Geriatric Emergencies

Geriatric Emergencies
Chapter 35 Geriatric Emergencies Chapter 35: Geriatric Emergencies

National EMS Education Standard Competencies (1 of 7)
Special Patient Populations Applies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs. National EMS Education Standard Competencies Special Patient Populations Applies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs.

Geriatrics Impact of age-related changes on assessment and care National EMS Education Standard Competencies Geriatrics • Impact of age-related changes on assessment and care

Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies Cardiovascular diseases Respiratory diseases Neurological diseases National EMS Education Standard Competencies • Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies Cardiovascular diseases Respiratory diseases Neurologic diseases

Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies (cont’d) Endocrine diseases Alzheimer disease Dementia National EMS Education Standard Competencies • Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies Endocrine diseases Alzheimer disease Dementia

Patients With Special Challenges Recognizing and reporting abuse and neglect Health care implications of Abuse Neglect National EMS Education Standard Competencies Patients With Special Challenges • Recognizing and reporting abuse and neglect Health care implications of • Abuse • Neglect • Homelessness • Poverty • Bariatrics • Technology dependent • Hospice/terminally ill • Tracheostomy care/dysfunction • Homecare • Sensory deficit/loss • Developmental disability

Trauma Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. National EMS Education Standard Competencies Trauma Applies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient.

Special Considerations in Trauma Recognition and management of trauma in the Geriatric patient Pathophysiology, assessment, and management of trauma in the National EMS Education Standard Competencies Special Considerations in Trauma • Recognition and management of trauma in the Pregnant patient Pediatric patient Geriatric patient • Pathophysiology, assessment, and management of trauma in the Cognitively impaired patient

Introduction Geriatrics is the assessment and treatment of disease in a person 65 years of age or older. Geriatric patients present as a special challenge for health care providers. Injuries and illness are affected by chronic conditions, multiple medications, and the physiology of aging. Lecture Outline I. Introduction A. Geriatrics is the assessment and treatment of disease in a person who is age 65 years or older. 1. The baby boomer generation, people born between 1946 and 1964, are more active and fit than people their age were in previous generations. 2. 65 years is used as the threshold age to be consistent with the definition used by other medical groups and governmental agencies. 3. How fast one ages is a function of genetics, lifestyle, and, perhaps, attitude. 4. The older population is growing to a larger percentage of the overall population. B. Geriatric patients present as a special challenge for health care providers because the classic presentation of injuries and illness are often altered by the presence of chronic conditions, multiple medications, and the physiology of aging. 1. As the older population increases, communities, companies, and hospitals are encouraging awareness of geriatric issues.

Generational Considerations (1 of 2)
It is important to understand and appreciate how the life of an older person might differ from yours. It takes time and patience to interact with an older person. Treat the patient with respect. Lecture Outline II. Generational Considerations A. It is important to understand and appreciate how the life of an older person might differ from yours. 1. Older people may have recently lost a spouse, face financial difficulties, or be struggling to stay independent. B. It takes time and patience to interact with an older person. 1. Have patience and treat the patient with respect.

Generational Considerations (2 of 2)
Make every attempt to avoid ageism. Not all older people have dementia. Not all older people are hard of hearing. Not all older people are sedentary or immobile. Lecture Outline 2. Make every attempt to avoid ageism, the stereotyping of older people that often leads to discrimination. a. Not all older people have dementia. b. Not all older people are hard of hearing. c. Not all older people are sedentary or immobile. 3. Older people can stay fit and be active, even though they are not able to perform at the same level as they did in their youth.

Communication and Older Adults (1 of 2)
Effective verbal communication skills are essential. Communication techniques Speak respectfully. Identify yourself. Be aware of how you present yourself. Look directly at the patient at eye level. Speak slowly and distinctly. Lecture Outline III. Communication and Older Adults A. Effective verbal communication skills are essential to the successful assessment and treatment of older patients. 1. The aging process brings with it changes in vision, hearing, taste, smell, touch, and pain sensation. 2. Changes in communication abilities accompany aging, such as dementia and other diseases. B. Communication techniques 1. Your first words to the patient and the attitude behind them can gain or lose a patient’s trust. a. Speak respectfully when you introduce yourself. b. Address the patient by using “sir” or “ma’am.” c. If you know the patient’s last name, use “Mr.,” “Mrs.,” or “Ms.” d. Never use familiar or casual terms when referring to your patients unless they have invited you to do so. 2. When you interview an older patient, the following techniques should be used: a. Identify yourself. b. Be aware of how you present yourself. c. Look directly at the patient at eye level and ensure good lighting. d. Speak slowly and distinctly.

Communication and Older Adults (2 of 2)
Communication techniques (cont’d) Have one person talk to the patient and ask only one question at a time. Do not assume that all older patients are hard of hearing. Give the patient time to respond. Listen to the answer. Explain what you will do before you do it. Lecture Outline e. Have one person talk to the patient and ask only one question at a time. f. Do not assume that all older patients are hard of hearing. g. Give the patient time to respond unless the condition appears urgent. h. Listen to the answer the patient gives you. i. Explain what you will do before you do it. j. Do not talk about the patient in front of him or her as though the patient is not there.

Common Complaints and the Leading Causes of Death in Older People (1 of 2)
The geriatric population is predisposed to a host of problems not seen in youth. Hip fractures are common. More likely to occur when bones are weakened by osteoporosis or infection Sedentary behavior can lead to pneumonia and blood clots. Lecture Outline IV. Common Complaints and the Leading Causes of Death in Older People A. The changing physiology of geriatric patients can predispose this population to a host of problems not seen in youth. 1. A simple rib fracture in an 80- or 90- year-old can result in pneumonia or even death. 2. A hip fracture from a low-mechanism fall is common in older people and may have dire consequences. a. Hip fractures are more likely to occur when bones are weakened by osteoporosis or infection. b. Sedentary behavior while healing can predispose the patient to pneumonia and blood clots.

© Jones and Bartlett Learning
Common Complaints and the Leading Causes of Death in Older People (2 of 2) Lecture Outline B. The most common conditions in geriatric patients are: 1. Hypertension 2. Arthritis 3. Heart disease 4. Cancer 5. Diabetes mellitus 6. Asthma 7. Chronic bronchitis or emphysema 8. Stroke C. The leading causes of death in the geriatric population include: 1. Heart disease 2. Cancer 3. Chronic lower respiratory disease 4. Stroke 5. Alzheimer disease 6. Influenza and pneumonia © Jones and Bartlett Learning

Changes in the Body (1 of 2)
The aging process is accompanied by changes in physiologic function. All tissues in the body undergo aging. Decrease in the functional capacity of various organ systems is normal, but can affect the way a patient responds to illness. Lecture Outline V. Changes in the Body A. Human growth and development peaks in the late 20s and early 30s, at which point the aging process begins. 1. The process of aging is gradual and starts much earlier than most people realize. 2. The aging process can vary dramatically from one person to another. B. The aging process is inevitably accompanied by changes in physiologic function, such as a decline in the function of the liver and kidneys. 1. All tissues in the body undergo aging. 2. The decrease in the functional capacity of various organ systems is normal but can affect the way in which a patient responds to illness.

Changes in the Body (2 of 2)
Normal changes should not be mistaken for signs of illness. Genuine symptoms should not be attributed to “just getting old.” Lecture Outline 3. Do not mistake the changes for signs of illness and give treatment when none is necessary. a. At the other end of the spectrum, do not attribute genuine disease symptoms to “just getting old” and neglect their treatment.

Changes in the Respiratory System (1 of 7)
Age-related changes can predispose an older adult to respiratory illness. Airway musculature becomes weakened. Alveoli in the lung tissue become enlarged and the elasticity decreases. The body’s chemoreceptors slow with age. Lecture Outline VI. Changes in the Respiratory System A. Anatomy and physiology 1. Age-related changes can predispose an older adult to respiratory illness. 2. One of the conditions contributing to breathing problems is weakening of the airway musculature, which can cause decreased breathing capacity. a. Older patients have less help from muscles in the chest wall when they have trouble breathing. 3. The alveoli in lung tissue can become enlarged and the elasticity decreases, making it harder to expel used air. 4. The body’s chemoreceptors, which monitor the changes in oxygen and carbon dioxide levels in the blood, slow with age, causing the body to respond more slowly to hypoxia.

