Ch44 Geriatric Emergencies.docx

Chapter Geriatric Emergencies Unit Summary As the number of individuals over the age of continues to increase EMS providers will be called upon to assist with the complications of chronic and acute health issues This chapter will provide the student with a foundational understanding of the various issues that are associated with the aging process including physiological psychological and social changes that accompany advanced age National EMS Education Standard Competencies Special Patient Populations Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment disposition plan for patients with special needs Geriatrics Impact of age-related changes on assessment and care pp - Changes associated with aging psychosocial aspects of aging and age-related assessment and treatment modifications for the major or common geriatric diseases and or emergencies Cardiovascular diseases pp - Respiratory diseases p Neurologic diseases pp - Endocrine diseases p Alzheimer disease pp - Dementia p Fluid resuscitation in the elderly pp Normal and abnormal changes associated with aging pharmacokinetic changes psychosocial and economic aspects of aging polypharmacy and age-related assessment and treatment modifications for the major or common geriatric diseases and or emergencies Cardiovascular diseases pp - Respiratory diseases pp - Neurologic diseases pp - Endocrine diseases pp - Alzheimer disease pp - Dementia p Acute confusional state pp - Fluid resuscitation in the elderly pp Herpes zoster p Inflammatory arthritis p Patients With Special Challenges Recognizing and reporting abuse and neglect pp - and see chapter Pediatric Emergencies Health care implications of Abuse pp - and see chapter Pediatric Emergencies Neglect pp - and see chapter Pediatric Emergencies Homelessness see chapter Patients With Special Challenges Poverty see chapter Patients With Special Challenges Bariatrics see chapter Patients With Special Challenges Technology dependent see chapter Patients With Special Challenges Hospice terminally ill see chapter Patients With Special Challenges Tracheostomy care dysfunction see chapter Patients With Special Challenges Home care see chapter Patients With Special Challenges Sensory deficit loss see chapter Patients With Special Challenges Developmental disability see chapter Patients With Special Challenges Trauma Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment disposition plan for an acutely injured patient Special Considerations in Trauma Recognition and management of trauma in Pregnant patient see chapter Obstetrics Pediatric patient see chapter Pediatric Emergencies Geriatric patient pp - Pathophysiology assessment and management of trauma in the Pregnant patient see chapter Obstetrics Pediatric patient see chapter Pediatric Emergencies Geriatric patient pp - Cognitively impaired patient see chapter Patients with Special Challenges Knowledge Objectives Describe the old-age dependency ratio p Describe the phenomenon the greying of America p Discuss the social economic and psychosocial factors affecting the older population pp - Discuss the physiologic changes that occur in the various body systems as people age pp - Describe the steps in the primary assessment for providing emergency care to a geriatric patient including the elements of the GEMS diamond pp - Discuss special considerations when performing the patient assessment process on a geriatric patient pp - Describe the pathophysiology of geriatric respiratory conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition pp - Describe the pathophysiology of geriatric cardiovascular conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition pp - Describe the pathophysiology of geriatric nervous system conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition pp - Describe the pathophysiology of geriatric gastrointestinal conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition pp - Describe the pathophysiology of geriatric renal conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition pp - Describe the pathophysiology of geriatric endocrine conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition pp - Describe the pathophysiology of sepsis the signs and symptoms and the emergency medical care strategies used in the management of sepsis p Describe the pathophysiology of geriatric toxicology the signs and symptoms and the emergency medical care strategies used in the management of adverse drug reactions p Discuss polypharmacy and medication noncompliance and their effects of patient assessment and management p Describe the pathophysiology of geriatric depression the signs and symptoms and the emergency medical care strategies used in the management of depression p Describe the pathophysiology of geriatric integumentary conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition p Describe the pathophysiology of geriatric musculoskeletal conditions the signs and symptoms and the emergency medical care strategies used in the management of each condition pp - Describe special considerations for a geriatric patient who has experienced trauma including performing the patient assessment process on a geriatric patient with a traumatic injury pp - Discuss elder abuse and neglect and its implications in assessment and management of the patient pp - Skills Objectives There are no skills objectives for this chapter Readings and Preparation Review all instructional materials including Chapter of Nancy Caroline s Emergency Care in the Streets Seventh Edition and all related presentation support materials Consider reviewing and incorporating material from MedicAlert s Geriatric Emergencies An EMT Teaching Manual This manual is designed to help instructors teach their students to effectively assess and aid geriatric patients in emergency situations http www medicalert org pdfs educational-services geriatric manual pdf To receive a comprehensive overview of prehospital care for the elderly population consider reviewing Geriatric Education for Emergency Medical Services GEMS available at www jblearning com ISBN Support Materials Lecture PowerPoint presentation Case Study PowerPoint presentation The GEMS Home page has many great resources including a glossary of terms pre- and posttest information and relevant links www gemssite com The Geriatric Mental Health Foundation web site highlights the needs and responses of older adults in disasters http www gmhfonline org gmhf consumer disaster prprdns html Enhancements Direct students to visit the companion website to Nancy Caroline s Emergency Care in the Streets Seventh Edition at http www paramedic emszone com for online activities Schedule a visit to a local nursing home or assisted living facility This can provide perspectives on the various disease processes the psychological effects of aging and retirement and allow the students to assess and interact with the patients and family members Arrange a visit to a senior center and have the students interact with the members Invite a staff member from the local hospice agency to speak with the students on the various aspects of death and dying Invite an attorney who specializes in EMS and ask him or her to discuss the legal challenges of advanced directives and do-not-resuscitate orders Content connections Chapter of Nancy Caroline s Emergency Care in the Streets Seventh Edition and all related presentation support materials provide a detailed presentation of physical psychological and social issues associated with aging Cultural considerations Different cultures regard older family members in ways that may not be familiar to the students Some cultures cherish their elders more than other cultures do valuing their wisdom and deferring to them for all decisions regarding personal health issues Other cultures may have rituals that are carried out when elder family members are dying or die in their presence It is important for EMS providers to understand how different cultures view older people as well as how these cultures deal with death and dying Teaching Tips Invite students to bring an elderly family member or friend to spend a class period with them Have the students and visitors work through scenarios incorporating the various challenges that can be experienced in the prehospital setting For example the elderly visitor could simulate loss of vision or hearing confusion polypharmacy and loss of mobility giving the student an opportunity to use their skills Make sure that the students complete a full assessment and practice transferring the patient to the stretcher Look up your location s legislation regarding the reporting of elderly abuse Be familiar with whether or not it is mandatory to report suspected abuse and how to properly report abuse whether mandatory or not Unit Activities Writing activities Assign each student to complete a report on a different common medical complication encountered in the elderly population including symptoms side effects and treatment options Student presentations Have the students present the findings of their written report Group activities Divide the class into groups and have them work through scenarios focusing on how to effectively communicate with family members who have just had a loved one die Visual thinking Add video segments of patient assessments performed on the elderly Ask the class to critique each case and generate a run report Pre-Lecture You are the Medic You are the Medic is a progressive case study that encourages critical-thinking skills Instructor Directions Direct students to read the You are the Medic scenario found throughout Chapter You may wish to assign students to a partner or a group Direct them to review the discussion questions at the end of the scenario and prepare a response to each question Facilitate a class dialogue centered on the discussion questions and the Patient Care Report You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper Lecture I Introduction A Geriatrics is the assessment and treatment of disease in those years or older According to the census Americans are age and older a A increase from the census The elderly are four times more likely to use EMS for transport to the ED B People years and older account for of all hospital stays in the United States Receive more of their care outside of hospitals a growing trend a Insurance and public health assistance programs reduce costs b Potential changes from health care legislation Have more contact with physicians than younger patients As the number of older Americans grows the need for physicians will increase a of seniors have at least one chronic medical condition b have two or more C The old-age dependency ratio the number of older people for every adults potential caregivers between the ages of and years Compares differences in age structure between time periods in a single society Compares age structures between two different societies a Can be used as an indicator of the aging of the population D The graying of America a term used by many social scientists to describe the increasing number of older Americans older people for every working-age caregivers projected older people for every working-age caregivers Supply of people providing resources for the older population not keeping pace with growth of older population a Need for caregivers will increase b Society will have difficulty keeping up with demand for services as population ages EMS personnel will need to offer cost-effective and efficient services Cost will also be a continuing concern due to a Insurance regulations b Costs associated with providing care c Facility issues E Most of prehospital geriatric patients will not reside in nursing homes CDC National Nursing Home Survey NNHS a nursing homes with million beds in the United States b Average nursing home stay was days Nursing home admissions increasing as numbers of elderly increase Countertrend of older persons maintaining independent lives a In of older people lived in the same residence they had lived in the year before b Half that moved stayed in the same county Living situations a At home with support from a spouse or family member and a visiting nurse b In a dependent care environment such as a senior center facility c In an assisted-living facility d In a total care nursing home skilled nursing facility F Determining how and where older adults will live is a difficult and complex process involving many issues including the patient s Marital status Financial resources Religious beliefs Ethnicity Gender General health G Decisions may place a burden on grown children and other members so their wishes must be considered by health care providers as well May seek advice from a Medical social workers b Professional care managers c Discharge planners at health care facilities d Other private and public resources Range of services includes a Delivered meals b Personal care c Housekeeping d Adult day care e Transportation f Caregiver support g Respite care h Emergency response systems EMS services and lifelines H The older person s financial situation frequently affects decisions about living conditions and services Older Americans are more likely to have wealth and assets including a Residential and business properties b Retirement accounts c Savings d Stocks Many have delayed retirement More likely to have health insurance coverage Not all retired people live in comfort however a More than of seniors have been uncertain about having enough food each day and this food insecurity may lead to i Poor nutrition ii Poor self-reported health iii Limited ability to care for self b Older people who live in poverty may make lifestyle choices that pose serious risks to their health i May skip medication doses to save money ii May use kerosene heaters rather than central heating I Psychosocial factors influence aging Feel useless or unproductive in society low self-esteem Feel frustrated due to inability to do things as easily as before Mourn the loss of activities they can no longer participate in Conversely feel freedom or accomplishment during retirement Crisis of integrity versus despair a Integrity they feel pride in life s accomplishments b Despair they may not have time to accomplish all of their goals i If despair more likely to feel depressed useless or that they are a burden Older people will likely feel bereavement over the loss of friends and loved ones a Likelihood of death increases during the year following the death of a spouse b As friends and family die elderly persons tend to feel more lonely and isolated c Death of spouse may increase financial concerns especially in lower-income families without adequate retirement funds or life insurance coverage d Those who were reliant on their spouse for daily assistance may not be able to meet their basic needs and require help from their children or other resources II Geriatric Anatomy and Physiology A Aging process begins in the late s and early s A linear process the rate at which a person loses function does not increase with age a Example A -year-old person ages just as fast as an -year-old but the older person exhibits cumulative results of aging b Organ and tissue aging may be accelerated by a variety of factors i Genetic qualities ii Preexisting disease iii Diet iv Exposure to toxins v Activity levels vi Psychosocial characteristics Aging varies widely from person to person a Example A -year-old may look frail while an -year-old person may be healthy enough to run a marathon Aging process is accompanied by physiologic function changes eg a decline in liver and kidney function a All body tissues undergo aging but not at the