Geriatric Care David Ankrom, BS, EMT-P, FP-C, EMS-I Flight Paramedic/ Clinical Instructor
Geriatric Care
David Ankrom, BS, EMT-P, FP-C, EMS-I
Flight Paramedic/ Clinical Instructor
Aging Statistics
• Almost 15% of people in the US are
over age 65.
• “Baby Boomers” will increase this
number.
• Expect to see an increase in emergency
calls involving older patients.
Ageism
• Stereotyping and
discrimination of older people
• Categorizing people as senile,
eccentric, or stubborn
• “Geezer,” “Lizard,” and
“GOMER” perpetuate ageism
• Use of “honey” or “dear” is a
milder form
The GEMS Diamond
• Remember the following when caring for
older people:
– Geriatric patients
– Environmental assessment
– Medical assessment
– Social assessment
Leading Causes of Death in Older People
• Disease of the heart
• Cancer
• CVA/Stroke
• COPD
• Pneumonia
The Aging Body:
Integumentary System
• Wrinkles
• Thinner skin
• Decreased fat
• Gray hair
The Aging Body:
Respiratory System
• Changes in airway
• Decreasing muscles of
ventilation
• Increased residual volume
• Decreased sensitivity of
chemoreceptors
The Aging Body:
Cardiovascular System
Development of
atherosclerosis
Decreasing cardiac output
Development of arrhythmias
Changes in blood pressure
The Aging Body:
Nervous System
• Brain shrinkage
• Slowing of peripheral nerves
• Slowed reflexes
• Decreasing pain
sensation
The Aging Body:
Sensory Changes
• Vision distorts and eye
movement slows.
• Hearing loss is more common.
• Taste decreases.
The Aging Body:
Renal, Hepatic, and GI Systems
• Kidneys become smaller.
• Hepatic blood flow decreases.
• Production of enzymes declines.
• Salivation decreases.
• Gastric motility slows.
The Aging Body:
Musculoskeletal System
• Decreased muscle mass
• Changes in posture
• Arthritic changes
• Decrease in bone mass
The Aging Body:
Immune System
• Less effective immune response
• Pneumonia and UTI are common.
• Increase in abnormal immune
system substances
General Patient Assessment
• Scene size-up includes environmental assessment:
– General appearance, cleanliness
– Temperature, food
– Drugs, alcohol, signs of abuse
• Initial assessment looks for life threats:
– Airway cannot be protected as well.
– Breathing can be complicated by previous disease.
– Circulatory system has slowed responses.
Mental Status Assessment
• Confusion is not normal.
• Distinguish chronic
changes from new ones.
• Enlist help from family.
• Establish a baseline
mental status.
• Don’t be misled.
Assessment
• Prioritize patient status.
• Detailed physical exam
• Ongoing assessment is required.
Assessing the Chief Complaint
• Determining the chief complaint can be hard.
• Start with what is bothering the patient most.
• Chief complaints may not be the life threat.
• Communication is a big component.
Chief Complaint:
Shortness of Breath
• Frequently life threatening
• Often respiratory or cardiac in origin
• Can occur for other reasons such as pain, bleeding, medications
• Are there associated signs and symptoms?
• Does patient have a history of respiratory complaints?
Respiratory Issues Related
to Aging
• Physiologic reserves are decreased.
• History of underlying disease
• Respiratory assessment can be challenging.
• Medications can complicate the situation.
Assessment of Respiratory
Complaints
• History may suggest the problem.
• SAMPLE history should be completed.
• Some questions to ask include:
– Have you ever had this before?
– How many pillows do you sleep on?
– Have you changed any of your medications?
Components of a
Respiratory Exam
• Inspection
• Palpation
• Percussion
• Auscultation
Pneumonia
• Major killer of older adults
• Presentation may differ in older people.
• Crackles, pus in sputum, fever, loss of
appetite
General Emergency Respiratory
Management
• Reduce patient’s anxiety by reassurance.
• Protect the airway.
• Allow position of comfort if patient can maintain.
• Oxygen is indicated.
• If patient has an inhaler, assist patient with a dose.