Pneumonia Inflammation/infection of the lung from bacterial, viral, or fungal causes 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. Lecture Outline B. Pathophysiology 1. Pneumonia a. Chronic lower respiratory disease, influenza, and pneumonia are in the top five causes of geriatric deaths. b. Pneumonia is an inflammation/infection of the lung from bacterial, viral, or fungal causes. c. It is the leading cause of death from infection in Americans older than 65 years. d. Aging causes some immune suppression and increases the risk of contracting infections like pneumonia.

Pneumonia (cont’d) Increased mucus production, pulmonary secretions, and infection all interfere with the ability of the alveoli to oxygenate the blood. Wear respiratory protection when you are assessing a patient with a potentially infectious respiratory disease. Lecture Outline e. Increased mucus production, pulmonary secretions, and the inflammatory effects of infection all interfere with the ability of the alveoli to oxygenate the blood. f. Management of pneumonia is the same for any patient; however, maintain a high index of suspicion for any geriatric patient with signs and symptoms of pneumonia. g. Remember to wear respiratory protection when assessing a patient with a potentially infectious respiratory disease.

Pulmonary embolism Condition that causes a sudden blockage of an artery by a venous clot A patient will present with shortness of breath and sometimes chest pain. Lecture Outline 2. Pulmonary embolism a. Pulmonary embolism is a condition that causes a sudden blockage of an artery by a venous clot. b. A patient with a pulmonary embolism will present with shortness of breath and sometimes chest pain. i. It can be confused with a cardiac, lung, or musculoskeletal problem.

Pulmonary embolism 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 Lecture Outline c. Risk factors include: i. Living in a nursing home or recent hospitalization for medical illness or surgery ii. Trauma iii. Cancer iv. History of blood clots or heart failure v. Presence of a pacemaker or central venous catheter vi Paralyzed extremities vii. Obesity viii. Recent long-distance travel ix. Sedentary behavior

Pulmonary embolism presents with: Tachycardia Sudden onset of dyspnea Shoulder, back, or chest pain Cough Syncope in patients in whom the clot is larger Anxiety Lecture Outline d. Patients present with: i. Tachycardia ii. Sudden onset of dyspnea iii. Shoulder, back, or chest pain iv. Cough v. Syncope in patients in whom the clot is larger vi. Anxiety

Pulmonary embolism presents with (cont’d): Apprehension Low-grade fever Hemoptysis Leg pain, redness, and unilateral pedal edema Fatigue Cardiac arrest (worst-case scenario) Lecture Outline vii. Apprehension viii. Low-grade fever ix. Hemoptysis x. Leg pain, redness, and unilateral pedal edema xi. Fatigue xii. Cardiac arrest (worst-case scenario) e. Treatment should focus on airway, ventilatory, and circulatory support. i. Any blood that is coughed up should be cleared from the airway. ii. Supplemental oxygen is mandatory.

Changes in the Cardiovascular System (1 of 5)
The heart hypertrophies with age. Cardiac output declines. Arteriosclerosis contributes to systolic hypertension. Many people tend to limit physical activity and exercise as they grow older. Lecture Outline VII. Changes in the Cardiovascular System A. Anatomy and physiology 1. A variety of changes occur in the cardiovascular system as a person grows older, with the net effect of a decrease in the efficiency of the system. a. The heart hypertrophies with age, probably in response to the chronically increased afterload imposed by stiffened blood vessels. b. Over time, cardiac output declines, mostly as a result of a decreasing stroke volume. c. Arteriosclerosis (a disease that causes the arteries to thicken, harden, and calcify) contributes to systolic hypertension, which places an extra burden on the heart. 2. Some changes in cardiovascular performance are probably not a direct consequence of aging, but rather reflect the deconditioning effect of a sedentary lifestyle. a. Many people tend to limit physical activity and exercise as they grow older.

Geriatric patients are at risk for atherosclerosis Accumulation of fat and cholesterol in the arteries Major complications include myocardial infarction and stroke. Affects more than 60% of people older than 65 years Lecture Outline B. Pathophysiology 1. With aging, a person’s ability to speed up contractions, increase contraction strength, and constrict or narrow blood vessels is decreased because of stiffer vessels. a. As stroke volume is reduced, cardiac output decreases. b. The heart may lose its ability to raise cardiac output to meet the needs of the body. 2. Geriatric patients are at risk for atherosclerosis, an accumulation of fat and cholesterol in the arteries. a. Major complications include myocardial infarction and stroke. b. Affects more than 60% of people older than 65 years c. Atherosclerosis makes stroke, heart disease, hypertension, and bowel infarction more likely.

The figure on this slide shows atherosclerosis, the buildup of fat and cholesterol in the arteries. © Jones and Bartlett Learning

Older people are at increased risk for 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. Lecture Outline 3. Older people are also at an increased risk for formation of an aneurysm, an abnormal, blood-filled dilation of the wall of a blood vessel. a. Severe blood loss can occur when an aneurysm ruptures. 4. The blood vessels themselves become stiff, which results in a higher systolic blood pressure. 5. Other anatomic changes include stiffening and degeneration of the heart valves, which may impede normal blood flow in and out of the heart. a. Aging also alters the heart’s electrical conduction system. b. This can cause a heart rate that is too fast, too slow, or too erratic to provide effective blood flow to the body. 6. Orthostatic hypotension is a drop in blood pressure with a change in position. a. The body is less able to adapt to rapid postural changes.

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. Lecture Outline 7. Another vessel-related problem is called venous stasis. a. Refers to the loss of proper function of the veins in the legs that would normally carry blood back to the heart b. Causes blood clots in the superficial veins (superficial phlebitis) and blood clots in the deep veins (deep venous thrombosis) c. Deep vein thrombosis can lead to pulmonary embolism. d. People with this condition usually exhibit edema, or swelling, of the legs and ankles. e. Eventually causes a reddish-brown discoloration on the skin and, in some cases, skin ulcers

Heart Attack (1 of 3) 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. Lecture Outline 8. Heart attack (myocardial infarction) a. The classic symptoms of a heart attack are often not present in geriatric patients. i. “Silent” heart attacks are particularly common in women and people with diabetes.

Heart Attack (2 of 3) Any of the following symptoms may be a manifestation 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 Lecture Outline b. Any of the following symptoms may be a manifestation of acute cardiac disease in older patients: i. Dyspnea ii. Epigastric and abdominal pain iii. Loss of bladder and bowel control iv. Nausea and vomiting v. Weakness, dizziness, light-headedness, and syncope vi. Fatigue vii. Confusion

Heart Attack (3 of 3) Other signs and symptoms include:
Issues with circulation Diaphoresis Pale, cyanotic, or mottled skin Abnormal or decreased breath sounds Increased peripheral edema Lecture Outline c. Other signs and symptoms that can indicate a cardiovascular problem include: i. Issues with circulation ii. Diaphoresis (profound sweating) iii. Pale, cyanotic, or mottled skin iv. Abnormal or decreased breath sounds v. Increased peripheral edema d. Obtain baseline vital signs. i. This information will provide you with a primary picture of the severity of your patient’s condition. ii. You can use these findings to measure against in your ongoing assessment of the patient. f. Treatment mostly consists of airway, ventilatory, and circulatory support. i. Give oxygen. ii. Continue to evaluate. iii. Cardiac problems can be expected to worsen suddenly, so be prepared.

Heart Failure (1 of 4) The signs and symptoms will differ depending on whether the right or left side of the heart is not functioning correctly. Lecture Outline 9. Heart failure a. The signs and symptoms will differ depending on the extent to which the right and/or left side of the heart is not functioning correctly.

Heart Failure (2 of 4) Right-sided heart failure occurs when the 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. Lecture Outline b. Right-sided heart failure occurs when the fluid backs up into the body. i. You will see jugular vein distention, ascites, and peripheral edema. ii. An enlarged liver may also be present, which is determined by palpation. iii. Right-sided heart failure is often caused by left-sided heart failure, so it is common to see signs of both.

