© 2013 Seattle / King County EMS
Introduction With advancing age various organ systems in
body begin to fail or show decreased function Elderly have less reserve in their organ
systems Loss of function (for example renal, cardiac,
endocrine or respiratory function) makes person more vulnerable to injury or illness
It is estimated organ systems lose approximately 1% of capacity per year starting at about 30 years of age
Consider the following: Increasing cholesterol will lead to more heart attacks Decrease in cardiac output will lead to more falls and
syncopy Decrease in lung elasticity lead to more respiratory
infections Decrease in bone and muscle mass leads to more
falls and fractures Multiple medical conditions leads to increased
medication interactions
© 2013 Seattle / King County EMS
Introduction
Good way to approach elderly patients – assume they are more vulnerable to injury or illness
Examples: Pneumonia in someone 80 years of
age is likely to be far more serious than in someone age 25
Fall in someone 85 may be very serious whereas in a younger person the fall may lead to no harm
© 2013 Seattle / King County EMS
Course Objectives1. Identify unique characteristics of the elderly
patients.2. Identify examples of diminishing stroke
volume in the elderly patient.3. Identify factors that affect outcome of the
elderly patient in trauma.4. Identify signs and symptoms of dementia and
or the pathophysiology.5. Identify signs and symptoms of cardiovascular
emergencies.6. Identify emergency care for a traumatized
elderly patient.7. Identify emergency care for the medical
elderly patient.
© 2013 Seattle / King County EMS
Terms Diuretic - A drug such as Lasix (furosemide)
and HCTZ (hyrdrochlorothiazide) used primarily to treat hypertension and congestive heart failure. Diuretics may cause dehydration, making the patient more susceptible to syncope or heat stress.
Dysrhythmia - Irregular or abnormal heart rate, also sometimes referred to as cardiac arrhythmia.
Elderly - There is no general agreement when a person becomes “old”. The common use of a calendar age to mark the threshold of old age assumes that everyone ages at the same rate which is not true.
Metabolism - The process by which cells take in energy (food and oxygen) so they can function. All bodily functions such as digestion, muscle contractions, and breathing require energy. Heat is a by-product of these processes.
© 2013 Seattle / King County EMS
New Terms Bradypnea - Slow breathing. It is defined as a
respiratory rate of less than 10 breaths per minute. Things to consider are ingestion of central nervous system (CNS) depressants (eg, narcotics, benzodiazepines), stroke, or per terminal conditions.
Dementia - (meaning "deprived of mind") is a serious loss of brain function that lead to problems in memory, thinking, language, behavior, and judgment. Dementia may be progressive or stable. The incidence of dementia increases with advancing age.
Elder Abuse - Harmful treatment toward an elderly person, includes physical, sexual, or emotional abuse, financial exploitation, and neglect.
© 2013 Seattle / King County EMS
New Terms continued Hematemesis - Vomiting blood. The source is generally the upper gastrointestinal (GI) tract. This can be confused with hemoptysis (coughing up blood). The spectrum of upper GI bleeding varies from occult (meaning not readily seen) bleeding that presents as anemia to acute, life-threatening hemorrhage resulting in hypotension and shock. Sources of life-threatening upper GI bleeding include peptic ulcer disease, esophageal varices, and Mallory-Weiss tears.
Huntington's disease, chorea, or disorder (HD) - Progressive neurological genetic disorder, which lead to loss of muscle coordination and some cognitive problems. Its onset is typically in middle age. It is the most common genetic cause of abnormal involuntary writhing movements called chorea and is much more common in people of Western European descent.
© 2013 Seattle / King County EMS
New Terms continued Hyperosmolar nonketotic state (HKS) - An uncommon type of diabetic coma. It has a high mortality. Other commonly used names are hyperosmolar hyperglycemic nonketotic coma (HHNKC) or hyperosmotic non-ketotic coma (HONKC). Patients with this condition have very high sodium caused by severe dehydration.
Neglect - Failure of a caretaker to provide goods or services necessary to avoid physical harm or mental anguish, such as abandonment, denial of food or health related services. It can be intentional of unintentional through ignorance or lack of training.
Vulnerable Adult - adults age 60 and older who cannot care for themselves. Also, includes adults age 18 and older who, have a legal guardian, are developmentally delayed, live in a DSHS licensed facility, receive in home care services, or have a personal care aide who is paid for their services.
