Geriatric Emergencies

Geriatric Emergencies

Introduction

  • Geriatrics is the assessment and treatment of disease in people 65 years of age or older.
  • Geriatric patients present a special challenge due to:
    • Chronic conditions.
    • Multiple medications.
    • The physiology of aging.

Generational Considerations

  • Understand and appreciate the life of older people, which may differ from younger generations.
  • It takes time and patience to interact with older individuals.
  • Treat the patient with respect, avoiding ageism.
  • Avoid stereotypes:
    • Not all older people have dementia.
    • Not all are hard of hearing.
    • Not all are sedentary or immobile.

Communication and Older Adults

  • Effective verbal communication is essential.
  • Communication techniques:
    • Speak respectfully and identify yourself.
    • Be aware of your presentation.
    • Look directly at the patient at eye level.
    • Speak slowly and distinctly.
    • Have one person talk to the patient at a time.
    • Ask only one question at a time.
    • Give the patient time to respond and listen to the answer.
    • Explain actions before performing them.

Common Complaints and Leading Causes of Death

  • The geriatric population is predisposed to specific problems.
  • Hip fractures are common, especially when bones are weakened by osteoporosis or infection.
  • Sedentary behavior can lead to pneumonia and blood clots.

Changes in the Body

  • The aging process is accompanied by changes in physiologic function.
  • All tissues in the body undergo aging.
  • A decrease in the functional capacity of various organ systems is normal but can affect the way a patient responds to illness.

Changes in the Respiratory System

  • Age-related changes can predispose older adults to respiratory illnesses.
  • Airway musculature becomes weakened.
  • Alveoli in the lung tissue become enlarged, and elasticity decreases.
  • The body’s chemoreceptors slow with age.
  • Decreased cough and gag reflexes.
  • Pneumonia
    • Inflammation/infection of the lung from bacterial, viral, or fungal causes.
    • The leading cause of death from infection in Americans older than 65 years.
    • Aging causes some immune suppression and increases the risk of contracting infections like pneumonia.
    • Increased mucus production, pulmonary secretions, and infection interfere with the ability of the alveoli to oxygenate the blood.
    • Management of pneumonia is the same for any patient.
  • Pulmonary Embolism
    • Sudden blockage of an artery by a venous clot.
    • A patient will present with shortness of breath and sometimes chest pain.
    • Can be confused with a cardiac, lung, or musculoskeletal problem.
    • Risk factors:
      • Living in a nursing home.
      • Recent surgery.
      • History of blood clots or heart failure.
      • Presence of a pacemaker or central venous catheter.
      • Obesity or sedentary behavior.
      • Recent long-distance travel.
      • Trauma, cancer, or paralyzed extremities.
    • Presents with:
      • Tachycardia.
      • Sudden onset of dyspnea.
      • Shoulder, back, or chest pain.
      • Cough.
      • Syncope in patients in whom the clot is larger.
      • Anxiety.
      • Apprehension.
      • Low-grade fever.
      • Hemoptysis.
      • Leg pain, redness, and unilateral pedal edema.
      • Fatigue.
      • Cardiac arrest (worst-case scenario).