Heart Failure (3 of 4) 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. Lecture Outline c. With left-sided heart failure, fluid backs up into the lungs. i. Causes pulmonary edema ii. The patient will have severe shortness of breath and hypoxia with crackles in the lungs.

Heart Failure (4 of 4) 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. If you suspect congestive heart failure, ask, “Do you sleep sitting up?” Lecture Outline d. Paroxysmal nocturnal dyspnea is a condition that is characterized by a sudden attack of respiratory distress that wakes the person at night when he or she is reclining. i. Caused by fluid accumulation in the lungs ii. Patients report coughing, feeling suffocated, and cold sweats; you will notice tachycardia. iii. If you suspect congestive heart failure, one question you can ask is, “Do you sleep sitting up?” e. Treatment should consist of airway, ventilatory, and circulatory support.

Stroke (1 of 4) 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 Lecture Outline 10. Stroke a. Stroke is a leading cause of death in older people. b. Preventable risk factors include smoking, hypertension, diabetes, atrial fibrillation, obesity, and a sedentary lifestyle. c. Uncontrollable factors include age, race, and gender.

Stroke (2 of 4) 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 Lecture Outline d. Signs and symptoms include: i. Acute altered level of consciousness ii. Numbness, weakness, or paralysis on one side of the body iii. Slurred speech iv. Difficulty speaking (aphasia) v. Visual disturbances vi. Headache and dizziness vii. Incontinence viii. Seizure

Stroke (3 of 4) Hemorrhagic strokes are less common and more likely to be fatal. Broken blood vessel causes bleeding into the brain. Ischemic strokes occur when a blood clot blocks the flow of blood to a portion of the brain. Lecture Outline e. Hemorrhagic strokes, in which a broken blood vessel causes bleeding into the brain, are less common and more likely to be fatal. f. Ischemic strokes occur when a blood clot blocks the flow of blood to a portion of the brain.

Stroke (4 of 4) 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. Lecture Outline g. The treatment goal is to salvage as much of the surrounding brain tissue as possible. h. Determining the onset of the symptoms of stroke is important. i. If the symptoms occurred within the past few hours, the patient will be a candidate for stroke center therapy. j. Transient ischemic attack (TIA) can present with the same signs and symptoms as a stroke; always manage the patient as if he or she is having a stroke.

Changes in the Nervous System (1 of 6)
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. Lecture Outline VIII. Changes in the Nervous System A. Anatomy and physiology 1. Changing in thinking speed, memory, and posture stability are the most common normal findings in older people. 2. The brain decreases in terms of weight (10% to 20%) and volume as a person ages. a. This increases the amount of space in the cranium, thus increasing the change for head injuries. b. Head injuries with a minimal mechanism are commonly missed in older patients. 3. There is a 5% to 50% loss of neurons in older people. a. Neurons are responsible for transmission of impulses, so the motor and sensory neural networks slow down with age. b. This affects the control of the rate and depth of breathing, heart rate, blood pressure, hunger, thirst, and body temperature. 4. 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. Lecture Outline 5. Vision a. Visual acuity, depth perception, and the ability of the eyes to accommodate to light change with age. b. Cataracts, clouding of the lenses or their surrounding membranes, interfere with vision and make it difficult to distinguish colors and see clearly. c. Decreased tear production leads to drier eyes. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Vision (cont’d) Inability to differentiate colors Decreased night vision Inability to see up close (presbyopia) Other diseases: Glaucoma Macular degeneration Retinal detachment Lecture Outline d. Older people develop an inability to differentiate colors and have decreased night vision. e. The inability to see up close is called presbyopia and it is caused by a loss of elasticity of the crystalline lens. f. A number of other disease processes plague the vision of older adults, including: i. Glaucoma ii. Macular degeneration iii. Retinal detachment

Hearing Hearing problems cause changes in the inner ear, making 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. Lecture Outline 6. Hearing a. Typical hearing problems cause changes in the inner ear and make hearing high-frequency sounds difficult. b. Changes in the ear can also cause problems with balance and make falls more likely. c. Presbycusis is a gradual hearing loss that occurs as we age. d. Heredity and long-term exposure to loud noises are the main factors that contribute to hearing loss. e. When assessing your patient, check for the use of hearing aids.

Taste Decrease in the number of taste buds Negative result might be lessened interest in eating, which can lead to: Weight loss Malnutrition Complaints of fatigue Lecture Outline 7. Taste a. The sense of taste can be diminished because of a decrease in the number of taste buds. b. The negative result might be lessened interest in eating, which can lead to: i. Weight loss ii. Malnutrition iii. 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 Lecture Outline 8. Touch a. An older person may have a decreased sense of touch and pain perception from the loss of the end nerve fibers. b. This loss can create situations in which an older person may be injured and not know it. i. Specifically, there is a decreased sensation of hot and cold.

Dementia (1 of 3) 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 Lecture Outline B. Pathophysiology 1. Dementia a. Dementia is the slow onset of progressive disorientation, shortened attention span, and loss of cognitive function. b. It is a chronic, generally irreversible condition that causes a progressive loss of cognitive abilities, psychomotor skills, and social skills.

Dementia (2 of 3) Dementia is the result of many neurologic diseases, and may be caused by: Alzheimer disease Parkinson disease Cerebrovascular accidents Genetic factors Lecture Outline c. Dementia is the result of many neurologic diseases and may be caused by: i. Alzheimer disease ii. Parkinson disease iii. Cerebrovascular accidents iv. Genetic factors d. Determine the patient’s normal mental status by questioning family members or friends; evaluate history, risk factors, and current medications.

Dementia (3 of 3) 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 Lecture Outline e. On assessment, the patient might exhibit loss of cognitive function. i. Patients may have short- and long-term memory problems and a decreased attention span, or they may be unable to perform their daily routines. ii. They also may show a decreased ability to communicate and appear confused. f. Other aspects of dementia can complicate your ability to assess and manage the patient. i. Sometimes patients are not only confused, but angry as well. ii. They will have impaired judgment. iii. They may be unable to vocalize areas of pain and current symptoms. iv. They may be unable to follow commands. g. Patients with dementia may express anxiety over movement out of their current residence. i. You must exercise extreme tolerance and patience.

Delirium (1 of 3) 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. Lecture Outline 2. Delirium a. Delirium is a sudden change in mental status, consciousness, or cognitive processes. b. Marked by the inability to focus, think logically, and maintain attention c. Delirium affects 15% to 50% of hospitalized people aged 70 years or older. d. Acute anxiety may be present in addition to the other symptoms. i. Usually memory remains intact.

Delirium (2 of 3) 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 Psychiatric disorders such as depression Malnutrition or vitamin deficiencies Environmental emergencies Lecture Outline e. This condition is generally the result of a reversible physical ailment, such as tumors or fever, or metabolic causes. f. Other important things to look for in the history are: i. Intoxication or withdrawal from alcohol ii. Withdrawal from sedatives iii. Medical conditions such as urinary tract infections, bowel obstructions, dehydration, fever, cardiovascular disease, and hyper- or hypoglycemia iv. Psychiatric disorders such as depression v. Malnutrition or vitamin deficiencies vi. Environmental emergencies

Delirium (3 of 3) Assess and manage the patient for:
Hypoxia Hypovolemia Hypoglycemia Hypothermia You may see changes in circulation, breath sounds, motor function, and pupillary response. Lecture Outline g. Assess and manage the patient for: i. Hypoxia ii. Hypovolemia iii. Hypoglycemia iv. Hypothermia h. Critical BLS and ALS interventions may include supplemental oxygen, treatment of shock, glucose, and rewarming measures. i. During the physical examination, you may see changes in circulation, breath sounds, motor function, and pupillary response. i. Hypotension can indicate hypovolemia. ii. Dilated pupils could suggest hypoxia. iii. Wheezing, crackles, and rhonchi j. Treatment should include airway, ventilatory, and circulatory support and oxygen with airway adjuncts.

