EMT Ch. 36- Geriatric Emergencies

geriatrics

assessment/treatment of disease in individuals 65+ yrs

common stereotypes of older pts

assuming pt:

• has dementia

• is hard of hearing

• has sedentary lifestyle

• is immobile

techniques for communicating with older pts

• identify self

• be aware of self presentation (avoid showing frustration/impatience through body language)

• look directly at pt at eye level & ensure good lighting

• speak slowly/distinctly (do not raise voice, try talking in lower tone)

• have one person talk to pt & only ask one question at a time

• do not assume all older pts are hard of hearing

• listen to answers pt gives for questions

• explain what will be done before doing it (use simple terms)

• do not talk about pt in front of them as though they were not there

common conditions in geriatrics

• hypertension

• arthritis

• heart disease

• cancer

• diabetes mellitus

• asthma

• chronic bronchitis/emphysema

• stroke

leading causes of death in geriatrics

• heart disease

• cancer

• injury

• chronic lower respiratory disease

• stroke

• alzheimer disease

• diabetes mellitus

• influenza & pneumonia

human growth/development peaks during:

late 20s, early 30s

changes in respiratory system

• weakening of airway musculature causing decreased breathing capacity

• alveoli become enlarged, elasticity decreases

  • decrease ability to bring in O₂ & remove CO₂

• chemoreceptors become less sensitive to changes in O₂ & CO₂ levels

• decreased cough/gag reflexes

leading cause of death from infection for geriatrics:

pneumonia

risk factors for pulmonary embolism

• recent hospitalization for illness/surgery (especially lower extremity) leading to sedentary behavior

• trauma

• cancer

• history of blood clots

• heart failure

signs/symptoms of pulmonary embolism

• tachycardia

• sudden onset dyspnea

• shoulder/back/chest pain

• cough

• syncope

• anxiety (sense of impending doom)

• apprehension

• low-grade fever

• hemoptysis

• leg pain

• redness

• swelling in one ankle/foot

• profound fatigue

• cardiac arrest

changes in cardiovascular system

• enlargement of heart

• decline in cardiac output & stroke volume

• arteriosclerosis (stiffening of arteries)

arteriosclerosis

disease causing arteries to thicken, harden, & calcify

atherosclerosis

accumulation of fat/cholesterol in arteries

true/false: geriatrics may have a “silent” heart attack where chest pain is not present

true

signs/symptoms indicating cardiovascular problem

• issues w/ circulation

• diaphoresis

• pale, cyanotic, mottled skin

• abnormal/decreased breath sounds

• increased peripheral edema

signs/symptoms of right-side heart failure

• JVD

• ascites

• peripheral edema

• enlarged liver

signs/symptoms of left-side heart failure

• pulmonary edema

• SOB

• hypoxia

• rales

paroxysmal nocturnal dyspnea

• sudden respiratory distress that awakens person at night when in reclining position

• caused by fluid accumulation in lungs

• signs/symptoms include coughing, feeling suffocated, cold sweats, tachycardia, orthopnea

changes in nervous system

• declines in mental function

  • language/sensory processing

  • longer retrieval times for short/long-term memory

• weight/volume of brain decreases 10-20%

• loss of 5-50% of neurons

  • affects control of rate/depth of breathing, HR, BP, hunger, thirst, body temp

• deterioration of senses

• visual/auditory changes

cateracts

• clouding of lenses/surrounding membranes of eyes

• causes difficulty w/ distinguishing colors, seeing clearly

  • increases risk of falls, accidents, mistakes w/ taking meds

glaucoma

• increased pressure in eye

• causes damage to optic nerve, headache, nausea/vomiting, visual disturbances

macular degeneration

• deterioration of macula (central portion of retina)

• causes vision loss in central part of visual field

retinal detachment

• retina is pulled away from choroid (thin layer of blood vessels supplying nutrients/O₂ to retina)

• retinal cells become deprived of O₂, causing permanent vision loss

• causes floaters, debris in visual field, sudden flashes of light/shadow, visual blurring

presbycusis

age-related hearing loss

dementia

• gradual onset of progressive/chronic disorientation, shortened attention span, loss of cognitive function

• risk factors include alzheimer disease, parkinson disease, CVA, genetics

• pts may be confused & angry, unable to vocalize areas of pain/current symptoms, exhibit disorganized thoughts, inattention, memory loss, disorientation, hallucinations, delusions, reduced LOC, anxiety

• may not understand need for transport

delirium

• sudden change in mental status, consciousness, cognitive processes

• marked by inability to focus, think logically, maintain attention

• caused by reversible physical ailment (tumor, fever, meds change), metabolic causes, alcohol/sedative intoxication/withdrawal, UTI, bowel obstruction, dehydration, fever, cardiovascular disease, hyperglycemia, hypoglycemia, depression, malnutrition, vitamin deficiencies

