Geriatrics - Special Considerations and Changes

Section 6: Special Considerations in Geriatrics

Cardiovascular Changes

• Overview: Aging affects the cardiovascular system, leading to decreased efficiency.

• Heart Hypertrophy:

  • The heart muscle enlarges, impacting its ability to pump effectively.

• Cardiac Output Decline:

  • Overall volume of blood pumped by the heart is reduced.

• Conditions:

  • Arteriosclerosis: Stiffening of the blood vessels.

  • Atherosclerosis: Build-up of plaque in arteries.

  • Aortic Stenosis: The aortic valve fails to open fully, causing obstruction.

• Electric Conduction System:

  • Pacemaker cells in the sinoatrial node decrease, leading to potential bradycardia and dysrhythmias.

• Muscle Degeneration:

  • Reduced contractility and stroke volume due to age.

• Causes of Cardiovascular Decline:

  • Sedentary lifestyle causing deconditioning.

  • Disabilities or psychological issues can restrict physical activity.

Respiratory Changes

• Lung Elasticity:

  • Decreased elasticity decreases overall lung function.

• Respiratory Muscles:

  • Weaker respiratory muscles lead to reduced strength.

• Calcification:

  • Costochondral cartilage stiffens, leading to decreased vital capacity and increased residual volume.

• Respiratory Drive:

  • Dulls sensitivity to blood gases; slower reaction times increase risks of hypercarbia and hypoxemia.

• Cough Reflex:

  • Declining reflex, body’s defense mechanism against secretions decline,increasing risk of aspiration and ineffective bronchial secretion clearance.

Renal Changes

• Kidneys:

  • Blood flow to kidneys reduced by 50%.

  • Smaller kidney size reduces filtration area.

  • less surface area = decreased ability for filtration

  • Sluggish response to sodium deficiency and decreased thirst mechanism leads to fluid imbalance.

• Bowel and Bladder:

  • Urinary incontinence: Not a normal aging part, but can be due to stress or urge incontinence, impacting social and emotional status.

• patients with decreased kidney function due to old age, medications and treatments may not have be as affective

Digestive Changes

• Taste and Smell:

  • Approximately one-third of taste buds may be lost by age 70.

  • Decreased olfactory receptors reduce food enjoyment.

• Saliva and Gastric Function:

  • Reduction in saliva and gastric secretions weaken

  • esophageal sphincter; slower gastric motility observed.

  • Drug detoxification declines with age.

• The liver’s ability to detoxify the body also declines, especially risky for patients taking multiple medications for old age or terminal diseases.

  • causing side effects

  • unwanted reactions between medications

Musculoskeletal Changes

• Bones:

  • General decrease in bone mass leads to brittleness and increased fracture risk.

  • Decrease in height and joint flexibility with age. (compression of vertebrae and arthritis)

• Muscle Mass:

  • Loss of muscle mass leads to decreased functional ability. (strength, balance and mobility)

  • Arthritis: Common degenerative condition affecting joint health.

• patients experiencing a terminal illness like cancer can face even more challenges, with mobility and strength being decreased and the added burden of fatigue and pain management, plus their ability to tolerate certain treatments and medications

Nervous System Changes

• Cognitive Skills:

  • Do not assume cognitive decline; elderly may possess substantial cognitive abilities.

• Neurological Examination:

  • Slower thinking, memory changes, and reduced postural stability.

• Brain Changes:

  • Weight and volume decrease 5-10% but reserve capacity remains. but that doesn’t necessarilly mean a decline in brain capacity and function

• Sensory Organs:

  • Decline in sight and hearing; increased risk for falls due to proprioceptive impairment. (lack of awareness where our body is)

  • presbycusis: gradual loss of hearing with age

• Medications and medical treatment won’t fix everything, continuing to approach and communicate with patients in a respectful and compassionate manner will allow for better communication and less stress.

Dementia and Delirium

• Dementia Types:

  • Alzheimer's (50-70%), Vascular, Frontotemporal, and others due to drug use or disease.

• Delirium Mnemonic:

  • Causes include drugs, emotional issues, low oxygen levels, infections, and undernutrition.

Integumentary Changes

• Skin Changes:

  • Thinner, drier skin leading to increased fragility and bruising. Lower oil and sweat production. subcutaneous fat also thins out, causing increase chance of bruising

  • hair becomes thinner or stops growing

  • melanin production decreases; graying hair and less skin pigmentation

• Blood Flow:

  • Decreased circulation affects healing and infection risk, making elderly more vulnerable to skin issues.

