GERIATRIC PATIENTS

1. LESSON 22 GERIATRIC PATIENTS

2. Introduction • Older adults are an increasingly large proportion of American population • Have more chronic health conditions that may lead to an emergency • Much emergency care given to geriatric patients • Be aware of possible age-related changes in geriatric patients and implications for assessment and treatment

3. Age-Associated Changes • Changes gradually occur throughout lifespan • By 65, human body has age-related changes in all body systems • Changes generally continue throughout lifespan • Rate and extent of changes depend on many factors • Never make assumptions about any patient based on age • Discrimination based on individual’s age is illegal

4. Changes in Sensory System • All senses become less acute with aging

5. Changes in Vision • Decreased general visual acuity • Reduced ability to differentiate colors • Diminished night vision • Diminished near vision • Decreased depth perception • Visual impairments are more common

6. Changes in Hearing • Decreased general hearing ability • Increased use of hearing aids • Diminished ability to hear high-pitched sounds • Hearing impairments are more common

7. Changes in Touch and Pain • Decreased sense of balance • Diminished ability to differentiate temperature • Decreased tolerance of hot and cold • Diminished perception of pain

8. Changes in Smell and Taste • Diminished smell and taste • May cause reduced appetite and nutritional deficiencies

9. Changes in Cardiovascular System • Heart muscle less powerful and blood vessels less elastic • Rising blood pressure over the years  may result in hypertension • Diminished heart output • Decreased functional blood volume

10. Changes in Cardiovascular System (continued) • Reduced circulation and lower perfusion in some body areas such as legs • Reduced ability of heart to beat faster when needed • Increased risk of heart attack • Increased risk of stroke

11. Changes in Respiratory System • Less flexible alveoli in lungs, reduced gas exchange • Less effective muscles for breathing • Inhaled substances (such as tobacco smoke) cause other changes in lungs and airways

12. Changes in Respiratory System (continued) • Diminished breathing capacity • Decreased forcefulness of coughing (and reduced ability to cough out an airway obstruction) • Increased risk of respiratory infections

13. Changes in Gastrointestinal System • Stomach and intestines function less well • Mouth changes, including use of dentures or other dental appliances, affect chewing and swallowing • Difficulties chewing and swallowing increase risk of foreign body airway obstructions • Digestive difficulties

14. Changes in Nervous System • Slower reflexes increase risk of falls • Diminished cough or swallowing reflexes • Diminished short-term memory • Other cognitive changes may affect behavior • Dementia, Alzheimer’s and senility are not normal changes of aging  but occur more commonly in older adults

15. Changes in Musculoskeletal System • Decreased bone density: bones fracture more easily, even without trauma • Osteoporosis decreases bone density • Diminished size and strength of muscles • Joint changes make arthritis more likely • Curvature of upper spine is more common

16. Other Age-Related Changes • Immune system and other changes may cause: • Increased risk of many types of infections • Less apparent signs and symptoms of infection when present (less likely to seek early treatment) • More frequent loss of bladder or bowel control (preserve patient’s privacy and dignity) • Less perspiring when warm (making heat emergencies more likely)

17. Chronic Disease • Many chronic conditions are more common in geriatric patients • Contributes to greater risk of injury or emergency illness • Medications for chronic illness may have assessment and treatment implications

18. Age Implications for Assessment and Treatment • Do not assume older individual is automatically different from other adults • Be aware of age-related changes and implications for assessment and treatment

19. Primary Assessment • Neck arthritis makes airway management more difficult • Do not remove patient’s dentures for ventilation or rescue breathing unless they interfere • Increased risk for airway obstructions caused by foreign body or swollen tissues from infection • Pulse may be irregular due to arrhythmia • If patient seems to have altered mental status or diminished cognition, ask family members about pre-emergency mental status

20. The Secondary Assessment • Ensure lighting is adequate • Position yourself at the patient’s eye level • Speak slowly and distinctly • Give patient time to respond • Some geriatric patients may deny symptoms  be thorough and use good communication skills • Older adults are more susceptible to traumatic injury • With reduced pain perception, injuries may not be immediately apparent

21. The Secondary Assessment(continued) • Chronic medical conditions may increase likelihood of fall or other trauma • Trauma more likely to cause bone fracture • Normal vital signs depend on general physical and health status • Vital signs may change rapidly with bleeding • Seek detail about medications taken • Medications may affect vital signs, blood clotting and other aspects of emergency care • Patient may not show severe signs of illness even when very ill