Changes in the Cardiovascular System

  • The heart hypertrophies with age.
  • Cardiac output declines.
  • Arteriosclerosis contributes to systolic hypertension.
  • Geriatric patients are at risk for atherosclerosis:
    • Accumulation of fat and cholesterol in the arteries.
    • Major complications include myocardial infarction and stroke.
  • Older people are at increased risk for the formation of an aneurysm:
    • Abnormal, blood-filled dilation of the blood vessel wall.
    • Severe blood loss can occur.
  • Blood vessels and heart valves become stiff and degenerate.
  • Heart rate becomes too fast, too slow, or too erratic.
  • Another vessel-related problem is venous stasis:
    • Loss of proper function of the veins in the legs that carry blood back to the heart.
    • Causes blood clots.
    • Deep vein thrombosis can lead to pulmonary embolism.
    • People usually exhibit edema of the legs and ankles.
  • Heart Attack
    • The classic symptoms of a heart attack are often not present in geriatric patients.
    • “Silent” heart attacks are particularly common in women and people with diabetes.
    • Manifestations of acute cardiac disease:
      • Dyspnea.
      • Epigastric and abdominal pain.
      • Loss of bladder or bowel control.
      • Nausea and vomiting.
      • Weakness, dizziness, light-headedness, syncope.
      • Fatigue or confusion.
    • Other signs and symptoms include:
      • Issues with circulation.
      • Diaphoresis.
      • Pale, cyanotic, or mottled skin.
      • Abnormal or decreased breath sounds.
      • Increased peripheral edema.
  • Heart Failure
    • The signs and symptoms will differ depending on whether the right or left side of the heart is not functioning correctly.
    • Right-sided heart failure occurs when fluid backs up into the body:
      • Causes jugular vein distention, ascites, peripheral edema, and an enlarged liver.
      • Right-sided heart failure is often caused by left-sided heart failure, so it is common to see signs of both.
    • With left-sided heart failure, fluid backs up into the lungs:
      • Causes a condition called pulmonary edema and shortness of breath.
      • The patient will have severe shortness of breath and hypoxia with crackles in the lungs.
    • Paroxysmal nocturnal dyspnea:
      • Characterized by a sudden attack of respiratory distress that wakes the person when he or she is reclining.
      • Caused by fluid accumulation in the lungs.
      • Patients report coughing, feeling suffocated, and cold sweats.
      • You will notice tachycardia.
  • Stroke
    • The leading cause of death in older people.
    • Preventable risk factors: smoking, hypertension, diabetes, atrial fibrillation, obesity, and a sedentary lifestyle.
    • Uncontrollable factors: age, race, and gender.
    • Signs and symptoms:
      • Acute altered level of consciousness.
      • Numbness, weakness, or paralysis on one side.
      • Slurred speech, difficulty speaking.
      • Visual disturbances.
      • Headache and dizziness.
      • Incontinence.
      • Seizure.
    • Hemorrhagic strokes are less common and more likely to be fatal.
    • Ischemic strokes occur when a blood clot blocks the flow of blood to a portion of the brain.
    • The treatment goal is to salvage as much of the surrounding brain tissue as possible.
    • If the symptoms occurred within the past few hours, the patient will be a candidate for stroke center therapy.
    • Transient ischemic attack (TIA) can present with the same signs and symptoms as a stroke.

Changes in the Nervous System

  • Changing in thinking speed, memory, and posture stability are the most common findings.
  • The brain decreases in weight and volume.
  • There is a 5% to 50% loss of neurons in older people.
  • The performance of most of the sense organs declines with increasing age.
  • Vision
    • Visual acuity, depth perception, and ability to accommodate to light change with age.
    • Cataracts interfere with vision.
    • Decreased tear production leads to drier eyes.
    • Inability to differentiate colors.
    • Decreased night vision.
    • Inability to see up close (presbyopia).
    • Other diseases:
      • Glaucoma.
      • Macular degeneration.
      • Retinal detachment.
  • Hearing
    • Changes in the inner ear make hearing high-frequency sounds difficult.
    • Problems with balance make falls more likely.
    • Presbycusis is a gradual hearing loss.
    • Heredity and long-term exposure to loud noises are the main factors.
  • Taste
    • A decrease in the number of taste buds.
    • Negative result might be a lessened interest in eating, which can lead to:
      • Weight loss.
      • Malnutrition.
      • Complaints of fatigue.
  • Touch
    • Decreased sense of touch and pain perception from the loss of the end nerve fibers.
    • An older person may be injured and not know it.
    • Decreased sensation of hot and cold.

Dementia

  • Slow onset of progressive disorientation, shortened attention span, and loss of cognitive function.
  • Chronic, generally irreversible condition that causes a progressive loss of:
    • Cognitive abilities.
    • Psychomotor skills.
    • Social skills.
  • Dementia is the result of many neurologic diseases and may be caused by:
    • Alzheimer disease.
    • Parkinson disease.
    • Cerebrovascular accidents.
    • Genetic factors.
  • On assessment, patients may:
    • Have short- and long-term memory loss.
    • Have a decreased attention span.
    • Be unable to perform daily routines.
    • Show a decreased ability to communicate.
    • Appear confused or angry.
    • Have impaired judgment.
    • Be unable to vocalize pain.

