GERIATRICS
INTRODUCTION
Optimal patient care requires that the EMT-I understand the physiologic effects of the aging process and why this is an important factor on the assessment and care of the elderly person. The following topics will be discussed during this lesson:
• Effects of Aging on the body system
• Factors causing altered mental status in the elderly
• Special patient assessment techniques for the elderly
• General prehospital care of the geriatric patient
• Geriatric Abuse and Neglect
• Do Not Resuscitate Orders
LESSON OBJECTIVES
At the end of this lesson the participants will be able to:
1. Discuss the expected physiologic changes that occur during the aging process.
2. Identify frequent drug related problems experienced by the geriatric patient.
3. Discuss environmental emergencies frequently experienced by the geriatric patient.
4. List 4 factors that complicate the clinical evaluation of an aged patient.
5. Discuss general prehospital treatment for the geriatric patient.
6. Discuss age related systemic decline as it relates to the different body systems.
7. Describe reasons the elderly are more susceptible to trauma.
8. List 2 causes of cardiac dysrhythmias in elderly.
9. Explain the need to distinguish the chief complaint from the primary problem
10. Discuss abuse and neglect of the elderly
11. Explain DNR and what it means in terms of prehospital care for the patient
KEY VOCABULARY
The following terms will be used during this lesson:
· Delirium - an acute, organic mental disorder marked by disordered thinking, disorientation, incoherence, defective perception such as delusions and hallucinations
· Dementia - a progressive mental disorder that is characterized by personality disintegration, disorientation of intellectual capacity. The two most common forms of dementia are multi-infarct and Alzheimer's
· Kyphosis - an abnormal condition of the spine characterized by extensive flexion.
· Osteoporosis - a reduction in the quantity of bone or atrophy of skeletal tissue, occurring most often in postmenopausal women or sedentary individuals
· Spondylosis - fixation or stiffness of the vertebrae
KEY CONCEPTS
The following section provides information and space for taking notes on the key concepts discussed by the instructor:
| · Youth oriented society · 65+ fastest growing group · 90% of elderly have a chronic illness · Nationally 36% of all EMS calls involve the elderly |
General Age Related Changes
| · Tissue decreases throughout body except for adipose · Body cells decrease up to 30% by age 65 o To compensate: cells enlarge |
Cardiovascular Changes
| · Heart muscle stiffens due to changes in connective tissue o Heart becomes less efficient · PVR increased: calcium deposits, collagen crosslinking o Heart must work harder · Conductive system of heart degenerates: number of dysrhythmias increase o Decreased cardiac output o Ability to respond to stress diminishes · Fibrosis (heart & peripheral vascular system) o Hypertension, arteriosclerosis & decreased cardiac function · Organ perfusion decreases (kidney decreases by 40-50% and brain by 20%) |
CNS Changes
| · Loss of brain cells o Up to 45% of cells in certain areas of cortex · Amount of O2 brain uses may decrease · Cerebral vessel changes o Blood flow to cerebral areas decreases · Reduction in nerve conduction o Reflexes as well as sensory and motor responses are slower · Sensory perception decreases o Hearing/vision: can create sense of confusion o Smelling: can't identify hazards o Sense of touch decreased: pain threshold higher |
Respiratory Changes
| · Cartilage calcifies: mobility of ribs decreases, chest wall stiffens o Incomplete lung expansion · Lungs lose elasticity and become more rigid o Vital capacity decreases up to 50% o Maximum breathing capacity decreases up to 60% o O2 uptake decreases up to 70% · Alveoli are fewer in number and larger in size o Air trapping · Abnormal or ineffective cough mechanism · Weaker thoracic inspiratory & expiratory muscles · Decreased cilia |
Renal Changes
| · Number of functioning nephrons decreases up to 30-40% · Renal blood flow decreases up to 50% o Increased amount of waste products in blood o Increased drug toxicity (drugs tend to accumulate in the blood with prolonged use and decreasing excretion) · Tubular function decreases o Concentration of urine less concentrated · Bladder capacity decreases o Urinary frequency o Nocturia · Bladder muscles weaker o Urinary retention more prevalent leading to infections · Prostate often enlarges o Difficulty in urination or urinary retention |
Gastrointestinal Changes
| · Volume of saliva decreases and esophageal motility decreases o Swallowing becomes difficult-foreign body obstruction · Weaker gag and delayed emptying of esophagus o Increases aspiration risk · Gastric secretions decrease by 20% o Digestion of foods less effective leading to nausea, poor appetite and diarrhea · Slower peristalsis and slower impulses predispose to constipation |
Musculoskeletal Changes
| · Osteoporosis o Brittle, easy to fracture o Vertebral bodies: causes change in posture o Flexion of hip and knees · Kyphosis o Increased curvature of thoracic spine · Decreased muscle, soft tissue o May become immobile which increases risk to pulmonary embolism · Increased fat tissue · Cartilage surface of joints deteriorates o Limiting joint activity and range of motion |
Thermoregulatory Changes
| · Risk of Hypothermia Increases o Decreased sympathetic stimulation o Decreased metabolic rate o Decreased subcutaneous tissue o Drug effects (Predisposing factors: low/fixed income, chronic illness, poor nutrition, endocrine disorders, CNS disorders, accident exposures) · Risk of Hyperthermia Increases o Decreased peripheral circulation o Chronic illness o Decreased water intake o Effects of drugs (predisposing factors: same as for hypothermia as well as altered sensory input and inadequate liquid intake) |
Immunologic Changes
| · Antigen-antibody response less effective · Immunoglobulin production decreases o Resistance to infection decreases o Tolerance to infection is worse o Sepsis more common |
Changes in Mental Function
| · Dementia (chronic mental impairment-progressive, irreversible, develops over weeks, months or years) o small strokes/atherosclerosis of cerebral blood vessels o aging o neurological diseases o Alzheimer’s: type of dementia that attacks the brain leading to impaired memory, thinking and behavior · Delirium (sudden onset-hours to days, involves disturbances of the consciousness) o Electrolyte imbalance/acidosis/hypo/hyperglycemia o Hypoxia o Acute infection o Subdural hematoma o Tumors & other mass lesions o Drug induced changes/ETOH · Depression o Isolation, loneliness, loss of self dependence, loss of strength, fear of the future o May be present as a physical disorder o May be malnourished, dehydrated, contemplating suicide or simply imagining physical ailments for attention o 9th leading cause of death is suicide |
Trauma (elderly more at risk)
Contributing Factors: slower reflexes, eyesight and hearing problems, shuffling gait, arthritis, loss of elasticity in peripheral blood vessels (susceptible to tearing), tissues and bones more fragile and vulnerability due to physical state leading to high risk of assault.