Syncope Assume this is a life-threatening problem until proven otherwise. Often caused by an interruption of blood flow to the brain Lecture Outline 3. Syncope (fainting) a. Always assume that this is a life-threatening problem until proven otherwise. b. Syncope is often caused by an interruption of blood flow to the brain. c. An older person who has a period of unconsciousness should be examined to determine the cause of the syncope. © Jones and Bartlett Learning

Neuropathy (1 of 4) 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. Lecture Outline 4. Neuropathy a. A disorder of the nerves of the peripheral nervous system in which function and structure of the peripheral motor, sensory, and autonomic neurons are impaired b. Symptoms depend on whether the nerves affected are motor, sensory, or autonomic and where the nerves are located.

Neuropathy (2 of 4) Motor nerves Muscle weakness Cramps Spasms
Loss of balance Loss of coordination Lecture Outline c. Motor nerves i. Muscle weakness ii. Cramps iii. Spasms iv. Loss of balance v. Loss of coordination

Neuropathy (3 of 4) Sensory nerves Tingling Numbness Itching Pain
Burning, freezing, or extreme sensitivity to touch Lecture Outline d. Sensory nerves i. Tingling ii. Numbness iii. Itching iv. Pain v. Burning, freezing, or extreme sensitivity to touch

Neuropathy (4 of 4) Autonomic nerves
Changes in blood pressure and heart rate Constipation Bladder and sexual dysfunction Lecture Outline e. Autonomic nerves i. Changes in blood pressure and heart rate ii. Constipation iii. Bladder and sexual dysfunction

Changes in the Gastrointestinal System (1 of 5)
Reduction in the volume of saliva Dental loss Gastric secretions are reduced. Changes in gastric motility occur. Incidence of certain diseases involving the bowel increases. Blood flow to the liver declines. Lecture Outline IX. Changes in the Gastrointestinal System A. Anatomy and physiology 1. Changes in the mouth include a reduction in the volume of saliva, with a resulting dryness of the mouth. a. Dental loss is widespread in the older population and contributes to nutritional and digestive problems. b. These oral changes increase the risk of choking. 2. Like oral secretions, gastric secretions are reduced as a person ages. a. Enough acid is still present to produce ulcers under certain conditions. b. Changes in gastric motility also occur, which may lead to slower gastric emptying. 3. Function of the small and large bowel changes little as a consequence of aging. a. The incidence of certain diseases involving the bowel increases as a person grows older. b. Nutrients from food are not as readily absorbed. 4. Blood flow to the liver declines. a. The activity of the enzyme systems involved with the detoxification of drugs declines as a person ages.

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 Lecture Outline B. Pathophysiology 1. Age-related changes in the gastrointestinal (GI) system include: a. Issues with dental problems b. Decrease in saliva and sense of taste, leading to poor nutrition c. Poor muscle tone of the smooth muscle sphincter between the esophagus and stomach that can cause regurgitation and lead to heartburn and acid reflux d. A decrease in hydrochloric acid in the stomach e. Alterations in absorption of nutrients and slowing peristalsis f. Weakening of the rectal sphincter 2. Changes in the liver predispose older patients to a number of problems. a. The liver, which is responsible for removing toxins and breaking down drugs in the body, shrinks with age. b. Blood flow to the liver declines, and there is decreased metabolism. c. This has a direct effect on how medications may affect the patient.

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. Lecture Outline 3. GI bleeding issues that affect older people are: a. GI bleeding caused by i. Inflammation ii. Infection iii. Obstruction of the upper or lower GI tract b. Usually heralded by hematemesis c. Bleeding that travels through the lower digestive tract usually manifests as melena (black, tarry stools). d. Red blood usually means a local source of bleeding, such as hemorrhoids. e. A patient with GI bleeding may experience weakness, dizziness, or syncope. f. Bleeding in the GI system can be life threatening.

Specific GI problems in older patients include: Diverticulitis Bleeding in the upper and lower GI system Peptic ulcer disease Gallbladder disease Bowel obstruction Lecture Outline 4. Specific GI problems that are more common in older patients include: a. Diverticulitis i. A condition in which the walls of the gut weaken and small pouches protrude from the colon along those weakened segments ii. Inflammation develops in one of these pouches iii. A geriatric patient generally presents with left lower quadrant pain and fever. b. Bleeding in the upper and lower GI system i. Upper GI bleeding occurs in the esophagus, stomach, or duodenum. ii. Irritation of the lining of the stomach or ulcers can cause forceful vomiting that tears the esophagus. iii. Long-term use of nonsteroidal anti-inflammatory drugs, hepatitis, and cancer can contribute to bleeding problems. iv. Lower GI bleeding occurs in the colon or rectum. c. Peptic ulcer disease i. More common in older adults, especially people who use NSAIDs ii. The patient will complain of a gnawing, burning pain in the upper abdomen that improves after eating but returns later. iii. Complications include bleeding, anemia, and bowel perforation. d. Gallbladder disease i. More common in older adults, and they have a higher risk of complications from gallstones ii. Patients will present with fever and right upper quadrant pain that may radiate to the shoulder. iii. Patients may also present with jaundice. e. Bowel obstruction i. The ability of the GI tract to move feces through the system slows with aging, and patients can experience problems having bowel movements. ii. When patients are straining to have a bowel movement, they can stimulate the vagus nerve, which can cause a vasovagal response. iii. This is a condition in which the heart rate drops dramatically and the patient becomes dizzy or passes out.

When assessing patients, ask about NSAID and alcohol use. Orthostatic vital signs can help determine if a patient is hypovolemic. Blood pressures and pulse rates are obtained with the patient lying, sitting, and standing. Note any drop in blood pressure and increase in heart rate that occurs as the patient moves to an upright position. Lecture Outline 5. When assessing patients, ask about NSAID and alcohol use. a. Presentation can include: i. Pale or yellow, thin skin ii. Frail musculoskeletal system iii. Peripheral, sacral, and periorbital edema iv. Hypertension v. Fever vi. Tachycardia vii. Dyspnea 6. Orthostatic vital signs can help determine if a patient is hypovolemic. a. Blood pressures and pulse rates are obtained with the patient lying, sitting, and standing. b. Note any drop in blood pressure and increase in heart rate that occurs as the patient moves to an upright position. c. Do not attempt to assess orthostatic vitals on a patient with obvious signs of shock, hypotension, altered level of consciousness, or possible spinal injury. 7. Treatment consists of airway, ventilatory, and circulatory support; oxygen should be delivered with adjuncts appropriate to the patient’s condition.

Acute Abdomen– Nongastrointestinal Complaints
Extremely difficult to assess in the prehospital setting Most serious threat from abdominal complaints is blood loss Abdominal aortic aneurysm (AAA) is one of the most rapidly fatal conditions. Walls of the aorta weaken, and blood leaks into the layers of the vessel If enough blood is lost, shock occurs. Lecture Outline 8. The acute abdomen—nongastrointestinal complaints a. Abdominal complaints in geriatric patients are extremely difficult to assess. b. In the prehospital setting, the most serious threat from abdominal complaints is blood loss, which can lead to shock and death. c. Abdominal aortic aneurysm (AAA) is one of the most rapidly fatal conditions. i. An AAA tends to develop in people who have a history of hypertension and atherosclerosis. ii. The walls of the aorta weaken, and blood begins to leak into the layers of the vessel, causing the aorta to bulge like a bubble on a tire. iii. If enough blood is lost into the vessel wall itself, shock occurs. iv. If the vessel wall bursts, it rapidly leads to fatal blood loss. v. A patient with an AAA most commonly reports abdominal pain radiating through to the back with occasional flank pain. vi. If you see or palpate a pulsating mass just above and slightly to the left of the navel, do not continue manipulation or allow other providers to palpate the mass. vii. Treat the patient for shock, including high-flow oxygen and thermal regulation, and provide prompt transport to the hospital.

