Challenges with Diagnosing and Managing Sepsis in Older Adults

ABSTRACT

Sepsis in older adults has many challenges that affect rate of septic diagnosis, treatment, and monitoring parameters. Numerous age-related changes and comorbidities contribute to increased risk of infections in older adults, but also atypical symptomatology that delays diagnosis. Due to various pharmacokinetic/pharmacodynamic changes in the older adult, medications are absorbed, metabolized, and eliminated at different rates as compared to younger adults, which increases risk of adverse drug reactions due to use of drug therapy needed for sepsis management. This review provides information to aid in diagnosis and offers recommendations for monitoring and treating sepsis in the older adult population.

KEYWORDS:

• Sepsis
• elderly
• antibiotic therapy
• immunosenescence
• inflammation
• vasopressor therapy

Key issues

• immunosenescence, additional comorbidities (including diabetes and chronic kidney disease), and inflammaging lead to increased risk of infection in older adults.

• Sepsis can be more difficult to diagnose in older adults, who tend to present with atypical symptoms and lack some of the classic systemic inflammatory response syndrome criteria, especially temperature ≥ 38°C.

• Drug selection can be challenging in this patient population due to multiple pharmacokinetic and pharmacodynamics changes related to aging.

• Older adults are at increased risk of contracting drug-resistant pathogens and additional Gram-negative bacteria; therefore, broad-spectrum antibiotics should be dosed appropriately during initial doses, but then may need to adjust doses based on renal function especially in older adults.

• Therapeutic drug monitoring (common for vancomycin and aminoglycosides) needs to occur to ensure that the antibiotics are not only effective, but also safe for older adults.

• Fluid resuscitation is a cornerstone of therapy for patients with severe sepsis. Administration of fluids beyond the initial bolus should be guided by fluid responsiveness.

• Vasopressors may be needed in order to help achieve appropriate mean arterial pressure (MAP) levels; however, appropriate MAP levels in older adults have not been specified, nor have the appropriate vasopressors for older adults been identified.

• Older adults are at higher risk of developing intensive care unit (ICU) delirium and clinicians need to perform routine delirium assessments, adequate pain control, prevention of constipation, and avoidance of benzodiazepines, anticholinergic agents, and other deliriogenic medications.

• As mortality increases with delayed sepsis diagnosis, clinicians should discuss goals of care and prognosis with patients and families; incorporate those goals into treatment and end-of-life care planning; and discussed when feasible, but no later than 72 h after ICU admission.

Financial & competing interests disclosure

C Alvarez is supported by the National Institutes of Health (NIDDK). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.