Chapter 35 Geriatric Emergencies

Chapt 35 Geriatric Emergencies -Geriatrics is the assessment and treatment of disease in a person who is 65 years or older. -Geriatric patients present as a special challenge for health care providers because the classic presentation of injuries and illness are often altered by the presence of chronic conditions, multiple medications, and the physiology of aging. Generational Considerations -It takes time and patience to interact with an older person. 1. Have patience and treat the patient with respect. 2. Make every attempt to avoid ageism, a stereotyping of older people that often leads to discrimination. Communication techniques 1. Your first words to the patient and the attitude behind them can gain or lose a patient’s trust. a. Speak respectfully when you introduce yourself. 2. When you interview an older patient, the following techniques should be used: a. Identify yourself. b. Be aware of how you present yourself. c. Look directly at the patient at eye level and ensure good lighting. d. Speak slowly and distinctly. Common Complaints and the Leading Causes of Death in Older People 1. A simple rib fracture in an 80- or 90-year-old can result in pneumonia or even death. 2. Hip fracture from a low-mechanism fall is common in older people and may have dire consequences. a. Hip fractures are more likely to occur when bones are weakened by osteoporosis or infection. b. Sedentary behavior while healing can predispose the patient to pneumonia and blood clots. 3. Many older patients are well aware of this and may be frightened. Changes in the Body -The aging process is inevitably accompanied by changes in physiologic function, such as a decline in the function of the liver and kidneys. 1. All tissues in the body undergo aging. 2. The decrease in the functional capacity of various organ systems is normal but can affect the way in which a patient responds to illness. Changes in the Respiratory System -Anatomy and physiology 1. Age-related changes can predispose an older adult to respiratory illness. a. Weakening of the airway musculature can cause decreased breathing capacity. b. Alveoli can become enlarged and elasticity decreases, making it harder to expel used air. c. Chemoreceptors slow with age, causing the body to respond more slowly to hypoxia. Pathophysiology 1. Pneumonia a. Pneumonia is an inflammation/infection of the lung from bacterial, viral, or fungal causes. b. It is the leading cause of death from infection in Americans older than 65 years. c. Aging causes immune suppression & increases risk of contracting infections like pneumonia d. Management of pneumonia remains the same; however, maintain a high index of suspicion for any geriatric patient with signs and symptoms of pneumonia. 2. Pulmonary embolism a. A condition that causes a sudden blockage of an artery by a venous clot b. Patient w/ pulmonary embolism will present with shortness of breath and sometimes chest pain c. Signs and symptoms d. Treatment Changes in the Cardiovascular System -Anatomy and physiology 1. The heart hypertrophies, usually in response to the chronically increased afterload imposed by stiffened blood vessels. a. Over time, cardiac output declines, mostly as a result of a decreasing stroke volume. b. Arteriosclerosis contributes to systolic hypertension, which places an extra burden on the heart. Pathophysiology 1. The ability to speed up contractions, increase contraction strength, and constrict or narrow blood vessels is decreased because of stiffer vessels. 2. Geriatric patients are at risk for atherosclerosis, an accumulation of fat and cholesterol in the arteries. a. Atherosclerosis makes stroke, heart disease, hypertension, and bowel infarction more likely. 3. Older people are also at an increased risk for the formation of an aneurysm. 4. The blood vessels themselves become stiff, which results in a higher systolic blood pressure. 5. Stiffening and degeneration of heart valves that may impede normal blood flow in and out of the heart 6. Electrical conduction system of heart undergoes changes leading to abnormal heart rates and rhythms. 7. Orthostatic hypotension is a drop in blood pressure with a change in position. a. Makes the body less able to adapt to rapid postural changes 8. Venous stasis can cause clots to develop in the veins, leading to deep vein thrombosis or pulmonary embolism 9. Heart attack (myocardial infarction) a. The classic symptoms of a heart attack are often not present in geriatric patients. b. Signs and symptoms of cardiovascular disease 10. Heart failure a. The signs and symptoms will differ depending on the extent to which the right and/or left side of the heart is not functioning correctly. b. Right-sided heart failure occurs when the fluid backs up into the body. i. Signs and symptoms c. With left-sided heart failure, fluid backs up into the lungs. This causes pulmonary edema and shortness of breath. 