Geriatric Care

David Ankrom, BS, EMT-P, FP-C, EMS-I

Flight Paramedic/ Clinical Instructor

Aging Statistics

• Almost 15% of people in the US are

over age 65.

• “Baby Boomers” will increase this

number.

• Expect to see an increase in emergency

calls involving older patients.

Ageism

• Stereotyping and

discrimination of older people

• Categorizing people as senile,

eccentric, or stubborn

• “Geezer,” “Lizard,” and

“GOMER” perpetuate ageism

• Use of “honey” or “dear” is a

milder form

The GEMS Diamond

• Remember the following when caring for

older people:

– Geriatric patients

– Environmental assessment

– Medical assessment

– Social assessment

Leading Causes of Death in Older People

• Disease of the heart

• Cancer

• CVA/Stroke

• COPD

• Pneumonia

The Aging Body:

Integumentary System

• Wrinkles

• Thinner skin

• Decreased fat

• Gray hair

The Aging Body:

Respiratory System

• Changes in airway

• Decreasing muscles of

ventilation

• Increased residual volume

• Decreased sensitivity of

chemoreceptors

The Aging Body:

Cardiovascular System

Development of

atherosclerosis

Decreasing cardiac output

Development of arrhythmias

Changes in blood pressure

The Aging Body:

Nervous System

• Brain shrinkage

• Slowing of peripheral nerves

• Slowed reflexes

• Decreasing pain

sensation

The Aging Body:

Sensory Changes

• Vision distorts and eye

movement slows.

• Hearing loss is more common.

• Taste decreases.

The Aging Body:

Renal, Hepatic, and GI Systems

• Kidneys become smaller.

• Hepatic blood flow decreases.

• Production of enzymes declines.

• Salivation decreases.

• Gastric motility slows.

The Aging Body:

Musculoskeletal System

• Decreased muscle mass

• Changes in posture

• Arthritic changes

• Decrease in bone mass

The Aging Body:

Immune System

• Less effective immune response

• Pneumonia and UTI are common.

• Increase in abnormal immune

system substances

General Patient Assessment

• Scene size-up includes environmental assessment:

– General appearance, cleanliness

– Temperature, food

– Drugs, alcohol, signs of abuse

• Initial assessment looks for life threats:

– Airway cannot be protected as well.

– Breathing can be complicated by previous disease.

– Circulatory system has slowed responses.

Mental Status Assessment

• Confusion is not normal.

• Distinguish chronic

changes from new ones.

• Enlist help from family.

• Establish a baseline

mental status.

• Don’t be misled.

Assessment

• Prioritize patient status.

• Detailed physical exam

• Ongoing assessment is required.

Assessing the Chief Complaint

• Determining the chief complaint can be hard.

• Start with what is bothering the patient most.

• Chief complaints may not be the life threat.

• Communication is a big component.

Chief Complaint:

Shortness of Breath

• Frequently life threatening

• Often respiratory or cardiac in origin

• Can occur for other reasons such as pain, bleeding, medications

• Are there associated signs and symptoms?

• Does patient have a history of respiratory complaints?

Respiratory Issues Related

to Aging

• Physiologic reserves are decreased.

• History of underlying disease

• Respiratory assessment can be challenging.

• Medications can complicate the situation.

Assessment of Respiratory

Complaints

• History may suggest the problem.

• SAMPLE history should be completed.

• Some questions to ask include:

– Have you ever had this before?

– How many pillows do you sleep on?

– Have you changed any of your medications?

Components of a

Respiratory Exam

• Inspection

• Palpation

• Percussion

• Auscultation

Pneumonia

• Major killer of older adults

• Presentation may differ in older people.

• Crackles, pus in sputum, fever, loss of

appetite

General Emergency Respiratory

Management

• Reduce patient’s anxiety by reassurance.

• Protect the airway.

• Allow position of comfort if patient can maintain.

• Oxygen is indicated.

• If patient has an inhaler, assist patient with a dose.

• Other medications as situation warrants within local protocol.

