ECRN Packet:

Culturally Diverse PatientsGeriatric Population

Medications for Home Use

Condell Medical Center EMS System

2006

Site Code #10-7214-E-1206

Revised by Sharon Hopkins, RN, BSN

EMS Educator

ObjectivesUpon successful completion of this module,

the ECRN should be able to:

• understand the sensitivity required when caring for a culturally diverse patient population.

• describe the unique assessment and care necessary for the geriatric population

• describe common medications taken by the population and potential impacts with clinical presentations

Culturally Diverse Patients

• Differences of any kind: race, class, religion, gender, sexual preference, personal habitat, physical ability

• Good healthcare depends on sensitivity toward these differences

• Every patient is unique

• Westernized medicine is not accepted by all

Culturally Diverse Patients• Key points

• Individual is the “foreground”, culture is the “background”

• Not all people identify with their ethnic cultural background

• Respect the patient’s beliefs• Every patient needs to be treated equally• Do not force someone to

have an intervention that is against their personal beliefs

Culturally Diverse Patients• Respect the integrity of cultural beliefs

• Patients may not share your explanation of causes of ill health and not accept conventional treatments

• Recognize your personal cultural assumptions, prejudices and belief systems.

• Avoid letting your prejudices interfere with patient care

Patient Rights• Patients have the right to self-determination• If the patient is of legal age (18 or older, not

emancipated), the patient has the right to refuse any care or treatment offered

• Document what has been refused and why• The patient, or person authorized to consent,

must sign for themselves– spouses, grandparents, older siblings, police officers

cannot sign a refusal– if telephone permission is taken, witness by 2

persons, and add the name of the person supplying permission

Groups By Region• Many groups overlap regions

• Older population usually refer to themselves by their ethnic region (ie: Chinese, Mexican)

• Younger population usually refer to themselves by racial terms (ie: Asian, Latino)

• Cannot always judge the ethnicity based on appearances - ask the patient if you need clarification

Culturally Diverse Patients

• Locale of practice– get to know the predominate cultures of

your area– the more you understand the culture, the

more effective a practitioner you can be– know resources available in your

hospital/community

Culturally Diverse Patients• Language barriers

– your assessment and accuracy of interpretation will be hindered when a language barrier is present

– if an interpreter is used, document their name and relationship

– in some cultures, use of children is insulting to adults and seen as too much responsibility placed on the child

– language lines are available - use them when gathering/sharing medically pertinent information

Culturally Diverse Patients And Body Language

• Very important especially when a language barrier exists

• Usually at a subconscious level

• Components of body languageeye contactfacial expressionsproximityposturegestures

Body Language - Eye Contact

• Can play a key role in establishing rapport

• Failure to make eye contact can be a sign of dishonesty

• Making eye contact can be a sign of disrespect in some cultures (Chinese)

Body Language - Facial Expressions

• One of the most obvious forms of body language

• Can convey mood, attitude, understanding, confusion, other emotions

• Smiles are usually universally understood• Smiling and winking can have different

connotations from a friendly gesture to flirting to disrespect (culture dependent)

Body Language - Proximity• Acceptability varies widely culture to culture• In the United States, twice the arm length is a

comfortable social distance - 4-12 feet• Personal space is 1.5 - 4 feet• Different messages are interpreted when standing above,

at, or below eye level– above eye level shows authority, can be intimidating

– at eye level indicates equality

– below eye level shows willingness to let patient have some control over the situation

Body Language - Posture• Range of attitudes conveyed from interest,

respect, subordination, disrespect

• Can replace or accompany verbal communication

• Some cultures it is impolite to show the bottom of the shoe because it is dirty; they will not sit with a foot crossed & resting on opposite knee

Culturally Diverse Patients - Financially Challenged

• May refuse health care due to its costs• We need to be an advocate for these

people and make sure they are offered initial medical screening

• Know your community and county resources to offer to this group of people

• As a reminder, use your own resources wisely

Culturally Diverse Patients - Financially Challenged

• Signs of impairment

– homelessness

– chronic illness with frequent hospitalizations

– poor personal hygiene

– self-employment

Resources for Referral• PADS - public access to provide shelter

– provide meals and shelter October 1 - April 30– open 7 pm - 7 am– goals -

• connect person with resources to be able to leave the street• commit to own effort for health and recovery• to gain personal and economic self-sufficiency with safe,

affordable permanent housing

• HealthReach Clinic - medical screening• 847-360-8800 (Waukegan)