same rate b Decrease in various organ systems functional capacity is normal but affects the way a person s body reacts to illness i Signs and symptoms may be different than those of a younger person with the same disease or disorder ii Diseases may last longer with more detrimental effects in an older person The aging process and its changes can affect the way health professionals react to an older patient s illness a Important to differentiate between normal physiologic changes and acute changes indicating a pathologic process i If a health care provider does not understand the normal changes of aging he or she might mistake them for illness and provide treatment that is not necessary ii A health care provider may attribute signs and symptoms to just getting old and fail to provide the needed treatment b Important to determine the patient s baseline level of function when caring for older patients B Changes in the respiratory system Respiratory capacity undergoes a large reduction with age a Decrease in lung elasticity b Decrease in size and strength of respiratory muscles c Calcification of costochondral cartilage chest walls stiffen Vital capacity decreases and residual volume increases a Total amount of air in the lungs does not change with age b Proportion of air used in gas exchange progressively declines c Air flow deteriorates somewhat Changes in blood flow distribution in the lungs results in declining partial pressure of oxygen PaO a At years breathing ambient air usually around mm Hg b At years around mm Hg c PaO - age Respiratory drive becomes dulled because of decreased sensitivity to arterial blood gases changes or decreased CNS response to these changes a Alveoli number also decreases Consequence of these changes older people have a slower reaction to hypoxia and hypercarbia Musculoskeletal changes such as kyphosis may limit lung volume and maximal inspiratory pressure a Chest expansion is limited by decreased muscle strength and mass requiring more energy to perform ventilation These changes physically limit the respiratory system in the ability to modify tidal volume or respiratory rate to compensate a The lungs defense mechanisms are less effective due to aging b Cough and gag reflexes decrease with age making aspiration easier c Ciliary mechanisms that help remove bronchial secretions are slowed C Changes in the cardiovascular system The cardiovascular system decreases in efficiency as changes occur during aging a The heart hypertrophies enlarges in response to chronically increased afterload from stiffened blood vessels b Cardiac output declines as a result of decreasing stroke volume c Arteriosclerosis contributes to systolic hypertension which may be a consequence of diseases such as i Diabetes ii Atherosclerosis iii Renal compromise d Arteriosclerosis is associated with an increased risk of i Cardiovascular disease ii Dementia iii Death e Vascular wall compliance is dependent on collagen and elastin production primary protein components of muscle and connective tissue i Normal blood pressure increases with aging leading to a Overproduction of abnormal collagen b Decreased quantities of elastin ii These changes contribute to vascular stiffening which results in a Widening pulse pressure b Decreased coronary artery perfusion c Changes in cardiac ejection efficiency Aortic sclerosis when the aortic valve thickens from fibrosis and calcification a Obstructs blood flow from the left ventricle b Ultimately leads to aortic stenosis i The aortic valve does not open fully decreasing blood flow from the heart c Peripheral vessel walls lose elasticity resulting in higher blood pressure putting the older patient at risk for i Peripheral vascular disease ii Dependent venous pooling iii Stasis ulcers The heart s electric conduction system also deteriorates over time a The number of pacemaker cells in the sinoatrial node decreases with age b Changes in conduction system may lead to bradycardia contributing to cardiac output decline c Other possible changes include i Failure of primary pacemaker ii Development of alternate pacemakers within the atria which function as the primary pacemaker d Often leads to atrial dysrhythmias such as atrial fibrillation possibly causing i Irregular heartbeats ii Clots distributed within the body e More difficult for aging conduction system to compensate for decreased circulatory volume or increased cellular demand by producing a faster heart rate Some cardiovascular performance changes reflect a sedentary lifestyle rather than a direct consequence of aging Changes leave cardiovascular system more vulnerable to any dysfunction a Aging heart is less efficient at baseline b The effects of any acute circulatory change much worse than in younger populations c All potential cardiac compromises should be recognized and treated quickly D Changes in the nervous system A neurologic examination will reflect aging-related changes in the nervous system a Most common normal neurological findings in the elderly are changes in i Thinking cognitive speed ii Memory iii Postural stability b Studies have shown age-associated declines in mental function especially i Slower central processing of sensory stimuli and language ii Longer retrieval times for short- and long-term memory c Changes affect mental status performance in a neurologic examination with common findings including i Slow responses to questioning ii Requests to repeat a question The brain decreases in weight and volume in aging a Functional significance not clear b Human brain has reserve capacity so smaller and lighter brain does not necessarily interfere with mental capabilities The brain is responsible for coordinating other body systems a As mental function declines regulation of specific body system functions may also decline such as i Respiratory rate and depth ii Pulse rate iii Blood pressure iv Hunger and thirst b Reflexes may slow leading to slow response to pain i Example Might take longer to move hand away from a hot surface causing more extensive burns c Temperature regulation and perception change in aging i Less capable of recovering from extreme temperature exposure ii Less likely to recognize the exposures Sensory changes a Most of the sensory organs performance declines with increasing age i Most common sensory impairments among the elderly include a Decreased ability to see and hear b Decreased ability to taste c Decreased tactile sensation b Do not assume elderly patients are blind or deaf i Use the same communication techniques as you would with others ii If communication is ineffective gradually modify communication techniques to fit the patient c As many as of older patients have vision problems i May begin as early as years ii Tear production decreases leading to a Sensations of dry or itchy eyes b Increased chances of mild eye injury and infection d Causes of visual impairment in the elderly include i Diabetes ii Age-related macular degeneration iii Retinal detachment may also be associated with diabetes e Most common visual disturbances in the elderly i Cataracts result of hardening of lenses over time a Lenses eventually become opaque preventing images from being transmitted to the rear of the eye b Patients may report blurred vision double vision spots and ghost images c Surgical treatment may be needed ii Glaucoma intraocular pressure damages the optic nerve a Potential of permanent peripheral and central vision loss b Treatment includes oral medications and eye drops f Visual acuity decreases even without disease processes are common in older people i Difficulty seeing at night ii Inability to adjust to rapid changes in lighting depth and color perception iii Development of presbyopia far-sightedness caused by loss of eye lens elasticity iv Difficulty differentiating between colors g Vision changes can affect i Level of independence ii Ability to read may lead to unintentional overdose iii Ability to drive a vehicle may lead to more accidents Some gradual hearing loss is common as people age a Presbycusis progressive hearing loss with a lessened ability to discriminate between background noise and a particular sound b Some lose the ability to interpret most speech decreasing their ability to communicate i Leads to feelings of isolation c Even if hearing loss is not severe enough to interfere with communication certain activities may be less enjoyable d Hearing loss may threaten safety because many warning systems are auditory Hearing aids are one of the most common assistive devices in the United States especially by older people a Consist of microphone and amplifier b Some models fit entirely in the ear canal and will likely need to be removed if ear canal inspection is necessary i If patient is conscious and able ask him or her to remove it c Almost always battery operated d Devices are expensive and not always covered by insurance be careful not to lose them during transport Meniere disease is a hearing-related impairment often found in older populations a Two out of people b Onset in middle age c Symptoms present in cycles lasting several months at a time and include i Vertigo ii Hearing loss iii Tinnitus iv Pressure in the ear Changes in appetite may occur in older populations because of a decrease in the number of taste buds a By age years the number of taste buds is reduced by one third b Change is gradual c Salty and sweet sensations are the first to decrease Loss of end nerve fibers during aging decreases the sense of touch a In conjunction with peripheral nervous system slowing this can result in a delayed reflex reaction Sense of smell is among the last to diminish a Older persons are more prone to upper respiratory infections which can affect the sense of smell Physiologic changes may make it difficult to produce speech that is loud enough clear and well-spaced a This could be from i Weakness ii Paralysis iii Poor hearing iv Brain damage b Cognitive changes may affect speech when the elderly person cannot recall information fast enough to carry on a conversation i Do not rush elderly patients for answers or interrupt them Sense of body position proprioception may become impaired a Postural stability comes from receptors in the joints and visual information i As these decline older people become less steady and may fall more ii May be exacerbated by other sensory changes E Changes in the digestive system Process begins in the mouth aging-related digestive system changes first noted here a Decrease in number of taste buds and olfactory receptor changes decreases senses of taste and smell i Decrease in food enjoyment may lead to malnutrition b Reduction of saliva volume leads to dry mouth c Loss of teeth from tooth and gum disease is widespread in the elderly i Not from aging itself ii Ill-fitting dentures may be painful may fit poorly or may interfere with chewing properly leading to likelihood of a Choking b Heartburn c Abdominal pain Gastric secretions are reduced in the elderly a Esophageal sphincter s weakening allows stomach acids into the esophagus causing i Heartburn ii Indigestion iii Acid reflux b Tends to be related to diet and eating practices i Symptoms could possibly indicate cardiac compromise c Gastric motility changes lead to slower gastric emptying i Important when assessing aspiration risk ii Contributes to heartburn and acid reflux Small and large bowel function changes little from aging but certain diseases increase diverticulosis a Rectal sphincter may decrease in size and strength causing fecal incontinence b Slowing peristalsis can lead to constipation i Constipation also caused or worsened by a Some medications b Diet changes c Decreased physical activity ii Can cause difficult straining bowel movements that can cause hemorrhoids iii Forceful straining or retching may lead to syncope or bradycardia iv Patient may try to treat constipation with diet and medications that may or may not be intended to treat constipation a If treated too aggressively may cause diarrhea which may lead to dehydration v If constipation cannot be resolved a physician or nurse may need to remove the stool manually The hepatic enzyme systems in the liver change with age with some systems activity declining and others activity increasing a Enzyme systems that detoxify drugs decline i Complicates drug absorption and results in drug toxicity ii If numerous medications are prescribed risk for hepatic damage or drug toxicity increases F Changes in the renal system Kidneys are responsible for a Maintaining body s fluid and electrolyte balance b Helping maintain body s long-term acid-base balance c Eliminating drugs from the body Kidneys weigh between and g in a young adult but only to g in a healthy -year old a Weight decline from loss of functioning nephron units b Causes a smaller effective filtering surface c Renal blood flow also decreases by as much as Acute illness often causes fluid and electrolyte imbalances a Aging kidneys respond slowly to sodium deficiency elderly patients lose a large amount of sodium before kidneys stop excreting urinary sodium i Problem exacerbated by a decreased thirst mechanism ii Results in severe dehydration b Elderly population at risk of overhydration with large sodium loads because of an aging kidney s lower glomerular filtration rate i IV saline solutions ii Heavily salted foods c Same factors apply when considering an older person s ability to handle potassium i Prone to serious or lethal hyperkalemia if the patient becomes acidotic or the potassium load is increased G Changes in the endocrine system In of US residents million people aged years and older had diabetes a Does not include the approximate of this population who were classified in the prediabetic category b The elderly are at greater risk for developing type diabetes because i Carbohydrate metabolism becomes more difficult ii Comorbid disorders have medications that may affect glucose metabolism An increase in antidiuretic hormone ADH can occur as people age a Can cause electrolyte imbalances and fluid balance issues b May present with signs of pedal or other peripheral edema i Determine baseline for edema worsening of edema more significant than its presence Menopause causes decreased hormone secretion especially estrogen a Important role in bone mass preservation so decreased levels may lead to decreased bone density and osteoporosis b Estrogen and progesterone level changes also cause menopausal symptoms H Changes in the immunologic system Every immune system function is affected by aging a Older persons are more prone to infection and secondary complications b Chronic conditions place the elderly at greater risk of serious infection and include i Diabetes ii Dementia iii Malnutrition iv Cardiovascular disease Infections manifest differently in older people a Fever usually indicates a severe infection b of older people with severe infection may have no fever because of the aging immune system s inability to initiate a fever c Leading cause of death from infection in patients older than years is pneumonia I Changes in the integumentary system The most visible signs of aging wrinkling and resiliency loss in the skin a Wrinkling is caused by the skin becoming thinner drier less elastic and more fragile b Subcutaneous fat which normally cushions blood vessels becomes thinner so bruising becomes more common c Elastin and collagen decrease i Thinner skin tears more easily ii More bleeding occurs before hemostasis takes over due to loss of elasticity d Skin is more prone to tenting when skin turgor is checked even if there is no dehydration Sebaceous glands produce less oil so skin is drier a Sweat gland