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Chapter 32

Geriatric Emergencies

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Objectives

• There are no 1985 objectives for this chapter.

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Geriatric Assessment

• Geriatric patients are generally considered to be persons who are older than 65 years.

• Almost 35 million individuals are older than 65 years.• Approximately 34% of EMS calls involve older people.

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The GEMS Diamond (1 of 6)

• G – Geriatric patients– Present atypically– Deserve respect– Experience normal changes with age

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The GEMS Diamond (2 of 6)

• E – Environmental Assessment– Check physical condition of patient’s home.– Check for hazardous conditions that may be present.– Are smoke detectors present and working?

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The GEMS Diamond (3 of 6)

• E – Environmental Assessment (cont.)– Is the home too hot or too cold?– Is there fecal or urinary odor in the home?– Is food present in the home?– Are liquor bottles present?– If the patient has a disability, are appropriate

assistive devices present?

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The GEMS Diamond (4 of 6)

• E – Environmental Assessment (cont.)– Does the patient have a telephone?– Are medications out of date, unmarked, or from many

physicians?– If living with others, is the patient confined to one part

of the home?– If the patient is residing in a nursing facility, does the

care appear to be adequate to meet the patient’s needs?

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The GEMS Diamond (5 of 6)

• M – Medical Assessment– Older patients tend to have a variety of medical

problems.– Obtaining a medical history is important in older

patients, regardless of the chief complaint.– Initial assessment.– Ongoing assessment.

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The GEMS Diamond (6 of 6)

• S – Social assessment– Assess activities of daily living.– Are these activities being provided for the patient?– Are there delays in obtaining food, medication, or

other necessary items?– If in a institutional setting, is the patient able to feed

him or herself?

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The Economic Impact of Aging

• Of the 40 million Medicare beneficiaries, approximately:– 34% (14 million) have no prescription medication

coverage.– 30% (12 million) have inadequate medication

coverage.– 12% (5 million) have Medicaid coverage.– 24% (10 million) have retirement coverage from prior

employment.

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Independent Living (1 of 2)

• Only a small percentage of older people live in a nursing home.

• Many older patients are able to live independently.• Most healthy older adults strive to live independently.• Activities of daily living (ADLs).

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Independent Living (2 of 2)

• Patients who become isolated from outside social events are susceptible to self abuse or alcohol or medication abuse.

• Sometimes older patients refuse to accept that they need assistance and may not be aware of the danger in insisting on caring for themselves.

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Dependent Living

• Sometimes known as “residential care”• Two levels of care

– The first is based on the needs of the person.– The second is based on restrictions placed upon the

individual.

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Leading Causes of Death for Older People

• Heart disease• Cancer• Stroke• Diabetes• Trauma

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Risk Factors Affecting Mortality in Older Patients

• Age greater than 75 years• Living alone• Recent death of significant other• Recent hospitalization• Incontinence• Immobility• Unsound mind

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Physiological Changes

• Common stereotypes– Mental confusion– Illness– Sedentary lifestyle– Immobility

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What Happens When We Age? (1 of 2)

• Motor nerves begin to deteriorate– Decreased reaction times

• Steady increase in blood pressure• Decreased ability to maintain normal temperature• Muscles become less flexible

– Strength declines

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What Happens When We Age? (2 of 2)

• Oxygen and carbon dioxide exchange in the lungs and at the cellular level declines.– Body fatigues faster than when younger.

• Metabolism rate decreases.– Weight gain may result.

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Effects of Aging: Skin

• Decrease in collagen• Increase in wrinkles• More bruises with minimal trauma• Longer healing process• Thermoregulatory problems

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Effects of Aging: Senses

• In our 40s, hearing begins to decline.• In our 50s, vision and tactile senses decrease.• In our 60s, taste sensation decreases.• In our 70s, we begin to lose our sense of smell.

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Effects of Aging: Vision

• Cataracts• Glaucoma• Macular degeneration

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Effects of Aging: Hearing

• Inner ear changes can affect balance.• Many older patients have hearing aids.• Approximately 75% of older patients have some type of

hearing deficit.• Increased buildup of cerumen (earwax) may also

contribute to hearing problems.