Resources for Referral• Catholic Charities

– to help families & individuals overcome tragedy, poverty, other life challenges

– Lake County

• adult agency 847-377-4504

• juvenile agency 847-377-7800

• Salvation Army 847-336-1800• Connection Crisis & Referral Hotline 847-689-1080• Department Chaplain• Hospital Social Worker

–

Geriatrics

Challenges in the Geriatric Population

• Fear of losing autonomy/independence– mobility - walking and by car– want to continue to live on own

• Patient fears financial burden of hospitalization• Patient is embarrassed by burden they become

to family and friends• Multiple disease processes affecting health• Difficulty in communicating pain and fears

Challenges in Dealing With the Geriatric Population

• Patient fatigues easily• Many layers of clothing hamper

detailed examination• Need for modesty and privacy• May minimize their symptoms

– fear that they may be hospitalized, illness will cost money they don’t have, illness may cause nursing home or alternate living arrangements with loss of independence

Challenges in the Geriatric Population

• Often suffer from concurrent illnesses

• Chronic problems make assessment of acute problems difficult

• Aging affects response to illness/injury

• Social/emotional factors have great impact on health

• Depression & isolation - highest suicide rates in people over 65

Sensory Related Changes• Vision

– cataracts cause blurring of vision; unable to distinguish between blue & purple

– if cataracts opaque (cloudy), may not see pupillary response with a penlight

– be in front of person & make touch contact with the patient before beginning to speak

• Hearing– decreased hearing– diminished sense of balance– speak slowly and distinctly; check for

hearing aids; write notes if necessary

• Taste & smell– altered (decreased sensitivity)– creates decreased appetite which causes poor nutritional

condition

• Touch– neuropathies cause decreased sensitivity to tactile senses– increased risk of injury without patient’s awareness

(ie:burns from heating pads; sores on feet becoming infected)

• Pain– lowered sensitivity - smaller amounts of pain

medication are necessary

Communicating with the Geriatric Population

• Make eye contact before speaking• Always identify yourself• Position yourself at the patient’s eye level• Locate hearing aid, eyeglasses, dentures• Turn on lights, turn off TV to minimize distractions• Use surname (Mr., Mrs., Ms.) until permission

given to address patient otherwise• Be patient and gentle - give time for the patient to

respond to your questions

Physiological Changes Affecting Mobility

Diminished visionLoss of exercise toleranceDiminished breathing capacity - become short

of breath quicker and lose energy to complete tasks

Slowed psychomotor skills - losing independence

Decreased reflex time to prevent falls - more prone to injury

Mobility in Geriatrics• Bone loss affects mobility

• Osteopenia - less than the normal amount of bone• Osteoporosis - bone mass so reduced that the

skeleton loses its integrity and becomes unable to perform it’s supportive function

– Loss of bone strength and size– Loss of flexibility

• Vulnerable areas in women– spine, wrist, hip, collarbone, upper arm, leg, pelvis

• Treatment - meds, weight bearing exercises like walking and lifting weights

Cardiovascular Changes in Geriatrics

• Left ventricle thickens and enlarges (hypertrophy) decreasing compliance

• Decreased responsiveness to catecholamine stimulation

• Diminished ability to raise the heart rate in response to stress

• Decreased function of SA & AV nodal cells increasing risk of dysrhythmias

• Cardiac output decreased by 30%

• Arteries become increasingly rigid• Increased blood pressure to pump through

rigid blood vessels• Reduced blood flow to all organs• Decreased peripheral resistance• Widened pulse pressure - increasing systolic

blood pressure• Heart muscle stiffens• Postural hypotension - vessels less reflexive

and blood pressure drops when patient stands up too fast

• Atherosclerosis - progressive, degenerative disease of medium and large sized arteries

Cardiovascular Disease• Risk factors for developing cardiovascular

disease• Previous MI• Angina• Diabetes• Hypertension• High cholesterol level• Smoking• Sedentary lifestyle

Geriatrics and Acute Myocardial Infarctions

• Elderly do not present with typical signs or symptoms of acute myocardial infarctions

• Silent MI’s are marked by atypical complaints such as fatigue, nausea, abdominal pain and breathlessness

• High index of suspicion for MI with unusual or absent warning signs/symptoms

• Mortality doubles after age 70

Heart Failure• A clinical syndrome where the heart’s

mechanical performance (pumping) is compromised and cardiac output cannot meet the body’s needs