activity decreases which hinders the ability to regulate heat b Hair follicles produce thinner hair or stop producing hair at all i Follicles produce less melanin making the hair gray or white c Melanocytes in the epidermis decrease i Skin appears paler ii Increased sensitivity to sun exposure d Remaining melanocytes grow larger leading to age spots or liver spots Blood vessels are affected by atherosclerosis providing less oxygenated blood to the skin a Epidermal cells develop more slowly and do not replace outgoing cells as quickly b Fingernails and toenails become thinner and more brittle i Changes are more profound when combined with inadequate nutrition ii Inadequate or incorrect care of toenails can result in infection iii Can lead to amputation when combined with peripheral vascular disease or diabetes J Homeostatic and other changes Homeostasis process by which the body maintains a constant internal environment a Works on a feedback principle a change in internal environment feeds back to induce a corrective response i Example When body temperature starts to rise sensors activate which activates compensatory responses ii Example When blood glucose rises pancreas is stimulated to secrete insulin Homeostatic capabilities decrease with aging a Specific illness or injury is more likely to result in deterioration i Example Elderly more likely to become dehydrated because the thirst mechanism becomes depressed ii Temperature-regulating mechanisms become disordered making the elderly more vulnerable to environmental stresses after minor exposures of heat or cold iii Lack of temperature regulation may explain why some elderly people do not get a fever during illness or infection iv May have warm flushed skin even when hypothermic Blood glucose level regulatory system becomes impaired with aging a Elevated blood glucose levels common b Moderate hyperglycemia normally does not harm the patient but overly aggressive treatment may produce hypoglycemia which may be damaging K Changes in the musculoskeletal system Aging causes decrease in bone mass in both men and women but especially in postmenopausal women a Bones are more brittle and break more easily b Joint problems occur as tendons and ligaments lose elasticity synovial fluids thicken and cartilage cushioning joints decreases c Height decreases and posture changes as intervertebral disks narrow and vertebrae compression fractures occur d Joints lose flexibility and may develop arthritis i More than half of the older population has some form of arthritis e Muscle mass and strength decreases f Muscles atrophy from prolonged limited mobility such as bed confinement after illness or surgery Musculoskeletal system changes make older patients more susceptible to bone fractures in falls a Increases the likelihood of falls because of i Joint stiffness ii Loss of tendon and ligament elasticity iii Weakness of muscles b Patients may have difficulty caring for themselves especially for tasks requiring fine motor coordination and hand and finger strength i Taking medication ii Caring for wounds Bone density and muscle mass loss may be slowed by physical activity a Older patients who started with larger muscles and history of physical labor are least susceptible to musculoskeletal decline b Less arthritic pain when patients consistently and gently use arthritic joints III Geriatric Patient Assessment A Illness is not an inevitable part of aging Complaints from elderly patients should not be ascribed to getting old a Aging is a continuous and normal development process and does not produce symptoms of disease by itself b Biologic effects of aging from i Normal wear and tear ii Genetic makeup Widespread misconception that the elderly are hypochondriacs a Hypochondria far less common in the elderly b Older patients tend to not complain even with real symptoms c If an older person calls for prehospital care there is usually a real problem Important to understand what is and is not part of the aging process a Regular signs and symptoms may be altered as a consequence of aging i Myocardial infarction may not include chest pain ii Pneumonia may not include fever iii Uncontrolled diabetes is more likely to present as hyperosmolar nonketotic coma hyperosmolar hyperglycemic nonketotic coma HONK HNCC than as diabetic ketoacidosis iv A variety of acute illnesses may present with just delirium b Likely to be multiple problems with an older patient including medical psychological and social i While proportion of elderly with a disability has decreased the total number with chronic disability has increased because there is a greater number of older people c Debilitating health conditions in this population include i Hypertension ii Arthritic symptoms iii Heart disease iv Cancer v Diabetes vi Stroke vii COPD d to of people older than years have some form of depression Co-occurrence of multiple pathologic conditions creates problems for both patients and health care providers a Symptoms of one disease may hide or alter symptoms of another condition i Example Patient with severe pain from arthritis may not realize some of the pain is being caused by thrombophlebitis b A function disturbance in one body system may have repercussions throughout the body causing a domino effect of multiple organ failure c May be difficult to determine which condition is causing which symptom d Chronic comorbidities make it more difficult to treat an acute problem because of medicine contraindications and needed dosage modifications B Scene size-up Ensure scene safety and take standard precautions Check for clues to help determine mechanism of injury or nature of illness Determine number of patients and consider any needed additional or specialized resources Be aware of factors affecting the assessment process in geriatric patients and be ready to accommodate them a Sensory alterations b Verbal communication skills c Mental and physical capabilities C Primary assessment Use the GEMS diamond a Form a relevant general impression b Check for potential clues such as i General living conditions ii Social and family support iii Activity level iv Medications v Overall appearance with respect to a Nutrition b General health c Cleanliness d Personal hygiene e Attitude and mental well-being c The GEMS diamond acronym is one way to remember assessment and treatment steps i Created to help providers recall key themes when caring for geriatric patients d G Recognize that the patient is a geriatric patient i Assessment should be geared to possible problems of this population a May present atypically e E Environmental assessment for clues to patient s condition or emergency i Home too hot or cold well-kept secure ii Hazardous conditions a It is important to find risks to prevent future accidents f M Medical assessment i Older patients may have numerous health problems and take many prescription over-the-counter and herbal medications ii Obtain a thorough history g S Social assessment to determine if a social network exists i May need assistance with activities of daily living ADL ii Social agencies are available that can give patients a listing of services provided h GEMS can help providers remember important issues and make appropriate referrals Airway and breathing a Anatomic changes in the elderly predispose them to airway problems i Loss of gag reflex and normal swallowing mechanisms ii Airway obstruction or aspiration can stem from a Level of consciousness changes b Dementia c Poststroke weakness or paralysis b Ensure patient s airway is open and not obstructed by i Dentures ii Vomiting iii Fluids iv Blood c May need to suction d Anatomic changes in aging affect a person s ability to breathe effectively with contributing factors including i Chest wall stiffness ii Brittle bones iii Weakening of airway musculature iv Decreased muscle mass e Loss of ability to cough and gag-reflex decrease make it harder to clear secretions f Decreased number of cilia lining the bronchial tree makes it more difficult to remove material from the lungs leading to infection g Decreased ability to exchange oxygen and carbon dioxide from i Damaged alveoli ii Lack of elasticity h Chronic respiratory diseases common in older people affect ability to breathe i Treat airway and breathing issues with oxygen as quickly as possible Circulation a Those with compromised circulation have few reserves in a circulatory crisis i Lower heart rates and weaker and irregular pulses common in elderly patients because less responsive nerve stimulation lowers heart contraction rate and strength ii Difficult to find radial pulse because of vascular changes and circulatory compromise a When choosing alternative pulse point such as the carotid artery press gently b Apical pulse over the heart another option b Possible irregular pulse because of heart rhythm problems c Circulation problems should be treated with oxygen as soon as possible Transport decision a Most important task i Determine life-threatening conditions ii Treat to the best of your ability iii Provide transport to priority patients b Priority patients include i Those with a poor general impression ii Airway or breathing problems iii Acute altered level of consciousness iv Shock v Severe pain vi Uncontrolled hemorrhage c Older people will easily decompensate i A general complaint of weakness and dizziness can be a sign of a serious heart problem d Consider early if advanced life support and immediate transport are appropriate e If possible transport to a facility where the patient has been treated before D History taking Use good communication skills to gather information a First words should focus on gaining trust i Introduce yourself ii Use respect when addressing the patient a Use their name not buddy honey grandma or dear iii Speak slowly distinctly and respectfully iv Do not raise your voice v Attempt to get the patient history from the patient whenever possible vi Getting a thorough history reflects education and experience a Knowledge of prescription medications helps to understand patient s diagnosis and medication compliance Listen to the patient and wait for their answers a Older people may need time to process questions and may speak slowly b Pay attention to tone listening for fear and confusion Nonverbal communication is important a Be aware of your eye contact gestures body position expressions and touch b Get face to face with patients and ensure good lighting c Have patients use any hearing aids or wear glasses for better communication i Take these aids along to the hospital for better communication as well Explain the plan especially if the patient is confused a Determine if the confused state is normal a new sign of a preexisting condition or a lack of understanding i Family members can help outline changes b Preserve the patient s dignity while discussing the history A comprehensive history includes a Chief complaint b Present illness or injury c Pertinent medical history d Current health care status and needs Pertinent medical history includes a Current cardiovascular health b Exercise tolerance c Diet history d Medications e Smoking and drinking habits f Sleep patterns g Other intrinsic and extrinsic factors Determining the chief complaint may be difficult with some elderly patients a May believe their symptoms are just part of getting old b May not mention legitimate symptoms because they don t want to be labeled a hypochondriac c May believe diagnosis will take away their independence May underreport serious symptoms but report vague and seemingly unimportant symptoms a May not want to give symptoms in front of spouse b May have several chief complaints from different sources If the chief complaint seems trivial use a standard list of screening questions to ensure that all needed information is available a Questions designed to evaluate major organ systems functions include i Cardiovascular a Have you had any pain or discomfort in your chest When b Have you had any pain in your left arm or jaw c Have you noticed any fluttering in your chest or fast heartbeats ii Respiratory a Do you ever get short of breath When b Have you had a cough lately Is it painful iii Neurologic a Can you explain the reason for calling - - b Have you had any dizzy spells Have you fainted c Have you had any trouble speaking d Have you had headaches recently e Have you noted any unusual weakness or odd sensations in your arms or legs iv Gastrointestinal a Have there been any changes in your appetite lately b Have you gained or lost any weight c Have there been any changes in your bowel movements d Have you had any nausea or vomiting v Genitourinary a Do you have any pain or difficulty urinating b Have you noticed any change in the color of your urine c Have you noticed any changes in the frequency of urination b If any positive answers follow up Once the chief complaint is found conduct a history of the present illness a May be complicated by chronic problems affecting the acute problem i To determine which symptoms are acute and which are chronic ask a How does this differ from last week b What happened today that made you decide to get help b Not generally feasible to do a complete medical history in the field i Obtain a SAMPLE history to determine recent hospitalizations and allergies Do a detailed history of the patient s medications a Include all medications prescription over-the-counter and herbal medicines b Ask the patient to list medications by name along with dosing and frequency Include i Prescribed medications that are not taken ii Medications provided by other sources c Ask permission to take medications to the hospital and then collect them all Obtaining a history from an elderly patient takes patience a Be prepared to listen for an extended period E Secondary assessment May need to adjust usual methods while doing a secondary assessment on an elderly patient a Use minimal physical manipulation patient may have poor cooperation and be fatigued b Older people more prone to hypothermia so be sure to maintain body temperature c Multiple layers of clothing may hamper inspection and palpation i Remove clothing as necessary ii Be sure to cover the patient when finished Secondary assessment includes systematic checking of the patient a Possible full-body exam or focused on body part or system involved b Complete set of baseline vital signs using appropriate monitoring devices Postural blood pressure changes vary among older people a Changes increase with increasing frailty and increase the risk of falls b Marked postural changes in blood pressure and pulse rate may indicate hypovolemia or overmedication Blood pressure tends to be higher in older people a A normal-range blood pressure might indicate hypotension b Determine baseline blood pressure if possible c Consider getting vital signs in both arms and checking pulses in all extremities to check for i Dependent edema ii Dehydration iii Patient s circulatory status Observe the respiratory rate a Tachypnea can indicate acute illness in the elderly even if there are few other signs b Listen to lung sounds in all fields noting adventitious sounds c Listen for carotid bruits and note jugular vein distention Note any upper or lower dentures The elderly may have pulmonary crackles without pathology Edema may be from chronic venous insufficiency instead of right-sided heart failure F Reassessment Conditions may deteriorate quickly in older adults reassess often a Repeat primary assessment b Reassess vital signs c Reassess patient s complaint d Recheck interventions e Treat any changes in condition IV Pathophysiology Assessment and Management of Respiratory Conditions