Chief Complaint: Chest Pain

• Often cardiac in nature

• Many experience pain differently.

• Medication history is important.

• Have the patient locate the pain.

• Expose the chest: scars, pacemaker,

medication patches

Cardiovascular Disease

• Most common cause of death in older people

• CAD and CHF top the list.

• Dyspnea is often the complaint.

How should you begin to differentiate cardiac from respiratory causes?

Taking a History

• Compare signs and symptoms to

previous events.

• Past diagnoses are a good place to

start.

• Medications may lead you to a cause.

• Compare events leading up to today

with patient’s normal activity.

Chronic Obstructive Pulmonary

Disease (COPD)

• Asthma

• Emphysema

• Chronic bronchitis

Clinical Presentation of Angina or AMI

• May experience no pain or atypical pain

• Less localized, vague, not "crushing" or "squeezing"

• Dyspnea, fatigue, syncope, nausea, confusion

• Palpitations upon effort or sweating

• Ask about discomfort, not pain.

Management of Angina and AMI

• Decrease anxiety, make patient comfortable

• Maintain ABCs, high-flow oxygen

• 325 mg Aspirin

• Nitroglycerin q 5 min

• IV, monitor, 12-lead ECG, consider morphine

• If hypotension develops, give 250 mL bolus

crystalloid.

Management of CHF

• Keep patient upright to allow fluid shunting.

• Maintain ABCs.

• High-flow oxygen

• CPAP or BiPAP can be a useful tool.

• IV, ECG monitor, advanced airway if needed, 12-lead ECG

• Medications: nitroglycerin, furosemide (Lasix), morphine, and aspirin if chest pain is present

Arrhythmias

• Many types affect the older population.

• Atrial fibrillation is common.

• Control of ABCs

• Rate control if rapid ventricular response

• 12-lead ECG is helpful.

Hypertension

• Affected organs: heart, eyes,

brain, kidneys

• Pressure should be lowered

slowly.

• A quick drop can result in

stroke, AMI, or death.

• Beta-blockers, sodium

nitroprusside, or IV nitroglycerin

Chief Complaint:

Altered Mental Status

• Some causes manifest quickly, others over days

• Medication reactions are a frequent issue.

• Determine LOC and orientation to person, place, and time.

• Check motor and sensory response.

• Get an ECG and blood sugar reading.

Chief Complaint:

Dizziness or Weakness

• Factors: balance, injury, oxygen, and energy

• History will help clarify the complaint.

• Check ECG, orthostatic changes, blood sugar

• Check for signs of stroke.

• Assess for signs of head trauma.

Age-Related Changes in the

Nervous System

• Be aware of normal changes in older patient’s

nervous system.

• Changes will affect neurologic examination:

– Cognitive (thinking)

– Speed

– Memory

• Postural stability

Causes of Altered Mental Status

• Can be difficult to determine in the older

patient

• Neurologic symptoms may be the result

of multiple causes.

• Use VITAMINS C & D mnemonic to recall

potential causes.

Vitamins C & D

• Vascular

• Inflammation

• Toxins, trauma, tumors

• Autoimmune

• Metabolic

• Infection

• Narcotics

• Systemic

• Congenital

• Degenerative

Stroke Facts

• Signs of stroke depend on type

– Ischemic

– Hemorrhagic

• Risk factors for stroke

– Modifiable and preventable

Seizures

• Massive discharge of neurons in brain

– Generalized motor seizures are most

common.

• Can be caused by many underlying

factors

Dementia

• Brain disorder with memory

impairment and loss of

mental abilities with normal

LOC

• Multiple causes, including

Alzheimer’s disease

• Gradual decline over many

years

Aggressive and Assaultive

Behaviors

• Severe depression or

dementia may cause

aggression.

• Aggression may be the

result of fear or altered

perception.

• Provider safety is

important.

Delirium

• Acute rapid

deterioration

• DELIRIUMS mnemonic

may help in

differentiating.