© 2013 Seattle / King County EMS
Geriatrics Geriatric: derived from the Greek word GERON
meaning “old man”
When does a patient become “geriatric”? There is no clear answer to this question. Some consider age 65 to be the boundary between adult and geriatric. Others consider the person’s underlying physical condition and mental function to mark this border. This boundary may from one individual to the next.
As a general concept a geriatric patient is someone who is more vulnerable to physical, mental, and medical issues as a result of their age.
The goal of geriatric care is to promote health by preventing and treating disease and disability in older people, and improving quality of life
© 2013 Seattle / King County EMS
Future needs Our population is is getting older as the “baby
boom” generation ages.
In 2009, people 65 years or older, who numbered 40 million, represented 13% of the U.S. population.
By 2030, it is predicted that there will be 70 million older people, increasing to almost 20% of the population.
As medical care continues to improve, the numbers and age of older patients will increase.
© 2013 Seattle / King County EMS
Heart Disease
Almost all cardiac diseases more common in elderly
Includes higher incidence of coronary heart disease, congestive heart failure, cardiomyopathy & heart dysrhythmias
© 2013 Seattle / King County EMS
Valves in the Heart Valvular heart disease leads to heart failure by causing impaired cardiac filling and then chronic volume overload, which results in secondary heart failure Infection can cause endocarditis (infection of the heart valves)
More likely to occur in older persons Increase is due to number of factors including higher number of prosthetic valves & increased hospitalizations with associated hospital-acquired infections in the elderly
© 2013 Seattle / King County EMS
Degeneration of the Cardiac Conductive System
Heart contraction – initiated by signal coming from SA node in atria Signal then travels to AV node by
special conducting cells Signal then conducted through
bundle of His to bundle branches in ventricular walls which in turn signal muscle fibers in walls to contract
© 2013 Seattle / King County EMS
Degeneration of the Cardiac Conductive System Block occurs when signal cannot progress or its
progress delayed Three degrees of block
1st degree (slow conduction in the atria) 2nd degree (Mobitz 1 and 2) (partial block in the AV
node) 3rd degree (complete block in the AV node)
Stokes Adams Syndrome: slowing of heart & often leads to syncope
Patient may become pale before fainting Normally syncope short lived
Seizures may occur with associated fall in blood pressure Often less than 30 seconds in duration
© 2013 Seattle / King County EMS
Stroke Volume Stroke volume (SV) – volume of blood
ejected with each contraction Ejection fraction (EF) – blood ejected by
left ventricle during contraction divided by total volume of left ventricle
Normal EF is approximately 60-65%
Video explanation available at EMS Online:
http://www.emsonline.net/geriatric2011/strokevol.asp
© 2013 Seattle / King County EMS
Congestive Heart Failure In heart failure, heart cannot pump enough
blood through body Can affect right, left, or more commonly both
sides of heart Can be chronic or acute Common symptoms of heart failure include:
Shortness of breath or difficulty breathing Feeling tired Swelling of the lower legs Elevated jugular venous pressure
© 2013 Seattle / King County EMS
Coronary Implications Aging heart has diminished stroke
volume, increased atherosclerosis, increased calcification in the valves & less effective conduction
Results may present as angina, myocardial infarction, heart failure, atrial fibrillation, aortic stenosis
Elderly patients often do not present with typical symptoms of acute myocardial infarction May be due to loss of sensory fibers though
exact reasons are not known
© 2013 Seattle / King County EMS
Coronary Implications
Acute myocardial infarction in elderly may include any combination of following symptoms: Fatigue Shortness or breath Syncope Hypotension
Be especially alert to atypical symptoms of MI in elderly patients
© 2013 Seattle / King County EMS
Emergencies
Older patients more likely to have conditions like emphysema & heart failure (pulmonary edema) and/or combination of these diseases Less ability to compensate compared
to younger patients Acute pulmonary edema often a
result of acute myocardial infarction (MI)
© 2013 Seattle / King County EMS
Pneumonia Common & significant health
problems for elderly Fourth leading cause of death in
this age group Nosocomial (hospital acquired)