• Other medications as situation warrants within local protocol.
Chief Complaint: Chest Pain
• Often cardiac in nature
• Many experience pain differently.
• Medication history is important.
• Have the patient locate the pain.
• Expose the chest: scars, pacemaker,
medication patches
Cardiovascular Disease
• Most common cause of death in older people
• CAD and CHF top the list.
• Dyspnea is often the complaint.
How should you begin to differentiate cardiac from respiratory causes?
Taking a History
• Compare signs and symptoms to
previous events.
• Past diagnoses are a good place to
start.
• Medications may lead you to a cause.
• Compare events leading up to today
with patient’s normal activity.
Chronic Obstructive Pulmonary
Disease (COPD)
• Asthma
• Emphysema
• Chronic bronchitis
Clinical Presentation of Angina or AMI
• May experience no pain or atypical pain
• Less localized, vague, not "crushing" or "squeezing"
• Dyspnea, fatigue, syncope, nausea, confusion
• Palpitations upon effort or sweating
• Ask about discomfort, not pain.
Management of Angina and AMI
• Decrease anxiety, make patient comfortable
• Maintain ABCs, high-flow oxygen
• 325 mg Aspirin
• Nitroglycerin q 5 min
• IV, monitor, 12-lead ECG, consider morphine
• If hypotension develops, give 250 mL bolus
crystalloid.
Management of CHF
• Keep patient upright to allow fluid shunting.
• Maintain ABCs.
• High-flow oxygen
• CPAP or BiPAP can be a useful tool.
• IV, ECG monitor, advanced airway if needed, 12-lead ECG
• Medications: nitroglycerin, furosemide (Lasix), morphine, and aspirin if chest pain is present
Arrhythmias
• Many types affect the older population.
• Atrial fibrillation is common.
• Control of ABCs
• Rate control if rapid ventricular response
• 12-lead ECG is helpful.
Hypertension
• Affected organs: heart, eyes,
brain, kidneys
• Pressure should be lowered
slowly.
• A quick drop can result in
stroke, AMI, or death.
• Beta-blockers, sodium
nitroprusside, or IV nitroglycerin
Chief Complaint:
Altered Mental Status
• Some causes manifest quickly, others over days
• Medication reactions are a frequent issue.
• Determine LOC and orientation to person, place, and time.
• Check motor and sensory response.
• Get an ECG and blood sugar reading.
Chief Complaint:
Dizziness or Weakness
• Factors: balance, injury, oxygen, and energy
• History will help clarify the complaint.
• Check ECG, orthostatic changes, blood sugar
• Check for signs of stroke.
• Assess for signs of head trauma.
Age-Related Changes in the
Nervous System
• Be aware of normal changes in older patient’s
nervous system.
• Changes will affect neurologic examination:
– Cognitive (thinking)
– Speed
– Memory
• Postural stability
Causes of Altered Mental Status
• Can be difficult to determine in the older
patient
• Neurologic symptoms may be the result
of multiple causes.
• Use VITAMINS C & D mnemonic to recall
potential causes.
Vitamins C & D
• Vascular
• Inflammation
• Toxins, trauma, tumors
• Autoimmune
• Metabolic
• Infection
• Narcotics
• Systemic
• Congenital
• Degenerative
Stroke Facts
• Signs of stroke depend on type
– Ischemic
– Hemorrhagic
• Risk factors for stroke
– Modifiable and preventable
Seizures
• Massive discharge of neurons in brain
– Generalized motor seizures are most
common.
• Can be caused by many underlying
factors
Dementia
• Brain disorder with memory
impairment and loss of
mental abilities with normal
LOC
• Multiple causes, including
Alzheimer’s disease
• Gradual decline over many
years
Aggressive and Assaultive
Behaviors
• Severe depression or
dementia may cause
aggression.
• Aggression may be the
result of fear or altered
perception.
• Provider safety is
important.
Delirium
• Acute rapid
deterioration
• DELIRIUMS mnemonic
may help in
differentiating.