• Caused by: ischemia, valvular disease, dysrhythmias, hyperthryoidism, anemia, cardiomyopathy

• In elderly, large incidence of non-cardiac causes• Generally divided into right and left heart failure• Ventricular output insufficient to meet the

metabolic demands of the body

Heart Failure• Left ventricular failure

– left ventricle fails as a forward pump– back pressure of blood in the pulmonary system leads to

pulmonary edema

• Right ventricular failure– right ventricle fails as a forward pump– back pressure of blood into the systemic venous circulation

leads to venous congestion

• Congestive heart failure– reduced stroke volume causes an overload of fluid in body

tissues

Signs and Symptoms of Heart Failure

• Dyspnea • Fatigue• Orthopnea - often sleeping on extra pillows to

be more upright• Dry, hacking cough progressing to frothy

sputum• Dependent edema due to right heart failure

(check most dependent part of body depending on mobility - feet or sacral area)

• Nocturia - urinating at nighttime• Anorexia, ascites (fluid in abdomen)

EMS Protocol Treatment Pulmonary Edema

• Routine medical care• Oxygen via nonrebreather initially

– BVM and intubation if needed• Stable patient with B/P >100 systolic

– Nitroglycerin 0.4 mg sl (can repeat every 5 minutes to a maximum of 3 doses)• venodilator - reduces return of blood to heart to

reduce workload of heart– Lasix 40 mg IVP (80 mg if on lasix)

• diuretic and venodilator - reduces fluid return & workload on the heart

Pulmonary Edema cont’d• Stable patient cont’d

– If B/P >100 systolic, morphine 2 mg slow IVP• repeat 2mg every 3 mins as needed; max 10 mg• reduce anxiety; venodilator

• Consider CPAP if B/P > 90• Unstable patient B/P <100 systolic

– contact medical control– consider cardiogenic shock protocol

• dopamine drip to raise blood pressure• fluid challenge would not be appropriate in patient

with crackles/rales (wet lungs)– treat dysrhythmias as they present

Dysrhythmias and Geriatrics• Common dysrhythmias

– PVC’s when over 80 years old– atrial fibrillation - increased risk for stroke

• Morbidity/mortality– Serious due to decreased tolerance due to decreased

cardiac output– The cerebral hypoperfusion leads to an increase in falls– Can lead to TIA’s and CHF (ineffective

pumping)

Aneurysm• A bulge in a blood vessel; if large enough can put

pressure on surrounding structures• May be aortic or cerebral • Associated risk factors

– Smoking– Hypertension– Diabetes– Atherosclerosis– Hyperlipidemia– Polycythemia– Heart disease

Hypertension• Blood pressure ranges

– optimal <120/<80– normal range <135/<85– hypertensive range >140/>90

• Risk factors for developing hypertension– African Americans– elderly– geographics (Southeastern United States)– males (after menopause, women equally vulnerable)– socioeconomic status - lower the status the greater the risk

Hypertension

• Morbidity/mortality– B/P greater than 160/95 doubles mortality in

men– If blood pressure remains uncontrolled, damage

seen to circulation (vascular system) and organscardiovascular disease (CVD) - stroke, MI,

heart failureend-stage renal disease

Hypertension• Awareness of the disease, it’s treatment, and control

have improved but are still suboptimal• Prevention and control

– Regular physical check ups– Follow medication routine if prescribed – Weight control– Exercise– Decreasing salt intake– Socially/emotionally active– Smoking cessation– Decreasing alcohol consumption

Hypertensive Emergencies• Definition

– acute elevation of systolic blood pressure >230/>120

• Signs & symptoms– epistaxis (nosebleed)– headache– visual disturbances– neurological changes - altered mental status and

seizures– nausea & vomiting

SOP Treatment Hypertensive Emergencies

• Routine medical care: IV-O2-monitor

• Blood pressure in both arms and record– keep arm level with the heart

• Vital signs and neuro status every 5 minutes– P-R-B/P-mental status-pupillary response-GCS

• Lasix 40 mg IVP (80mg if on Lasix at home) - diuretic & vasodilator

• If Medical Control orders, give NTG sl- vasodilator

Stroke - Cerebrovascular Accident

• 3rd leading cause of death in the USA

• Occlusive stroke - 80% incidence– causes brain ischemia– time to hospital treatment (TPA - fibrinolytic

clot bluster) must be <3 hours from time of onset– most important question - “what time did the

symptoms start?”