A Chronic lower respiratory disease influenza and pneumonia in top five causes of geriatric death Most common cause of death in older patients is Pneumococcus bacterial infection B Pneumonia Involves inflammation of the lung secondary to infection by a Bacteria b Viruses c Other organisms Has biggest impact on very young and elderly with those considered at risk including a The elderly b Those with underlying health problems i COPD ii Diabetes mellitus iii Vascular diseases c Those with a depressed immune system i AIDS ii Cancer therapy iii Organ transplantation d Those who are generally immobile confined to bed or have conditions that limit deep breathing Regular pneumonia symptoms often supplanted in the elderly who often present with a Acute confusion delirium b Normal temperature c Minimal to absent cough d Abdominal pain e Auscultated rhonchi in the affected lobes f Wheezing from inflammation of the bronchi Treatment is supportive and includes a Fluids b Oxygen via a nasal cannula or mask c Analgesics to reduce fever Preventive measures include a Pneumococcus vaccine given once b Booster doses after to years will not prevent infection from other bacteria c Cessation of smoking d Respiratory exercises when confined to bed Receiving facility will determine if antibiotics should be given C Chronic obstructive pulmonary disease The name given to a set of diseases characterized by bronchial obstruction and airway inflammation such as a Chronic bronchitis b Emphysema c Asthma Distinguishing between these diseases is difficult so diagnosis and treatment may be incorrect a Affects approximately of elderly population i Tobacco use a correlating factor b Reflects age-related loss of the lungs elastic tissue and decreased ability to fight off infection c These factors may increase COPD s baseline disability and cause an increased risk of acute exacerbation often from infection d Patient may experience dyspnea upon exertion i In later stages of disease minor physical activities and walking may be difficult Preventive measures include a Smoking cessation b Avoidance of certain environmental pollutants c Immunization for influenza and pneumococcal pneumonia d Long-term oxygen therapy for hypoxemic patients is helpful e Treatment also includes pulmonary rehabilitation to improve functional status and quality of life and inhaled beta-adrenergic agents and inhaled or oral steroids Treatment goals are to reduce symptoms and complications a Presenting symptoms include i Shortness of breath ii Fatigue iii Decreased activity level Treatment includes a Immediate assessment and supplemental oxygen to correct respiratory difficulties b CPAP has proven to decrease morbidity and mortality of COPD c Bronchodilators to decrease shortness of breath d Inhaled or oral steroids for inflammation e Antibiotics to treat infection D Asthma Approximately in elderly people is affected by or has a history of asthma a Onset can occur in old age with symptoms including i Shortness of breath ii Chronic or nocturnal cough iii Wheezing b Patients with asthma that worsens with exertion may be more susceptible to attacks as they age c Management is similar in the elderly population to other groups except when asthma and cardiac disease coexist i Beta-adrenergic agents may exacerbate cardiac symptoms ii Clinical guidelines for younger and older patients are the same E Pulmonary embolism Occurs when a blood vessel supplying the lung becomes blocked by a clot a Can cause irreversible damage or infarction b Embolus released from a damaged heart or a vein in the lower extremity pelvis or abdomen c Caused by deep venous thrombosis DVT when an embolus breaks free from a vein Prevention based on patient s risk level a High surgical patients are at highest risk for potential emboli i Prophylaxis recommended a Warfarin and or heparin b Compression stockings b Moderate c Low Risk increases with age a Increased immobility b Increased vascular stasis in lower extremities c Bed confinement further decreases blood flow to legs and feet d Increased incidence of diseases associated with pulmonary embolus i Cancer ii Heart attack iii Cardiac dysrhythmias iv Clotting disorders Classic triad of dyspnea chest pain and hemoptysis is often altered or absent in an elderly patient a Pulmonary emboli may be silent or present only with tachypnea b If pulmonary embolus is suspected check the lower leg for i Swelling ii Erythema iii Warmth or tenderness c Handle the leg gently and monitor for respiratory changes Prehospital treatment largely supportive after ensuring airway and ventilation a Consider lysing the thrombus and using anticoagulation therapies after a risk assessment is performed b Follow with rapid transport V Pathophysiology Assessment and Management of Cardiovascular Conditions A The heart s lifetime workload affects the cardiovascular system throughout the entire body Human heart beats billion times and moves million liters of blood in the average lifetime Heart diseases are the leading cause of death among older adults in the United States a Coronary artery disease CAD is the number one cause b Heart attack or myocardial infarction is a major cause of morbidity and mortality i Potential of mortality from heart attack increases dramatically after years of age B Myocardial infarction Myocardial infarction MI or heart attack death of part of the heart muscle from blockage of one of the coronary arteries a Chest pain may not be as intense present atypically or be absent in elderly patients b Elderly patients may report i Dyspnea ii Syncope iii Weakness iv Confusion v Nausea vi Vomiting vii Fatigue c Major risk factors include i Tobacco use ii Hypertension iii Diabetes iv Obesity v Psychosocial factors vi Lack of physical activity vii High cholesterol viii Alcohol consumption ix Genetic history d Preventive strategies include i Measures to prevent the first MI ii Avoidance of recurring MIs iii Lifestyle interventions including a Cessation of tobacco use b Eating a healthy diet c Controlling blood glucose d Exercising e Controlling weight f Controlling hypertension g Taking aspirin C Congestive heart failure The older population is a high-risk group for congestive heart failure CHF a Most common reason for hospitalization in people years and older b On the rise because i Better care of other cardiac diseases that allow the patient to live long enough to develop CHF ii More effective management of heart failure once it develops c Risk factors include i Gender ii Ethnicity iii Family history and genetics iv Long-term alcohol abuse v Multiple medical conditions a CAD b Emphysema c Hyperthyroidism d Thiamin vitamin B deficiency e Human immunodeficiency virus infection d Prevention based on lifestyle changes including i Tobacco use cessation ii Healthy diet iii Blood glucose control iv Exercise v Weight control vi Hypertension control Acute exacerbation of CHF results in pulmonary edema a May present with dyspnea or orthopnea b Mental status changes may occur because of decreased oxygenation to all organ systems i Sensation of air hunger c Peripheral edema may indicate worsening CHF i In the absence of other symptoms may be indicative of other circulatory integumentary or infectious conditions CHF presentation in the elderly may mimic symptoms and signs of old age or be shared by other chronic illnesses a Example dyspnea or exertion easy fatigability etc Acute CHF exacerbations often linked to a Poor diet b Medication noncompliance c Onset of dysrhythmias d Acute myocardial ischemia Prehospital treatment unchanged from other populations but must become familiar with the patient s medications and their implications for treatment a Evaluation of ETCO should be done immediately and monitored throughout transport b Example Patients taking long-term furosemide may not respond to a usual dose administered as acute therapy c Treatment should include i Close fluid monitoring and avoidance of fluid overload ii Use of CPAP iii Digoxin or diltiazem if patient has atrial fibrillation or atrial flutter iv Anticoagulation therapy for atrial dysrhythmias to prevent thromboembolism May be exacerbated by fluid imbalances especially overhydration a Weakened heart unable to pump normal vascular volumes so an increase in volume may stress the heart further b Weigh IV fluid administration needs against possible harm i Slight changes can cause significant negative outcomes ii Achieving the correct balance of fluid and electrolyte administration complicated when both dehydration and CHF are present D Dysrhythmias Occur when electrical system controlling the heartbeat has an interruption or malfunction a Cause heartbeats that are i Too fast ii Too slow iii Irregular iv Absent b Many people experience harmless dysrhythmias they call i Skipping ii Fluttering iii Fast heartbeat c Dysrhythmias in the older population usually the result of i Age-related heart changes ii Existing cardiac disease iii Adverse drug effects iv Combination of factors Classified by the part of the heart from which they originated a Tachydysrhythmias and bradydysrhythmias speed up or slow down the heart b Premature beats alter the heartbeat regularity c Atrial fibrillation from the atria increases risk of stroke and heart failure most common in the elderly i Allows blood stasis encouraging clot formation with a clot traveling to the brain ii Blood in the atria enters the ventricles when valves open iii About kicked in by atrial contraction iv When that remains in the atria new signs and symptoms of heart failure may appear or a stable heart may decompensate Bradycardias more common in the elderly a An aging conduction system produces sinus abnormalities b CAD may produce high-degree blocks c Beta blockers or calcium channel blockers may slow the heart d Relatively benign conditions such as constipation can cause bradycardia e Treatment is the same as in younger adults f Survival depends on i Prearrest health of the patient ii Early deployment of links in chain of survival a Early recognition b Early CPR c Early defibrillation d Early ALS e Postresuscitative measures E Hypertension More than half of all older people are hypertensive a Mostly from isolated systolic hypertension from arterial elasticity loss b Controlling systolic and or diastolic hypertension helps prevent stroke and MIs c Geriatric hypertensive emergencies require controlled blood pressure decline that often cannot be done in the field d Nitroglycerin use for hypertensive emergencies is heavily debated e If rapid onset of symptomatic systolic hypertension i Antihypertensive therapy to reduce systolic pressure F Aneurysms Aneurysm incidence increases with age A weakness in an artery that produces a balloon defect that weakens the arterial wall a May be congenital or acquired b Contributing factors for acquired aneurysms include i Hypertension ii Atherosclerotic disease iii Obesity c Blood pressure reading of more than mm Hg doubles mortality risk in men and can lead to kidney and eye damage d Life-threatening aneurisms can develop in the brain chest or abdomen i New headache or change in chronic headache pattern could indicate early cerebral bleeding ii Can cause stroke e Anticoagulant use for cardiac disease increases damaging effects of aneurysm i Increases time necessary to stop bleeding f Preventative measures to control risk factors associated with hypertension and atherosclerotic diseases include i Proper diet ii Exercise iii Smoking cessation iv Cholesterol control Aneurysms are generally asymptomatic until they become large or rupture a Early symptoms related to compression by the aneurysm i Difficulty swallowing ii Hoarseness from pressure on the laryngeal nerve b Abdominal or back pain if abdominal aortic aneurysms c Asymptomatic thoracic and abdominal aneurysms that do not expand or exceed a certain size are usually treated without surgery but are regularly reassessed d If an older patient has back pain carefully examine chest and abdomen e Treatment of abdominal emergencies is surgery so it is essential to i Recognize problem early ii Assess iii Stabilize iv Transport rapidly G Traumatic aortic disruption Also known as aortic dissection the inside artery wall tears and blood collects between arterial wall layers a May occur from trauma or sustained hypertension especially when an abdominal aortic aneurysm exists b Weakens the arterial wall and makes it prone to rupture c Thoracic dissection can cause chest pain and may look like cardiac ischemia i Obtain blood pressure readings in both arms if a patient has chest pain ii A thoracic dissection is suggested if systolic blood pressure is different by mm Hg or higher H Stroke A significant cause of death and disability in elderly people a More than of all stroke deaths are in people over age b Leading cause of long-term disability c Mainly caused by atherosclerosis d Responsible for of every deaths e Risk doubles each decade after years with increase of risk factors including i Hypertension primary risk factor ii Age iii Family history iv Smoking v Diabetes vi High cholesterol vii Heart disease viii Normal aging changes such as vascular elasticity loss f Prevention aimed at i Reducing risk factors ii Improving diet iii Increasing exercise iv Lowering cholesterol Prehospital care includes a Early recognition b Discovery of conditions that mimic strokes c Timely transport to appropriate facility d Use of stroke assessment tool as appropriate i Take history into account older person with arthritis may not move as well on one side ii Ask family or friends about deviations from the patient s normal behavior physical abilities or activity pattern Family members or caregivers can give input into a Baseline cognitive status b Personality c ADL Evaluate patient s ability to perform basic cognitive functions such as recalling events and remembering and following commands a Caregivers will likely know patient s normal responses or if personality change is a new onset or symptoms of underlying disorder b Caregivers will know the patient s baseline ability to perform ADLs I Transient ischemic attack Also called TIAs and ministrokes a temporary blood supply disturbance to the brain resulting in sudden temporary decrease in brain function a Symptoms same as stroke but usually last less than hours b Warning sign of future stroke c No lasting brain damage but significance should not be minimized i Most likely cannot determine in the field if patient is having a stroke or TIA so treat for stroke ii Patients with previous TIAs have a much higher risk of having a stroke instead of another TIA VI Pathophysiology Assessment and Management of Neurologic Conditions A Normal age-related cognitive changes Are relatively isolated not associated with specific disease states Onset and progression not sudden or extreme and do not extend into other abnormalities B Delirium Delirium is a symptom not a disease a Also known as acute brain syndrome or acute confusional state b Temporary state a reflection of underlying disturbance and usually reversible Characterized by a Disorganized thoughts b Inattention c Memory loss d Disorientation e Striking personality and affect changes f Hallucinations g Delusions h Decreased level of consciousness Confusion and disorientation fluctuate with time a Bizarre behavior from hallucinations b Rapid alteration between mental states lethargy and agitation c Serious attention disruption d Disorganized thinking e Changes in perception and sensation Symptoms may mimic a Intoxication b Drug abuse c Severe psychological disorders Assessment and management is complicated a Assess for recent changes in level of