1 GERIATRICS Gerontology: The study of the problems of all aspects of aging EMT297 Summer 2008.

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GERIATRICS

Gerontology: The study of the problems of all aspects of aging

EMT297Summer 2008

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Three stages of life

• You believe in Santa Claus

• You don’t believe in Santa Claus

• You are Santa Claus

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Great truths about growing old• Wrinkles don’t hurt• Growing old is mandatory; growing

up is optional• When you fall down, you wonder

what else you can do while you’re down there…

• You know all the answers, but nobody bothers to ask the questions.

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ELDERS ARE WELL ABLE TO APPRECIATE WHAT IT MEANS TO LIVE IN

THE PRESENT….. WHAT THEY HAVE TODAY IS

ALL THEY HAVE.

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MAKING THE MOST OF TODAY IS AN ART WE SHOULD ALL CULTIVATE - AND AN OLD

PERSON IS COMPELLED TO CULTIVATE.

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Aging in America

•Old is only how you feel and what you are still able to do!!!

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Geriatrics• Ageism• What age makes a person

geriatric?– 20 years older than me!– How old will you be in 2025?

A Look at Life in 2025Who Ages the

best?• People with

long-lived parents

• Satisfying job• Plenty of money• Married OR with

close friends

Some Stats• 50% of Auto vs.

Pedestrian involve the pedestrian being an elderly person

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Statistics– Geriatric population grew by

74% between 1970 – 1999 – to almost 35 million•30% of the $800 billion health care budget

•40% of hospital bed days•1998 - @ 41% of all ambulance transports to ED’s are with elderly

•2030-Magic year. Average baby boomer turns 80 years old - 20% population 65 or older

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• ALL OF THE RULES FOR ASSESSING AND TREATING YOUNGER PATIENTS DO NOT NECESSARILY APPLY TO ELDERS– Infections may not be accompanied by

a fever.– An abdominal catastrophe may not

cause abdominal pain– Forgetfulness may indicate a brain

tumor– Incontinence can be a sign of a heart

attack– 1/3-1/2 of elderly heart attack victims

do NOT feel crushing chest pain; primary symptoms are confusion, syncope.

Aging in America

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We really do fall apart when we get old…. 1% rule

•Total body fat decreases by as much as 15-30%

•Total body water significantly decreases

•25% all suicides reported are patients over 65.

Homes are a Menace• Area Rugs• High Shelves• Stairways

without railings• Bathtubs• Sharp Counter

Corners• Still doing crazy

things

Keys• We lose reserve

as we age• Our margin of

error gets smaller and smaller

• Fluid mobilization impaired with age

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A and P changes -General decline in organ systemsand stress response

Skin– Loss of

elasticity, collagen•Increased injury

•Dryness•Age spots

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Eyes– Cataracts– Glaucoma

– Poor peripheral vision

– Arcus senilis– Loss of accommodation– Hyperopia– Decreased depth perception

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Hearing– Ossicle degeneration

•Loss of high frequency hearing

– Atrophy of cochlear hair cells and auditory neurons•Decreased acuity and pitch discrimination

•Decreased sense of balance

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Respiratory system •Vital capacity decreases 50%•Maximum breathing capacity decreases 60%

•Maximum work rate and oxygen uptake decreases 70%

•PaO2 70 torr (nl 90 torr)

•Loss of cilia, diminished cough reflex and impaired gag reflex = pulmonary diseases

Cardiovascular System

CV System• Heart - less

flexible• Decreased

Cardiac Output• Less responsive

to catecholamines

• Altered electrical function

CV System• Arterioschlerosis

– Cholesterol deposits

– Vessel Narrowing

• Varicose Veins

• Medications: To compensate for CV condition

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Renal system•30-40% decrease in number of functioning nephrons

•Renal blood flow decreases 50%– Increased risk of toxicity from all drugs and toxins

Genitourinary•Loss of bladder control

–urinary infections•Prostate enlargement

–Tumors and urinary retention

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Nervous system– As much as 45% brain cell

loss in certain cortical areas– 6-7% reduction in brain

weight– Decreased cerebral blood

flow & increased resistance– Decreased cerebral

oxygen consumption – 15% reduction in

nerve conduction

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Musculoskeletal system•Decrease in height of 2-3 inches due to narrowing of vertebral discs