• Hemorrhagic stroke - 20% incidence– higher percentage of death

Risk Factors For Stroke• Elderly• Atherosclerosis• Hypertension• Immobility• Limb paralysis• Congestive heart failure• Atrial fibrillation• Diabetes • Obesity

Signs and Symptoms of Stroke• Elevated blood pressure• Altered mental status or mood• Coma• Paralysis or extremity weakness• Slurred speech• Seizures

Note: Suspect stroke in any elderly person with a sudden change in mental status. Always check blood sugar level in setting of altered mental status

Cincinnati Stroke Scale Assessment

Facial droop - have patient smile big enough to show their teeth

Arm drift - patient closes their eyes and extends arms out straight, palms facing up for 10 seconds

Abnormal speech - have the patient repeat back a response given (speech may have already been detected during normal conversation)

Documentation of Cincinnati Stroke Scale Results

• Facial droop right, left, or no droop present

• Arm driftright, left, or no arm drift

• Abnormal speechslurred speech or clear speech

• Even normal responses with no deficits must be documented to show the assessment was performed

Endrocrine Emergencies in Geriatrics

• Diabetes and Thyroid Disease– Due to the aging process and multiple disease

processes the signs and symptoms may not appear to be classic

– Suspect thyroid disease in an elderly patient who has vague symptoms of “illness”

• 20% of the elderly have diabetes• 40% have impaired glucose tolerance• Type II (non-insulin dependent) is the most

common form of diabetes and related to obesity

Endocrine Disorders• Hyperthyroidism

– Weight loss– Mentation changes -

nervousness, irritability– Tachydysrhythmias,

palpitations– Hyperactivity, nervousness,

irritability– Heat intolerance– Abdominal pain– Diarrhea– Weak leg muscles perspirations

• Hypothyroidism– Low metabolic state appetite with weight gain– Vague musculoskeletal complaints– Lethargy, fatigue, sluggishness– Cold intolerance– Constipation– Anemia– Depression, forgetfulness– Hyponatremia ( Na)– Moon face

Endocrine Complications

• Hyperthyroidism– impaired glucose tolerance -

problems with sugar processing (“pre-diabetic” condition)

– type II diabetes

– tachycardia

– atrial fibrillation

• Hypothyroidism– bradycardia

Integumentary (skin) Emergencies

• Risk factors– Epidermal cellular turnover decreases– Slower wound healing– Increased risk for secondary infection– Increased risk of skin tumors, fungal or

viral infections– Hair becomes finer and thinner

Pressure Ulcers• Results from hypoxia to tissue cells• Usually over bony areas• Common in immobile patients

– those confined to bed or wheelchairs

• Increased incidence in patients with: – altered sensory perception– skin exposure to moisture, especially prolonged– decreased activity & inability to shift positions– poor nutrition– friction or shear (ie: being pulled and dragged

across a surface instead of being lifted)

Prevention of Pressure Ulcers

• Immobile patients turned every 2 hours• Adequate hydration and nutrition provided• Personal hygiene maintained• Environment kept clean• Insure immobile patients do not have wrinkled bedsheets

or clothes• Prescribed antibiotics or medications provided as ordered

Traumatic Deaths in Geriatrics• Trauma is the fifth leading cause of death• Mortality rates markedly increased in the elderly• One-third of traumatic deaths are in 65 - 74 year olds

secondary to vehicular trauma

• 25% result from falls• 50% of persons >80 years old die from

falls • Post-injury disability more common in the

elderly

Risk Factors Related to Trauma• Osteoporosis and muscle weakness increases the risk

of fractures– women more vulnerable after menopause– men are also at risk for this disease

• Reduced cardiac reserve decreases ability to compensate for blood loss

• Decreased respiratory function increases risk for adult respiratory distress syndrome (ARDS)