Delirium

  • Sudden change in mental status, consciousness, or cognitive processes.
  • Marked by the inability to focus, think logically, and maintain attention.
  • Affects 15% to 50% of hospitalized people aged 70 years or older.
  • Acute anxiety may be present.
  • Generally, the result of a reversible physical ailment, such as tumors, fever, or metabolic causes.
  • In the history, look for:
    • Withdrawal from alcohol or sedatives.
    • Medical conditions.
    • Depression.
    • Malnutrition or vitamin deficiencies.
    • Environmental emergencies.
  • Assess and manage the patient for:
    • Hypoxia.
    • Hypovolemia.
    • Hypoglycemia.
    • Hypothermia.
  • You may see changes in circulation, breath sounds, motor function, and pupillary response.

Syncope

  • Assume this is a life-threatening problem until proven otherwise.
  • Often caused by an interruption of blood flow to the brain.

Neuropathy

  • Disorder of the nerves of the peripheral nervous system.
  • Function and structure of the peripheral motor, sensory, and autonomic neurons are impaired.
  • Symptoms depend on which nerves are affected and where they are located.

Changes in the Gastrointestinal System

  • A reduction in the volume of saliva.
  • Dental loss.
  • Gastric secretions are reduced.
  • Changes in gastric motility occur.
  • The incidence of certain diseases involving the bowel increases.
  • Blood flow to the liver declines.
  • Age-related changes in the GI system:
    • Issues with dental problems.
    • Decrease in saliva and sense of taste.
    • Poor muscle tone of the sphincter between the esophagus and stomach.
    • Decrease in hydrochloric acid.
    • Alterations in absorption of nutrients.
    • Weakening of the rectal sphincter.
  • GI bleeding can be caused by inflammation, infection, or obstruction of the upper or lower GI tract:
    • Usually heralded by hematemesis.
    • Bleeding that travels through the lower digestive tract usually manifests as melena.
    • Red blood usually means a local source of bleeding, such as hemorrhoids.
    • A patient with GI bleeding may experience weakness, dizziness, or syncope.
  • Specific GI problems in older patients include:
    • Diverticulitis.
    • Bleeding in the upper and lower GI system.
    • Peptic ulcer disease.
    • Gallbladder disease.
    • Bowel obstruction.
  • When assessing patients, ask about NSAID and alcohol use.
  • Orthostatic vital signs can help determine if a patient is hypovolemic.
  • Treatment consists of airway, ventilatory, and circulatory support.
  • Acute Abdomen—Nongastrointestinal Complaints
    • Extremely difficult to assess in the prehospital setting.
    • The most serious threat from abdominal complaints is blood loss.
    • Abdominal aortic aneurysm (AAA) is one of the most rapidly fatal conditions.

Changes in the Renal System

  • Age brings changes in the kidneys:
    • Reduction in renal function.
    • Reduction in renal blood flow.
    • Tubule degeneration.
  • Changes in the genitourinary system:
    • Decreased bladder capacity.
    • Decline in sphincter muscle control.
    • Decline in voiding senses.
    • Increase in nocturnal voiding.
    • Benign prostatic hypertrophy (enlarged prostate).
  • Incontinence is not a normal part of aging and can lead to skin irritation, skin breakdown, and urinary tract infections:
    • Stress incontinence occurs during activities such as coughing, laughing, sneezing, lifting, and exercise.
    • Urge incontinence is triggered by hot or cold fluids, running water, or thinking about going to the bathroom.
  • The opposite of incontinence is urinary retention or difficulty urinating:
    • In men, enlargement of the prostate can place pressure on the urethra, making voiding difficult.
    • Bladder and urinary tract infections can also cause inflammation.
    • In severe cases of urinary retention, patients may experience renal failure.