22. The Secondary Assessment(continued) • Depression is common and may affect patient’s behavior and communication • Nutrition may be inadequate or home poorly heated or cooled • Size up the scene for clues to patient’s condition • With suspicious injuries, consider possibility of elder abuse • Do not let many layers of clothing prevent you from adequate examination • Reassess frequently because patient may deteriorate quickly

23. Implications for Treatment • Handle patient very carefully • With upper spine curvature, padding may be needed during spinal immobilization • With decreased cough reflex, suctioning may be needed • Prevent hypothermia in a cool environment • Provide reassurance and support

24. Trauma • Trauma often has more serious effects in geriatric patients • Never assume any injury is minor based on mechanism of injury or because signs and symptoms do not seem severe • Falls are a particular concern • Cause fractures of hip, spine or other bones • Treat all falls as severe or possibly life-threatening

25. Trauma (continued) • Carry out physical examination carefully • Manually stabilize or splint area • Coinciding medical and traumatic emergencies more likely • Never assume injury is only issue to be addressed • Perform full secondary assessment with complete history • Closely monitor vital signs and breathing • Reassess more frequently

26. Medical Emergencies • May be caused or exacerbated by chronic illness • Common reason for EMR calls • Signs and symptoms may not be classic picture • Heart attack may not cause pain or chest symptoms • Keep an open mind during assessment

27. Special Considerations in Medical Emergencies • Denial of symptoms does not mean patient feels nothing • Patient may not consider symptoms a concern • Heart attack and stroke may produce minimal symptoms • Never dismiss respiratory symptoms in geriatric patients

28. Special Considerations in Medical Emergencies (continued) • Take thorough history of medications, consider accidental overdose or drug interaction • Do not move patient from bed or wheelchair except for lifesaving care • Remember dementia is not normal  consider altered mental status related to illness

29. Elder Abuse • Half a million elders in United States abused or neglected each year • In 90% of cases, abusing person is family member • The older a person is, the greater the risk for abuse • Most likely abused are those who: • Need help with daily activities • Have lost bladder control • Behave unusually because of altered mental status

30. Most Important Signs of Elder Maltreatment • Frequent, unexplained crying • Unexplained fear of or suspicion of particular person in the home

31. Signs and Symptoms of Physical Abuse • Bruises, black eyes, welts, lacerations and rope marks • Bone fractures, skull fractures • Open wounds, cuts, punctures, untreated injuries, injuries in various stages of healing • Strains, dislocations and internal injuries or bleeding • Broken eyeglasses, physical signs of being subjected to punishment, signs of being restrained

32. Signs and Symptoms of Physical Abuse (continued) • Medication overdose or underuse of prescribed drugs • Elder’s report of being hit, slapped, kicked or mistreated • Elder’s sudden change in behavior • Caregiver’s refusal to allow visitors to see elder alone

33. Signs and Symptoms of Sexual Abuse • Bruises around the breasts or genital area • Unexplained venereal disease or genital infections • Unexplained vaginal or anal bleeding • Torn, stained or bloody underclothing • Elder’s report of being sexually assaulted or raped

34. Signs and Symptoms of Emotional/Psychological Abuse • Emotional upset or agitation • Extreme withdrawal, lack of communication and responsiveness • Elder’s report of being verbally or emotionally mistreated

35. Signs and Symptoms of Neglect • Dehydration, malnutrition, untreated bed-sores and poor personal hygiene • Unattended or untreated health problems • Hazardous or unsafe living conditions • Unsanitary or unclean living conditions • Elder’s report of being neglected

36. Signs and Symptomsof Abandonment • Desertion of elder at hospital, nursing facility or similar institution • Desertion of elder at shopping center or other public location • Elder’s own report of being abandoned

37. Signs and Symptomsof Self-Neglect • Dehydration, malnutrition, untreated medical conditions, poor personal hygiene • Hazardous or unsafe living conditions • Unsanitary or unclean living quarters • Inappropriate or inadequate clothing, lack of necessary medical aids • Grossly inadequate housing or homelessness

38. Emergency Care for Suspected Victims of Elder Abuse • Perform standard assessment • Perform standard patient care • Give emergency care for injuries or illness found • Ensure privacy while providing care • Provide emotional support • Do not directly confront patient with your suspicions, especially if family members are present • Note everything patient says about cause of injuries

39. Emergency Care for Suspected Victims of Elder Abuse (continued) • If you see physical abuse occurring or a crime committed, or if someone at the scene is threatening and potentially violent, call law enforcement personnel • Tell responding EMS personnel in private about your suspicions • Elder abuse is a mandatory reportable event • Follow local protocol to document your observations and file appropriate report • Be especially careful in your documentation