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Effects of Aging: Taste (1 of 2)

• Decreasing number of taste buds• One-third fewer taste buds at age 70• Salty and sweet sensations are first to diminish• May not be able to discern fresh food from spoiled food

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Effects of Aging: Taste (2 of 2)

• Because of their diminished ability to taste salt, some patients oversalt their food.

• Hypertensive patients may have to consider alternate seasoning.

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Effects of Aging: Touch

• Decreases from the loss of end nerve fibers• Slowing of the PNS• Delayed reflexes• Touch of caregiver may be a source of comfort to the

elderly patient

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Effects of Aging: Smell

• It is among the last senses to diminish.• Upper respiratory infections can affect the sense of

smell.

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Effects of Aging: Respiratory

• Decreased elasticity of alveoli• Decreased ability to exchange oxygen and carbon

dioxide• Decreased number of cilia, which lessens the ability to

cough• Increased chance of foreign-born airway obstruction

(FBAO) due to decrease of muscle mass and strength

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Effects of Aging: Cardiovascular

• The average heart will beat approximately 3 billion times in a lifetime.

• Aging decreases a person’s ability to:– Increase heart rate.– Increase cardiac contraction strength.– Constrict or narrow blood vessels due to

atherosclerosis.• Older people are also at risk for an aneurysm.

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Effects of Aging: Renal

• In older people, kidney function declines because of a 30%-40 % decrease of number and function of nephrons.

• Nephrons are cells that make up the kidneys.• Decreased renal functions result in a decreased ability

to filter the blood.

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Effects of Aging: Nervous System (1 of 2)

• Short-term memory loss• A decrease in the ability to perform psychomotor skills• Slower reflex times

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Effects of Aging: Nervous System (2 of 2)

• Specific neurological conditions and problems– Parkinson’s Disease– Alzheimer’s Disease

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Effects of Aging: Musculoskeletal

• The disks between the vertebrae begin to narrow.• Decrease in muscle mass causes loss of strength,

resulting in increased chance of fractures.• Decreased bone density.• Posture problems.

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Effects of Aging: Gastrointestinal

• Decreased volume of saliva and gastric juices• Slowing of the intestinal tract• Decreased liver functions

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Effects of Aging: Immune System

• Overall decrease in ability to fight infection• Sepsis

– Results from infection– May affect any part of the body:

• Simple dental abscess (common)• Infection in one or more body organs or systems (more

severe)

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Advance Directives (1 of 3)

• Specific legal documents that direct family and caregivers about what kind of medical treatment the patient wishes to receive

• Takes effect when patient cannot speak for himself or herself

• Also known as a “living will”• “Do Not Resuscitate” (DNR) or “do not attempt

resuscitation” (DNAR) orders

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Advance Directives (2 of 3)

• Durable power of attorney• Hospice services• Specific guidelines vary from state to state• General guidelines that you should consider:

– Patients have the right to refuse treatment, including resuscitative efforts.

– A DNR order is valid in a health care facility only if it is in the form of an order written by a physician.

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Advance Directives (3 of 3)

– You should periodically review state and local protocols and legislation regarding advance directives.

– When you are in doubt or when there are no written orders, you should begin resuscitative measures.

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Patient Assessment (1 of 2)

• Scene size-up– Recall the “E” of the GEMS diamond.– Establish scene safety.– Look for clues to determine your patient’s ADL.– Does the patient live alone?– What is the general condition of the home?– Is there food, water, light, heat, and ventilation?– Are there many pill bottles around, indicating

treatment for multiple ailments?

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Patient Assessment (2 of 2)

• Initial assessment– Chief complaint– ABCs– One responder speaks to the patient– One responder gathers information

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Most Common Geriatric Complaints

• Shortness of Breath• Chest Pain• Altered Mental Status• Abdominal Pain• Dizziness or Weakness• Fever• Trauma

• Pain• Falls• Nausea, vomiting, and

diarrhea

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Shortness of Breath

• Can be acute or chronic.• May have an underlying cause.• Respiratory or cardiac?• Form questions in a way that limits answers to yes or

no.• Check for a history of respiratory problems.

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Chest Pain

• May experience and present differently from the general population.

• Patients may delay calling for help.• Acute or chronic?• Have patient describe pain in his or her own words.• Patient may not have pain but instead dyspnea,

weakness, or syncopal episodes.