Changes in the Endocrine System

  • Reduction in thyroid hormones (thyroxine):
    • Signs and symptoms:
      • Slower heart rate.
      • Fatigue.
      • Drier skin and hair.
      • Cold intolerance.
      • Weight gain.
  • Other endocrine changes include:
    • An increase in the secretion of antidiuretic hormone, causing fluid imbalance.
    • Hyperglycemia.
    • Increases in the levels of norepinephrine, possibly having a harmful effect on the cardiovascular system.
  • Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a type 2 diabetic complication in older people:
    • On assessment, you may see:
      • Warm, flushed skin.
      • Poor skin turgor.
      • Pale, dry, oral mucosa.
      • Furrowed tongue.
      • Signs of shock.
  • Assessment of the patient should include:
    • Obtaining blood pressure.
    • Distal pulses.
    • Auscultation of breath sounds.
    • Temperature.
    • Assessment of blood glucose level (if permitted by local protocol).
  • Treatment should include airway, ventilatory, and circulatory support.

Changes in the Immune System

  • Infections are commonly seen in older people because of their increased risk:
    • Less able to fight infections.
    • Anorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptoms.
    • Pneumonia and UTIs are common in patients who are bedridden.
    • Signs and symptoms may be decreased because of loss of sensation, lack of awareness, or fear of being hospitalized.

Changes in the Musculoskeletal System

  • Decrease in bone mass, especially in postmenopausal women.
  • Bones become more brittle and tend to break more easily.
  • Joints lose their flexibility.
  • A decrease in the amount of muscle mass often results in less strength.
  • Changes in physical abilities can affect older adults’ confidence in mobility.
  • Muscle fibers become smaller and fewer.
  • Motor neurons decrease in number.
  • Strength declines.
  • Ligaments and cartilage of the joints lose their elasticity.
  • Cartilage goes through degenerative change.
  • Osteoporosis is characterized by a decrease in bone mass:
    • Reduction in bone strength and greater susceptibility to fracture.
    • The extent of bone loss depends on:
      • Genetics, body weight.
      • Smoking, alcohol consumption.
      • Level of activity, diet.
  • Osteoarthritis is a progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs, and leads to joint stiffness:
    • Results from wear and tear.
    • Affects joints in the hands, knees, hips, and spine.

Changes in Skin

  • Proteins that make the skin pliable decline with age.
  • The layer of fat under the skin becomes thinner.
  • Bruising becomes more common.
  • Sweat glands do not respond as readily to heat.
  • Pressure ulcers become a problem:
    • Sometimes referred to as bedsores or decubitus ulcers.
    • The pressure from the weight of the body cuts off the blood flow to the area of skin.
    • With no blood flow, a sore develops.
  • Stages of ulcer development:
    • Stage I: Nonblanching redness with damage under the skin.
    • Stage II: Blister or ulcer that can affect the dermis and epidermis.
    • Stage III: Invasion of the fat layer through to the fascia.
    • Stage IV: Invasion to muscle or bone.

Toxicology

  • Older people are more susceptible to toxicity.
  • Kidneys undergo many changes with age.
  • Decreased liver function makes it harder for the liver to detoxify the blood and eliminate medications and alcohol.
  • Typical OTC medications can have negative effects when mixed with each other or with herbal substances, alcohol, and prescription medications.
  • Polypharmacy refers to the use of multiple prescription medications by one patient:
    • Negative effects can include overdosing and negative medication interaction.
    • Medication noncompliance occurs due to:
      • Financial challenges.
      • Inability to open containers.
      • Impaired cognitive, vision, and hearing ability.

Depression

  • Depression is not part of normal aging, but a medical disease, treatable with medication and therapy.
  • If depression goes unrecognized or untreated, it is associated with a higher suicide rate in the geriatric population.
  • Risk factors include a history of depression, chronic disease, and loss.
  • The following conditions contribute to the onset of significant depression:
    • Substance abuse.
    • Isolation.
    • Prescription medication use.
    • Chronic medical condition.

Suicide

  • Older men have the highest suicide rate of any age group in the United States.
  • Older persons choose much more lethal means than younger victims.
  • Generally have diminished recuperative capacity to survive an attempt.
  • Common predisposing events and conditions include:
    • Death of a loved one.
    • Physical illness.
    • Depression and hopelessness.
    • Alcohol abuse.
    • Alcohol dependence.
    • Loss of meaningful life roles.
  • When assessing the patient who is displaying signs of depression, it is appropriate to ask if he or she is considering suicide.
  • If the answer is “yes,” the next question should be, “Do you have a plan?”
  • Include this information in your report.