Changes in the Renal System (1 of 4)
Age brings changes in the kidneys. Reduction in renal function Reduction in renal blood flow Tubule degeneration Lecture Outline X. Changes in the Renal System A. Anatomy and physiology 1. The largest component of the urinary system is the kidneys, or renal organs. 2. Age-related changes in the genitourinary system specific to the kidney include: a. A reduction in renal function b. A reduction in renal blood flow c. 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) Lecture Outline 3. For the genitourinary system in general, there is: a. Decreased bladder capacity b. Decline in sphincter muscle control c. Decline in voiding senses d. Increase in nocturnal voiding e. Benign prostatic hypertrophy (enlarged prostate) 4. The kidneys are responsible for maintaining the body’s fluid and electrolyte balance and have important roles in maintaining the body’s long-term acid– base balance and eliminating drugs from the body. a. The kidneys decline in weight as a person ages. b. Renal blood flow decreases by as much as 50%.

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. Lecture Outline B. Pathophysiology 1. Acute illness in older patients is often accompanied by derangements in fluid and electrolyte balance. 2. Bowel and bladder continence require anatomically correct GI and genitourinary tracts, functioning and intact sphincters, and properly working cognitive and physical functions. a. Incontinence is not a normal part of aging and can lead to skin irritation, skin breakdown, and urinary tract infections. b. As people age, the capacity of the bladder decreases. c. Two major types of incontinence are distinguished: stress and urge. i. Stress incontinence occurs during activities such as coughing, laughing, sneezing, lifting, and exercise. ii. Urge incontinence is triggered by hot or cold fluids, running water, and even thinking about going to the bathroom. d. Treatment consists of medications, physical therapy, and possibly surgery.

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. Lecture Outline 3. The opposite of incontinence is urinary retention or difficulty urinating. a. In men, enlargement of the prostate can place pressure on the urethra, making voiding difficult. b. Bladder and urinary tract infections can also cause inflammation. c. In severe cases of urinary retention, patients may experience renal failure.

Changes in the Endocrine System (1 of 4)
Reduction in thyroid hormones (thyroxine) Signs and symptoms: Slower heart rate Fatigue Drier skin and hair Cold intolerance Weight gain Lecture Outline XI. Changes in the Endocrine System A. Anatomy and physiology 1. The endocrine system functions as the control center of the body. 2. A significant change that occurs in an older person is decreased metabolism of thyroxine. 3. Thyroxine affects the body’s metabolism, temperature, growth, and heart rate. a. A reduction in thyroid hormones can cause a condition called hypothyroidism. 4. Most of the signs and symptoms people experience are attributed to the process of aging and include: a. Slower heart rate b. Fatigue c. Drier skin and hair d. Cold intolerance e. 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 Lecture Outline 5. Other endocrine changes include: a. An increase in the secretion of antidiuretic hormone, causing fluid imbalance b. Hyperglycemia c. 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 Lecture Outline B. Pathophysiology 1. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a diabetic complication in older people and occurs more often in people with type 2 diabetes. 2. The signs and symptoms of HHNS and diabetic ketoacidosis often overlap. a. Hyperglycemia b. Polydipsia (thirst) c. Polyuria (urination) d. Polyphagia (hunger) e. Dizziness f. Confusion g. Altered mental status h. Seizures 3. On assessment, you may see changes in circulation such as: a. Warm, flushed skin b. Poor skin turgor c. Pale, dry, oral mucosa d. Furrowed tongue 4. The patient may present with signs and symptoms of hypotension and shock, including tachycardia. 5. The blood glucose level will be variable in DKA, whereas in HHNS, the value is typically 600 mg/dL or higher. 6. DKA will present with Kussmaul respirations, while HHNS will not.

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) Lecture Outline 7. Assessment of the patient should include: a. Obtaining blood pressure b. Distal pulses c. Auscultation of breath sounds d. Temperature e. Assessment of blood glucose level (if permitted by local protocol) 8. Treatment should include airway, ventilatory, and circulatory support; provide oxygen with adjuncts appropriate to the patient’s condition.

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. Lecture Outline XII. Changes in the Immune System A. Infections are commonly seen in older people because they generally have an increased risk of infection and are less able to fight infections once they occur. 1. Many older patients may be unable to develop a fever, and in fact may be hypothermic as a manifestation of severe systemic infection. 2. Anorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptoms of infection in these patients. 3. Pneumonia and urinary tract infection are common in patients who are bedridden. 4. When infection occurs, signs and symptoms may be decreased or minimized by the patient because of the: a. Loss of sensation b. Lack of awareness c. Fear of being hospitalized

Changes in the Musculoskeletal System (1 of 4)
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. Lecture Outline XIII. Changes in the Musculoskeletal System A. Anatomy and physiology 1. Aging brings a widespread decrease in bone mass in men and women, but especially among postmenopausal women. a. Bones become more brittle and tend to break more easily. b. The disks between the vertebrae of the spine begin to narrow, and a decrease in height of between 2″ and 3″ may occur through the lifespan, along with changes in posture. c. Joints lose their flexibility and may be further immobilized by arthritic changes. d. 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. Lecture Outline B. Pathophysiology 1. Changes in physical abilities can affect older adults’ confidence in their mobility. a. Muscle fibers become smaller and fewer. b. Motor neurons decrease in number. c. Strength declines. d. Ligaments and cartilage of the joints lose their elasticity. e. Cartilage goes through degenerative change. 2. The stooped posture of older people comes from atrophy of the supporting structures of the body. a. Two of every three older patients will show some degree of kyphosis. b. Lost height in older adults generally results from compression in the spinal column.

Osteoporosis is characterized by a decrease in bone mass Reduction in bone strength and greater susceptibility to fracture Extent of bone loss depends on: Genetics, body weight Smoking, alcohol consumption Level of activity, diet Lecture Outline 3. Osteoporosis, a condition that affects men and women, is characterized by a decrease in bone mass leading to reduction in bone strength and greater susceptibility to fracture. a. The extent of bone loss that a person undergoes is influenced by numerous factors, including: i. Genetics ii. Smoking iii. Level of activity iv. Diet v. Alcohol consumption vi. Hormonal factors vii. Body weight b. The most rapid loss of bone occurs in women during the years following menopause. i. Many postmenopausal women use hormone replacement therapy as a means to reduce the loss of bone. c. Calcium and vitamin D supplementation is another treatment for the condition, and many other medications are available to improve bone strength.

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 Lecture Outline 4. Osteoarthritis is a progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs in joints, and leads to joint stiffness. a. Results from wear and tear and, in some cases, from repetitive trauma to the joints b. Affects 35% to 45% of the population older than 65 years c. Affects several joints of the body, most commonly those in the hands, knees, hips, and spine d. Patients complain of pain and stiffness that gets worse with exertion. e. Patients are typically treated with anti-inflammatory medications and physical therapy.

Changes in Skin (1 of 3) Proteins that make the skin pliable decline with age. Layer of fat under the skin becomes thinner Bruising becomes more common. Sweat glands do not respond as readily to heat. Lecture Outline XIV. Changes in Skin A. The proteins that make the skin pliable decline with age. 1. The layer of fat under the skin also becomes thinner because of the redistribution of fluids and proteins. 2. Bruising becomes more common because the skin can tear more easily. 3. Exocrine (sweat) glands do not respond as readily to heat because of atrophy and changes to the tissues of the dermal layer of the skin.

Changes in Skin (2 of 3) Pressure ulcers become a problem.
Sometimes referred to as bedsores or decubitis 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. Lecture Outline B. Another problem that affects the skin is pressure ulcers, sometimes referred to as bedsores or decubitis ulcers. 1. The pressure from the weight of the body cuts off the blood flow to the area of skin. 2. With no blood flow to the skin, a sore develops. 3. To help prevent these ulcers, take special care to pad under any bony prominences and in the voids in a patient who may be immobilized for an extended period.

Changes in Skin (3 of 3) 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 Lecture Outline 4. You may see these ulcers in the following various stages of development: a. Stage I: Nonblanching redness with damage under the skin b. Stage II: Blister or ulcer that can affect the dermis and epidermis c. Stage III: Invasion of the fat layer through to the fascia d. Stage IV: Invasion to muscle or bone 5. Decubitis ulcers can be painful and cause complications such as bleeding, sepsis, and bone inflammation called osteomyelitis.