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Altered Mental Status

• It is not normal.• Determine onset of signs.• VITAMINS C & D mnemonic

– Vascular– Inflammation– Toxins– Trauma

Tumors

Autoimmune

Metabolic

Infection

Narcotics

Systemic

Congenital

Degenerative

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Abdominal Pain

• Among the most frustrating assessments for the EMT-I.• One half of patients with abdominal pain will require

hospital admission.• One third will need surgical intervention.• Acute vs. chronic may help in your assessment.• Supportive care and transport.

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Dizziness or Weakness

• Causes – Cardiac problems– Inner ear problems– Hypotension– Hypertension

• Assess patient for signs of a stroke.• Ask patient if weakness, dizziness, or both are always

present or only present during certain activities.

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Fever

• The body’s immune response to combat an infection.• What are the circumstances surrounding the fever?• When was the fever first noticed?

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Trauma

• Can be more debilitating in an older patient than a younger patient.

• Was there an underlying medical cause?

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Pain

• Many older patients live with pain on a daily basis.• Activities are modified because of pain.• Weather can exacerbate their pain.• EMS may have been called because of an increase in

their pain.

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Falls

• How did it happen?• When did it happen? (day or night)• What causes the fall?

– Tripping: visual problems– Slipping: loose floor coverings– Medical: syncopal episode

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Nausea, Vomiting, and Diarrhea

• Has an underlying cause• Could be a indicator of a MI• May be self-diagnosed as the “stomach flu”• May cause dehydration• Check for unusual color in diarrhea or vomit

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Focused History and Physical Exam

• 80% of a medical diagnosis is based on the patient’s history.

• The history is a key component in helping to assess a patient’s problem.

• To obtain an accurate history, patience and good communication skills are essential.

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Communicating with Older Patients (1 of 4)

• Maintain eye contact.• Speak in a steady tone.• Repeat questions if

necessary.• Communication can be

both verbal and nonverbal.• Remain patient. Don’t

pressure patient into answering a question.

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Communicating with Older Patients (2 of 4)

• Create an engaging and friendly environment by turning off the television or decreasing the volume on your portable radios.

• Position yourself at the patient’s level.• To avoid confusion, repeat the patient’s answer back to

him or her. This allows the patient to adjust his or her answer if necessary.

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Communicating with Older Patients (3 of 4)

• Treat your older patient with respect.• Use courtesy titles: Mr., Mrs., or Ms., and his or her last

name.• Have only one responder ask questions to avoid

confusing the patient.• Ask open-ended questions.• Write down answers to avoid repetition.

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Communicating with Older Patients (4 of 4)

• Ask family member, if present, to clarify information gathered from the patient.

• Thoroughly document patient’s past medical history.• Symptoms of one disease may make the assessment of

another more difficult.

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• Known as polypharmacy• Defined as the simultaneous

use of many medications• People older than 75 use an

average of 11 prescriptions a year

• Obtain a list of medications and dosages

• Inquire about new or recently stopped medications, including OTC medications

Use of Multiple Medications(1 of 4)

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Use of Multiple Medications(2 of 4)

• List any home remedies.• Interaction between medications may contribute to the

patient’s symptoms or problem.• Side effects are misunderstood by the patient as “signs

of getting old.”• Patient may not have taken a particular medication

because of difficulty in opening the bottle.

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Use of Multiple Medications (3 of 4)

• Patients may see multiple physicians who may not be aware of each other’s prescribed medications.

• Check for a written list of medications and dosages.

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Use of Multiple Medications (4 of 4)

• These documents contain the patient’s medical history, current medications, and any allergies:– Envelope of life– Vial of life– Usually located in the

refrigerator marked by a sticker or magnet

• Patients may describe their pills by color and size rather than by name

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Additional Considerations (1 of 2)

• The sensation of pain is diminished in an older patient.• 20%-30% of older patients have “silent” heart attacks

(MIs).• Older patients are prone to hypothermia.• Inspection and palpation can be hampered by multiple

layers of clothing.

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Additional Considerations (2 of 2)

• Remove only the clothing necessary for an accurate assessment.

• Cover patient when assessment is complete.• Preserve the patient’s dignity at all times.

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Response to Nursing and Skilled Care Facilities (1 of 3)

• Commonly located in all areas• Critical information to be gathered from nursing staff

– What is the patient’s chief complaint today?– What is the patient’s admitting diagnosis?