11. Stroke a. Stroke is a leading cause of death in older people. b. Preventable risk factors include smoking, obesity, and a sedentary lifestyle. c. Uncontrollable factors include age, race, and gender. d. Signs and symptoms e. Hemorrhagic strokes, in which a broken blood vessel causes bleeding into the brain, are less common and more likely to be fatal. f. Ischemic strokes occur when a blood clot blocks the flow of blood to a portion of the brain. g. Determining the onset of the symptoms of stroke is important. Changes in the Nervous System -Anatomy and physiology 1. Changing in thinking speed, memory, and posture stability are the most common normal findings in older people. 2. The brain decreases in terms of weight (10% to 20%) and volume as a person ages, increasing the amount of space in the cranium and chance for head injuries. 3. There is a 5% to 50% loss of neurons in older people. a. This affects the control of the rate and depth of breathing, heart rate, blood pressure, hunger, thirst, and body temperature. b. The performance of most of the sense organs declines with increasing age. 4. Vision a. Visual acuity, depth perception, and the ability of the eyes to accommodate to light change with age, as well as ability to differentiate colors. b. Cataracts can increase the likelihood of falls and medication errors. c. Decreased tear production leads to drier eyes. d. Presbyopia is the inability to see close up. 5. Hearing a. Changes in the inner ear make hearing high-frequency sounds difficult. b. Changes in the ear can also cause problems with balance and make falls more likely. c. Presbycusis is a gradual hearing loss that occurs as we age. 6. Taste a. The sense of taste can be diminished because of a decrease in the number of taste buds, which can lead to lessened interest in eating. 7. Touch a. An older person may have a decreased sense of touch and pain perception from the loss of the end nerve fibers. Pathophysiology 1. Dementia a. Slow onset of progressive disorientation, shortened attention span, & loss of cognitive function b. A chronic, generally irreversible condition that causes a progressive loss of cognitive abilities, psychomotor skills, and social skills. d. Determine the patient’s normal mental status by questioning family members or friends; evaluate history, risk factors, and current medications. 2. Delirium a. A sudden change in mental status, consciousness, or cognitive processes b. Marked by the inability to focus, think logically, and maintain attention c. Delirium affects 15% to 50% of hospitalized people aged 70 years or older. d. Usually result of a reversible physical ailment, such as tumors or fever, or metabolic causes e. Assess and manage the patient. 3. Syncope (fainting) a. Always assume that this is a life-threatening problem until proven otherwise. b. Syncope is often caused by an interruption of blood flow to the brain. 4. Neuropathy a. A disorder of the nerves of the peripheral nervous system in which function and structure of the peripheral motor, sensory, and autonomic neurons are impaired b. Symptoms depend on whether the nerves affected are motor, sensory, or autonomic and where the nerves are located. Changes in the Gastrointestinal System -Anatomy and physiology 1. Changes in mouth include a reduction in the volume of saliva, with a resulting dryness of the mouth. a. Dental loss is widespread in older population, contributes to nutritional and digestive problems. 2. Gastric secretions are reduced. 3. Changes in gastric motility leads to slower gastric emptying. 4. The incidence of certain diseases involving the bowel increases as a person grows older. 5. Blood flow to the liver declines and enzyme activity decreases. Pathophysiology 1. Age-related changes in the gastrointestinal (GI) system include: a. Issues with dental problems b. Decrease in saliva and sense of taste leading to poor nutrition c. Poor muscle tone of the smooth muscle sphincter between the esophagus and stomach that can cause regurgitation and lead to heartburn and acid reflux 2. Changes in the liver predispose older patients to a number of problems. 3. GI bleeding issues that affect older people caused by inflammation, infection, and obstruction of the upper or lower GI tract. a. Common causes b. Signs and symptoms 4. Specific GI problems that are more common in older patients a. Diverticulitis b. Bleeding in the upper and lower GI system c. Peptic ulcer disease d. Gallbladder disease e. Bowel obstruction 5. When assessing patients, ask about NSAID and alcohol use. 6. Orthostatic vital signs can help determine if a patient is hypovolemic. 8. The acute abdomen—nongastrointestinal complaints a. In the prehospital setting, the most serious threat from abdominal complaints is blood loss, which can lead to shock and death. b. Abdominal aortic aneurysm (AAA) is one of the most rapidly fatal conditions. Changes in the Renal System -Anatomy and physiology 1. Age-related changes to the kidney include: a. A reduction in renal function b. A reduction in renal blood flow c. Tubule degeneration 3. Changes in the genitourinary system include: a. Decreased bladder capacity b. Decline in sphincter muscle control c. Decline in voiding senses d. Increase in nocturnal voiding e. Benign prostatic hypertrophy (enlarged prostate) Pathophysiology 1. Acute illness in older patients is often accompanied by derangements in fluid and electrolyte balance. 