Toxicology (1 of 3) Older people are more susceptible to toxicity because of: Decreased kidney function Altered gastrointestinal absorption Decreased vascular flow in liver Kidneys undergo many changes with age. Decreased liver function makes it harder for the liver to detoxify the blood and eliminate medications and alcohol. Lecture Outline XV. Toxicology A. Older people are more susceptible to toxicity because of: 1. Decreased kidney function 2. Altered GI absorption 3. Decreased vascular flow in the liver B. The kidneys undergo many changes with age. 1. Decreased liver function makes it harder for the liver to detoxify the blood and eliminate substances such as medications and alcohol. 2. These metabolic issues can also make it difficult for physicians to find the appropriate dosage for new medications.

© Jones & Bartlett Learning. Courtesy of MIEMSS.
Toxicology (2 of 3) Typical OTC medications can have negative effects when mixed with each other or with herbal substances, alcohol, and prescription medications Lecture Outline C. Typical OTC medicines used by older people include aspirin, antacids, cough syrups, and decongestants. 1. Many people believe OTC medications cannot be dangerous. 2. These medications can have negative effects when mixed with each other and/or with herbal substances, alcohol, and prescription medications. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Toxicology (3 of 3) 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 Lecture Outline D. Polypharmacy refers to the use of multiple prescription medications by one patient. 1. Patients may not remember what medications one doctor prescribed or may not want to tell one doctor about seeing another. 2. Negative effects can include overdosing and negative medication interaction. 3. Both overdose and underdose can lead to serious problems. 4. Medication noncompliance in older patients is also an issue and may occur because of: a. Financial challenges b. Inability to open containers c. Impaired cognitive, vision, and hearing ability

Depression (1 of 2) 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. Lecture Outline XVI. Behavioral Emergencies A. Depression 1. Depression is not part of normal aging, but rather a medical disease. This common, often debilitating psychiatric disorder affects millions of older Americans. 2. In contrast with the normal emotional experiences of sadness, grief, loss, and temporary bad moods, depression is extreme and persistent and can interfere signi¬ficantly with an older adult’s ability to function. 3. Depression is treatable with medication and therapy. 4. If depression goes unrecognized or untreated, it is associated with a higher suicide rate in the geriatric population than in any other age group.

Depression (2 of 2) Risk factors include 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 Lecture Outline 5. Risk factors for depression include: a. History of depression b. Chronic disease c. Loss 6. The following conditions contribute to the onset of significant depression: a. Substance abuse b. Isolation c. Prescription medication use d. Chronic medical conditions 7. Treatment of severe depression in older adults usually consists of behavioral counseling, medication, or a combination of both.

Suicide (1 of 3) 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 Lecture Outline B. Suicide 1. Most older adult suicide victims have recently been diagnosed with depression and have seen their primary care physician within the month before the event. 2. Older men have the highest suicide rate of any age group in the United States. a. At highest risk are white men age 85 years and older who use firearms as their suicide method of choice. b. Older persons who attempt suicide choose much more lethal means than younger victims and generally have diminished recuperative capacity to survive an attempt. c. Unlike younger people, geriatric patients typically do not make suicidal gestures or attempt to get help. d. Instead, the rate of completed suicide is disproportionately high in the geriatric population. e. Many geriatric patients see no other way out when they have a terminal illness or debilitating cardiac or neurologic condition (such as severe heart disease or stroke).

Suicide (2 of 3) 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 Lecture Outline 3. Some common predisposing events and conditions include: a. Death of a loved one b. Physical illness c. Depression and hopelessness d. Alcohol abuse e. Alcohol dependence f. Loss of meaningful life roles

Suicide (3 of 3) 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. Lecture Outline 4. When assessing the patient who is displaying signs of depression, it is appropriate to ask if he or she is considering suicide. a. If the answer is “yes,” the next question should be, “Do you have a plan?” b. Include this information in your report.

The GEMS Diamond (1 of 4) 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 Lecture Outline XVII. The GEMS Diamond A. The GEMS diamond was created to help you remember what is different about older patients. 1. It is not intended to be a format for the approach to geriatric patients, nor is it intended to replace the ABCs of care. 2. Instead, it serves as an acronym for the issues to be considered when assessing every older patient.

The GEMS Diamond (2 of 4) Geriatric patient Environmental assessment
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. Lecture Outline B. “G” stands for geriatric patient. 1. Consider that older patients are different from younger patients and may present atypically. 2. Be familiar with the normal changes of aging and treat older patients with compassion and respect. C. “E” stands for an environmental assessment. 1. Assessing the environment can help give clues to the patient’s condition and the cause of the emergency. 2. Preventive care is very important for a geriatric patient who may not carefully study the environment or may not realize where risks exist.

The GEMS Diamond (3 of 4) Medical assessment
Older patients tend to have a variety of medical problems and numerous medications. Obtain a thorough medical history. Lecture Outline D. “M” stands for medical assessment. 1. Older patients tend to have a variety of medical problems and may be taking numerous prescription, over-the-counter, and herbal medications. 2. Obtaining a thorough medical history is very important.

The GEMS Diamond (4 of 4) 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. Lecture Outline E. “S” stands for social assessment. 1. Older people may have less of a social network because of the death of a spouse, family members, and friends. 2. Older people may also need assistance with activities of daily living. 3. 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 Lecture Outline XVIII. Special Considerations in Assessing a Geriatric Medical Patient A. Assessing an older person can be challenging because of: 1. Communication issues 2. Hearing and vision deficits 3. Alteration in consciousness 4. Complicated medical histories 5. Effects of medication

Scene Size-up (1 of 2) 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. Lecture Outline B. Scene size-up 1. Scene safety a. Geriatric patients are commonly found in their own homes, retirement homes, or skilled nursing facilities. i. Many older people live alone. ii. Access to them may be hampered if their condition prevents them from getting to the door. iii. Police or fire department assistance may be required. b. Many older people try to maintain their independence as long as they can. i. You need to take note of negative or unsafe environmental conditions. ii. Look for clues that might explain the patient’s medical history or current problem. c. In a nursing home or residential care facility, you will need to locate the patient’s room and find a staff member who can explain why you were called. d. In any case in which the patient’s mental status is altered, you need to find someone who can tell you the patient’s history and whether the patient’s behavior or level of consciousness is normal or altered.

Scene Size-up (2 of 2) 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. Lecture Outline 2. Mechanism of injury/nature of illness a. The NOI may be difficult to determine in older people who may have an altered mental status or dementia. b. You must ask the family member, caregiver, or bystander why he or she called. c. Multiple and chronic disease processes may also complicate the determination of the NOI. d. Complaints from an older person may be vague. e. Chest pain, shortness of breath, and an altered level of consciousness should always be considered serious.

Primary Assessment (1 of 6)
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. Lecture Outline C. Primary assessment 1. Address life threats. 2. Determine the transport priority of your patient based on his or her condition and maintain a high index of suspicion for serious injuries even with mechanisms of injury that might seem minor in younger patients. 3. As you approach the patient, you should be able to tell if the patient is generally in stable or unstable condition. a. 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. Lecture Outline 4. Airway and breathing a. Anatomic changes that occur as a person ages predispose geriatric patients to airway problems. i. Aging and disease can compromise a patient’s ability to protect his or her airway with loss of a gag reflex and normal swallowing mechanisms. ii. Changes in level of consciousness, dementia, and poststroke weakness or paralysis can cause airway obstruction or aspiration. b. Ensure that the patient’s airway is open and is not obstructed by dentures, vomitus, fluid, or blood. c. Suction may be necessary.