• Drugs and toxins
• Emotional
• Low PO2
• Infection
• Retention
• Ictal
• Under nutrition/dehydration
• Metabolism
• Subdural hematoma
Parkinson’s Disease
• Loss of flexibility and fluidity in movement
• Decrease in the production of dopamine in
brain
• Four cardinal signs:
– Resting tremors
– Rigidity
– Slowness of movement
– Postural instability
Neurologic Assessment
• Begins immediately upon
making patient contact
– AVPU
• Neurologic assessment of
face
• Neurologic assessment of
extremities
• Past medical history
• History of trauma
Stroke Evaluation
• Time of onset
• Cincinnati Prehospital
Stroke Scale
– Facial droop
– Arm drift
– Speech
• LA and NIH scales
Patient Management
• For any patient with altered mental status, airway and ventilatory support have priority.
– Supplemental oxygen at a minimum
– Consider need for positive pressure ventilations.
• Monitor ECG, pulse Ox, and blood sugar.
Seizure Considerations
• Continued airway support
• Pad all hard objects near patient.
• Administer an anticonvulsant.
– Intravenously or via rectal route
Infection and Sepsis
• Sepsis
• Bacteremia
• Septic shock
• Risk factors
– Age-related
– Institutionalization
Sepsis
• Causes of sepsis
• Prevention
– High index of suspicion
– Universal precautions
– Sterile technique for invasive care
– Hand washing
Chief Complaint: Trauma
• Exam follows the ABCs.
• Look for potential medical causes.
• Past history may change the
needs of the patient.
• Find the patient’s baseline status.
• Fractures are serious injuries.
Trauma: Injury Patterns
• Leading cause of death: falls, MVC,
burns
– Fewer MVCs, but with more severe
injuries
– Burns are associated with activities of
daily living.
• Penetrating trauma is less common.
• Physical injury from elder abuse
How Aging Affects Trauma
• Decreased pulmonary function and
abilities
• Hard to increase cardiac output
• Brain shrinkage allows bleeding.
• Musculoskeletal system changes
increase chance of injury.
Musculoskeletal Injuries
• Thoracic and lumbar spine injuries increase.
• Upper extremities have high loss of function.
• Less able to tolerate pelvic injuries
– Hip fractures are debilitating and can be fatal.
• Lower extremity fractures occur with less force.
ABCDEs for the Older Patient
• Airway: Dentures and lessened cough reflex
• Breathing: Checking chest wall and respiratory
drive
• Circulation: Quality of pulses
• Disability: Evaluating the patient's norms
• Exposure: Modesty and hypothermia
Assessment of the
Older Trauma Patient
• Early baseline vitals
• SAMPLE history
• New pain or old
• Physical exam
• Must include medical
evaluation
Considerations
• Conditions that may alter
physical assessment:
– Cataracts or asymmetrical
pupils
– Previous CNS condition
– Previous surgeries
– Decreased pain response
Trauma Management
• Treatment based on ABCs
• Early spinal immobilization with padding
• High-flow oxygen
• Prevention of hypothermia
• Rapid transport to appropriate center
• IV access and cardiac monitoring
Chief Complaint: Falls
• Generally result from contributing
factors
• Look for medical reason for fall.
• Assess for injury and life threats.
• ECG, blood glucose, pulse oximetry
Risk Factors for Falls and Injuries
• Sensory impairment
• Brain diseases that affect
balance
• Dementia
• Musculoskeletal disorders
• Medications
• Advanced age
Assessing a Fall Patient
• Symptoms
• Previous falls
• Location of fall
• Activity at time of fall
• Time of fall
• Trauma, both psychological
and physical
Preventing Falls in Older People
• Review of medications
• Improvement of sensory function
• Elimination of environmental obstacles
• Strength and balance exercises
Summary
• Number of people over age 65 is rising
• Changes with age affect assessment findings in older
patients.
• Common complaints fall into ten main areas.
• Cardiac diseases are the number one cause of death.
• Respiratory and cardiac diseases are more likely in later
years.
• Assessment is modified for older patient.
• Management includes maintaining ABCs.
• We must understand and accept aging.