34 Geriatric Emergencies

Multimedia Directory Slide 39 Information About Alzheimer Disease Video Slide 40 Elder Mistreatment and Abuse Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Topics The Geriatric Patient Planning Your Time: Plan 60 minutes for this chapter. The Geriatric Patient (60 minutes) Note: The total teaching time recommended is only a guideline. Core Concepts Age-related changes in the elderly Communicating with older patients Assessing and caring for older patients Illness and injury in older patients

The Geriatric Patient Teaching Time: 60 minutes Teaching Tips: Use specific examples to discuss the changes of aging. Relate the changes to real-world issues and treatment concerns. Invite an older person to discuss the changes of aging. Teach that the changes of aging are not always uniform. Different patients are affected differently. Urge students to treat all older patients as individuals and never to make assumptions. Invite a pharmacist to discuss medication issues related to older patients. Discuss abuse scenarios. What is the role of the EMT in your state? Are there mandated reporting laws?

Age-Related Changes After age 30, organ systems lose 1 percent of function each year. Maximum heart rate declines. Older patient with internal bleeding will not exhibit heart rate as rapid as expected. If unaware, EMT may miss that older patient is in shock. Covers Objective: 34.2 Point to Emphasize: Aging produces a variety of physical changes. These changes often limit the body's ability to compensate for illness and injury. Discussion Topic: Describe age-related changes to the major systems of the body. Knowledge Application: Have students work in small groups. Assign each group a body system and have the group present age-related changes in that system. Discuss the impact on assessment and treatment.

Communicating with Older Patients Causes of patient's communication difficulties Changes in hearing, vision, memory, and dentition Residual effects of stroke or dementia First assume altered mental status as the result of present injury/illness. Covers Objective: 34.2 Talking Points: Always attempt to communicate with the older patient first rather than assuming the patient will give an unreliable history and asking others about the patient. Do not assume that confusion is caused by dementia unless someone else who knows the patient can confirm this is a chronic condition.

Communicating with Older Patients Covers Objective: 34.2 Talking Points: Make sure the patient can see and hear you. Speak at a volume necessary for the patient to hear you. Treat the patient with respect and dignity. Begin by calling the patient by a title and last name (for example, Mrs. Sanchez). Whenever possible, speak to the patient at eye level. This may involve crouching or even kneeling. Always try to communicate directly with an older patient rather than asking others about her.

TABLE 34-2 Effects of Aging and Implications for Communication

History and Assessment of Older Adult Patient Scene size-up and safety Look inside and outside residence for clues to physical and mental abilities. Condition of residence Half-eaten food House dirty or clean Items left out that patient can trip on Covers Objective: 34.2 Discussion Topic: Discuss how scene size-up might be a valuable tool when assessing an older patient. What clues about the patient's condition might you find in his surroundings? continued on next slide

History and Assessment of Older Adult Patient Primary assessment Forming a general impression Assessing mental status Assessing the airway Assessing breathing Assessing circulation Identifying priority patients Covers Objective: 34.2

TABLE 34-1 Effects of Aging and Implications for Assessment and Decision Making

TABLE 34-1 (continued) Effects of Aging and Implications for Assessment and Decision Making

TABLE 34-1 (continued) Effects of Aging and Implications for Assessment and Decision Making

TABLE 34-1 (continued) Effects of Aging and Implications for Assessment and Decision Making

Primary Assessment Covers Objective: 34.2 Older people are twice as likely as younger people to use EMS. © Michal Heron

FIGURE 34-3 Always try to communicate directly with an older patient rather than asking others about her.

Identifying Priority Patients Covers Objective: 34.2 Talking Points: Identifying priority in older patients may be difficult, because they are less likely to complain about severe symptoms. For example, older patients having a heart attack experience less pain. Even if symptoms seem mild or vague keep a high index of suspicion for serious conditions. Finding a radial pulse in an older patient is usually no different from finding a pulse in other patients.

History and Assessment of Older Adult Patient Secondary assessment History Take time needed to get full information. Find out whether patient is compliant with medical advice. Ask family members, others familiar with patient's condition. Physical exam Baseline vital signs Covers Objective: 34.2 Discussion Topic: Discuss how the changes of aging might affect your assessment technique. How might you have to adjust? What strategies might you use to improve history taking with an older patient? Knowledge Application: Use a programmed patient to create assessment scenarios. Discuss how age-related changes might impact the assessment. continued on next slide

History and Assessment of Older Adult Patient Steps of the physical exam Head and neck Chest and abdomen Pelvis and extremities Hip and proximal femur commonly fractured in fall. Weakening of bone results in injuries to wrists and proximal humerus. Covers Objective: 34.2 Talking Points: When conducting a physical exam, keep the patient's dignity in mind. Many older patients have a high threshold for pain and may not react to pain from a fracture. Be sensitive to this when performing an exam. Knowledge Application: Have students work in pairs. Assign one of the students a disability (physical or psychosocial) and have the other conduct a patient history. Discuss the effect of the disabilities on the assessments.

