1. 34
Geriatric Emergencies

2. 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.

3. 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

4. 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?

5. 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.

6. 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.

7. 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.

8. 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

9. 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

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

11. 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.

12. 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

13. 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.

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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.

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

26. 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.

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

28. 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?

29. 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.

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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.

39. 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

40. 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

41. Chapter Review

42. 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

43. 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

44. 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.

45. 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

46. 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.

47. 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.

48. 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.