• Impaired renal function decreases ability to adapt to fluid shifts

• Unsteady gait increases risks of falls

Traumatic Emergencies

– Orthopedic Injuries• Pelvic fractures are highly lethal due to severe

hemorrhage and associated soft tissue injury

• Decreased pain perception may mask major fracture

• A large percentage of elderly will die within one year of a hip fracture

Orthopedic Injuries• Hip fractures most common acute injury• Elderly are susceptible to stress fractures of femur,

pelvis, tibia• Packaging should include adding bulk and padding

between the patient and the back board• Kyphosis (rounding of the back) may require extra

padding under shoulders to maintain alignment– often caused by osteoporosis, arthritis, vertebral

slippage• Try to remove backboards as soon as possible &

document removal

External Rotation

Fracture site

Fracture repaired with plate & screws

Orthopedic Injuries From Falls

• Major cause of morbidity/mortality• 10,000 deaths each year• One third of elderly fall at home each year

– 1 in 40 are hospitalized– Cause significant mobility problems and functional

dependence• Evaluate home for safe conditions

– use of non-skid rugs– adequate lighting - hallways and at night– sturdy hand rails on stairs and in bathrooms– items within reach (ie: kitchen)– environment clear of clutter

Traumatic Head Injuries• Poorer outcome when injury associated with loss of

consciousness

• Brain shrinkage as one ages allows more space and greater brain movement

• Increased incidence of subdural hematoma frequency of falls lead to more head injuries

– brain shrinkage allows for more room to bleed

– bleeding is venous - slow development of symptoms

• headache

• mental status changes

Spinal Column Injuries

• Progressive arthritic and degenerative changes and osteoporosis associated with the aging process lead to higher incidence of bony injuries

• Injuries have a negative impact on the function and quality of life

• Pain ability to perform activities of daily living

• A psychosocial impact and threat to loss of independence

Compression Fractures of Spine• Occurs in 25% of post-menopausal women in the USA (up

to 40% in women over 80)• Applied force may be minimal (lifting an object, stepping

out of tub, sneezing) or more significant (major fall, MVC)• Acute onset low back pain, tenderness to palpation usually

over T 8-12 and L 1-4• Rarely neurological symptoms• Transported in position of most comfort• Treatment symptomatic & conservative - rest, pain

control, physical therapy

Burns in the Elderly• 1000 die each year from home fires• People over 60 have higher mortality

rate from burns• Increased morbidity/mortality due to

preexisting disease, skin changes (thinning & slower healing time), altered nutrition, increased risk to

infection, decreased reaction time to

move away from source

Treatment of Burn Injuries• Fluid important to prevent renal tubular damage

from altered blood flow through the kidneys• Normal aging changes cause a decreased

response in heart rate and stroke volume to hypovolemia

• Hydration assessed in initial hours after burn injury by B/P, pulse, and urine output (1-2 ml/kg/hour minimally)

• Rapid IV administration of fluid may cause volume overload (monitor lung sounds and vital signs frequently)

Toxicology & Geriatrics

• Alterations in body composition, drug distribution, metabolism and excretion increases the risk for toxicity in elderly when exposed to over-the-counter medications, prescription medications, and other substances

Risk Factors Related To Toxicology • Decreased kidney function alters elimination• Increased likelihood of CNS side effects• Altered GI absorption• Decreased liver blood flow alters metabolism and

excretion• History of alcoholism• Vision and memory changes result in

noncompliance• Poor dexterity and eyesight decreases ability to

choose correct medication and/or dosage

Prevention • Label medications clearly and in larger print• Provide assistance with nutrition and medication

administration as needed• Consult with physician frequently• Make sure all physicians are aware of all medications

taken– over-the-counter; prescription; herbal remedies

• Limit OTC drug administration• Segregate storage in medicine cabinet

– ingested medications on one shelf– topical medications on a different shelf

Elder Abuse• May occur in home or institutional setting• EMS & RN’s are mandated by State of Illinois to

report suspicions to hot line• Abuse

– any physical injury, sexual abuse or mental injury inflicted on a person, aged 60 or older, other than by accidental means

• Neglect– failure to provide adequate medical or personal

care or maintenance in which failure results in physical or mental injury or deterioration of condition

Elder Abuse Reporting

• Document objectively and describe injuries using measurements and colors and not vague terms

• Suspicions reported to ED staff by EMS

• Abuse Hot Line– M-F 0830 - 1700: 1-800-252-8966– All other times: 1-800-279-0400

Medications for Home Use• Antidepressants

– depression is a chronic illness of feeling hopeless and of losing interest

– SSRI (selective serotonin reuptake inhibitors)• improves mood• lexapro, prozac, paxil, zoloft