•Posture changes - slight flexion of knee and hip joints, spine deterioration

–Kyphosis- exaggeration of the normal posterior curvature of the spine

–Spondylosis - abnormal rigidity, fixation of joint

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•Decrease in total skeletal muscle weight

•Widening and weakening of certain bones

–Osteoporosis-softening of bone tissue due to the loss of essential minerals, esp.. calcium

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•Endocrine System–>20% of older adults develop diabetes

–Unrecognized thyroid and parathyroid problems

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– GI system and Metabolic

•Volume of saliva decreases 1/3;

gastric secretions diminish

•Structural changes occur

throughout GI tract

•Esophageal motility decreases

•Fecal impactions

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Psychological/Social

– Loss of physical function

•Decreased activity

– Loss of friends/family

•Depression

– Loss of social support

•Increased isolation and anxiety

•Increased risk of suicide

attempts

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Assessment

Complicating factors•Chief complaint may be trivial•Patient may fail to report important symptoms

•Paramedic may fail to note important symptoms

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•Likely to suffer from more than one disease at a time

•Aging changes the patient’s response to illness or injury

•Pain may be diminished or absent

•Thermoregulatory system may be depressed

•Social and emotional factors may have greater impact on health

Complicating Factors (cont.)

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When Assessing the Older Adult• Position yourself at eye level,

facing patient, in their visual field

• Speak slowly and distinctly• Listen to their ENTIRE answer• Use a gentle touch• Go slowly and explain

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Communications

Diminished sight

•Increases anxiety

•Talk to patient

calmly

•Position yourself so

patient can see you

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•Try to determine if patient’s mental status is changed

•Don’t assume confused, disoriented patient is “just senile”

•Alcoholism is more common than you think

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•Don’t assume the patient is deaf

•Don’t shout•Write notes if necessary•Speak slowly and

directly to the patient•Whenever possible,

verify history

Diminished hearing

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Diminished mental abilities

•Patient often confused, can’t remember details

•Noise of radio, ECG, strange voices add to confusion

•Senility and/or acute organic brain syndrome look similar; delirium, confusion, restlessness, excitement, hostility

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• May keep patient from cooperating

• Pt. may be malnourished, dehydrated, overdosed, contemplating suicide, or imagining ailments for attention.

Depression

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History taking - Common patient complaints

– Fatigue, weakness– Dizziness, vertigo,

syncope– Falls– H/A– Insomnia– Dysphagia– Loss of appetite– Inability to void– Constipation/

diarrhea

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PMH - complicated, important

– Usually multiple drugs– Medication errors and

noncompliance are common– Find all drugs and record to take

to hospital with patient (try to leave)

– Try to establish old vs new drugs incl. OTC

– Try to verify Hx with reliable family/neighbors

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– Observe surroundings for indication of pt’s ability to care for self

– Observe for evidence of drug/alcohol use

– Look for medic-alert tags, POLST form, etc

– Observe for signs of violence/abuse

PMH

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Physical Exam In Elders

– Pt. may tire easily; Assessment usually takes longer

– Commonly wears excessive clothing

– Be aware that pt. may minimize or deny sx due to fear

– Peripheral pulses may be difficult to evaluate

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– Must distinguish sx of chronic disease from acute problems, i.e.,•loss of skin elasticity and mouth breathing; aging vs dehydration

– Pay attention to impairments– Make eye contact– Grasp the hand - feel for

temperature, grip, skin condition

Physical Exam

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– Address the patient by last name– Use open-ended questions– Observe for

•Behavior•Dress/grooming•Ease of rising/sitting•Fluency of speech•Involuntary movement•Nourishment

Physical Exam

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– Breathing - adequate?– Circulation - adequate?

Irregularity? Check bilateral radial pulses, Auscultate both carotids for bruits

– BP - systolic <90 or >140 mmHg: diastolic <60 or >90 mmHg may indicate problems

– Level of consciousness

Physical Exam

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Case study

• On a hot, humid day you are called to the neighborhood park where a 68 y/o man is c/o weakness. On arrival you see the man sitting on a park bench in shorts and a T-shirt. He is very diaphoretic and leaning with his arms and head in his lap. You discover that the patient has been playing tennis. He normally plays 2-3 hrs/day. After two sets today, he could barely run down the ball and was missing point after point.