• Drugs and toxins

• Emotional

• Low PO2

• Infection

• Retention

• Ictal

• Under nutrition/dehydration

• Metabolism

• Subdural hematoma

Parkinson’s Disease

• Loss of flexibility and fluidity in movement

• Decrease in the production of dopamine in

brain

• Four cardinal signs:

– Resting tremors

– Rigidity

– Slowness of movement

– Postural instability

Neurologic Assessment

• Begins immediately upon

making patient contact

– AVPU

• Neurologic assessment of

face

• Neurologic assessment of

extremities

• Past medical history

• History of trauma

Stroke Evaluation

• Time of onset

• Cincinnati Prehospital

Stroke Scale

– Facial droop

– Arm drift

– Speech

• LA and NIH scales

Patient Management

• For any patient with altered mental status, airway and ventilatory support have priority.

– Supplemental oxygen at a minimum

– Consider need for positive pressure ventilations.

• Monitor ECG, pulse Ox, and blood sugar.

Seizure Considerations

• Continued airway support

• Pad all hard objects near patient.

• Administer an anticonvulsant.

– Intravenously or via rectal route

Infection and Sepsis

• Sepsis

• Bacteremia

• Septic shock

• Risk factors

– Age-related

– Institutionalization

Sepsis

• Causes of sepsis

• Prevention

– High index of suspicion

– Universal precautions

– Sterile technique for invasive care

– Hand washing

Chief Complaint: Trauma

• Exam follows the ABCs.

• Look for potential medical causes.

• Past history may change the

needs of the patient.

• Find the patient’s baseline status.

• Fractures are serious injuries.

Trauma: Injury Patterns

• Leading cause of death: falls, MVC,

burns

– Fewer MVCs, but with more severe

injuries

– Burns are associated with activities of

daily living.

• Penetrating trauma is less common.

• Physical injury from elder abuse

How Aging Affects Trauma

• Decreased pulmonary function and

abilities

• Hard to increase cardiac output

• Brain shrinkage allows bleeding.

• Musculoskeletal system changes

increase chance of injury.

Musculoskeletal Injuries

• Thoracic and lumbar spine injuries increase.

• Upper extremities have high loss of function.

• Less able to tolerate pelvic injuries

– Hip fractures are debilitating and can be fatal.

• Lower extremity fractures occur with less force.

ABCDEs for the Older Patient

• Airway: Dentures and lessened cough reflex

• Breathing: Checking chest wall and respiratory

drive

• Circulation: Quality of pulses

• Disability: Evaluating the patient's norms

• Exposure: Modesty and hypothermia

Assessment of the

Older Trauma Patient

• Early baseline vitals

• SAMPLE history

• New pain or old

• Physical exam

• Must include medical

evaluation

Considerations

• Conditions that may alter

physical assessment:

– Cataracts or asymmetrical

pupils

– Previous CNS condition

– Previous surgeries

– Decreased pain response

Trauma Management

• Treatment based on ABCs

• Early spinal immobilization with padding

• High-flow oxygen

• Prevention of hypothermia

• Rapid transport to appropriate center

• IV access and cardiac monitoring

Chief Complaint: Falls

• Generally result from contributing

factors

• Look for medical reason for fall.

• Assess for injury and life threats.

• ECG, blood glucose, pulse oximetry

Risk Factors for Falls and Injuries

• Sensory impairment

• Brain diseases that affect

balance

• Dementia

• Musculoskeletal disorders

• Medications

• Advanced age

Assessing a Fall Patient

• Symptoms

• Previous falls

• Location of fall

• Activity at time of fall

• Time of fall

• Trauma, both psychological

and physical

Preventing Falls in Older People

• Review of medications

• Improvement of sensory function

• Elimination of environmental obstacles

• Strength and balance exercises

Summary

• Number of people over age 65 is rising

• Changes with age affect assessment findings in older

patients.

• Common complaints fall into ten main areas.

• Cardiac diseases are the number one cause of death.

• Respiratory and cardiac diseases are more likely in later

years.

• Assessment is modified for older patient.

• Management includes maintaining ABCs.

• We must understand and accept aging.