– Tricyclic antidepressants• amitriptyline, nortriptyline

– MAO inhibitors• could have potentially life-threatening drug

& food interactions• nardil, parnate

Medications for Home Use• Antianxiety

– to relieve anxiety– benzodiazepines most common category

• Anticoagulants– to inhibit the ability to clot; does not dissolve

an existing clot– coumadin, lovenox, heparin, plavix, aspirin

Medications for Home Use• Lipid management

– to reduce cholesterol and LDL levels which when elevated increases risks of coronary heart disease (CHD)

– statins: lipitor, lescol, zocor, pravachol, mevacor, baycol, crestor, pitava

– non-statin: zetia, niacin, velchol, torcetrapib, panavir

Medications for Home Use• ACE inhibitors

– allow blood vessels to enlarge or dilate to decrease B/P

– used to control B/P, treat heart failure, prevent kidney damage in hypertensive & diabetic patients

– catopril (capoten), lotensin, vasotec, lisinopril (prinivil & zestril), monopril, ramipril (altace), aceon, accupril, univasc, mavik

Medications for Home Use• Beta blockers

– relieves stress on heart by blocking some involuntary nervous system control on the heart

– slows heart rate, decreases force of contractions, reduces blood vessels contractions

– used to treat cardiac dysrhythmias, atrial fibrillation, hypertension, angina, post-MI (reduces morbidity), glaucoma, migraines, anxiety

– most generic names end in “olol”– atenolol (tenormin), metoprolol (lopressor), propranolol

(inderal), nadolol (corgard), carvedilol (coreg)

Medications for Home Use• Calcium channel blockers

– block entry of calcium into muscle cells of heart and arteries to decrease the strength and rate of heart contractions and dilate arteries

– used to treat high blood pressure, arrhythmia (atrial fibrillation), angina, used post-MI

– verapamil (calan, isoptin), diltiazem (cardizem), nifedipine (procardia), bepridil (vascor), amlodipine (norvasc)

Medications for Home Use• Diuretics

– to reduce the vascular fluid volume– used to treat heart failure, hypertension, fluid

retention– aldactone, aldactazide, bumex, diuril,

hydrochlorothiazide, HCTZ, hydrodiuril, dyazide, dyrenium, lasix (furosemide)

• Diabetes– inadequate insulin activity for glucose metabolism – actos, amaryl, avandia, diabeta, glucophage,

glucotrol, prandin, precose, starlix

Medications for Home Use

• GI system– to treat acid reflux, excess acid, GERD,

irritable bowel– aciphex, asacol, mylanta, pepcid,

prevacid, prilosec, propulsid, reglan, rolaids, tagamet, tums, zantac, lomotil, bentyl, imodium

Medications for Home Use• Insomnia and sleep disorders

– sleep deprivation affects the body’s metabolism

– insomniacs are at increased risk for host of diseases; decreases motor skill and affects memory and mental performance

– being awake 24 hours is equivalent to a blood alcohol level of 0.1

– ambien, halcion, restoril, lunesta benzodiazepines like lorazepam (ativan), diazepam (valium)

Medications for Home Use• Erectile dysfunction

– to improve erectile function (impotence) in men and sexual arousal in women

– increases amount of blood flow, does not automatically produce an erection but allows one after physical and psychological stimulation

– not to be taken if MI, stroke or life-threatening dysrhythmia in last 6 months

– not to be mixed with nitrate use (NTG) in same 24 hours period -blood vessel dilation could be too much to reverse & could cause death

– viagra (sildenafil), cialis, levitra

Pearls of Medication• Benzodiazepines

– when mixed with alcohol increases depressant effects - watch for respiratory depression

• Anticoagulants– increases risk for bleeding complications

• Beta blockers– patient won’t respond with tachycardia even in shock due to

effects of drugs

• Hypertensive patient– a normal reading (ie: 100/70) may be shock for the patient with a

chronically elevated blood pressure

References• Bledsoe, B. E., Porter, R. S., Cherry, R. A. Paramedic Care Principles & Practices.

Brady 2006.• www.aafp.org• www.allaboutvision.com• www.americanheart.org• www.aoa.org/documents/CPG-8.pdf• www.clara.abbott.com• www.dynomed.com/encyclopedia/encyclopedia/spine/ Compression_Fracture.htm• www.glaucoma.org• www.nihseniorhealth.gov• www.nlm.nih.gov/medlineplus/cataract.html• www.pads-crisis-services.net• www.richmondeyecare.com/vets2html