors that interfere with this dynamic balance in old age including ageing changes, social influences, disease-related changes and medications (Table 8.2).

Older people are particularly susceptible to accidental hypothermia because thermoregulatory ability is progressively impaired with age. There is reduced ability to generate heat because of a decrease in lean body mass, impaired mobility, inadequate diet and reduced shivering in response to the cold. Older people are also susceptible to increased heat loss through a reduced ability to vasoconstrict appropriately. They may have abnormal adaptive responses, and may be prone to exposure to the cold through falls or illness (Mallet, 2002). Table 8.3 identifies the clinical features that a person suffering from hypothermia may present with.

With body temperature falling, metabolic rate decreases and brain metabolism slows down. Mental processes and respiration also decrease and bradycardia occurs. Bradycardia is often followed by cardiac irritability and a susceptibility to arrhythmia, including fatal arrhythmias. At this stage, the patient may slip into a coma and death can result due to respiratory arrest or arrhythmia.

Core circulatory blood volume increases due to peripheral vasoconstriction. The kidneys respond to increased circulatory volume by increasing urine output, known as a cold diuresis. Large volume urine will be pale and dilute with a lowered specific gravity.

Hyperglycaemia is common once body temperature falls to 30°C. Hypothermia inhibits insulin release from the beta cells in the pancreas and increases the cells’ resistance to insulin. As a result, blood glucose is not readily transported in to the cells and blood glucose levels rise (Brooker and Nicol, 2003). Coagulopathy (a disorder of the blood where it fails to clot normally) develops with prolonged hypothermia.

Assessment

Assessment of temperature includes using a low-reading thermometer. There are a variety of thermometers available for use including the tympanic thermometer that measures the tympanic membrane (at the end of the ear canal) temperature, and this is regarded as measuring core temperature which is important in detecting hypothermia. Before using the tympanic thermometer, it is worth checking if one ear is better than the other for insertion of the tympanic thermometer. The ear that has recently been resting on a pillow should be avoided, and the ear where a hearing aid has been recently used should also be avoided. Both circumstances can cause a rise in the tympanic temperature. The ear should be checked for wax and an ear that is inflamed should be avoided (Woodrow, 2006). If possible, it is advisable to use the same site and method consistently when measuring the temperature (Mallet, 2002).

The environmental temperature should also be considered if it is cold, and the presence of any of the signs and symptoms of hypothermia should be observed and recorded. Other information that should form the assessment includes background or social factors that may predispose to hypothermia.

(Reproduced from McLafferty et al. (2009). With permission from the RCN.)

Prevention of hypothermia

Hypothermia is a largely preventable disorder in older people. Nurses have a very important role to play in the prevention and early detection of hypothermia as there are a number of simple measures that can be taken to prevent the development of this problem. Nurses

Table 8.2 Risk factors for hypothermia.

Table 8.3 Signs and symptoms of hypothermia. (Reproduced from Worfolk (1997). With permission from Elsevier.)

also have an important role to play in the education of older people in relation to hypothermia. Nurses, first of all, need to be aware of the age-related changes that can influence an older person’s ability to keep warm, and secondly, they need to incorporate this knowledge when giving advice.

Older people should be advised to avoid extreme cold. They should dress warmly in a layered fashion. Wearing lots of layers of clothes traps the body heat more effectively than one thick layer. The thermostat at home in the living area should be set between 65°F and 75°F or about 21°C. The DH (2007) advises that the temperature in the bedrooms should be kept above 18°C. If the bedroom is cold, then extra heat can be provided by using a hot water bottle or an electric blanket. The two items should not be used together. In very cold weather, staying warm in bed is a very important goal, so additional clothes including bed socks and even wearing a nightcap may be useful. If an older person is unable to afford to set thermostats at the appropriate level, help should be sought from agencies to supplement their pension. Nurses should be able to advise older people where they can seek help if they are unable to afford to keep warm.

Emergency numbers should be kept in a safe and readily available place. Emergency numbers include plumbing, heating engineers and the relevant NHS helplines. It is also important that neighbours and friends visit regularly to make sure an older person is coping especially in the cold weather (Kare and Shneiderman, 2001).

Other issues that need to be taken into account include the type of heating that is being used. Some forms of heating are much more economical than others. There are government schemes to help older people replace heating systems if the heating in their homes is less than adequate. It is worth checking that older people can work the heating system that is in place and that it is well maintained.

Help the Aged (2008) offers the following advice that can be passed on by nurses to their patients:

• Have regular hot meals and drinks. Food is very important in the provision of warmth, so regular hot meals and drinks will help ward off the cold (DH, 2007).
  
• Buy easy to prepare hot food with plenty of carbohydrates and vitamins.
  
• Move regularly whether it is walking around the house or outside. If outside, it is important that stout footwear is worn to reduce the risk of slips or falls.
  
• Do not sit for too long at a time. The DH (2007) recommends that people move about at least once every hour.
  
• Wear thick socks and tights.
  
• Wear a hat and gloves when going outside.
  
• Take a flask of hot drink to bed.

When visiting an older person at home, nurses should:

• Take a room thermometer on every home visit to check the environmental temperature.
  
• Contact social services if there is a concern about whether an older person is having a problem paying bills or because there is a concern about their mental state.
  
• Review the person’s medication.
  
• Review the person’s alcohol consumption.

The DH (2007) recommends that all older people who are eligible should have the influenza vaccination as a preventative measure. They also provide a document on keeping warm, which is updated regularly as does the Scottish Government. This document not only gives relevant advice in relation to keeping warm in Winter, it also provides telephone contact numbers in relation to help and services for older people. According to DH (2007), there are billions of pounds of benefits that are unclaimed each year, and patients should be encouraged to find out if they are entitled to any extra benefits. There are also winter fuel payments of £250 that are not means tested and are given to households where one or more adults are over the age of 60 and are entitled to this annual sum. The payment rises for people over the age of 80. There are also cold weather payments when the weather is exceptionally cold to older people who are eligible for this payment.

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