consciousness or orientation looking for i Acute onset of anxiety ii Inability to think logically or maintain attention iii Inability to focus b Also assess for changes in i Vital signs ii Temperature iii Glucose level iv Medications In the elderly delirium often replaces or confounds typical presentations of a Medical problems b Adverse medication effect c Drug or alcohol withdrawal Causes of delirium include a Medications b Poisons c Electrolyte imbalances d Nutritional deficiencies e Respiratory cardiovascular or nervous system disorders f Hyperglycemia or hypoglycemia g Environmental emergencies h Trauma i Infections j Neurologic and endocrine causes most important to consider i Alzheimer disease ii Parkinson disease iii Diabetes The mnemonic DELIRIUMS helps to identify causes a D drugs or toxins including intoxication or withdrawal b E emotional psychiatric c L low PaO carbon monoxide poisoning COPD CHF acute myocardial infarction pneumonia d I Infection pneumonia urinary tract infection sepsis e R Retention of stool or urine f I Ictal seizures g U Undernutrition or underhydration h M Metabolism thyroid or endocrine electrolytes kidneys i S Subdural hematoma Onset of confusion or disorientation is abrupt hours to days and usually resolves with treatment of the underlying problem a Treatment focused on resolution of cause b May be complicated to get an accurate medical history due to confusion or uncooperative behavior C Dementia Dementia produces irreversible brain failure a Signs and symptoms may take months to years to show and include i Short-term memory loss or shortened attention span ii Jargon aphasia iii Hallucinations iv Confusion v Disorientation vi Difficulty learning and retaining new information vii Personality changes social withdrawal inappropriate behavior b Patient can have both delirium and dementia Conditions that impair vascular and neurologic brain structures may cause dementia and include a Infections b Strokes c Head injuries d Poor nutrition e Medications Two most common degenerative dementias both of which cause structural damage to the brain are a Alzheimer disease b Multi-infarct or vascular dementia Dementia may also be caused by a Brain tumors b Emotional disorders c Parkinson disease d Huntington chorea to of the elderly will eventually have dementia and the percentage increases with age Risk factors that predispose a patient include a Low education level b Female gender c African American Diagnosed when two or more cognitive and psychomotor brain functions are impaired such as a Language b Memory c Visual perception d Emotional behavior and or personality e Cognitive skills Patients with dementia have a Progressive loss of cognitive function b Long-term or short-term memory impairments or both c Loss of communication skills d Inability to perform daily activities e Increased ability to become lost even in familiar places f Changes in temperament and affect especially increasing anger Most emergency care requests will be related to new dementia-related symptoms or behavioral disruptions a No treatment for dementia but underlying medical problems that cause acute changes can be treated b Obtain the patient s baseline abilities and behaviors from caregivers c Ask specifically about changes that led to request for services d Check information from the patient with that of caregivers Be cautious when caring for patients with dementia a Although in weakened condition they may attempt to harm you because of confusion or anxiety b An increased risk of caregiver abuse to the patient because they cannot accurately report injury or neglect To help alleviate caregiver stress refer them to a Home health agencies b Respite care programs c Other community services D Alzheimer disease Most common type of dementia a Progressive loss of function begins with subtle symptoms i Losing things and having difficulty recalling names ii Losing ability to think reason clearly solve problems and concentrate iii Forgetting identities of close family members and own experiences b Alzheimer disease symptoms may present as i Confusion ii Changes in personality or judgment iii Extreme difficulty with daily activities c Cannot be cured or reversed as of About million people are diagnosed with Alzheimer disease costing the United States more than billion annually a million diagnosed patients by the year is projected b Risk factors i A demonstrated genetic link a likelihood a twin will develop the disease as well ii African American iii Latino more likely to develop the disease earlier iv Less than years of school Progression classified into stages a Mild cognitive impairment MCI earliest stage pre-Alzheimer stage because not all patients with MCI will progress to Alzheimer disease characterized by i Forgetfulness especially conversations or recent events ii Difficulty in performing more than one task at once iii Diminished problem-solving skills iv Increased time needed to perform more difficult tasks b Early-stage Alzheimer disease involves more cognitive impairment including i Language problems ii Item misplacement iii Getting lost on familiar routes iv Personality changes and loss of social skills v Loss of interest in previously enjoyed activities vi Difficulty in performing moderately complex tasks that were once easy c Symptoms become more profound as Alzheimer disease progresses and include i Forgetting current event details and parts of life history ii Changing sleep patterns iii Difficulty reading and writing iv Danger and risk assessment impairment v Disorganized language use and nonsensical sentences vi Hallucinations and delusions vii Dangerous or violent behavior and agitation viii Difficulty performing basic tasks d Severe or end-stage Alzheimer disease patients forget things learned in the first or years of life i Cannot understand language ii Cannot recognize close family members iii Cannot perform basic self-care tasks iv Cannot interact verbally with family members or caregivers v May have medical devices such as gastric tubes and urinary catheters to perform tasks such as eating and voiding Not diagnosed by specific tests but by excluding other dementia causes a Can only diagnose through autopsy after death i Neurofibrillary tangles from thickened neurofilaments encircling and obscuring nerve cell nuclei ii Neurotic plaques when dead neurons accumulate into clusters iii Senile plaque when accumulated around proteins Prehospital treatment of Alzheimer disease centers on supportive care and treating symptoms a Communicate slowly and check for other illnesses b If patient is combative or dangerous consider antipsychotics or benzodiazepines i Only use if verbal communication does not work c Daily medications may include i Antidepressants ii Cholinesterase inhibitors to help prevent further decline No single cause has been identified but it is not believed to be a normal aging process a Age is a significant factor but it is not the only factor E Parkinson disease An age-related neurologic disorder with two or more of the following symptoms a Resting tremor of an extremity b Slowness of movement c Rigidity or stiffness of extremities or trunk d Poor balance Caused by degeneration of the substantia nigra the area of the brain that produces dopamine a Dopamine is used by cells to transmit impulses thus the loss of muscle function when dopamine is decreased Can affect one or both sides of the body produces wide range of functional loss May present as a Dyskinesia b Dementia c Depression d Autonomic dysfunction e Postural instability F Seizures Incidence increased in the elderly partly because of increase in risk factors a Stroke b Dementia c Primary or metastatic brain tumors d Acute metabolic disorders Prehospital treatment is the same as for younger patients VII Pathophysiology Assessment and Management of Gastrointestinal Conditions A Constipation is a frequent problem in older people but it should not be the initial assumption when a patient presents with acute abdominal pain Investigate the possibility of causes with high mortality first a Bleeding from acute abdominal aneurysm b Dead bowel from mesenteric ischemia When assessing a gastric emergency ask patient about a Food and fluid intake b History of abdominal complaints c Current bowel and bladder habits d Medications and supplements Symptoms often vague Abdominal gastric complaints often require surgery B Bowel obstruction Large bowel obstructions in the elderly are likely caused by a Cancer b Impacted stool c Sigmoid volvulus d Small bowel obstruction secondary to gallstones increases with age i One third to one half of all elderly people have cholelithiasis ii Most remain asymptomatic iii If there is one or more cholecystitis the gallbladder adheres to the small bowel creating a fistula gallstone ileus a Stone drops into the bowel and causes an obstruction b May account for as many as of geriatric small bowel obstructions e Large and small intestine obstruction from i Adhesions from previous surgery or infection ii Infection iii Fascial defect in the abdominal wall hernia when a bowel segment is forced in C Biliary disease Biliary disease may present either with or without small bowel obstruction in elderly patients and include a Cirrhosis b Hepatitis c Cholecystitis Signs and symptoms include a Jaundice may be more pronounced in paler patients b Fever may be repressed in older patients c Right upper quadrant pain with possible radiation to upper back or shoulder i May be altered with unusual referral paths or absence of abdominal pain d Vomiting or nausea Pain management may be necessary for acute cholecystitis a Be cautious in opiate use in older patients i Decreased ability to compensate for cardiovascular and respiratory changes from these medications D Peptic ulcer disease Older patients are more likely to have stomach or duodenal ulcers peptic ulcer disease a Main risk factors i Regular use of NSAIDs ii Helicobacter pylori iii Other medications iv Social factors high-stress professions v Certain personality types b Main symptom is dyspepsia that usually improves immediately after eating and returns hours later c Other causes of dyspepsia include i Acid reflux ii Gastritis iii Gastric cancer E Gastrointestinal bleeding More common with age almost always from either physiologic changes leading to increased likelihood of systemic bleeding or pathologic process impacting the digestive system a Normal aging changes increase time to hemostasis i Decreased vascular tone ii Thinned epithelial tissues b Decreased peristalsis increases likelihood that irritating substances will damage gastric lining c Coagulation altered by common medications i Warfarin ii Aspirin iii Heparin d Gastrointestinal pathologic processes that may cause bleeding include i Ulcers and varices ii Cancers of the stomach esophagus colon and rectum iii Diverticulitis iv Cirrhosis v Bowel obstructions Sources may vary but signs and symptoms vary more by location of bleeding than origin a Bleeding from esophagus i Most commonly associated with varices and alcohol abuse ii Violent vomiting that contains almost no food and a large amount of bright red uncoagulated blood b Bleeding from stomach i Associated with peptic ulcer disease ii Either red or darker coffee-ground emesis c Bloody stool i Indicates bleeding from lower gastrointestinal system although blood from the stomach may be digested with stool appearing dark and tarry ii Bright red blood in stool is usually from large intestine or rectum and may be caused by a Diverticulitis b Large bowel obstruction c Anal fissures d Hemorrhoids d The darker the blood the further the distance between bleeding site and exit portal Upper GI hemorrhage bleeding from the esophagus stomach or duodenum a If severe a true medical emergency b Older people are more prone to upper GI bleeding and often need urgent surgery c Greater risk of complications and death d Cannot determine upper GI bleeding cause without an endoscopic examination i Obtain a thorough history to provide clues a Regular use of NSAIDS or alcohol may cause bleeding from irritated linings or from ulcers in the duodenum or stomach b Forceful vomiting may cause esophageal tears c Cirrhosis of the liver may cause varices in the esophagus which can rupture and cause massive bleeding d Stomach or esophageal cancer can cause upper GI bleeding determine recent weight loss or difficulty swallowing Lower GI hemorrhage bleeding from the colon and rectum a Never simply attribute to hemorrhoids the source can also be colon polyps or cancer b Minor lower GI bleeding small amounts of red blood covering formed stools or small amounts noticed on toilet paper c Severe lower GI bleeding significant amounts of red blood or maroon-colored stools d Identify risk factors i History of previous lower GI bleeding ii Symptoms or signs of colon cancer iii Recent constipation or diarrhea iv Use of medications such as blood thinners e Treat for shock f If hematocrit and hemoglobin decrease significantly during interfacility transport blood administration may be needed g Severe lower GI bleeding requires immediate transport Signs and symptoms of GI bleeding are associated with hypovolemia and include a Agitation b Dizziness c Syncope d Hypotension e Changes in mental status f Signs and symptoms associated with underlying disease process i Jaundice ii Hepatomegaly iii Constipation or diarrhea iv Pain with voiding v Nausea vi Abdominal pain More important to assess bleeding severity than to determine its cause a Slower bleeding emesis with coffee-grounds appearance i Pulse rate and systolic blood pressure normal b Brisk bleeding hematemesis vomiting red blood or melena black tarry stools i Melena is a more common presenting symptom than pain c Prehospital treatment is supportive and includes pain control Treatment focuses on recognition and management of hypovolemic shock and transport to a facility that can provide definitive care a Patients will often need surgery b Be cautious in fluid resuscitation and note that an older adult s compensatory mechanisms may be altered c Patient may be on blood-thinning medications VIII Pathophysiology Assessment and Management of Renal Conditions A Urinary tract infections Urinary tract infections UTI are the most common hospital-associated infection that causes sepsis in the United States a Usually develop in the lower urinary tract when normal flora bacteria that naturally populate the skin grow in the urethra b Overall more common in women because the relatively short urethra is in close proximity to the vagina and rectum c After age years men have an increased risk of UTIs because of urethra obstruction by the prostrate Common risk factors include a Diabetes b Prostatitis c Cystocele d Urethrocele e Kidney obstruction f Indwelling urinary catheters Patients may present with a Fever b Shortness of breath c Gastrointestinal symptoms d Neurologic symptoms e Poor urinary output f Increased urinary frequency g Hematuria h Painful urination i Strong odor If patient has an indwelling catheter check for a Sediment b Opacity c Color d Presence of blood Later signs and symptoms include a Hypotension b Tachycardia c Diaphoresis d Pale skin B Renal failure Sudden decrease in rate of filtration through the glomeruli leading to toxin accumulation in the blood a Renal failure develops if kidneys are no longer able to i Excrete waste ii Concentrate urine iii Control electrolytes pH or blood pressure b Approximately of US adults older than years have chronic renal failure c Risk factors for chronic renal failure include i Diabetes ii Cardiac disease iii Pyelonephritis iv Hypertension v