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• He c/o he was very dizzy and fell while playing. The patient c/o feeling generally weak. He denies any chest pain or SOB.

• PMH:– Bursitis or right shoulder– “Weak kidneys”

• Meds: OTC Advil prn• As you talk to the patient you note that

he is having trouble concentrating and you sometimes have to shout or shake him to get his attention.

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• PE:– BP 100/60– P 130– R 26– T hot to touch– Skin, hot, diaphoretic, flushed– CBG: 126– Neuro: active, alert, oriented x 3, coherent

but lethargic, PERRL; moves all ext. spont. – note a diffuse trembling of right forearm muscles

– EKG: sinus tachycardia– BBS: =, clear

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• DDX:?

• Tx:?

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Trauma

• More at risk, esp. falls, assault• 100% mortality in elders with BP

<80mmHg for 15 min. or more• Slower reflexes/reaction time• Poor eyesight and hearing• Arthritis• Blood vessels less elastic

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• Tissue and bones more fragile• More prone to head injury,

even with minor trauma• Signs of brain compression

may develop more slowly• Impaired balance and mobility

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• Often significant spondylosis; frequent spinal injury

• Arthritic spine changes compress nerve roots

• If injury to cervical spine, cord injury more likely

• Sudden neck movement may cause cord injury; often less than usual amount of pain

• Idiopathic fractures

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Case Study

• You are called to assess a 92 y/o woman who tripped and fell at her home. She c/o pain to her left wrist. You see a thin, elderly woman in obvious pain holding her left hand and forearm. She says that she did not see the throw rug in the hallway and tripped over it. She did not fall down because she braced herself on the wall with her left hand.

• PMH: cataracts, htn, osteoporosis• Meds: Vasotec and calcium

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• PE:– Swollen left wrist with cyanosis;

PMS normal; no movement.– Large abrasion to elbow– Vitals:

• BP 186/106; P 112; RR 18• Cap refill normal except for left hand• Pt has poor vision on exam

– DDX?

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• Tx:

– Splint, ice, elevate left wrist

– Transport

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Cardiovascular system

• May require higher arterial pressures for organ perfusion

• Hypovolemia and hypotension are poorly tolerated

• Response to drugs may be altered

• Syncope - increased morbidity in pt over 60

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• MI less likely to present with classic sx

• CHF -acute and chronic• Dysrhythmias - degeneration

of conduction system• Aortic dissection

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Respiratory system• Asthma/COPD common• Danger of alkalosis with PPV• Danger of ruptured bullae with PPV• Rib fractures common with CPR• CA• PE• Pulmonary edema• Respiratory infections

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Renal system

• Decreased ability of kidneys to maintain normal acid-base balance

• Decreased renal function puts elder at risk for fluid overload and pulmonary edema secondary to IV therapy

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Neurological disorders

• Coma• CVA - more common in elders; at

higher risk because of atherosclerosis, HTN, immobility, CHF, atrial fibrillation

• TIA’s common • Seizures may be mistaken for

CVA; not all major motor seizures

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• Dizziness common complaint; common causes are alcohol and drug effects

• Senile dementia; loss of neurons begin slowly in 40’s and 50’s

• Sundowning

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Delirium– Acute, reversible, potentially life-threatening– Abrupt disorientation for time, place– Hallucinations, illusions

Dementia – Slow, progressive loss of awareness for time, place– Unable to learn new things or remember recent

events– Long-term memory may be intact

Organic Brain Syndrome– Acute or chronic disease or injury– Causes: infection, intoxication, trauma, circulatory

disturbance, epilepsy, metabolic, endocrine diseases

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Case History• You are called to the front yard of a

house where PD is calming a screaming elderly man. They were driving by, when they saw him running aimlessly around the street. You see the man making aimless grabbing movements in the air above his head and are barely able to understand him saying something about birds and money.

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• Slowly you approach him and are able to get him to sit on the grass. For a few words he seems to follow what you say, then again he grabs over his head. His name is Thompson, he says, but you can’t get more than that. The people in the house have never seen the man before.