FIGURE 34-2 Aging skin becomes thin, dry, and frail, requiring a gentle touch during care and transport.

Extrication of an elderly patient from a motor-vehicle collision. Head and Neck Covers Objective: 34.2 Talking Points: Injuries to the head and face are very common in older patients who have sustained a fall or been involved in a motor-vehicle collision. Immobilizing an elderly patient may be challenging due to stiffness in the neck and the head being moved forward from its normal position. Extrication of an elderly patient from a motor-vehicle collision.

Chest and Abdomen Covers Objective: 34.2 Talking Points: The picture shows a shingles rash around the torso. This area is not commonly injured in elderly patients. Serious abdominal pain that would cause younger people agony may produce only slight discomfort in elderly patients. They may have decreased breath sounds because of decreased lung capacity and movement of the chest wall. Listen to the lungs for wheezes or crackles, which can be signs of respiratory or cardiac problems. A shingles rash often appears as a narrow, beltlike band around the torso. © Edward T. Dickinson, MD

History and Assessment of Older Adult Patient Steps of the physical exam Pelvis and extremities Check extremities for edema and swelling. When significant, these can be signs of underlying heart, vascular, or liver disease. Covers Objective: 34.2 Talking Points: When conducting a physical exam, keep the patient's dignity in mind. Many older patients have a high threshold for pain and may not react to pain from a fracture. Be sensitive to this when performing an exam. Knowledge Application: Have students work in pairs. Assign one of the students a disability (physical or psychosocial) and have the other conduct a patient history. Discuss the effect of the disabilities on the assessments. continued on next slide

History and Assessment of Older Adult Patient Steps of the physical exam Spine Very commonly injured in motor-vehicle collisions Abnormal curvature may make immobilization challenging. Do best to keep vertebrae in alignment and reduce patient's discomfort. Covers Objective: 34.2 Talking Points: When conducting a physical exam, keep the patient's dignity in mind. Many older patients have a high threshold for pain and may not react to pain from a fracture. Be sensitive to this when performing an exam. Knowledge Application: Have students work in pairs. Assign one of the students a disability (physical or psychosocial) and have the other conduct a patient history. Discuss the effect of the disabilities on the assessments. continued on next slide

History and Assessment of Older Adult Patient Reassessment More common for older adults to show a slow, steady decline in condition. You may be lulled into a false sense of security. Reassess at regular intervals and compare with previous findings. Reassess mental status. Maintain an open airway. Covers Objective: 34.2 Talking Points: When conducting a physical exam, keep the patient's dignity in mind. Many older patients have a high threshold for pain and may not react to pain from a fracture. Be sensitive to this when performing an exam. continued on next slide

History and Assessment of Older Adult Patient Reassessment Monitor breathing. Reassess pulse. Monitor skin color, temperature, and moisture. Reassess vital signs every 5 minutes if unstable, or 15 minutes if stable. Ensure that all appropriate care and treatments are being given. Covers Objective: 34.2 Talking Points: When conducting a physical exam, keep the patient's dignity in mind. Many older patients have a high threshold for pain and may not react to pain from a fracture. Be sensitive to this when performing an exam.

Reassessment Covers Objective: 34.2 Talking Points: Rather than showing a sudden change in condition, it is more common for older patients to show a slow, steady decline. Talking with the patient during transport can be therapeutic for the patient and enlightening for the EMT.

Think About It What is commonly seen when assessing an elderly patient's blood pressure? What is most commonly fractured in female elderly patients? What are some challenges you might face in immobilizing elderly patients? Covers Objective: 34.2 Talking Points: Elderly patients commonly have an elevated systolic reading. The femoral head is most commonly fractured in female patients who have fallen. Stiffness of the neck and the head being moved forward must be dealt with when immobilizing elderly patients.

Illness and Injury in Older Patients Elderly patients prone to some problems because of age-related changes Problems present differently than in younger patients. May present with vague signs or symptoms Covers Objective: 34.3 Class Activities: Demonstrate the changes of aging. Use various techniques (blacked-out glasses, restrictive clothing, wheelchairs, and so on) to give students the sensation of age-related issues. Discuss these changes from the perspective of experience. During this activity, have teams of students assess the simulated older patients. Discuss the challenges encountered by both provider and patient.