Autoimmune disorders vi Glomerulonephritis vii Polypharmacy d May require lifelong hemodialysis or kidney transplant If a hemodialysis treatment is missed it can become an ALS emergency a Symptoms include i Hypertension ii Headache iii Anxiety iv Fatigue v Anorexia vi Vomiting vii Increased dark urination viii Altered mental status ix Seizures b Obtain a -lead ECG may help determine electrolyte changes c Monitor i All vital signs regularly but do not take blood pressure on same arm that has a fistula ii ETCO iii Breath and bowel sounds d Transport to a facility with hemodialysis capabilities e Administer IV fluids as necessary f Treat any dysrhythmias according to current ACLS guidelines C Incontinence Bowel and bladder continence require a Anatomically correct gastrointestinal and genitourinary tracts b Functioning and intact sphincters c Properly working cognitive and physical functions Urinary incontinence has a social and emotional impact a Few admit the problem b Fewer seek help Can lead to a Skin irritation b Skin breakdown c UTIs As people age a Capacity of bladder decreases b Strength of the sphincter muscles decreases i Pressure on the urinary sphincter triggers recognition of the need to urinate ii Decrease in sphincter tone may keep older people from realizing their bladder is full causing involuntary bladder contractions iii May cause nighttime incontinence because they may be less likely to wake up when they need to urinate c Elderly people may recognize the need to urinate but their ability to get to the restroom may be limited i Placing a toilet chair in the bedroom may eliminate incontinence in this case Treatment consists of a Bladder training programs b Medications c Physical therapy d Surgery depending on cause Be discreet and nonjudgmental when working with incontinence a If time help patients gather their incontinence supplies before transport b If patient loses bladder control cover him or her until clothes can be changed c During long transports try to reduce the time the patient wears urine-soaked clothing i Temporary discomfort and embarrassment ii New or worsening skin breakdown Urinary retention or difficulty urinating is the opposite of incontinence a Difficulty voiding or absence of voiding may come from many medical causes i Benign prostate enlargement benign hypertrophy prostatic hypertrophy places pressure on the urethra and makes voiding difficult and frequent a Difficulty sleeping because of frequent need to urinate with little urine production ii Bladder and urinary tract infections may cause inflammation a May result in urine retention b Pain may lead patients to intentionally avoid urination iii Placement and removal of urinary catheter can cause retention iv Loss of bladder wall elasticity patients retain a small amount of urine leading to increased risk of UTIs b Temporary retention may lead to i Pain ii Abdominal distention iii Acute or chronic renal failure in severe or prolonged cases IX Pathophysiology Assessment and Management of Endocrine Conditions A Many endocrine changes will have been diagnosed earlier in life before prehospital intervention in the older population became necessary Geriatric patients may present with diseases such as a Grave disease hyperthyroidism b Addison disease hypoadrenalism c Cushing syndrome hyperadrenalism d Osteoporosis e Diabetes B Diabetic disorders Results from an inability to oxidize complex carbohydrates because of impaired pancreatic ability namely production of insulin a Insulin moves carbohydrates out of the bloodstream into cells to be metabolized b With diabetes the body cannot handle all the glucose in the blood c One of every five people over the age of years has diabetes i Usually type diabetes formally known as adult onset or non-insulin-dependent diabetes mellitus NIDDM ii Type diabetes insulin-dependent diabetes mellitus IDDM or juvenile diabetes d Normal aging changes contribute to diabetes development with risk factors including i Multiple chronic diseases the most common risk factor ii Family history of diabetes iii Genetics iv Age v Diet vi Obesity vii Sedentary lifestyle e Diabetes management is complicated when other diseases are present particularly infections i Elderly are likely to have several comorbid disorders that complicate management Diabetes can cause two life-threatening conditions a Hypoglycemia blood glucose levels drop to mg dL or less b Hyperglycemia blood glucose exceeds the normal range of to mg dL Geriatric patients are at increased risk for hypoglycemia due to a Confusion about medication doses or usage b Inadequate or irregular dietary intake c Inability to recognize warning signs due to cognitive problems d Blunted warning signs Delirium may be the only indication of hypoglycemia in an older patient a Other symptoms include i Mental status changes and confusion ii Diaphoresis iii Decreased respiratory effort Symptoms of hyperglycemia include a Fatigue b Poor wound healing c Blurred vision d Frequent infections e Symptoms of chronic hyperglycemia include the three P s i Polyuria excessive urine output ii Polydipsia excessive thirst iii Polyphagia excessive eating f New onset diabetes often produces no symptoms in geriatric patients Risk factors for HONK HHNC a Infection most frequent cause b Hyperthermia c Hypothermia d Cardiac disease e Pancreatitis f Stroke Patient may present with hyperglycemia greater than mg dL with a Acute confusion b Dehydration signs may be altered in the elderly Hyperglycemia and hyperosmolarity lead to osmotic dieresis and osmotic shift of fluid to the intravascular space a Signs and symptoms include i Dizziness ii Confusion iii Altered mental status iv Polydipsia Prehospital treatment is the same as for younger patients except a more cautious approach to fluid resuscitation should be taken Assessment of hyperglycemia and hypoglycemia is complicated by many age-associated changes a Changes in peripheral vascular function make many older patients paler and cooler at baseline b Changes in regulatory mechanisms and secretory functions of the skin may make diaphoresis less prominent c Baseline alterations of mentation may be confused with acute mental status changes Assess all vital signs every minutes a Obtain a -lead ECG to evaluate for other causes b Monitor ETCO and ventilatory status by capnography throughout transport Treatment is the same as for other populations except for added care with fluid resuscitation and electrolyte balance a Recognizing a return to baseline function levels is important may not be as universal in older people Prevention of type diabetes includes lifestyle changes such as a Dietary restrictions b Exercise c Weight control Long-term management includes a Limiting carbohydrates b Insulin and oral antihyperglycemic agents c Preventing systemic effects i Aggressive wound management ii Frequent renal function screening iii Pain management for neuropathy C Thyroid disorders Many older patients are asymptomatic with disease diagnosed by a routine blood test a Adult hypothyroidism sometimes called myxedema b Condition manifests by general slowing of body s metabolic process from a reduction or absence of thyroid hormone c Hypothyroidism signs and symptoms may look like normal aging i Cold intolerance ii Constipation iii Dry skin iv Weakness v Weight gain d Prior thyroidectomy more common in elderly patients with most of them on synthetic thyroid hormones Presentation can be blunted in acute-onset hyperthyroidism thyrotoxicosis a Tachycardia is generally present b Less tremor anxiety or hyperactive reflexes than younger populations c Atrial fibrillation more likely d May present with symptoms of weakness lethargy and depression small percentage Patients with hyperthyroidism or hypothyroidism may require supplemental oxygen a Hypoglycemia may need dextrose D b Hypothyroid often diminished respiratory effort requiring positive-pressure ventilation Continued hormone level decrease may cause myxedema coma a Accompanied by physiologic decompensation b Four to eight times more likely in women c Occurs primarily in the older population X Pathophysiology Assessment and Management of Immunologic Conditions A Infection can be severe and dangerous in the elderly Sepsis may occur from infections a Results from presence of microorganisms or their toxic products in the bloodstream b Patient may be i Hot and flushed ii Tachycardic iii Tachypneic c Other signs include i Oral temperature of greater than oF oC or less than oF oC ii Respiratory rate of more than breaths min or PaCO less than mm Hg iii Pulse rate of greater than beats min d Consider measuring lactate levels with a point-of-care device Sepsis can be caused by bacteria fungi or viruses XI Pathophysiology Assessment and Management of Toxicologic Conditions A As the number of uses for medications increases for the elderly population there is a proportional increase in the possibility of adverse drug reactions and interactions The elderly are prone to adverse reactions even at doses that would be safe for younger patients reflecting changes in a Drug elimination because of diminished hepatic function b Drug elimination because of diminished renal function c Body composition increased body fat decreased body water altering distribution of drugs throughout the body d Responsiveness of drugs that affect the CNS Body changes may affect medication use by geriatric patients a Reading small print on medicine bottles becomes more difficult leading to errors in administration of medication i Vision declines with age ii Night vision is less acute b Patients may take more than their normal medication doses because i Short-term memory loss may keep patients from remembering that they ve already taken their medications c Inability to distinguish flavors may cause patients to take multiple doses B Polypharmacy and medication noncompliance More than of all prescribed and over-the-counter drugs sold in the United States are consumed by the elderly a Older persons dwelling in communities take an average of three to five medications per day b Nursing home patients take an average of six to seven medications daily and two or three additional ones as needed Polypharmacy may be necessary but it becomes problematic when medications interact a Dosages not adjusted for multiple medications b Multiple organs affected c Elderly are prone to having multiple chronic diseases i Leads to multiple medications ii Increases likelihood of adverse reactions iii Leads to further treatment with more medications d Person s chance of being hospitalized increases with the number of medications taken i Should be considered when assessing chief complaint ii Best dosage in elderly patients is the lowest drug that achieves a therapeutic effect Patients may not receive their medication because of caregiver theft a May happen at home or in long-term care facilities b Suspect if patients report intense pain with corresponding vital signs Medication noncompliance is associated with negative health effects in older patients a Many do not follow instructions or advice on medication use b Noncompliance includes i Failure to fill a prescription ii Improper medication administration iii Discontinuation of medication against advice iv Taking inappropriate medication c Other issues include i Taking medications prescribed by different physicians who do not know full medication regimen ii Taking over-the-counter or medication prescribed for someone else d Compliance may be complicated by complicated drug regimens that may change i Changes may be difficult to remember ii Patient may not understand prescribed drug regimen iii May have difficulty opening medication containers C Pharmacokinetics Toxic effects of drugs may be caused by aging-related alterations in pharmacokinetics the absorption distribution metabolism and excretion of drugs a Elderly patients are predisposed to reactions to physiologic changes in body systems and body composition i Example Increase in proportion of adipose tissue can prolong a medication s half-life ii Medications affecting the CNS are the most common source of adverse reactions iii Benzodiazepines are most often associated with toxic effects iv Consider reducing dosage for medications affecting the CNS a Example Consider mcg instead of mcg of fentanyl b A reduction in the nervous system response such as a decrease in parasympathetic activity increases the risk of adverse anticholinergic effects c Most bronchodilator medications are more ineffective because of reduced beta-adrenergic receptor sensitivity d Diuretics and antihypertensive medications can cause hypotension and orthostatic changes because of reduced cardiac output and decrease in total body water e Decreased glucose tolerance can cause hyperglycemic effects from some medications such as i Diuretics ii Corticosteroids Pharmacokinetics can be influenced by a Diet b Smoking c Alcohol consumption d Other drug use Drugs that depend on liver and kidney metabolism and excretion may accumulate to toxic levels a Little is known about optimal dosages for older people nearly all studies are done in a younger population b Generally dosages need to be reduced for older people Certain drugs and classes of drugs that produce toxic effects more often in the elderly are outlined in Table a Toxic effects present with i Psychiatric symptoms ii Cognitive impairment D Drug and alcohol abuse The preferred substance of abuse among older persons is alcohol a Use is on the rise b A smaller but increasing part of the older population uses illicit drugs c Prescription drug abuse is also common i Many older persons see multiple physicians for various disorders that may need pain management and require sedation ii Some states have a statewide system used by pharmacies in that state to monitor and control scheduled medication distribution d Most users are men i More than half carry the addiction into older age ii One third develop abuse problems after reaching years in response to life-changing events a Loss of spouse b Declining health c Low self-esteem Prevalence of alcohol and drug abuse in this population can be attributed to a The number of prescribed medications b Heightened vulnerability to abuse c Decreased body mass and total body water leads to higher blood alcohol concentrations d Digestive renal and hepatic system changes lead to slower alcohol elimination from the body Substance abuse will grow as the geriatric population experiences even more chronic disabilities a Recognizing substance abuse in the elderly can be difficult i May be well hidden or accepted by family and friends ii Important to ask about issue because it can complicate a field assessment XII Pathophysiology Assessment and Management of Psychological Conditions A Depression is not a part of normal aging A medical disease occurring in about of persons older than years a May be a normal short-term reaction to a particular event b A larger concern when persisting for weeks with symptoms including i Sadness ii Restlessness iii Fatigue iv Hopelessness Depression is a major health problem in the geriatric population a Incidence growing in relation to progressive aging of the population b Trend attributed to increases in i Polypathology ii Psychosocial stress iii Age-related brain changes leading to cognitive impairment iv Medical illness v Dependency on health care services c May occur when patient takes a variety of medication made more likely when there are multiple medical conditions resulting in possible toxic effects Depression is treatable with medication and therapy a If unrecognized or untreated is associated with higher suicide