pneumonia fairly common among older patients Especially for thoracic or abdominal
surgery, on a respirator, or undergoing tube feeding
Serious underlying illness – major risk factor for developing pneumonia in elderly
© 2013 Seattle / King County EMS
Pulmonary Embolism Pulmonary embolism (PE) – obstruction
of pulmonary artery caused by blood clot Travels to pulmonary artery from another
location (atria or lower leg) Incidence of PE increases with age
Risk factors: Prolonged bed rest Underlying cancer Recent surgery
Video DVT & PE: http://www.emsonline.net/geriatric2011/pulmonary.asp
© 2013 Seattle / King County EMS
COPD Chronic condition caused by
damage to alveoli Usually caused by smoking Patients may be chronically short
of breath and on home oxygen. Acute exacerbations may present
with shortness of breath, productive sputum, and noisy lung sounds (wheezing, rhonchi)
Patients often take inhalers and steroids
© 2013 Seattle / King County EMS
Asthma
Nebulizers often prescribed
Typically chronic disease caused by episodic bronchospasm (constriction) of lung’s small airways
Treated with two kinds of medicines: Quick-relief medicines
to stop bronchospasm & reduce inflammation
Long-term control medicines to prevent recurrence
© 2013 Seattle / King County EMS
Disorders
Disorders & conditions of neurovascular system include:
Blood vessel aneurysms in brain Stroke syndromes Vascular malformations of brain &
spinal cord Dementia (Alzheimer’s type
dementia is most common) typically associated with atrophy of brain cells Exact causes of dementia largely
unknown
© 2013 Seattle / King County EMS
Delirium State of confusion
that can last days, weeks or even months
Associated with hospitalization & may last from hours to days
Onset of delirium usually fairly sudden
Can be treated & often temporary, even in people with advanced illness
Precipitating cause of delirium include: Drug side effects Dehydration Pain Urinary or other
infections Poor vision or hearing Strokes Bleeding Heart problems Breathing problems
© 2013 Seattle / King County EMS
Dementia
Show signs of disorientation May not know what day of week, day
of month, or even what year it is May not know where they are May not know relatives or people
around them Often loss of memory especially
short term memory Progressive & largely untreatable
© 2013 Seattle / King County EMS
Dementia Caused by series of small strokes Two most common types of dementia
Vascular dementia Alzheimer’s Disease
People with advanced Parkinson's disease may also develop dementia
© 2013 Seattle / King County EMS
Alzheimer’s Disease
Alzheimer’s type dementia has no cure
Most common type of dementia & accounts for up to 70 percent of cases
As many as 5.3 million Americans living with Alzheimer’s type dementia
Sixth-leading cause of death in United States
Video Information re: brain changes: http://www.emsonline.net/geriatric2011/delirium.asp
© 2013 Seattle / King County EMS
Strokes Stroke (also known as a cerebral vascular accident – CVA) is a medical emergency Occurs when blood flow to portion of brain stops Two major types of strokes
Ischemic strokes –blood clot in vessel or artery in brain (80%) Hemorrhagic strokes – blood vessel bursts & bleeds into brain (20%)
Blood supply to brain is interrupted, cells begin to die due to lack of oxygen, glucose & other nutrients
© 2013 Seattle / King County EMS
TIAs
Transient ischemic attacks (TIAs) – blood supply to brain temporarily interrupted
Symptoms of TIA resolve within 24 hours
While person is having stroke symptoms – impossible to distinguish stroke from TIA
© 2013 Seattle / King County EMS
Thrombolytic Therapy & CVA Selected patients with CVA can
benefit from rapid thrombolytic therapy designed to dissolve clot causing CVA
Effective thrombolytic therapy – should be given within 4.5 hours of onset of stroke Hospital requires one hour for
evaluation & CT this means symptoms onset to arrival at hospital should generally be <3.5 hours
Most hospitals in King County designated as stroke centers & equipped & staffed to rapidly make diagnosis & treat acute CVA
© 2013 Seattle / King County EMS
Thrombolytic Therapy & CVAFAST Narrative to rapidly determine if patient has experienced a stroke
A short telephone report to the hospital should include items 1— 4
Signs/Symptoms Record
1. Face: Is it symmetrical? YES/NO
Arm: Is one arm weak? YES/NO
Speech: Is it slurred or abnormal? YES/NO
Time: What time was patient last known to be normal?
Note Time
2. Is the patient on Coumadin (Warfarin)? YES/NO
3.Glucometry. Glucose should be over 60. Severe hypoglycemia can present like a stroke.