• assess for hypoxia, hypovolemia, hypoglycemia, hypothermia

possible causes of syncope

• dysrhythmias/heart attack

• vascular/volume changes

• neurologic cause

changes in GI system

• reduction in volume of saliva/gastric secretions

• dental loss

  • may lead to nutritional/digestive problems, choking

• decrease in gastric mobility/emptying

• blood flow to liver declines

• liver shrinks & ability to detoxify/remove drugs from blood declines

changes in renal system

• mostly kidney specific

  • reduction in renal function, blood flow, tubule degeneration

• decreased bladder capacity

• decline in sphincter muscle control

• decline in voiding senses

• increase in nocturnal voiding

• benign prostatic hypertrophy (enlarged prostate, men)

changes in endocrine system

• decreased metabolism of thyroxine leading to hypothyroidism

  • affects metabolism, temp, growth, HR

• increase in secretion of antidiuretic hormone

  • causes fluid imbalance, hyperglycemia, increase in levels of norepinephrine (harmful to cardiovascular system)

true/false: fevers are unable to develop in many older pts

true

primary symptoms of infection

• anorexia

• fatigue

• weight loss

• falls

• changes in mental status

changes in musculoskeletal system

• decrease in bone mass

• osteoporosis develops

• vertebral disks narrow, decreasing height

• joints lose flexibility, arthritis may develop

• decrease in muscle mass, decrease in strength

kyphosis (humpback, hunchback)

• forward curling of spine

• caused by atrophy of supporting structures of body

decubitus ulcers (bedsores)

• pressure ulcers forming when pt is lying/sitting in same position for long duration

• can develop in as little as 45 min

pathologic changes causing geriatrics to be susceptible to toxicity

• decreased kidney function

• altered GI absorption

• decreased vascular flow in liver altering metabolism & excretion

risk factors for depression

• history of depression

• chronic disease

• loss (function, independence, family)

• substance abuse

• isolation

• prescription meds use

GEMS diamond- G

geriatric pts

• present atypically

• deserve respect

• experience changes w/ age

GEMS diamond- E

environmental assessment

• physical condition of living space; need for repairs; security

• hazardous conditions present (poor wiring, uneven floors, unventilated gas heaters, broken window glass, clutter)

• present/functional smoke detectors

• temperature of home

• fecal/urine odor in home

• care of pets

• presence of adequate/unspoiled food

• presence of empty liquor bottles lying around

• soiled/dirty bedding

• if pt has disability, presence of appropriate/adequate condition assistive devices (wheelchair, walker)

• access to telephone

• prescribed, expired, unmarked meds

• if living w/ others, confinement to one part of home

• if residing in nursing facility, care appear to meet pt’s needs

GEMS diamond- M

medical assessment

• presence of variety of medical problems, makes assessment more complex

  • trauma pts may have underlying medical conditions related to traumatic event

• obtain medical history regardless of primary complaint

• primary assessment

• reassessment

GEMS diamond- S

social assessment

• assess activities of daily living (ADLs) (eating, dressing, bathing, toileting)

  • if provided, determine by whom

• delays in obtaining food, meds, hygiene

• regular visits from family, lives w/ family, lives w/ spouse

• if in institutional setting, determine if pt can feed self, if food is sitting uneaten on food tray, lying in own urine/feces for prolonged durations

• presence of social network, ways to interact socially w/ others on daily basis

special considerations when assessing geriatrics

• take note of issues that would make home environmentally unsafe

• introduce self, show respect, use patience to gain pt’s confidence

• assessment may be complicated by multiple medical/traumatic conditions, alterations in LOC, & hearing/vision impairments

• airway, breathing, circulation, vitals are changed by normal processes of aging

• polypharmacy may be present, be aware of possibility of overdose, underdose, drug interactions

• body does not have flexibility/reserves of younger person when facing illness/injury

• more easily affected by poor nutrition

• cannot thermoregulate easily, tend to be cold

• memory/cognition may be impaired

• skin may be fragile & tear easily, consider safe/appropriate transfer options

methicillin-resistant staphylococcus aureus (MRSA)

• common infection among people living in close quarters

• can be found in decubitus ulcers, feeding tubes, indwelling urinary catheters

• signs/symptoms depend on type of infection, affecting skin, bloodstream, lungs, urinary tract

• primarily spread by broken skin-to-skin contact or contact w/ contaminated surfaces

vancomycin-resistant enterococci (VRE)

• bacteria normally present in intestines & female reproductive tract

• can cause infection under right circumstances

• resistant to vancomycin

respiratory syncytial virus (RSV)

• causes infection of upper/lower respiratory tracts

• primarily affects children, geriatrics w/ lung disease/weakened immune systems

• signs/symptoms similar to common cold but are more severe/last longer

• virus is highly contagious & found in discharges from nose/throat of infected person

• transmitted through direct contact w/ droplets & touching contaminated surfaces

clostridium difficile (c diff)

• most common cause of hospital-acquired infectious diarrhea

• normally grows in intestines

• signs/symptoms range from minor diarrhea to life-threatening inflammation of colon

• typical alcohol-based hand sanitizers do not kill this bacteria

palliative care

• care for dying pts focusing on relieving pain & providing emotional support/comfort for pt & loved ones

elder abuse

• any action on part of geriatric pt’s family, caregiver, other associated person that takes advantage of older person’s person, property, emotional state

• can be verbal, physical, sexual, acts of omission/negligence

signs of elder abuse

• caregiver apathy about pt’s condition

• overly defensive reaction by caregiver to questions

• caregiver does not allow pt to answer questions

• repeated visits to ED/clinic

• history of being accident-prone

• unexplainable soft-tissue injuries

• unbelievable, vague, inconsistent explanations of injuries

• psychosomatic complaints

• chronic pain w/o medical explanation

• self-destructive behavior

• eating/sleeping disorders

• depression/lack of energy

• history of substance/sexual abuse

types of physical abuse

• assault

• neglect/abandonment

• dietary (malnutrition)

• poor maintenance of home

• poor personal hygiene

• sexual assault

types of psychological abuse

• benign neglect

• verbal

• treating person as infant

• deprivation of sensory stimulation

types of financial abuse

• theft of valuables

• embezzlement