© 2011 National Safety Council 22-1 GERIATRIC PATIENTS LESSON 22

© 2011 National Safety Council 22-2 Introduction Older adults are an increasingly large proportion of American population Have more chronic health conditions that may lead to an emergency Much emergency care given to geriatric patients Be aware of possible age-related changes in geriatric patients and implications for assessment and treatment

© 2011 National Safety Council 22-3 Age-Associated Changes Changes gradually occur throughout lifespan By 65, human body has age-related changes in all body systems Changes generally continue throughout lifespan Rate and extent of changes depend on many factors Never make assumptions about any patient based on age Discrimination based on individual’s age is illegal

© 2011 National Safety Council 22-4 Changes in Sensory System All senses become less acute with aging

© 2011 National Safety Council 22-5 Changes in Vision Decreased general visual acuity Reduced ability to differentiate colors Diminished night vision Diminished near vision Decreased depth perception Visual impairments are more common

© 2011 National Safety Council 22-6 Changes in Hearing Decreased general hearing ability Increased use of hearing aids Diminished ability to hear high-pitched sounds Hearing impairments are more common

© 2011 National Safety Council 22-7 Changes in Touch and Pain Decreased sense of balance Diminished ability to differentiate temperature Decreased tolerance of hot and cold Diminished perception of pain

© 2011 National Safety Council 22-8 Changes in Smell and Taste Diminished smell and taste May cause reduced appetite and nutritional deficiencies

© 2011 National Safety Council 22-9 Changes in Cardiovascular System Heart muscle less powerful and blood vessels less elastic Rising blood pressure over the years  may result in hypertension Diminished heart output Decreased functional blood volume

© 2011 National Safety Council Changes in Cardiovascular System (continued) Reduced circulation and lower perfusion in some body areas such as legs Reduced ability of heart to beat faster when needed Increased risk of heart attack Increased risk of stroke

© 2011 National Safety Council Changes in Respiratory System Less flexible alveoli in lungs, reduced gas exchange Less effective muscles for breathing Inhaled substances (such as tobacco smoke) cause other changes in lungs and airways

© 2011 National Safety Council Changes in Respiratory System (continued) Diminished breathing capacity Decreased forcefulness of coughing (and reduced ability to cough out an airway obstruction) Increased risk of respiratory infections

© 2011 National Safety Council Changes in Gastrointestinal System Stomach and intestines function less well Mouth changes, including use of dentures or other dental appliances, affect chewing and swallowing Difficulties chewing and swallowing increase risk of foreign body airway obstructions Digestive difficulties

© 2011 National Safety Council Changes in Nervous System Slower reflexes increase risk of falls Diminished cough or swallowing reflexes Diminished short-term memory Other cognitive changes may affect behavior Dementia, Alzheimer’s and senility are not normal changes of aging  but occur more commonly in older adults

© 2011 National Safety Council Changes in Musculoskeletal System Decreased bone density: bones fracture more easily, even without trauma Osteoporosis decreases bone density Diminished size and strength of muscles Joint changes make arthritis more likely Curvature of upper spine is more common

© 2011 National Safety Council Other Age-Related Changes Immune system and other changes may cause: -Increased risk of many types of infections -Less apparent signs and symptoms of infection when present (less likely to seek early treatment) More frequent loss of bladder or bowel control (preserve patient’s privacy and dignity) Less perspiring when warm (making heat emergencies more likely)

© 2011 National Safety Council Chronic Disease Many chronic conditions are more common in geriatric patients Contributes to greater risk of injury or emergency illness Medications for chronic illness may have assessment and treatment implications

© 2011 National Safety Council Age Implications for Assessment and Treatment Do not assume older individual is automatically different from other adults Be aware of age-related changes and implications for assessment and treatment

© 2011 National Safety Council Primary Assessment Neck arthritis makes airway management more difficult Do not remove patient’s dentures for ventilation or rescue breathing unless they interfere Increased risk for airway obstructions caused by foreign body or swollen tissues from infection Pulse may be irregular due to arrhythmia If patient seems to have altered mental status or diminished cognition, ask family members about pre- emergency mental status

© 2011 National Safety Council The Secondary Assessment Ensure lighting is adequate Position yourself at the patient’s eye level Speak slowly and distinctly Give patient time to respond Some geriatric patients may deny symptoms  be thorough and use good communication skills Older adults are more susceptible to traumatic injury With reduced pain perception, injuries may not be immediately apparent

© 2011 National Safety Council The Secondary Assessment (continued) Chronic medical conditions may increase likelihood of fall or other trauma Trauma more likely to cause bone fracture Normal vital signs depend on general physical and health status Vital signs may change rapidly with bleeding Seek detail about medications taken Medications may affect vital signs, blood clotting and other aspects of emergency care Patient may not show severe signs of illness even when very ill