2. Incontinence is not a normal part of aging and can lead to skin irritation, skin breakdown, and urinary tract infections. a. As people age, the capacity of the bladder decreases. 3. The opposite of incontinence is urinary retention or difficulty urinating. a. Bladder and urinary tract infections can also cause inflammation. b. In severe cases of urinary retention, patients may experience renal failure. Changes in the Endocrine System -Anatomy and physiology 1. A significant change that occurs in an older person is decreased metabolism of thyroxine, a condition called hyperthyroidism. 2. Most of the signs and symptoms people experience are attributed to the process of aging and include: a. Slower heart rate, Fatigue, Drier skin and hair, Cold intolerance Pathophysiology 1. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a diabetic complication in older people and occurs more often in people with type 2 diabetes 2. The signs and symptoms of HHNS and diabetic ketoacidosis often overlap. 3. Assessment findings in patients with HHNS 4. The patient may present with signs and symptoms of hypotension and shock, including tachycardia. 5. The blood glucose level will be variable in DKA, whereas in HHNS the value is typically 600 mg/dL or higher. 6. DKA will present with Kussmaul respirations, while HHNS will not. Changes in the Immune System -Infections are commonly seen in older people because they generally have an increased risk of infection and are less able to fight infections once they occur. 1. Many older patients may be unable to develop a fever, and in fact may be hypothermic as a manifestation of severe systemic infection. 2. Anorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptoms of infection. 3. Pneumonia and urinary tract infection are common in patients who are bedridden. 4. When infection occurs, signs and symptoms may be decreased or minimized by the patient. Changes in the Musculoskeletal System -Anatomy and physiology 1. Aging brings a widespread decrease in bone mass in men and women, but especially among postmenopausal women. a. Bones become more brittle and tend to break more easily. c. Joints lose their flexibility and may be further immobilized by arthritic changes. Pathophysiology 1. Changes in physical abilities can affect older adults’ confidence in their mobility. a. Strength declines. b. Ligaments and cartilage of the joints lose their elasticity. 2. The stooped posture of older people comes from atrophy of the supporting structures of the body. 3. Osteoporosis causes a decrease in bone mass, leading to reduction in bone strength and greater susceptibility to fracture. 4. Osteoarthritis is a progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs in joints, and leads to joint stiffness. a. Affects several joints of the body, most commonly those in the hands, knees, hips, and spine b. Patients complain of pain and stiffness that gets worse with exertion. Changes in Skin -The proteins that make the skin pliable decline with age. 1. The layer of fat under the skin also becomes thinner because of the redistribution of fluids and proteins. 2. As the elasticity of the skin declines, bruising becomes more common because the skin can tear more easily. 3. Exocrine (sweat) glands do not respond as readily to heat because of atrophy and changes to the tissues of the dermal layer of the skin. Pressure ulcers (bedsores or decubitis ulcers) 1. The pressure from the weight of the body cuts off the blood flow to the area of skin, causing sores to develop. 2. To help prevent these ulcers, take special care to pad under any bony prominences and in the voids in a patient who may be immobilized for an extended period. 3. You may see these ulcers in various stages of development. 4. Decubitis ulcers can be painful and cause complications such as bleeding, sepsis, and bone inflammation called osteomyelitis. Toxicology -Older people are more susceptible to toxicity because of: 1. Decreased kidney function 2. Altered GI absorption 3. Decreased vascular flow in the liver Polypharmacy refers to the use of multiple prescription medications by one patient. 1. Negative effects can include overdosing and negative medication interaction. 2. Medication noncompliance in older patients may occur because of financial challenges; inability to open containers; and impaired cognitive, vision, and hearing ability. Behavioral Emergencies -Depression 1. Depression is not part of normal aging, but rather a medical disease. 2. Depression is treatable with medication and therapy. 3. If depression goes unrecognized or untreated, it is associated with a higher suicide rate in the geriatric population than in any other age group. 