Check/Note reading
4. Glasgow Coma Scale Score Note Score
5. Time of hospital notification Note time
6. Time you left the scene enroute to hospital Note time
© 2013 Seattle / King County EMS
Glasgow Coma Scale Score Means of measuring & monitoring level of consciousness Calculate score based on best eye, verbal, & motor response
Lowest score possible is 3, highest is 15 GCS part of Code CVA
© 2013 Seattle / King County EMS
Glasgow Coma Scale Score
Glasgow Coma ScaleEye Response Best Verbal
ResponseBest Motor Response
Spontaneously opens - 4
Oriented and talking - 5
Obeys commands - 6
Opens to voice - 3 Disoriented and confused - 4
Locates pain - 5
Opens to pain - 2 Inappropriate words - 3
Withdraws from pain - 4
No response - 1 Incomprehensible - 2
Flexes to pain - 3
No response - 1 Extends to pain - 2
No response - 1
© 2013 Seattle / King County EMS
Parkinson's Disease Disorder affects part of brain that
controls muscle movement Symptoms may include:
Trembling of hands, arms, legs, jaw & face
Stiffness of the arms, legs & trunk Slowness of movement Poor balance & coordination
People may have trouble walking, talking or doing simple tasks
Disease slowly progresses
© 2013 Seattle / King County EMS
Huntington's Disease Huntington's disease (also known
as Huntington’s Chorea) – progressive disease causes brain cell damage leading to uncontrolled movements & mental deterioration
Inherited disease Signs & symptoms typically
develop in middle age Disease usually progresses slowly
though it can progress rapidly in younger patients
© 2013 Seattle / King County EMS
Disorders Geriatric patients experience general decline in renal function Renal filtration falls average of 50% between ages of 20 & 90 Kidney mass decreases by 20% Many drugs eliminated through renal filtration
Underlying renal dysfunction often cause of decreased drug efficacy & other medication-related problems in older patients
© 2013 Seattle / King County EMS
Disorders Urinary incontinence, inability to maintain bladder control, more common in older patients Some causes of incontinence in the elderly are:
Decrease in bladder capacity Involuntary bladder contractions Decreased ability to delay voiding Medications that affect bladder control Decline in sphincter muscle control Prostate cancer Severe dementia
© 2013 Seattle / King County EMS
Diabetic Issues
Incidence of type 2 diabetes increases with age
Complications of diabetes include: Kidney failure Blindness Heart disease Stroke Lower extremity
amputations
© 2013 Seattle / King County EMS
Type 2 Diabetes Type 2 diabetes associated with older
age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity & race or ethnicity
More children have been diagnosed with type 2 diabetes
Believed obesity & insulin resistance are to blame
Unknown if resistance is due to obesity itself or a combination of inactivity & increased consumption of refined sugars
© 2013 Seattle / King County EMS
Type 2 Diabetes
Because the mechanism is different than for an insulin-dependent diabetic, type 2 diabetics require special care when they become hypoglycemic.
Even if you are able to increase the blood sugar of a type 2 diabetic with sugar or food, that person must still be monitored in a medical facility. It is not uncommon for the blood sugar to fall again.
© 2013 Seattle / King County EMS
Hypothyroid Issues Approximately 0.5% to 5% of older adults have hypothyroidism 5% to 10% have subclinical hypothyroidism Most cases in elderly people due to chronic autoimmune inflammation of thyroid
© 2013 Seattle / King County EMS
Hypothyroid Issues Symptoms of
hypothyroidism often nonspecific in older adults & may include: Dry skin Slowed thinking Weakness Constipation Anemia
Symptoms usually have insidious onset & slow rate of progression Result, diagnosis of
hypothyroidism often missed
Elderly patients with mild hypothyroidism may become severely hypothyroid if they experience serious illness
© 2013 Seattle / King County EMS
Disorders Osteoporosis common in geriatric
patients (especially women) Often loss of total muscle mass Falls common & often result in fractured
hips or collapsed vertebrae Hip fracture – 10th leading cause of
hospital admission in elderly Most result from
falls at home
Osteoporosis bone resembles Swiss cheese
© 2013 Seattle / King County EMS
Trauma Trauma more serious in elderly
compared to younger patient Falls leading cause of trauma
Falls can lead to moderate to severe injuries, such as hip fractures & head trauma
Elderly patients on Coumadin (anticouagulant) Fall or experience trauma (such as a motor
vehicle accident with a head strike) Very high risk of internal bleeding Must be evaluated in hospital
© 2013 Seattle / King County EMS
Polypharmacology
Use of three or four medications – important risk factor for falls in geriatric patients
Use of multiple medications also lead to mental confusion or other undesirable side effects
© 2013 Seattle / King County EMS
Elder Abuse/Vulnerable Adult As an EMT, under Washington State law (RCW 74.34.035) mandated reporter of suspected elder abuse Who is a vulnerable adult?
