Objectives • There are no 1985 objectives for this chapter.
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.
The GEMS Diamond (1 of 6) • G – Geriatric patients • Present atypically • Deserve respect • Experience normal changes with age
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?
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?
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 • Are medications out of date, unmarked, or from many physicians?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?
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.
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?
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.
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).
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.
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.
Leading Causes of Death for Older People • Heart disease • Cancer • Stroke • Diabetes • Trauma
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
Physiological Changes • Common stereotypes • Mental confusion • Illness • Sedentary lifestyle • Immobility
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
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.
Effects of Aging: Skin • Decrease in collagen • Increase in wrinkles • More bruises with minimal trauma • Longer healing process • Thermoregulatory problems
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.
Effects of Aging: Vision • Cataracts • Glaucoma • Macular degeneration
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.
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
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.
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
Effects of Aging: Smell • It is among the last senses to diminish. • Upper respiratory infections can affect the sense of smell.
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
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.
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.
Effects of Aging: Nervous System (1 of 2) • Short-term memory loss • A decrease in the ability to perform psychomotor skills • Slower reflex times
Effects of Aging: Nervous System (2 of 2) • Specific neurological conditions and problems • Parkinson’s Disease • Alzheimer’s Disease
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.
Effects of Aging: Gastrointestinal • Decreased volume of saliva and gastric juices • Slowing of the intestinal tract • Decreased liver functions
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)
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
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.
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.
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?
Patient Assessment (2 of 2) • Initial assessment • Chief complaint • ABCs • One responder speaks to the patient • One responder gathers information
Shortness of Breath Chest Pain Altered Mental Status Abdominal Pain Dizziness or Weakness Fever Trauma Pain Falls Nausea, vomiting, and diarrhea Most Common Geriatric Complaints
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.
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.
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
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.
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.
Fever • The body’s immune response to combat an infection. • What are the circumstances surrounding the fever? • When was the fever first noticed?
Trauma • Can be more debilitating in an older patient than a younger patient. • Was there an underlying medical cause?
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.
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