in the elderly population b Can mimic effects of other medical problems c Risk factors in older people include i History of depression ii Chronic disease iii Loss of function independence significant others d May be difficult to recognize in the elderly because they tend to not complain about their feelings Majority of elder suicides occur in people who a Were recently diagnosed with depression b Had seen their primary care physician within a month of the event Geriatric patients generally do not attempt to get help or make suicidal gestures a Completed suicide rate is disproportionately high in the elderly population b Often a way out from terminal illness or debilitating cardiac or neurologic condition c Highest risk Caucasian men years and older who use firearms as their method B When a geriatric patient is having a psychological emergency determine if it is a true behavioral emergency or a behavioral crisis Behavioral emergency a significant risk of serious harm to self or others without intervention a Serious suicidal state b Potential violence c Impaired judgment causing risk of injury or death Behavioral crisis patient cannot cope and is overwhelmed C When dealing with mental illness or psychotic episode note that the patient will be out of touch with reality Many psychotic behavior forms may be possible including schizophrenic and paranoid behaviors a All associated symptoms may not be present during an episode b Clues may include i Patient becoming angry or excited for no reason ii Patient displays antisocial or loner behavior iii Patient sleeps during the day and is awake at night Underlying medical conditions may be possible causes for altered behavior Obtain information about changes in the patient s normal routine from family friends or caregivers XIII Pathophysiology Assessment and Management of Integumentary Conditions A Older patients are at higher risk for secondary infection Many wounds take longer to heal in older persons Cumulative sun and toxin exposure increase the chance of developing skin cancer B Herpes zoster Also known as shingles herpes zoster is caused by reactivation of the varicella virus on nerve roots a More common in the elderly population especially if they had chicken pox before the age of year b Immunosuppressed and cancer patients have a higher risk c Affects any nerve in the body but the most commonly affected are i Thoracic nerve ii Ophthalmic division of the trigeminal nerve d Symptoms i Begins with pain in the affected area ii Cluster of tiny blisters erupting on reddened skin at the affected area iii Unusually unilateral rash Most common complication is postherpetic neuralgia a Treatment includes i Narcotic pain relievers for severe pain ii Antiviral medications acyclovir and famciclovir preferably within hours of disease activation to decrease a Healing time b New lesion formation c Pain C Cellulitis Cellulitis acute inflammation in the skin caused by bacterial infection a Usually affects lower extremities b Symptoms include i Fever ii Chills iii General malaise iv Warmth swelling redness tenderness and enlarged nodes in affected area v Elevated white blood cell count and presence of bacteria c Treatment includes i Antibiotic therapy ii Adequate fluid intake iii Local dressing on any open sores D Pressure ulcers A major concern of elderly patients especially when bedridden a Occur when pressure is applied to body tissue resulting in lack of perfusion and necrosis b Possible risk factors i Brain or spinal cord injury ii Neuromuscular disorders iii Nutritional problems c Exacerbated by fecal and urinary incontinence especially when patient is exposed for prolonged periods of time d Be particularly aware of pressure sores in cases of spinal immobilization i Ensure adequate padding through posterior to prevent sores e Most commonly located on i Lower legs ii Sacrum iii Greater trochanter iv The glutes Pressure ulcers are classified as a Stage persistent area of skin redness that does not disappear when pressure is relieved b Stage partial thickness is lost and may appear as an abrasion blister or shallow crater c Stage full thickness of skin is lost exposing subcutaneous tissue deep crater with or without undermining adjacent tissue d Stage full thickness of skin and subcutaneous tissues are lost exposing muscle or bone More than of US nursing home patients have some stage of ulcer a Half have stage ulcers most common type b of nursing home population have stage ulcers least common type i Of those with a stage ulcer or higher receive specialty wound care Prehospital treatment is mostly BLS a Ulcers that are not treated can become significantly infected and lead to sepsis b Monitor body temperature and vital signs c Administer oxygen and establish an IV line d Consider administration of a fluid bolus XIV Pathophysiology Assessment and Management of Musculoskeletal Conditions A Physical ability changes can affect older adults confidence in their mobility Physical activity may be limited because of a fear of falling a Muscle system may atrophy and weaken with age b Muscle fibers become smaller and fewer c Motor neuron numbers decline d Strength declines e Ligaments and joint cartilage lose elasticity f Cartilage is subject to degenerative changes which contributes to arthritis Stooped posture of elderly from atrophy of the body s supporting structures a Two out of three older patients will have some degree of kyphosis b Lost height from spinal column compression i First in the disks ii Then from osteoporosis in the vertebral bodies B Osteoporosis Characterized by decrease in bone mass leading to a Bone strength reduction b Greater susceptibility to fracture Extent of bone loss influenced by a Genetics b Smoking c Level of activity d Diet e Hormonal factors f Body weight and structure g Use of anticonvulsant medications steroids and alcohol Risk factors include a Being a woman i Caucasian and Asian women more likely than African American or Hispanic women Two categories a Type I osteoporosis i Most rapid bone loss occurring in women during the years following menopause ii Most common fractures radius and hip fractures b Type II osteoporosis i In both men and women ii Most common fractures hip and vertebral fractures iii Vertebral fractures may cause dorsal kyphosis Hormone replacement therapy had been the preferred treatment but newer medications specifically targeting the bones are now available a These bisphosphonates include i Alendronate Fosamax ii Ibandronate Boniva b These medications i Have lower risks than HRT ii Are useful for bone loss in men Other treatments include a Calcium and vitamin D supplementation b Other medications that improve bone strength c Activity and low-impact exercises to maintain bone and muscle strength C Arthritis Osteoarthritis a progressive disease of the joints that promotes formation of bone spurs in joints leading to stiffness a Thought to result from i Joint wear and tear ii Repetitive joint trauma b Affects to of people older than years c Typically affects several joints most commonly i Hands ii Knees iii Hips iv Spine d Patients report i Pain and stiffness that worsen with exertion ii Increasing pain with temperature changes and humidity e End result is substantial disability and disfigurement f Treatment includes i Anti-inflammatory medications ii Physical therapy Rheumatoid arthritis RA long-term autoimmune disorder classified by inflammation of joints and surrounding tissue a Symptoms generally bilateral and most commonly affect i Hands ii Feet iii Wrists iv Ankles v Knees b Patients may note i Pain and stiffness in the joints ii Smaller finger and toe joints usually affected before larger joints c May observe i Baseline deformities ii Poor range of motion d Prehospital care is strictly supportive i If RA causes pleurisy-associated chest pain treat according to pain management protocols XV Management of Medical Emergencies in Elderly People A With the exception of patients who need immediate ABCs intervention most prehospital care is supportive focusing on pain relief and palliative support Additional treatment depends on the specific emergency and chief complaint XVI Pathophysiology Assessment and Management of Geriatric Trauma Emergencies A In people older than years deaths from injury account for one fourth of all trauma deaths in the United States Injury is the seventh leading cause of death in the older population Factors that place the elderly at higher risk of trauma include a Slower reflexes b Visual and hearing deficits c Equilibrium disorders d Overall reductions in agility Factors that lead to less favorable trauma outcomes for the elderly include a Changes in the body s homeostatic compensatory mechanisms b Aging effects on body systems c Preexisting conditions Treatment is successful when trauma-related blood loss is compensated enough for a Increased pulse rate b Increased respirations c Adequate vasoconstriction Unsuccessful recovery from trauma likely if it results in a Decreased respiratory function b Impaired renal activity c Ineffective vasoconstriction The elderly are more likely to sustain serious injury from trauma because a Stiffened blood vessels and fragile tissue is easier to tear b Demineralized bones more vulnerable to fracture B Most geriatric trauma cases involve falls or motor vehicle crashes Falls increase with increasing age a In more than people died from fall-related injuries b of these were older than years c Increased mortality in geriatric patients from falls is directly related to i Patient s age ii Preexisting disease processes iii Complications related to trauma Falls are associated with a Higher incidence of anxiety and depression b Loss of confidence c Postfall syndrome i Geriatric patients develop a lack of confidence and anxiety around potential falls ii May become immobile risk incontinence and develop pneumonia or pressure ulcers from lack of movement C Falls among elderly are divided into two categories see Table Extrinsic causes external tripping or slipping on something Intrinsic causes internal from dizzy spells or syncopal attack D Risk of falls increase with preexisting gait abnormalities and cognitive impairment Patients with osteoporosis have lower-density bones so even awkward turns may fracture a bone Obtain a careful history to ensure there was no dizziness or palpitations just before the fall Home safety assessments by EMS may reduce fall incidence a Components of this assessment may include i Clear pathways to and from the bathroom ii Handrails in bathtubs and on steps iii No loose rugs or other objects are on the floor iv Wheelchair ramps with grip tape v Caregivers are trained to lift and move patients E Motor vehicle crashes are the second leading cause of accidental death among the elderly An older patient is five times more likely to be fatally injured in a motor vehicle crash a Excessive speed is rarely a factor Higher risk because of a Vision impairment b Errors in judgment c Underlying medical conditions Pedestrian deaths involving the elderly can often be attributed to a Vision and hearing impairments b Diminished agility F Pathophysiology Age-related changes make the elderly vulnerable to certain types of injuries a Head trauma a serious problem with older people more vulnerable to intracranial bleeding especially subdural hematoma from i Increased fragility of cerebral blood vessels ii Enlargement of subdural space iii Decreased supportive tissue of the meninges b A hematoma often develops over days or weeks i By the time symptoms appear the incident may have been forgotten or caretakers may feel guilty for the incident c Most important early symptom is a headache that may be worse at night i Headache may appear on same side as the injury d As intracranial pressure increases i State of consciousness becomes depressed ii Patient becomes drowsy Older patients are more vulnerable to cervical spinal cord injury and cord compression even after minor injuries because of age-related changes a Degenerative spinal changes cervical spondylosis cause arthritic spurs and vertebral canal narrowing b Nerve roots from the spine become compressed and pressure on the spinal cord increases c Even a sudden movement of the neck may cause spinal cord injury Because of age-related rib brittleness and overall stiffening of the chest wall from costochondral cartilage calcification injuries to an elderly person s chest are likely to result in a Rib fracture b Flail chest Abdominal trauma often causes liver injury Orthopedic injuries are common results of falls of geriatric patients including fractures in in order of severity and frequency a Hip i Occasionally occur without trauma from vigorous hip musculature contracture ii Osteoporosis most important risk factor b Femur c Pelvis d Tibia e Upper extremities f Half of older women and one in eight older men will at some time have an osteoporosis-related fracture Burns have a significant risk of morbidity and mortality in older people a Risk of mortality increases if i Preexisting medication conditions are present ii Defense mechanisms against infection are weakened iii Fluid replacement is complicated by renal compromise b When assessing a burn patient monitor hydration status by assessing current i Vital signs ii Mucus membranes iii Urine output typically to mL h or to cc kg hr Internal temperature regulation slows in the elderly especially with increasing age a Body s ability to recognize temperature fluctuation is delayed because of a slowed endocrine system b Heat gain or loss from environmental changes is slowed by i Atherosclerotic vessels ii Slowed circulation iii Decreased sweat production c Thermoregulation is adversely affected by i Chronic disease ii Medications iii Alcohol use d About half of hypothermia deaths occur in older people i Most indoor hypothermia deaths involve the elderly ii Harsh winters are a factor iii Long exposure can cause hypothermia even if temperatures are above freezing e Hyperthermia death rates more than double in the elderly i Arizona has more heat-related deaths than all other states combined thanks to its long hot summers and high geriatric population f Be aware of environmental emergencies in extreme hot and cold especially in lower socioeconomic areas i May require public awareness and preplanning ii May need to keep patient compartment at a higher-than-normal temperature to maintain the patient s temperature G Assessment and management of trauma Check the mechanism of injury a Falls cause the largest number of injuries in elderly people b Motor vehicle injuries c Burns and other injuries Check for signs and symptoms of a possible medical problem before the trauma a Example A syncopal event occurred while driving causing a car crash Initial management follows the basic ABCs with some special concerns a When securing an airway check for dentures i If intact and in place leave them there ii If broken or loose remove them and place in a safe container b And older patient may have lessened airway and gag reflexes so suction aggressively when needed Check for rib fracture when assessing for breathing a If assisted ventilation is needed gently use a bag-mask i Exert just enough pressure to inflate the lungs to lower the risk of pneumothorax ii Administer supplemental oxygen early Normal blood pressure in a younger person may be hypotension in an older person a If possible determine the patient s baseline blood pressure and circulatory status Neurologic status assessment should be done according the AVPU scale Expose the entire injured area to check for injuries Once primary assessment is complete a Try to obtain