The GEMS Diamond

  • Created to help you remember what is different about older patients.
  • Not intended to be a format for the approach to geriatric patients or replace the ABCs of care.
  • Serves as an acronym for the issues to be considered when assessing every older patient.
  • Geriatric patient:
    • Older patients may present atypically.
    • Be familiar with the normal changes of aging.
  • Environmental assessment:
    • The environment can help give clues to the patient’s condition and the cause of the emergency.
  • Medical assessment:
    • Older patients tend to have a variety of medical problems and numerous medications.
    • Obtain a thorough medical history.
  • Social assessment:
    • Older people may have less of a social network.
    • They may need assistance with activities of daily living.
    • Consider obtaining information pamphlets about some of the agencies for older people in your area.

Special Considerations in Assessing a Geriatric Medical Patient

  • Assessing an older person can be challenging because of:
    • Communication issues.
    • Hearing and vision deficits.
    • Alterations in consciousness.
    • Complicated medical histories.
    • Effects of medications.

Scene Size-Up

  • Geriatric patients are commonly found in their own homes, retirement homes, or skilled nursing facilities.
  • Many older people live alone.
  • Access may be hampered if their condition prevents them from getting to the door.
  • Take note of negative or unsafe conditions.
  • Mechanism of injury/nature of illness:
    • May be difficult to determine in older people with altered mental status or dementia.
    • Ask the family member, caregiver, or bystander why he or she called.
    • Multiple and chronic disease processes may also complicate the determination of the NOI.
    • Chest pain, shortness of breath, and an altered level of consciousness should always be considered serious.

Primary Assessment

  • Address life threats.
  • Determine the transport priority.
  • Form a general impression.
  • You should be able to tell if the patient is generally in stable or unstable condition.
  • Use the AVPU scale to determine the patient’s level of consciousness.
  • Airway and breathing:
    • Anatomic changes that occur as a person ages predispose geriatric patients to airway problems.
    • Ensure that the patient’s airway is open and not obstructed by dentures, vomitus, fluid, or blood.
    • Anatomic changes affect a person’s ability to breathe effectively.
    • Loss of mechanisms that protect the upper airway cause a decreased ability to clear secretions.
    • Airway and breathing issues should be treated with oxygen as soon as possible.
  • Circulation:
    • Poor perfusion is a serious issue in the older adult.
    • Physiologic changes may negatively affect circulation.
    • Vascular changes and circulatory compromise might make it difficult to feel a pulse.
  • Transport decision:
    • Any complaints that compromise the ABCs should result in prompt transport.
    • Determine conditions that are life-threatening.
    • Treat them to the best of your ability.
    • Provide transport to priority patients.

History Taking

  • Investigate the chief complaint.
  • Find and account for all medications.
  • Obtain a thorough patient history.
  • Determine early whether the altered LOC is acute or chronic.
  • Multiple disease processes and multiple and/or vague complaints can make assessment complicated.
  • Collect a SAMPLE history.
  • You may have to rely on a relative or caregiver to help you.
  • List the patient’s medications or take the medications with you to the hospital.
  • The last meal is particularly important in patients with diabetes.
  • Transport to a facility that knows the patient’s medical history, if possible.

Secondary Assessment

  • Physical examinations:
    • An older patient may not be comfortable with being exposed.
    • Protect his or her modesty.
    • Consider the need to keep your patient warm during the exam.
  • Vital signs:
    • The heart rate should be in the normal adult range but may be compromised by medications such as beta-blockers.
    • Weaker and irregular pulses are common.
    • Circulatory compromise may make it difficult to feel a radial pulse; consider other pulse points.
    • Blood pressure tends to be higher.
    • Capillary refill is not a good assessment.
    • The respiratory rate should be in the same range as in a younger adult.
    • Be sure to auscultate breath sounds.
    • Carefully assess pulse oximetry data.

Reassessment

  • Reassess the geriatric patient often.
  • Reassess the vital signs.
  • Reassess the patient’s complaint.
  • Recheck interventions.
  • Identify and treat changes in the patient’s condition.
  • Communication and documentation:
    • Communicate your findings and the interventions you used to emergency department personnel.
    • Document all history, medication, assessment, and intervention information.