Airway and breathing (cont’d) 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. Lecture Outline d. Anatomic changes also affect a person’s ability to breathe effectively, including: i. Increased chest wall stiffness ii. Brittle bones iii. Weakening of the airway musculature iv. Decreased muscle mass e. Loss of mechanisms that protect the upper airway, such as cough and gag reflexes, cause a decreased ability to clear secretions. f. A decrease in the number of cilia that line the bronchial tree results in the inability of the patient to remove material from the lung, which can cause infection. g. In some patients, the alveoli are damaged, and a lack of elasticity results in a decreased ability to exchange oxygen and carbon dioxide. h. 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. Lecture Outline 5. Circulation a. Poor perfusion is a serious issue in an older adult. b. Physiologic changes may negatively affect circulation. i. Less-responsive nerve stimulation may lower the rate and strength of the heart’s contractions. ii. Lower heart rates and weaker and irregular pulses are common in older patients. c. Vascular changes and circulatory compromise might make it difficult to feel a radial pulse in an older patient. d. Circulation problems in older adults should be treated with oxygen as soon as possible. e. Determine if cardiac abnormalities in an older patient indicate an acute emergency or a chronic condition; acute emergencies should be managed rapidly.

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. Lecture Outline 6. Transport decision a. Patient assessment is more complicated in an older adult, and multiple problems can exist. b. Any complaints that compromise airway, breathing, or circulation should result in transportation of the patient as a priority patient. c. Your most important task is to determine conditions that are life threatening, treat them to the best of your ability, and provide transport to priority patients.

Priority patients are those who have: Poor general impression Airway or breathing problems Acute altered level of consciousness Shock Severe pain Uncontrolled bleeding Older people will easily decompensate. Lecture Outline d. Priority patients include patients who have: i. Poor general impression ii. Airway or breathing problems iii. Acute altered level of consciousness iv. Shock v. Severe pain vi. Uncontrolled bleeding e. Older people do not have the reserves that younger people do, and they will easily decompensate. f. Consider early on if ALS treatment and immediate transport is appropriate and available.

History Taking (1 of 2) 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. Lecture Outline D. History taking 1. Investigate the chief complaint. a. Find and account for all medications. b. Communication may be more complicated with an older adult, but it is critical that you obtain a thorough patient history. c. The determination should be made early on as to whether the altered level of consciousness is acute or chronic. i. Chronic mental status impairment is not a normal process of aging but is caused by a pathologic or disease process; you should never accept confusion as normal. ii. Older people may not show severe symptoms even if they are very ill. d. Multiple disease processes and multiple and/or vague complaints can make assessment complicated. i. Ask questions to assess the nature of the problem, and determine whether it may or may not be life threatening. ii. Take a full set of vital signs; ask what is “normal” for that patient.

History Taking (2 of 2) 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. Lecture Outline 2. SAMPLE history a. You may have to rely on a relative or caregiver to help you in collecting a SAMPLE history. b. Note the signs you observe and your general impression. c. Make sure you have a list of the patient’s medications or take the medications with you to the hospital, if possible. d. The last meal is particularly important in a patient with diabetes, but negative nutrition can have a negative effect on a patient. e. It is advantageous to provide transport to a facility that knows the patient’s medical history.

Secondary Assessment (1 of 3)
May be performed on scene, en route to the emergency department, or not at all 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 exam. Lecture Outline E. Secondary assessment 1. The secondary assessment may be performed on scene, en route to the emergency department, or not at all. 2. Physical examinations a. Your older patient may not be comfortable with being exposed. b. Protect his or her modesty. c. 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. Lecture Outline 3. Vital signs a. The heart rate should be in the normal adult range but may be compromised by medications such as beta-blockers. b. Weak and irregular pulses are common in older patients. c. Circulatory compromise may make it difficult to feel a radial pulse in an older patient, and other pulse points may need to be considered.

Vital signs (cont’d) 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. Lecture Outline d. Blood pressure tends to be higher in older people. e. Capillary refill is not a good assessment because of skin changes and reduced circulation to the skin. f. The respiratory rate should be in the same range as in a younger adult, but remember that chest rise will be compromised by increased chest wall stiffness. g. Be sure to auscultate breath sounds to listen for: i. Crackles associated with pulmonary edema ii. Rhonchi or rattles associated with pneumonia iii. Wheezes associated with asthma h. Monitoring devices i. Careful interpretation of pulse oximetry data is necessary in older adults because the pulse oximetry device requires adequate perfusion to get an accurate reading. ii. Adhesive probes might help confirm accuracy of the data. iii. Determine what the patient’s normal blood pressure is; your baseline blood pressure and any change from the patient’s normal baseline can alert you to a potential problem.

Reassessment (1 of 4) 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. Lecture Outline F. Reassessment 1. Reassess the geriatric patient often because the condition of an older adult may deteriorate quickly. 2. Reassess the vital signs. 3. Reassess the patient’s complaint. 4. Recheck interventions. 5. Identify and treat changes in the patient’s condition.

Reassessment (2 of 4) Interventions Maintain position of comfort.
Assist ventilation as needed. Administer glucose for a patient with diabetes. In specific cases, you may also assist with nitroglycerin, aspirin, or inhalers. Provide psychological support. Lecture Outline 6. Interventions a. Accommodate positioning requests when possible, especially when patient is experiencing shortness of breath. b. Allow the patient to maintain a position of comfort, unless contraindicated. c. Assist ventilation as needed. d. Administer glucose for a patient with diabetes who has altered mental status and a manageable airway. e. In specific cases, you may also assist with nitroglycerin, aspirin, or inhalers; pharmacologic interventions require medical direction and are based on local protocol f. Administration of oxygen may be a useful therapy for many geriatric problems. i. Be mindful of monitoring the level of consciousness in a patient with COPD. g. Be prepared to ventilate if breathing becomes inadequate. h. Listen to your patient, respond to your patient, and provide reassurance.

Reassessment (3 of 4) Communication and documentation
Communicate your findings and the interventions you used to emergency department personnel. Document all history, medication, assessment, and intervention information. Lecture Outline 7. Communication and documentation a. Communicate your findings and the interventions you used to emergency department personnel. b. Document all history, medication, assessment, and intervention information.

Reassessment (4 of 4) The table on this slide provides guidelines for assessing geriatric patients. © Jones and Bartlett Learning

Trauma and Geriatric Patients (1 of 10)
Conditions that create risk and complicate assessment: Slower homeostatic compensatory mechanisms Limited physiologic reserves Normal effects of aging on the body Existing medical issues Lecture Outline XIX. Trauma and Geriatric Patients A. In general, the risk of serious injury or death is more common in older patients who experience trauma than in younger patients. 1. Conditions that create risk and complicate the assessment of geriatric patients: a. Slower homeostatic compensatory mechanisms b. Limited physiologic reserves c. Normal effects of aging on the body d. Existing medical issues

Physical findings in an older adult may be more subtle and more easily missed. Mechanisms are much more minimal. Recuperation from trauma is longer and often less successful. Many injuries are undertriaged and undertreated. Lecture Outline 2. Physical findings in an older adult may be more subtle and more easily missed. a. The mechanisms that cause serious injury in older people are usually much more minimal than in younger people. b. Recuperation from trauma is longer and often less successful in older people. c. Many injuries in older people are undertriaged and undertreated.

Because of changes in the body, older pedestrians are more likely to have life-threatening complications after being struck by a vehicle. Commonly suffer injury to the legs and arms Other injuries can be caused by a secondary collision onto the street, often involving the head. Lecture Outline B. Because of changes in the body, older pedestrians are more likely to have life-threatening complications after being struck by a vehicle. 1. Older pedestrians commonly suffer injury to the legs and arms. 2. Other injuries can be caused by a secondary collision onto the street, often involving the head.