a complete history of the trauma from patient and bystanders i Patient may have sustained injury hours or days prior to ambulance call or symptoms may have come from a medication regimen ii Ask a If a fall from how high b Any symptoms beforehand such as dizziness c If struck by car how fast was the car going d If patient was driving any medical symptoms before the crash such as dizziness or passing out e Was car moving erratically before the crash b Obtain a list of all regular medications especially those that may affect response to anesthesia and resuscitation i Beta blockers ii Antihypertensives iii Diabetes medications c Conduct a secondary assessment as usual watching for signs of injury to i Head ii Cervical spine iii Ribs iv Abdomen v Long bones d Pain may be difficult to assess if patient s pain perception is decreased e Additional treatment will depend on specific injuries but keep in mind i Need for caution inserting IV catheters and isotonic solutions a Balance the need for adequate perfusion pressure with the risk of overloading with sodium b Use smaller boluses and reassess for signs of pulmonary edema ii Monitor cardiac rhythm throughout especially if previous or continuing cardiac disease iii Preserve temperature a Temperature regulation is slowed in the elderly iv Frail elderly patients may not be able to tolerate traction splints for a femoral fracture a If possible place on well-padded backboard and place pillows secured in place v Consider pain medication a The elderly may need lower doses vi Immobilize the cervical spine before transporting a Pad the backboard targeting areas where the bone is near the surface b Pressure ulcers can develop in as little as minutes XVII Elder Abuse A Elder abuse any form of mistreatment that results in harm or loss to an older person Types of abuse a Physical b Sexual c Emotional d Neglect e Financial i Improper use of an older person s funds property or assets Average victim of elder abuse a years old b Female c Has multiple chronic conditions i Patients unable to function on their own ii Dependent for at least part of their care Abuser is almost always known to the abused a Often a family member b Often occurs in patient s or caregiver s home c Sometimes occurs in long-term care facilities Clues to spotting elder abuse a Check for unexplained injuries that do not fit the stated cause b Environmental and social clues i Overall hygiene ii How the patient interacts with caregivers c Listen to concerns expressed by older patients about their care If patient is stable but in an unsafe situation check if the patient will allow transport to a hospital a If patient refuses check if they will accept help from local adult protective services APS b Patient may be afraid of caregiver retaliation if they accept help c If the situation is immediately unsafe notify law enforcement personnel and remain with the patient only if it is safe to do so B Many states have elder abuse statutes Reporting of suspected abuse is mandatory in some areas a Only one in five cases of elder abuse is reported The definition of elder abuse varies from state to state a It is important to learn legislation applying to the area If elder abuse is suspected as a cause of geriatric injury a Objectively document observations b Report findings and suspicions to the receiving facility XVIII End-of-Life Care A Paramedics will be involved with end-of-life care for patients Do not resuscitate DNR does not mean do not respond to the needs of a terminal patient Paramedics should a Treat various disorders b Administer medications c Perform various treatments that do not include artificial ventilations or cardiovascular assistance Paramedics should demonstrate a caring and concerned attitude for DNR patients a Some visits may have no transport decisions but are valuable to the patient Many communities have a local hospice which a Provides terminal care for patients b Provides support for their families Prehospital care personnel and hospice organizations can collaborate on providing quality care to terminal patients XIX Summary A Elderly people constitute an ever-increasing proportion of patients presenting to the health care system especially to the emergency care sector B Health problems of older people are quantitatively and qualitatively different than those of younger people and require special approaches C The aging process is accompanied by physiologic function changes this decrease in the functional capacity of various organ systems may affect the way the patient responds to illness D With age the respiratory capacity undergoes significant reduction because of decreases in elasticity of the lungs and the size and strength of respiratory muscles calcification of costchrondral cartilage and musculoskeletal changes E A variety of changes in the cardiovascular system occur as the person ages The heart hypertrophies Arteriosclerosis develops and the electric conduction system of the heart deteriorates F Nervous system changes lead to a decrease in sense organ performance as evidenced by hearing loss and visual changes G Digestive system changes include a decrease in taste buds and a reduction in saliva and gastric secretions which may interfere with food enjoyment leading to malnutrition in elderly people H Geriatric patients may experience renal system changes and although the kidneys may be able to handle day-to-day demands they might not be able to meet unusual challenges from illness Acute illness is then often accompanied by derangements in fluid and electrolyte balance I Endocrine system changes may lead to diabetes and thyroid abnormalities in older patients J Nearly every immune system function is affected by aging so older persons are more prone to infection and secondary complications K Integumentary system changes include thinner skin and elasticity loss so skin tears easily and more bleeding occurs L A progressive loss of homeostatic capabilities accompanies aging so a specific illness or injury in elderly people is more likely to result in generalized deterioration M A decrease in bone mass accompanies aging especially in postmenopausal women Bones become more brittle and tend to break more easily N When assessing elderly patients it may difficult to know what is and what is not part of the aging process Also signs and symptoms of disease may be altered from their presentation in younger patients as a consequence of aging O The GEMS diamond was designed to assist in assessment and treatment of elderly patients and it can be integrated into the patient assessment process to help form a general impression of the patient P The primary assessment addresses immediately life-threatening pathologic problems and the secondary assessment includes a systematic assessment of the patient It may include a full-body exam or a focused assessment on the body part or system involved Q The physical exam of older patients can be difficult because of poor cooperation and easy fatigability that may require you to keep manipulations of the patient to a minimum R Stroke is a significant cause of death and disability in elderly people with more than of all stroke deaths occurring in persons older than years Stroke is the leading cause of long-term disability at any age S Heart disease remains the leading cause of death among older adults in the United States with heart attacks being the major cause of morbidity and mortality in those older than years its potential for mortality increases significantly in people older than years T In the elderly delirium often replaces or confounds the typical presentation caused by a medical problem adverse medication effect or drug withdrawal Disorders that cause delirium may also include poisons electrolyte imbalances nutritional deficiencies and infections U Dementia produces irreversible brain failure Disorders that cause dementia include conditions that impair vascular and neurologic structures within the brain such as infections stroke head injuries poor nutrition and medications V Gastrointestinal problems in elderly people include peptic ulcer disease small bowel obstruction due to gallstones and stomach or duodenal ulcers W The most common hospital-associated infection to cause sepsis in the United States is urinary tract infection UTI X An elderly patient with diabetes is at increased risk for hypoglycemia from medications inadequate or irregular dietary intake inability to recognize warning signs due to cognitive problems and blunted warning signs The only indication of hypoglycemia in an elderly patient may be delirium Y Older patients with diabetes whose blood glucose levels tend to be high are prone to hyperosmolar nonketotic coma HONK also called hyperosmolar hyperglycemic nonketotic coma HHNC The most frequent cause is infection Presentation is usually acute confusion and dehydration Z Elderly people are particularly prone to adverse drug reactions because of changes in drug metabolism because of diminished hepatic function drug elimination because of diminished renal function body composition including increased body fat and decreased body water altering the distribution of drugs through the various body compartments and the responsiveness to drugs of the central nervous system AA Alcohol abuse among older persons is on the rise and is the preferred substance of abuse A much smaller but growing segment of the geriatric population uses illicit drugs BB Depression in the elderly can mimic many other medical problems such as dementia Risk factors include a history of depression chronic disease and loss CC Osteoporosis is characterized by a decrease in bone mass leading to reduction in bone strength and greater susceptibility to fracture Osteoarthritis is a progressive disease process of the joints that destroys cartilage promotes formation of bone spurs in joints and leads to joint stiffness DD An elderly person is at higher risk of trauma than a younger person because of slower reflexes visual and hearing deficits equilibrium disorders and an overall reduction in agility EE Most geriatric trauma cases involve falls or motor vehicle crashes Falls are evenly divided between those from extrinsic causes tripping on a loose rug or slipping on ice and those resulting from intrinsic causes dizzy spell or syncopal attack FF Elder abuse is any form of mistreatment that results in harm or loss to an older person abuse can be in five distinct types physical sexual emotional neglect and financial GG Hospice care allows people with terminal illnesses to receive palliative care in their own homes Prehospital personnel are involved with end-of-life care for many patients Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor s presentation As time permits these activities may be presented in class They are also designed to be used as homework activities Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care The activity incorporates both critical thinking and application of paramedic knowledge Instructor Directions Direct students to read the Assessment in Action scenario located in the Prep Kit at the end of Chapter Direct students to read and individually answer the quiz questions at the end of the scenario Allow approximately minutes for this part of the activity Facilitate a class review and dialogue of the answers allowing students to correct responses as may be needed Use the quiz question answers noted below to assist in building this review Allow approximately minutes for this part of the activity You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper Answers to Assessment in Action Questions Answer B Environmental assessment Rationale The environmental assessment portion of the GEMS diamond can give clues to the patient s condition or the cause of the emergency In this case the loose rugs are a contributing factor to falls Preventive care is important for a geriatric patient Pointing out findings and risks such as loose rugs or unstable handrails to caregivers and patients can help these problems be addressed hopefully eliminating future accidents Answer A an extrinsic factor Rationale Environmental hazards such as loose rugs poor lighting and slippery surfaces are all forms of extrinsic or external causes Falls among the elderly are divided equally between those resulting from extrinsic factors and those resulting from intrinsic factors ie dizziness or a syncopal episode The risk of falls also increases in people with preexisting gait abnormalities and cognitive impairment You need to gather a careful history when you are assessing a patient who has fallen Although the patient may attribute the fall to an accidental extrinsic cause such as tripping over the loose rug meticulous questioning may reveal other intrinsic issues prior to the fall The patient may remember a period of dizziness or palpitations just before the fall The incidence of falls increases with increasing age Although most falls do not produce serious injury elderly people account for of all fall-related deaths This increased mortality in geriatric patients is directly related to the patient s age preexisting disease processes and complications related to the trauma Answer D Social assessment Rationale The social assessment of the GEMS diamond relates to the patient s social network and activities of daily living Older patients have less of a social network due to the death of friends spouses and family members and may not have anyone to turn to for help with simple tasks You should have information about social services to provide to the patient when you encounter someone with a need for assistance Answer C Dementia Rationale Dementia is a progressive problem that produces irreversible brain failure Disorders that cause dementia include conditions that impair vascular and neurologic structures within the brain such as infections strokes head injuries poor nutrition and medications The percentage of patients with dementia increases with advancing age Signs and symptoms of dementia can take months to years to become apparent and may include short-term memory loss or shortened attention span jargon aphasia hallucinations confusion disorientation difficulty in learning and retaining new information and personality changes such as social withdrawal or inappropriate behavior It is also important to note that patients with dementia may also have delirium which is typically temporary and usually reversible When you are assessing a patient for delirium look for recent changes in the patient s level of consciousness or orientation Look for an acute onset of anxiety an inability to think logically or maintain attention and an inability to focus Also assess for changes in vital signs temperature glucose level and medications Answer A polypharmacy Rationale Because the patient is taking many medications she may be experiencing problems as a result of overmedicating or medication interaction It is not uncommon for patients to also be taking several herbal remedies that they do not consider to be medications but such can still interfere with their normal prescriptions Elderly patients are particularly prone to having multiple chronic diseases which may lead to a vicious cycle Multiple diseases lead to the use of more medications thus increasing the likelihood of adverse reactions which in turn leads to more medications being prescribed Medication noncompliance is another major problem in the elderly population Some patients may take only half of what they are prescribed in an effort to save money Patients on a fixed income may reason that if they only take a half dose the prescription will last twice as long However they