Trauma and Geriatric Patients

  • Conditions that create risk and complicate assessment:
    • Slower homeostatic compensatory mechanisms.
    • Limited physiologic reserves.
    • Normal effects of aging on the body.
    • Existing medical issues.
  • Physical findings in an older adult may be more subtle and easily missed.
  • Mechanisms are much more minimal.
  • Recuperation from trauma is longer and often less successful.
  • Many injuries are under-triaged and under-treated.
  • Older pedestrians are more likely to have life-threatening complications after being struck by a vehicle:
    • Commonly suffer injury to the legs and arms.
    • Secondary impacts can also cause serious injuries.
  • Older people are more likely to experience burns because of altered mental status, inattention, and a compromised neurologic status.
    • The risk of mortality is increased when:
      • Preexisting medical conditions exist.
      • The immune system is weakened.
      • Fluid replacement is complicated by renal compromise.
  • Higher mortality from penetrating trauma in older adults, especially gunshot wounds.
  • Falls are the leading cause of fatal and nonfatal injuries in older adults:
    • Nearly half of fatal falls in geriatric patients result in traumatic brain injury.
  • Anatomic changes and trauma:
    • Changes in pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older patients more susceptible to trauma.
    • A geriatric patient’s overall physical condition may lessen the body’s ability to compensate for simple injuries.
  • Osteoporosis predisposes older people to hip and pelvic fractures:
    • Contributing factors:
      • Stresses of ordinary activity.
      • A standing fall.
      • Vitamin D and calcium deficiencies.
      • Metabolic bone diseases.
      • Tumors.
  • With age, the spine stiffens as a result of shrinkage of disk spaces, and vertebrae become brittle:
    • Compression fractures of the spine occur.
  • Because brain tissue shrinks with age, older patients are more likely to sustain closed head injuries:
    • Acute subdural hematomas are among the deadliest of all head injuries.
    • Serious head injuries are often missed because the mechanism may seem relatively minor.
  • Other factors that predispose an older patient to a serious head injury include:
    • Long-term abuse of alcohol.
    • Recurrent falls or repeated head injury.
    • Anticoagulant medication.

Environmental Injury

  • Internal temperature regulation is slowed.
  • Half of all deaths from hypothermia occur in older people:
    • Including most indoor hypothermia deaths.
  • Death rates from hyperthermia are more than doubled in older people:
    • People older than 85 years are at the highest risk.

Special Considerations in Assessing Geriatric Trauma Patients

  • Trauma is never isolated to a single issue when you are assessing and caring for a geriatric patient.

Scene Size-Up (Trauma)

  • Look for clues that indicate your patient’s traumatic incident may have been preceded by a medical incident.
  • Bystander information may help.
  • MOI is important in establishing whether an injury is considered critical, and it affects treatment and transport considerations.

Primary Assessment (Trauma)

  • Address life threats.
  • Determine the transport priority:
    • Recommended that older trauma patients be transported to a trauma center.
  • Form a general impression:
    • Is the patient’s condition stable or unstable?
    • Use AVPU and the Glasgow Coma Scale to determine mental status.
  • Airway and breathing:
    • Older patients may have a diminished ability to cough, so suctioning is important.
    • Assess for the presence of dentures.
  • Circulation:
    • Manage any external bleeding immediately.
    • Drinking alcohol and taking anticoagulant medications can make internal bleeding worse or external bleeding more difficult to control.
    • Older patients can more easily go into shock.
    • Patients who were hypertensive prior to injury may have a normal blood pressure when they are actually in shock.

History Taking (Trauma)

  • Investigate the chief complaint.
  • Considerations in your assessment must include past medical conditions, even if they are not currently acute or symptomatic.

Secondary Assessment (Trauma)

  • Physical examinations:
    • Performed in the same manner as for any adult but with consideration of the higher likelihood of damage from trauma.
    • Any head injury can be life-threatening.
    • Check lung sounds.
    • Look for bruising and other evidence of trauma.
  • Vital signs:
    • Assess the pulse, blood pressure, and skin signs.
    • Capillary refill is unreliable because of compromised circulation.
    • Remember that some older people take beta-blockers, which will inhibit their heart from becoming tachycardic.