60 years or older Functional, mental or physical inability to care for self Found incapacitated Has developmental disability Receiving services from home health, hospice, or licensed home care agency Receiving services from an individual provider
© 2013 Seattle / King County EMS
Elder Abuse/Vulnerable Adult Signs of abuse and neglect include: Unexplained injuries or behavior Reports of physical, mental, or sexual abuse Reports of being abandoned or deserted without basic necessities
Lack of food, hydration, clothing, proper housing (heat), or hygiene Failing to provide basic life necessities, not taking action to prevent harm or pain
Lack of physical aids like hearing aids, dentures, or eyeglasses, wheelchairs, canes Failure to provide safe living conditions Untreated injuries or health problems Intentionally taking advantage of a vulnerable adult either financially, or personally Undue influence or coercion
© 2013 Seattle / King County EMS
Elder Abuse/Vulnerable Adult Injuries can result from following
behaviors & actions: Pushing, striking, slapping, burning, biting,
or pinching to severe beatings Restraints with ropes or chains Force-feeding Incorrect positioning - creating pressure
sores Improper use of restraints or medications
If you encounter any of these environments or injuries & you suspect abuse, call Department of Social and Health Services
(DSHS) at 1-800-562-6078, your local police, or Adult Protective
Services
If you encounter any of these environments or injuries & you suspect abuse, call Department of Social and Health Services
(DSHS) at 1-800-562-6078, your local police, or Adult Protective
Services
© 2013 Seattle / King County EMS
End of life issues
Medical care of the elderly should always address the issue of quality of life. This includes care towards the end of a person’s life.
Advanced directives such as the POLST detail the type of care that a person would like to receive, ranging from full treatment of intubation, CPR, and medications, to comfort care only.
© 2013 Seattle / King County EMS
Withholding Resuscitation for Compelling Reasons Expected Natural Death
Patients who are mentally competent have the right to refuse medical care, including resuscitation. Patients who are dying have the same rights. You have the responsibility to determine a patient's resuscitation wishes and honor them if possible.
Compelling reasons permit EMS personnel to withhold resuscitation from a patient in cardiac arrest when two criteria are BOTH present. These are: End stage of a terminal condition Written or verbal information from family, caregivers
or patient stating that patient did not want resuscitation
© 2013 Seattle / King County EMS
Withholding Resuscitation for Compelling Reasons Expected Natural Death
If both criteria are not met, you should initiate a resuscitation effort.
If both criteria are met, you should withhold a resuscitation effort. If resuscitation was already started, it should be stopped.
You must document compelling reasons on your run report when they are used as a basis for withholding resuscitation.
Follow your own agency’s guidelines when dealing with end-of-life issues.
© 2013 Seattle / King County EMS
Case Studies
Video Case Study #1http://www.emsonline.net/geriatric2011/case1.asp
Video Case Study #2http://www.emsonline.net/geriatric2011/case2.asp
© 2013 Seattle / King County EMS
SummaryDiminishing stroke volume in the elderly patient Stroke volume (SV) is volume of blood ejected with each contraction Ejection fraction (EF) is blood ejected by left ventricle during contraction divided by total volume of left ventricle Normal EF is approximately 60-65%
Pneumonia Most common & significant health problems for the elderly Fourth leading cause of death in this age group Serious underlying illness is major risk factor for developing pneumonia in the elderly
© 2013 Seattle / King County EMS
SummarySigns and symptoms of dementia Disorientation – may not know timeframes, where they are, who their relatives are Memory loss, mostly short-term
Strokes A stroke (also known as a cerebral vascular accident – CVA) is a medical emergency Strokes occur when blood flow to a portion of the brain stops Require rapid evaluation & rapid transport
© 2013 Seattle / King County EMS
SummaryPolypharmacology Use of multiple medications Can lead to mental confusion
Elder Abuse/Vulnerable Adult Mandated reporter of elder abuse Signs of abuse & neglect include:
Unexplained injuries or behavior Reports of physical, mental, or sexual abuse Lack of food, hydration, clothing, proper housing
(heat), or hygiene Lack of physical aids like hearing aids, dentures, or
eyeglasses, wheelchairs, canes Failure to provide safe living conditions Untreated injuries or health problems Undue influence or coercion
© 2013 Seattle / King County EMS
Questions
Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp
EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp
Susan KolwitzProgram ManagerEmail support: [email protected]
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