(Why is he or she there?)

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Response to Nursing and Skilled Care Facilities (2 of 3)

• Compare patient’s present condition with his or her condition before the onset of the symptoms.

• Ask the staff about the patient’s mobility, ADL, and ability to speak.

• Is today’s behavior different from his or her normal behavior?

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Response to Nursing and Skilled Care Facilities (3 of 3)

• When transferring a patient, the facility will provide a transfer record that contains the following:– Patient’s medical history– Lists of medications and dosages– Previous diagnosis– Vital signs– Allergies– Additional information

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Trauma (1 of 4)

• Mechanism of injury• Systemic impact of aging and trauma• Falls and trauma

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Trauma (2 of 4)

• Mechanism of injury– Falls are leading cause of trauma.– Motor vehicle trauma is the second leading cause of

trauma death for older people.– Older patients are five times more likely than younger

patients to die in a car crash.– Pedestrian accidents and burns are common

mechanisms of injury.

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Trauma (3 of 4)

• Systemic impact of aging and trauma– Decreased ability to isolate trauma in the older

patient.– A hip fracture may have a systemic impact on the

older patient. – Decreased ability to increase heart rate.– Decreased oxygen exchange.– Patient must be considered unstable.

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Trauma (4 of 4)

• Falls and trauma– From syncope, cardiac rhythm disturbance, or

medication interaction.– Why did the fall occur?– Motor vehicle crash resulting from a medical

condition.– More prone to sustain closed head injuries.– More prone to fractures.– Splinting may be challenging.

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Cardiovascular Emergencies (1 of 2)

• Syncope (fainting)– Results from temporary decrease in blood flow to the

brain.– May or may not be serious.– Should be treated as a loss of consciousness.– Transport to hospital to determine cause.

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Cardiovascular Emergencies (2 of 2)

• Myocardial Infarction (MI)– Classic symptoms may not be present in older

patients.– One third of older patients have “silent” MIs.

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Possible Causes of Syncope in an Older Patient

• Cardiac dysrhythmias• Dysrhythmias• MIs• Vascular and volume• Neurologic

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Common Signs and Symptoms of MI in the Older Patient

• Dyspnea• Generalized weakness• Syncope• Confusion• Altered mental status

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Acute Abdomen

• Because of the aging of the nervous system, abdominal complaints are extremely difficult to assess in the older patient.

• Some of the life-threatening abdominal problems are:– Internal bleeding– AAA– Gastrointestinal bleeding– Bowel obstructions

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Altered Mental Status

• The two terms that are often used to describe a change in mental status are:– Delirium– Dementia

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Delirium (1 of 2)

• Inability to focus, think logically, and maintain attention• Acute anxiety• May be caused by tumors, fever, or drug or alcohol

intoxication or withdrawal• May be present from metabolic causes

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Delirium (2 of 2)

• If a patient has an acute onset of delirious behavior, you should rapidly assess the patient for the following three conditions:– Hypoxia– Hypovolemia– Hypoglycemia

• Any of these conditions may be fatal if left untreated

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Dementia

• Slow onset or progressive disorientation, shortened attention span, and loss of cognitive function.

• Develops over a period of years.• Alzheimer’s disease or genetic factors may cause

dementia.• Considered irreversible.• Patient’s history will be the key in distinguishing

between delirium and dementia.• Dementia is not caused by a emergent event, but

delirium is.

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Elder Abuse

• This problem is largely hidden from society.• Definitions of abuse and neglect among older patients

vary.• Victims are often hesitant to report an incident.• Signs of abuse are often overlooked.

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• Repeated visits to the emergency room• A history of being “accident-prone”• Soft-tissue injuries• Vague explanation of injuries• Psychosomatic complaints

Assessment of Elder Abuse(1 of 2)

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• Chronic pain• Self-destructive behavior• Eating and sleeping disorders• Depression or a lack of energy• Substance and/or sexual abuse

Assessment of Elder Abuse(2 of 2)

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Signs of Physical Abuse

• Signs of abuse may be obvious or subtle.• Obvious signs include bruises, bites, and burns.• Look for injuries to the ears.• Consider injuries to the genitals or rectum with no

reported trauma as evidence of abuse.