  • making elderly more susceptible to skin tumors, reactions or medications.

  • shingles and cellulitis being most prominent in older patients

  • temperature regulation becomes impaired with age, unable to react and control temperature as efficiently

Trauma and Injury Considerations

• Injury Risk:

  • Elderly fall risk is significant, accounting for 75% of fall-related deaths.

  • Slower reflexes, vision/hearing deficits increase vulnerability to injury.

• Common Injuries:

  • Hip fractures most prevalent, alongside chest, head, and spinal cord injuries.

Toxicology Considerations

• Medication Issues:

  • Changes in metabolism, renal function, and body composition influence drug efficacy.

  • Polypharmacy: Common among elderly, increasing risk of adverse effects.

• Noncompliance:

  • Lack of adherence due to difficulties with medications, leading to therapeutic errors.

Societal Issues and Mental Health

• Isolation and Loneliness:

  • Elderly living alone represent a vulnerable demographic due to lack of support.

• Psychiatric Conditions:

  • Depression prevalent but often unrecognized. Treatment can significantly improve quality of life.

• Elder Maltreatment:

  • Various forms of physical, emotional, and financial abuse prevalent; often unreported.

Conclusion

• Assessment in Geriatric Patients:

  • Key to recognize normal aging versus disease symptoms. The elderly may have multiple co-existing conditions that complicate diagnosis and treatment.

Recommendations for Care

• Scene and Initial Assessment:

  • Evaluating living conditions, social support, and medication usage is essential in understanding patient needs. Adapt paramedic practices to enhance community

  • support for elderly individuals.

Connections to oncology and terminal illnesses

• elderly patients with pre-existing medical conditions such as decreased lung capacity or a long time smoker can be diagnosed with lung cancer, further compromising their ability to perform gas exchange and sufficient breaths

• elderly patients going through chemotherapy, their liver may not be able to process medications as efficiently and cause worse or prolonged side effects from it.

• even patients with terminal illnesses have decreased mobility can face simple challenges like getting around the house, performing basic tasks like picking things up. impacting their independence and quality of life

• oncology: branch of medicine that deals with the diagnosis and treatment of cancer

• terminal illnesses: refers to diseases that inevitably result in the death of patient

• consent: granting permission to treat a patient, can be expressed verbally or in writing, implied or voluntary

• ***advance directive (“living will”): written instructions from the patient that outlines the actions that should be taken if the patients health declines and they becomes incapacitated. you can also leave this directive with somebody to ensure your wishes are followed specifically.

• ***power of attorney: written authorization that empowers an individual to represent or act on behalf of person in private, medical or other business affairs. (FINANCIALLY)

• ***goals of care: medical order used to describe and communicate the general aim or focus of care including location of that care.

• DNR; for it to be valid, it needs to be CLEARLY signed by the patient, their legal representative and the physician. so in the case of cardiac or respiratory arrest, the medical team is made aware of the next steps to be taken, whether to continue resuscitating or stop.

• the most common cancers in elderly patients are, lung cancer, breast cancer and prostate cancer.

• history:

  • when was the diagnosis?

  • when past or present treatments have they received?

  • Has the cancer metastasized?

    • where is the primary tumor and are there any secondary sites?

  • any concerns the patients or family has?

    • medications?

    • side effects?

Assessments for

• due to age and illnesses, their vitals maybe different from what is expected, our normal is not the same as their normal.

• presentation can be different for each patient. making sure to ask family or the patient what their normal is and the patient usually present with.

• consider the the illness they have, in regards to cancer, lung sounds may be different than expected.

• patients in later stages of cancer are prescribed higher dosages of medications, make sure to understand that their doses are different from normal people

• managing a patient with a terminal illness, it is critical to check the level of care for the patient, treatment or comfort.

  • if the patient has a DNR or an advanced directive

  • if there is no valid DNR, advanced directive or power of authority present, we have to provide the necessary standard of care needed for the patient.

Palliative care is the approach to improve quality of life for people who are facing serious, complex or terminal illnesses, by preventing or relieving suffering. Not just physical problems, but emotional psycho-social and spiritual problems. not just caring for the disease but also for the person carrying the disease.

• also comes with comfort and preparing the family for the transitions involved in end-of-life care, ensuring they understand the process and providing support during this challenging time.

• making sure to be there not only for the patient but for the family.

  Hospice: specific kind of care that falls under the umbrella term palliative care, this type of care is considered when the illness is incurable and or too far advanced, the only treatment is to focus on comfort for both the patient and the family.