Common injuries
| · Head injuries (decrease in size and weight of brain-while skull size constant) o Allows more room for brain to move o S/S of head injuries develop slower since there is more room to swell · Cervical spine injuries due to osteoporosis and spondylosis o Sudden movements of neck can lead to spinal cord injury · Falls o Hip and pelvis fractures often result |
Physiologic Changes and Trauma
| · Decreased response of the heart o Difficult to adjust to hypovolemia o May require higher than normal arterial pressure for perfusion of vital organs · Decreased Renal function o Difficult to maintain acid/base balance and compensate for fluid changes · Decreased respiratory function o Decreased O2 consumption leading to anoxia of organs · Age reduces tolerance of all organs for anoxia · Physical deformities (arthritis, spinal, frozen limbs) must be considered when immobilizing and packaging |
Complicating Factors in Patient Assessment
| · Little experience being interviewed o Less open then today's younger generation o Need to understand why information is needed and that it will be kept in confidence · Chief complaint may seem trivial or vague o May fail to report important symptoms o Need to distinguish patient's chief complaint from their primary problem · Suffer from more than one disease at a time o Chronic problems make it difficult to assess acute problems o Multiple medications can interact and cause side effects · Age changes responses to illness or injury o Pain may be diminished or absent leading to underestimating the severity of the illness · Temperature regulation altered or depressed o May have absence of fever or a minimal fever even with a severe infection · Depression o Inhibits cooperation o May mimic dementia o May be mistaken for other diseases |
Assessment Tips
| · Allow more time o Allow for slower reflexes o Allow for review of longer history they possess · May need hints (memories can be poor) o Ask if ever got sick or a rash from food or medications rather than asking if they have any allergies · Make eye contact · Determine if hard of hearing-many are not o If they are speak directly at them, they may need to read your lips · Speak clearly and slowly · Don't dwell on unanswered questions o Return to question later |
Field Management
| · Goal is to identify acute illnesses that may be life threatening (patient complaint may be different than primary problem) · Treatment is essentially the same for all ages-however consideration should be given to altered organ functions and plan management accordingly o (i.e. fluids can easily lead to CHF, epinephrine can cause problems within the heart) · BLS Care o Primary/secondary o High flow O2 prn o Monitor VS o Position of comfort · Assist with ALS Care o Monitor EKG prn o Medications/IV prn |
Geriatric Abuse/Neglect
(physical, psychological, or financial abuse from caregivers/family)
| · Average abused: > 80, multiple medical problems and dementia is usually present · No socioeconomic bounds · Occurs when no longer independent o Family has hard time upholding their commitment to care for patient · The abuser life is usually stressful (sleep deprivation, marital discord, financial problems, work) o Abuse occurs as abusers life gets worse and patient declines · Signs & symptoms o Unexplained trauma, deprivation of food, care, medications or services o Abused is often reluctant to speak to professional or neighbors · Reporting o Phone ASAP o Follow up with written report within 2 days · Phone Numbers o Abuse/neglect in Nursing Home o Day Time: (800 334-9473) o After hours: (800 231-4024) o Abuse/Neglect in private home (also for elderly unable to care for themselves) o Day Time (213 351-5401) Adult Protective Services o After hours (800 992-1660) Elder Abuse/Neglect Hotline |
DNR (Do Not Resuscitate)
| · DNR's may be honored by EMTs and EMT-Ps · Acceptable forms in LA County o L.A. County form o State of California form o State EMS authority approved DNR medallion (Medic Alert Foundation Tag) o Doctor's order if in a licensed health care facility (i.e.: nursing home) · Identifying patients: presence of a witness who can identify the patient or an ID with patient · SUPPORTIVE CARE SHOULD BE PROVIDED (examples of care): EMTo O2 o Maintain airway: o Oral/nasopharyngeal airway o Suction o Splint, dressings, or slings o Control external hemorrhage o Position of comfort Additional EMT-P Interventions o Visualize airway and remove obstruction o Establish IV o Administer pain medication (base order only) · Care that should be WITHHELD (according to policy 815) are interventions whose purpose is to restore cardiac activity and respirations: These include: o CPR o Defibrillation o Advanced airway management o Cardiotonic drugs · Transportation can be BLS · Documentation o |