• PE– BP 192/110, P 136, RR 24, PERL– No facial droop, no focal weakness– Large abrasion on the left parietal area. You

notice tears on the knees of his pants with fresh abrasions on his knees. Rest of exam is normal.

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• Impression?

• Is he a danger to himself?

• Is he a danger to others?

• How sudden was his deterioration?

• Tx?

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• Tx:

– Restrain

– IV

– CBG

– Naloxone

– C-spine immobilization

– Transport

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Environmental emergencies (50-60,000/yr)• Constant high or low temps

poorly tolerated• Predisposing factors for

hypothermia;– Accidental exposure– Drugs– CNS disorders– Endocrine disorders– Low income

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• Decreased thermoregulatory functioning

• Commonly prescribed meds inhibit sweating

• Low income

Predisposing Factors For Hyperthermia

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Case study

• A 68-year-old woman is found unresponsive in her kitchen. You smell gas fumes from the stove. There is no sign of trauma. CBG is 120 mg/dcL.

• DDX?• TX?

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Case study

• A man in his 70’s is found unresponsive in his apartment basement. You note empty pints of alcohol near the pt, and that the room is very cold.

• DDX?• Tx?

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Gastrointestinal disorders

• GI bleed most common– Upper GI

•Peptic ulcers•Esophageal varices•Mallory-Weis syndrome

– Lower GI•Diverticulitis (70% of life-

threatening bleed in elders)•Tumors• Ischemic colitis

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Pharmacology

• Elders use 25% of all prescribed and OTC drugs sold in U.S.

• Absorption, metabolism, etc. altered

• Compensatory mechanisms less effective

• Underdose, Overdose a problem; may be accidental

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• 30% all hospital admissions related to drug-induced illness

• Common toxic drugs:– Digitalis, Antiparkinsonian drugs,

Diuretics, Anticoagulants, Lidocaine, Quinidine, Propranolol, Theophylline, Narcotics, Sedatives, Phenothiazines, Tricyclic antidepressants

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Case study

• A 72 y/o woman is found unresponsive and apneic in her bedroom You discover an empty bottle of Placidyl in the medicine cabinet. There is no sign of trauma. CBG is 100

• DDX?• Tx:?

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Common Atypical Presentation of Illness• Infection – frequent falls rather than fever or

↑WBCs• Acute abdomen – constipation and

↓decreased appetite rather than severe pain

• Pneumonia – vague chest pain and dry mouth rather than fever

• CHF – fatigue rather than dyspnea• MI – dyspnea and confusion rather than

fever• UTI – confusion

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Normal Therapies That Can Be Worse Than The Problem• Lying flat• High flow oxygen• Fluid therapy• Immobilized joints• Ice packs• Medications• Multiple questioners

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Abuse• The infliction of physical pain,

injury, debilitating mental anguish, unreasonable confinement, or willful deprivation by a caregiver of services necessary to maintain the mental and physical health of a geriatric client.

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• S/S:– Average age 80– Pt may have chronic

diseases/disorders– Unexplained trauma is primary

finding

• Profile of potential geriatric abuser– Stressed - sleep deprivation,

marital discord, etc.– Life may be in disarray; as patient

deteriorates, abuse develops

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Injury and Illness Prevention• Take supplements, especially

calcium and vitamin D• Increase physical activity and

exercise• Alter environment to improve safety

– Grab bars in bathroom– No throw rugs– Better lighting– Unobstructed paths

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Prevention

• Regular vision screening• Driving cautions

– Seatbelt use– Reduce speed– Day time driving– Avoid in bad weather– Avoid left turns– Early screening

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Summary

• Respect your patients modesty and other needs

• Explain actions clearly • Geriatric patients may minimize

or deny symptoms• Gather medication list to take

with you, but try to leave meds at home

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Observed changes in older adults frequently represent the normal aging process. These changes may also represent a body system that is malfunctioning.

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More great truths about aging• Forget the health food… you need

all the preservatives you can get.• You find time may be a great

healer, but it’s a lousy beautician.• Wisdom comes with age, but

sometimes age comes alone.

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Life is not a journey to the grave with the intention of arriving safely

in a pretty and well preserved body, but rather to skid in

broadside thoroughly used up, totally worn out and proclaiming -

“Wow, what a ride”