Reassessment (Trauma)

  • Repeat the primary assessment:
    • A geriatric patient has a higher likelihood of decompensating after trauma.
  • Interventions:
    • Broken bones are common and should be splinted.
    • Do not force a patient with joint flexion or kyphosis into a “normal” position.
    • Provide blankets and heat to prevent hypothermia.
  • Communications and documentation:
    • Communication can be challenging.
    • Provide psychological support as well as medical treatment.

Response to Nursing and Skilled Care Facilities

  • Many calls will occur at a nursing home or other skilled care facility.
  • Calls can be challenging.
  • Patients often have an altered level of consciousness.
  • Staff may be spread thin and may not know how to assist you.
  • Ask, “What is wrong with the patient that is new or different today?”
  • Infection control needs to be a high priority for EMTs:
    • Methicillin-resistant Staphylococcus aureus (MRSA) infections are common.
    • Many infections in hospitals are caused by vancomycin-resistant enterococci.
    • The respiratory syncytial virus causes an infection of the upper and lower respiratory tracts.
    • Clostridium difficile is a bacterium responsible for the most common cause of hospital-acquired infectious diarrhea.
      • Typical alcohol-based hand sanitizers do not inactivate or kill C difficile.
    • SARS-CoV-2:
      • Affects older, more vulnerable people.
      • Spreads from person-to-person through airborne droplets created by speaking, coughing, and sneezing.

Dying Patients

  • More patients are choosing to die at home rather than in a hospital.
  • Dying patients receive palliative care.
  • Be understanding, sensitive, and compassionate.
  • Determine if the family wishes for the patient to go to the hospital or stay in the home.

Advance Directives

  • Specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves.
  • May take the form of a do not resuscitate (DNR) order:
    • Gives you permission not to attempt resuscitation for a patient in cardiac arrest.
    • DNR does not mean “do not treat.”
    • Basic ABCs should still be provided.
  • Another type of order is the POLST (Physician Orders for Life Sustaining Treatment), which gives medical orders in addition to the advanced directives.
  • If there is any question regarding orders or when there are no written orders, initiate resuscitation.

Elder Abuse and Neglect

  • Any action on the part of an older person’s family member, caregiver, or other person that takes advantage of the older person’s:
    • Person
    • Property
    • Emotional state
    • Includes acts of commission and acts of omission.
  • Has been largely hidden from society.
  • Definitions of abuse and neglect among the geriatric population vary.
  • Victims are often hesitant to report the problem.
  • The abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her for reporting the abuse.
  • Elder abuse occurs more often in women older than 75 years.
  • Abusers of older people are sometimes products of child abuse themselves.
  • Take note of the environment and conditions a patient lives in, and of soft- tissue injuries that cannot be explained by the person’s lifestyle and physical condition.
  • Suspect abuse when answers are concealed or avoided.
  • Suspect abuse when you are given unbelievable answers.
  • Information that may be important in assessing abuse includes:
    • Caregiver apathy about the patient’s condition.
    • Overly defensive reaction by the caregiver.
    • The caregiver does not allow the patient to answer questions.
    • Repeated visits to the ED or clinic.
    • A history of being accident-prone.
    • Unbelievable or vague explanations of injuries.
    • Psychosomatic complaints.
    • Chronic pain without medical explanation.
    • Self-destructive behavior.
    • Eating and sleep disorders.
    • Depression or a lack of energy.
    • Substance and/or sexual abuse history.

Signs of Physical Abuse

  • Inflicted bruises are usually found on the buttocks and lower back, genitals, inner thighs, face, and ears.
  • Pressure bruises caused by the human hand may be identified by oval grab marks, pinch marks, or handprints.
  • Human bites are typically inflicted on the upper extremities and can cause lacerations and infection.
  • Typical abuse from burns is caused by contact with:
    • Cigarettes.
    • Matches.
    • Heated metal.
    • Forced immersion in hot liquids.
    • Chemicals.
    • Electrical power sources.
  • Check for signs of neglect, such as:
    • Lack of hygiene.
    • Poor dental hygiene.
    • Poor temperature regulation.
    • Lack of reasonable amenities in the home.
  • Regard injuries to the genitals or rectum with no reported trauma as evidence of sexual abuse in any patient.
  • Geriatric patients with altered mental status may never be able to