Medication Side Effects and Interactions Compliance Some older adults must make the choice between food and expensive medication. Even when a medication is taken as directed, it can have a number of adverse effects. Covers Objective: 34.3 Point to Emphasize: Older patients often encounter difficulty with medications. Accidental overdose, drug interactions, and noncompliance are common issues. Discussion Topic: Discuss how medications are affected by the changes of age. Knowledge Application: Assign a research project. Assign particular medications and have students research how their medication might affect an older patient differently from a younger patient. continued on next slide

Medication Side Effects and Interactions Drug-patient interactions Can occur because of inability to clear medications from body as quickly as before Drug-drug interactions When two drugs interact Covers Objective: 34.3 Point to Emphasize: Older patients often encounter difficulty with medications. Accidental overdose, drug interactions, and noncompliance are common issues. Discussion Topic: Discuss how medications are affected by the changes of age. Knowledge Application: Assign a research project. Assign particular medications and have students research how their medication might affect an older patient differently from a younger patient.

Medication Side Effects and Interactions Covers Objective: 34.3 Point to Emphasize: Older patients often encounter difficulty with medications. Accidental overdose, drug interactions, and noncompliance are common issues. Discussion Topic: Discuss how medications are affected by the changes of age. Knowledge Application: Assign a research project. Assign particular medications and have students research how their medication might affect an older patient differently from a younger patient. Older patients often take multiple medications.

FIGURE 34-7 Many elderly persons use a pill organizer to help them remember when to take medications.

Shortness of Breath Can result from diseases that cause this symptom in younger patients, such as asthma or pulmonary embolism Elderly patients more likely to have emphysema, or a combination of these diseases Chief complaint of patient experiencing a cardiac problem Covers Objective: 34.3 Talking Points: Older patients experiencing cardiac problems are more likely to complain about shortness of breath than about chest pain. Keep a high index of suspicion for cardiac problems in these patients.

FIGURE 34-8 Elderly patients with emphysema or other forms of lung disease may depend on a home oxygen unit and nasal cannula. © Michal Heron

Chest Pain Complaint of chest pain can indicate many conditions. Angina Myocardial infarction Pneumonia Aortic aneurysm Covers Objective: 34.3

Chest Pain Talking Points: Chest pain in this population can be related to a lot of causes. The most common are angina, myocardial infarction, pneumonia, and aortic aneurysm.

Altered Mental Status Can be due to: Adverse effects from medications Hypoglycemia Stroke Sepsis Generalized infection in bloodstream Hypothermia Pneumonia Covers Objective: 34.3 Talking Points: Do no assume that an altered mental status is normal for an elderly patient until you check with someone who knows the patient and can describe the patient's baseline status. Critical Thinking: You are called to assess a 74-year-old male who has fallen at the local mall. His friend states that the patient had a stroke a year ago and is unable to speak. How might you conduct a thorough assessment, given this patient's disability?

Altered Mental Status Talking Points: Some of the more common causes of altered mental status in the older patient are adverse effects from medications (many drugs have sedating effects that are more pronounced in the elderly), hypoglycemia (perhaps from taking too much diabetic medication), stroke (from chronic or untreated hypertension), generalized infection in the bloodstream (the immune system may not fend off microbes as well as it used to), and hypothermia (the elderly patient may lose heat at a temperature that is comfortable for others). Pneumonia may also be at play. An altered mental status resulting from hypoxia may be the only outward sign of pneumonia. Critical Thinking: You are called to assess a 74-year-old male who has fallen at the local mall. His friend states that the patient had a stroke a year ago and is unable to speak. How might you conduct a thorough assessment, given this patient’s disability?

Abdominal Pain and Gastrointestinal Bleeding Often a sign of a serious condition such as: Abdominal aortic aneurysm Bowel obstruction or blockage Diverticulosis Internal bleeding Cancers of gastrointestinal tract Ulcers Adverse effects of medications Covers Objective: 34.3 Talking Points: These must be taken very seriously, as they could be due to life-threatening conditions.

Abdominal Pain and Gastrointestinal Bleeding Talking Points: These must be taken very seriously, as they could be due to life-threatening conditions such as abdominal aortic aneurysm, diverticulitis, or bowel obstruction. Ask patient if they have had black, tarry stools.

Dizziness, Weakness, and Malaise Do not take complaints lightly. Can be associated with a number of serious conditions Can be life-threatening Be diligent in assessment, even for vague symptoms. Covers Objective: 34.3 Knowledge Application: Use a programmed patient and create various geriatric response scenarios. Have students practice scene size-up and assessment. Focus on detecting abuse and handling psychosocial issues.