© 2011 National Safety Council Depression is common and may affect patient’s behavior and communication Nutrition may be inadequate or home poorly heated or cooled Size up the scene for clues to patient’s condition With suspicious injuries, consider possibility of elder abuse Do not let many layers of clothing prevent you from adequate examination Reassess frequently because patient may deteriorate quickly The Secondary Assessment (continued)

© 2011 National Safety Council Implications for Treatment Handle patient very carefully With upper spine curvature, padding may be needed during spinal immobilization With decreased cough reflex, suctioning may be needed Prevent hypothermia in a cool environment Provide reassurance and support

© 2011 National Safety Council Trauma Trauma often has more serious effects in geriatric patients Never assume any injury is minor based on mechanism of injury or because signs and symptoms do not seem severe Falls are a particular concern -Cause fractures of hip, spine or other bones -Treat all falls as severe or possibly life-threatening

© 2011 National Safety Council Trauma (continued) Carry out physical examination carefully Manually stabilize or splint area Coinciding medical and traumatic emergencies more likely Never assume injury is only issue to be addressed Perform full secondary assessment with complete history Closely monitor vital signs and breathing Reassess more frequently

© 2011 National Safety Council Medical Emergencies May be caused or exacerbated by chronic illness Common reason for EMR calls Signs and symptoms may not be classic picture Heart attack may not cause pain or chest symptoms Keep an open mind during assessment

© 2011 National Safety Council Special Considerations in Medical Emergencies Denial of symptoms does not mean patient feels nothing Patient may not consider symptoms a concern Heart attack and stroke may produce minimal symptoms Never dismiss respiratory symptoms in geriatric patients

© 2011 National Safety Council Special Considerations in Medical Emergencies (continued) Take thorough history of medications, consider accidental overdose or drug interaction Do not move patient from bed or wheelchair except for lifesaving care Remember dementia is not normal  consider altered mental status related to illness

© 2011 National Safety Council Elder Abuse Half a million elders in United States abused or neglected each year In 90% of cases, abusing person is family member The older a person is, the greater the risk for abuse Most likely abused are those who: -Need help with daily activities -Have lost bladder control -Behave unusually because of altered mental status

© 2011 National Safety Council Most Important Signs of Elder Maltreatment Frequent, unexplained crying Unexplained fear of or suspicion of particular person in the home

© 2011 National Safety Council Signs and Symptoms of Physical Abuse Bruises, black eyes, welts, lacerations and rope marks Bone fractures, skull fractures Open wounds, cuts, punctures, untreated injuries, injuries in various stages of healing Strains, dislocations and internal injuries or bleeding Broken eyeglasses, physical signs of being subjected to punishment, signs of being restrained

© 2011 National Safety Council Signs and Symptoms of Physical Abuse (continued) Medication overdose or underuse of prescribed drugs Elder’s report of being hit, slapped, kicked or mistreated Elder’s sudden change in behavior Caregiver’s refusal to allow visitors to see elder alone

© 2011 National Safety Council Signs and Symptoms of Sexual Abuse Bruises around the breasts or genital area Unexplained venereal disease or genital infections Unexplained vaginal or anal bleeding Torn, stained or bloody underclothing Elder’s report of being sexually assaulted or raped

© 2011 National Safety Council Signs and Symptoms of Emotional/Psychological Abuse Emotional upset or agitation Extreme withdrawal, lack of communication and responsiveness Elder’s report of being verbally or emotionally mistreated

© 2011 National Safety Council Signs and Symptoms of Neglect Dehydration, malnutrition, untreated bed-sores and poor personal hygiene Unattended or untreated health problems Hazardous or unsafe living conditions Unsanitary or unclean living conditions Elder’s report of being neglected

© 2011 National Safety Council Signs and Symptoms of Abandonment Desertion of elder at hospital, nursing facility or similar institution Desertion of elder at shopping center or other public location Elder’s own report of being abandoned

© 2011 National Safety Council Signs and Symptoms of Self-Neglect Dehydration, malnutrition, untreated medical conditions, poor personal hygiene Hazardous or unsafe living conditions Unsanitary or unclean living quarters Inappropriate or inadequate clothing, lack of necessary medical aids Grossly inadequate housing or homelessness

© 2011 National Safety Council Emergency Care for Suspected Victims of Elder Abuse Perform standard assessment Perform standard patient care Give emergency care for injuries or illness found Ensure privacy while providing care Provide emotional support Do not directly confront patient with your suspicions, especially if family members are present Note everything patient says about cause of injuries

© 2011 National Safety Council Emergency Care for Suspected Victims of Elder Abuse (continued) If you see physical abuse occurring or a crime committed, or if someone at the scene is threatening and potentially violent, call law enforcement personnel Tell responding EMS personnel in private about your suspicions Elder abuse is a mandatory reportable event Follow local protocol to document your observations and file appropriate report Be especially careful in your documentation