4. Risk factors for depression The GEMS Diamond -The GEMS diamond was created to help you remember what is different about older patients. 1. It serves as an acronym for the issues to be considered when assessing every older patient. “G” stands for geriatric patient. -Be familiar with normal changes of aging and treat older patients with compassion and respect “E” stands for an environmental assessment. 1. Assessing the environment can help give clues to the patient’s condition and the cause of the emergency. “M” stands for medical assessment. 1. Older patients tend to have a variety of medical problems and may be taking numerous prescription, over-the-counter, and herbal medications. 2. Obtaining a thorough medical history is very important. “S” stands for social assessment. 1. Older people may have less of a social network because of the death of a spouse, family members, and friends. 2. Older people may also need assistance with activities of daily living. 3. Consider obtaining information pamphlets about some of the agencies for older people in your area. Special Considerations in Assessing a Geriatric Medical Patient -Challenges encountered during assessment: 1. Communication issues, Hearing/vision deficits, Alteration in consciousness, Complicated medical hx Trauma and Geriatric Patients -In general, the risk of serious injury or death is more common in older patients who experience trauma than in younger patients. 1. Conditions that create risk and complicate the assessment of geriatric patients: a. Slower homeostatic compensatory mechanisms b. Limited physiologic reserves c. Normal effects of aging on the body d. Existing medical issues 2. Physical findings may be subtler and more easily missed. 3. The healing process is longer. -Older people have a higher risk of burn injuries because of altered mental status, inattention, and a compromised neurologic status. 1. Risk of mortality from burns is increased when: a. Preexisting medical conditions exist b. The immune system is weakened c. Fluid replacement is complicated by renal compromise -There is higher mortality from penetrating trauma in older adults. 1. Penetrating trauma can easily cause serious internal bleeding. -Falls are the leading cause of fatal and nonfatal injuries in older adults. 1. Nearly half of fatal falls in geriatric patients result in traumatic brain injury. -Anatomic changes and trauma 1. Changes in pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older patients more susceptible to trauma. a. The brain shrinks, leading to higher risks of cerebral bleeding following head trauma. b. Skeletal changes cause curvature of the upper spine that often requires additional padding during spinal immobilization. c. Loss of strength, sensory impairment, and medical illness all increase the risk of falls. 2. A geriatric patient’s overall physical condition may lessen the ability of the patient’s body to compensate for the effects of even simple injuries. 3. Osteoporosis predisposes older patients to hip and pelvis fractures. 4. Compression fractures of the spine are more likely to occur. 5. As brain tissue shrinks with age, older patients are more likely to sustain closed head injuries, such as subdural hematomas. a. Acute subdural hematomas are among the deadliest of all head injuries. b. Serious head injuries are often missed in older patients because the mechanism may seem relatively minor. Environmental Injury 1. Changes in the endocrine system results is delayed internal temperature regulation. 2. Heat gain and loss is further delayed from impaired circulation, decreased sweat production, chronic diseases, medication use, and alcohol use. 3. Half of all deaths from hypothermia occur in older people; most indoor hypothermia deaths involve geriatric patients. 4. Death rates from hyperthermia more than double in older people compared with younger people; people older than 85 years are at highest risk. Special Considerations in Assessing Geriatric Trauma Patients -Scene size-up/Scene safety -Primary assessment 1. Address life threats. 2. Determine the transport priority of the patient. 3. Form a general impression. a. Try to get information from someone familiar with the patient, if possible. b. Use the AVPU and the Glasgow Coma Scale to determine mental status. 4. Airway and breathing 5. Circulation -History taking 1. Considerations in your assessment of the patient’s condition and stability must include past medical conditions, even if they are not currently acute or symptomatic. -Secondary assessment 1. Physical examinations should be performed on a geriatric trauma patient in the same manner as for any adult but with consideration of the higher likelihood of damage from trauma a. Any head injury can be life threatening in an older adult. b. When examining the chest, consider that breathing is may be impaired. c. Look for bruising and other evidence of trauma. 