Depression and Suicide In older adults, can be caused by: Conditions that limit activity Medications that sap energy Loss of friends and spouse Biochemical imbalance Covers Objective: 34.3

Rash, Pain, Flulike Symptoms Shingles or herpes zoster Virus reawakens after years. Appears as beltlike band around torso Scabs over after a few days Pain on side of torso EMT can contract it from fluid. Covers Objective: 34.3

Falls Death may result from complications of fall. Bruised ribs, cannot cough because of pain, develops pneumonia May indicate more serious problem Abnormal heart rhythm, stroke, internal bleeding Assess for cause of fall as well as injuries from fall. Covers Objective: 34.3

Elder Abuse and Neglect Ways in which older adults can be abused or neglected Physically Psychologically Financially Can be difficult to detect Many states have laws that require reporting of suspicions. Covers Objective: 34.3

Effects on Relationships Over time, one member of a couple often becomes a caregiver for a sick partner. If caregiver becomes sick or injured, their situation may become difficult or impossible. Caregiver guilt or burnout You may need to make short-term arrangements for the partner. Covers Objective: 34.3

Elder Abuse and Neglect Covers Objective: 34.5 Point to Emphasize: Elder abuse is a far too common problem. EMTs must learn to recognize the signs of abuse and neglect. Talking Points: Neglect can be physical, psychological, or financial. Physical abuse includes pushing, shoving, hitting, or shaking, and occasionally sexual abuse. Physical neglect includes improper feeding, poor hygiene, or inadequate medical care. Psychological abuse and neglect include threats, insults, or ignoring an older person ("the silent treatment"). Financial abuse and neglect include exploitation or misuse of an older person's belongings or money. Discussion Topic: Discuss assessment findings that might lead you to suspect abuse. Discuss strategies for addressing such concerns. A shingles rash can appear anywhere on the body, including the face. © Edward T. Dickinson, MD

Loss of Independence Help patient who is losing independence due to illness/injury. Treat patient with dignity. Do not minimize fears and concerns. Lock up house. Arrange for care for pets. Be reassuring. Empathize. Covers Objective: 34.6

TABLE 34-3 Making a Home Safer for the Elderly

Think About It What are some important facts to remember when treating elderly patients? What are the best preventative measures for an EMT who comes in contact with shingles? What is a side effect of NSAID use? Covers Objective: 34.3 Talking Points: It is important to remember that elderly patients have physiological, sociological, and psychological changes to consider in order to treat them properly. Standard precautions and attention to hygiene are of utmost importance when coming in contact with a shingles patient. A side effect of NSAID use is GI bleeding.

Information About Alzheimer Disease Video Covers Objective: 34.3 Video Clip Information About Alzheimer's Disease What is Alzheimer's disease? What are some risk factors associated with this disease? Describe the progression of this disease. Discuss the available treatments for patients with Alzheimer's disease. Why is research in this field important? Click on the screenshot to view a video on the subject of Alzheimer disease. Back to Directory

Elder Mistreatment and Abuse Video Covers Objective: 34.5 Video Clip Elder Mistreatment and Abuse Video What is elder mistreatment? Discuss the different types of elder abuse. Discuss the reporting requirements for suspected elder abuse. How many people experience elder abuse each year? Click on the screenshot to view a video on the topic of elder mistreatment and abuse. Back to Directory

Chapter Review

Chapter Review Although we can make some generalizations about age-related changes, older people are individuals who can differ significantly in their health care needs. The prevalence of many diseases grows with age, increasing the proportion of the individuals in thee older population who requires health care. continued on next slide

Chapter Review Age-related decline in system function alters the body's response to illness and injury, requiring modified interpretation of assessment findings and complaints. Multiple medical problems and medications can lead to unpredictable problems and drug interactions. continued on next slide

Chapter Review Changes in the nervous system, along with isolation, financial problems, loss of loved ones, and chronic health problems, all increase the risk for depression in the elderly. Depression can interfere with a person's self-care and ability to communicate.

Remember Aging produces common body changes, with different impacts on different patients. Evaluate older patients individually. In some cases, EMT must adapt assessment and treatment procedures to account for age-related anatomic and psychosocial changes. continued on next slide

Remember Medication difficulties are common in older patients. EMTs must keep this in mind when assessing and treating this age group. Elder abuse is a far too common problem. EMTs must learn to recognize the signs of abuse and neglect.

Questions to Consider What size blood pressure cuff might be better suited to an elderly patient? What challenges might you encounter when assessing the mental status of an elderly patient? Talking Points: Students should recognize that adult-size blood pressure cuffs may not be appropriate for elderly patients whose muscles have lost most of their tone. Discuss the challenges of assessing mental status of various elderly patients, starting with the assumption that any altered status may be due to the present illness/injury, having to verify information with family, and so on.

Critical Thinking You are called to the nursing facility for an 85-year-old female who is having trouble breathing and is very confused. What do you suspect may be wrong with this patient? What actions would you take in treating this patient? Talking Points: Students should go through an assessment for this patient step by step, and think about what the underlying cause for her distress might be.