2. Vital signs a. Assess the pulse, blood pressure, and skin signs. b. Capillary refill is unreliable in older people because of compromised circulation. c. Remember that some older people take beta-blockers, which will inhibit their heart from becoming tachycardic as you would expect in shock. - Reassessment 1. Remember that a geriatric patient has a higher likelihood of decompensating after trauma. 2. Broken bones are common and should be splinted in a manner appropriate to the injury. a. Effective application of conventional splints and backboards may be difficult or impossible unless a large amount of padding is used. b. Trying to force a patient into a “normal” anatomic position can harm the patient. c. In hip and pelvic fractures, avoid log rolling the patient. d. Provide blankets and heat to prevent hypothermia. 3. Communication and documentation a. Provide psychological support, as well as medical treatment. b. Document assessment, treatment, & reassessment, including any changes in the patient’s status Assessment of Falls 1. Whenever you assess a geriatric patient who has fallen, it is important to find out why the fall occurred. 2. Look carefully for clues from the patient, bystanders, and the environment. Response to Nursing and Skilled Care Facilities -Many calls will occur at a nursing home or other skilled care facility. 1. Calls to these types of facilities can sometimes be challenging. a. Patients often have an altered level of consciousness and may not be able to give you a nature of illness or mechanism of injury. b. The most important piece of information you need to establish immediately is, “What is wrong with the patient that is new or different today that made you call 9-1-1?” c. Talk to the staff who directly care for the patient on a daily basis. 2. Infection control needs to be a high priority for EMTs when visiting these facilities. a. An infection in an older patient can lead to life-threatening sepsis. b. Methicillin-resistant Staphylococcus aureus (MRSA) infections are common among people who are living in close quarters, such as nursing homes. c. Many infections in hospitals are caused by vancomycin-resistant enterococci (VRE). d. Respiratory syncytial virus (RSV) causes an infection of the upper and lower respiratory tracts. Dying Patients 1. Dying patients receive what is called palliative, or comfort, care. a. Focuses on relieving pain and providing emotional support and comfort for the patient and his or her loved ones 2. Your interaction with a dying patient with have a long-term effect on the family. a. Be understanding, sensitive, and compassionate. Advance directives are specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves. -Advance directives may take the form of a do not resuscitate (DNR) order. 2. For a DNR order to be valid, the form must be signed by the patient or legal surrogate and by one or more physicians or other licensed health care providers. 3. DNR does not mean “do not treat.” Elder Abuse and Neglect -Elder abuse is defined as any action on the part of an older person’s family member, caregiver, or other associated person that takes advantage of the older person’s person, property, or emotional state. 1. Abuse can result from acts of commission (words or actions that cause harm), such as verbal, physical, or sexual assault. 2. Victims of elder abuse are often hesitant to report the problem to law enforcement agencies or human and social welfare personnel. a. The abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her for reporting the abuse. b. The abused person is often frail, with multiple chronic medical conditions or dementia. 5. Elder abuse occurs most often in women older than 75 years. 8. Consult local authorities, but in general you should assume that you have the same obligation to report suspected elder abuse as you do suspected child abuse. Assessment of elder abuse 1. Be suspicious of abuse when answers to questions about what caused injury are concealed or avoided. 2. Suspect abuse when you are given unbelievable answers. 3. Information that may be important in assessing possible abuse includes the following: a. Caregiver apathy about the patient’s condition b. Overly defensive reaction by caregiver to your questions c. Caregiver does not allow patient to answer questions d. Repeated visits to the emergency department or clinic e. A history of being accident-prone Signs of physical abuse 1. Inflicted bruises are usually found on the: a. Buttocks and lower back, genitals, and inner thighs b. Cheeks or earlobes c. Neck d. Upper lip e. Inside of the mouth 2. Pressure bruises caused by human hand may be IDed by oval grab marks, pinch marks, or handprints 3. Human bites are typically inflicted on the upper extremities and can cause lacerations and infection. 5. Investigate multiple bruises in various states of healing. 6. Appearance of being undernourished 7. Check for signs of neglect, such as evidence of: a. Lack of hygiene, Poor dental hygiene. Poor temperature regulation 8. Regard injuries to genitals or rectum with no reported trauma as evidence of sexual abuse in any pt. *****If geriatric pt. Has a head injury take to hospital