Older people are more likely to experience burns because of altered mental status, inattention, and a compromised neurologic status. Risk of mortality is increased when: Preexisting medical conditions exist The immune system is weakened Fluid replacement is complicated by renal compromise Lecture Outline C. Older people are more likely to experience burns because of altered mental status, inattention, and a compromised neurologic status. 1. Risk of mortality from burns is increased when: a. Preexisting medical conditions exist b. The immune system is weakened c. Fluid replacement is complicated by renal compromise

Higher mortality from penetrating trauma in older adults, especially gunshot wounds Penetrating trauma can easily cause serious internal bleeding. 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. Lecture Outline D. There is higher mortality from penetrating trauma in older adults, especially in the case of gunshot wounds. 1. Penetrating trauma can easily cause serious internal bleeding. E. Falls are the leading cause of fatal and nonfatal injuries in older adults. 1. 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. Lecture Outline F. Anatomic changes and trauma 1. Changes in pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older patients more susceptible to trauma. a. The brain shrinks, leading to higher risks of cerebral bleeding following head trauma. b. Skeletal changes cause curvature of the upper spine that often requires additional padding during spinal immobilization. c. Loss of strength, sensory impairment, and medical illness all increase the risk of falls. 2. A geriatric patient’s overall physical condition may lessen the ability of the patient’s body to compensate for the effects of even simple injuries. a. A geriatric patient’s blood pressure drops sooner than in a younger adult patient during a traumatic emergency.

As a result of osteoporosis, older patients are prone to fractures, especially of the hip. Contributing factors: Stresses of ordinary activity A standing fall Vitamin D and calcium deficiencies Metabolic bone diseases Tumors Lecture Outline 3. As a result of bone loss from osteoporosis, older patients of both sexes are prone to fractures, especially of the hip. a. Hip fractures are much more common among women. b. Contributing factors include: i. Stresses of ordinary activity ii. A standing fall iii. Vitamin D and calcium deficiencies iv. Metabolic bone diseases v. Tumors c. Injuries to the hip tend to be recurring.

Geriatric patients with osteoporosis are also at risk for pelvic fractures. With age, the spine stiffens as a result of shrinkage of disk spaces, and vertebrae become brittle. Compression fractures of the spine occur. Lecture Outline d. Older patients with osteoporosis are also at risk for pelvic fractures. e. Recovering from these kinds of injuries can be complicated for an older person. 4. With age, the spine stiffens as a result of shrinkage of disk spaces, and vertebrae become brittle. a. Compression fractures of the spine are more likely to 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. Lecture Outline 5. Because brain tissue shrinks with age, older patients are more likely to sustain closed head injuries, such as subdural hematomas. a. Acute subdural hematomas are among the deadliest of all head injuries. i. Tiny veins between the surface of the brain and its outer covering stretch and tear, allowing blood to collect. ii. Blood fills the skull very rapidly, compressing brain tissue, which often results in brain injury. b. Serious head injuries are often missed in older patients 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 Lecture Outline c. Other factors that predispose an older patient to a serious head injury include: i. Long-term abuse of alcohol ii. Recurrent falls or repeated head injury iii. 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 highest risk Lecture Outline G. Environmental Injury 1. Internal temperature regulation slows with age owing to: a. Slowed endocrine system b. Slowed circulation c. Decreased sweat production in the skin d. Chronic disease, medication use, and alcohol use 2. Half of all deaths from hypothermia occur in older people; most indoor hypothermia deaths involve geriatric patients. a. Living where harsh winters occur is a risk factor. b. Hypothermia can also develop at temperatures above freezing when an older person is exposed for a prolonged period. 3. Death rates from hyperthermia more than double in older people compared with younger people; people older than 85 years are at 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. Lecture Outline XX. Special Considerations in Assessing Geriatric Trauma Patients A. Trauma is never isolated to a single issue when you are assessing and caring for a geriatric patient.

Scene Size-up 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. Lecture Outline B. Scene size-up 1. Scene safety a. Ensure your own safety first. b. Take standard precautions. c. Consider the number of patients. d. Determine if you need additional or specialized resources. 2. Mechanism of injury/nature of illness a. Look for clues that indicate whether your patient’s traumatic incident may have been preceded by a medical incident. b. Bystander information may help determine if a loss of consciousness occurred. c. MOI is important in establishing whether an injury is considered critical, and it affects treatment and transport considerations.

Address life threats. Determine the transport priority. Recommended that older trauma patients be transported to a trauma center Form a general impression. Is patient’s condition is stable or unstable? Use AVPU and the Glasgow Coma Scale to determine mental status. Lecture Outline C. Primary assessment 1. Address life threats. 2. Determine the transport priority of the patient. a. It is recommended that older trauma patients be transported to a trauma center. 3. Form a general impression. a. As you approach the patient, you should be able to tell if he or she is generally in stable or unstable condition. b. Determining neurologic status may be difficult if you do not know the patient’s baseline. i. Try to get information from someone familiar with the patient, if possible. c. Use the AVPU and the Glasgow Coma Scale to determine mental status. i. An important consideration with any patient is the inability to remember the event.

Airway and breathing If the patient is talking to you, the airway is patent. Patients who have noisy respirations have airway compromise. Older patients may have a diminished ability to cough, so suctioning is important. Assess for the presence of dentures. Lecture Outline 4. Airway and breathing a. If the patient is talking to you, the airway is patent. b. Patients who have noisy respirations have airway compromise. c. Older patients may have a diminished ability to cough, so suctioning is important. d. Assess for the presence of dentures but do not remove them unless they are creating an airway patency problem. e. In an unresponsive patient, open the airway with a modified jaw-thrust maneuver. f. Perform a thorough respiratory assessment and physical assessment of the chest, and treat accordingly. g. Use pulse oximetry to monitor oxygenation.

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 BP when they are actually in shock. Lecture Outline 5. Circulation a. Manage any external bleeding immediately. b. Drinking alcohol and taking anticoagulant medications that can make internal bleeding worse or external bleeding more difficult to control. c. Physiologic changes secondary to aging can worsen the effects of trauma. d. Older people do not heal from trauma as easily as younger adults. e. Older patients can more easily go into shock. f. Patients who were hypertensive prior to injury may have a normal blood pressure when they are actually in shock.

History Taking Investigate the chief complaint.
Considerations in your assessment must include past medical conditions, even if they are not currently acute or symptomatic. Lecture Outline D. History taking 1. Investigate the chief complaint. a. Considerations in your assessment of the patient’s condition and stability must include past medical conditions, even if they are not currently acute or symptomatic.

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. Lecture Outline E. Secondary assessment 1. Physical examinations a. Should be performed on a geriatric trauma patient in the same manner as for any adult but with consideration of the higher likelihood of damage from trauma b. Any head injury can be life threatening in an older adult. c. When examining the chest, consider that breathing may be impaired. d. Check lung sounds, and look to see if there is any evidence of pacemakers or previous cardiac surgery. e. Decreased muscle size in the abdomen may mask abdominal trauma. f. Look for bruising and other evidence of trauma. g. Injury to the liver or spleen may present with diffuse abdominal pain, or pain may refer to the left shoulder.

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. Lecture Outline 2. Vital signs a. Assess the pulse, blood pressure, and skin signs. b. Capillary refill is unreliable in older people because of compromised circulation. c. Remember that some older people take beta-blockers, which will inhibit their heart from becoming tachycardic as you would expect in shock.

Reassessment (1 of 3) Repeat the primary assessment. Interventions
A geriatric patient has a higher likelihood of decompensating after trauma. Interventions Broken bones are common and should be splinted. Lecture Outline F. Reassessment 1. Repeat the primary assessment. a. Remember that a geriatric patient has a higher likelihood of decompensating after trauma. 2. Interventions a. Broken bones are common and should be splinted in a manner appropriate to the injury.

© Jones & Bartlett Learning. Courtesy of MIEMSS.
Reassessment (2 of 3) Interventions (cont’d) Do not force a patient with joint flexion or kyphosis into a “normal” position. Provide blankets and heat to prevent hypothermia. Lecture Outline b. Effective application of conventional splints and backboards may be difficult or impossible unless a large amount of padding is used. c. Trying to force a patient into a “normal” anatomic position can harm the patient. d. In hip and pelvic fractures, avoid log rolling the patient. e. In general, padding should be done for comfort and to help decrease the likelihood of decubitis ulcers forming. f. Provide blankets and heat to prevent hypothermia. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Reassessment (3 of 3) Communications and documentation
Communication can be challenging. Provide psychological support as well as medical treatment. Lecture Outline 3. Communication and documentation a. Communication with older people can be challenging. b. Provide psychological support as well as medical treatment. c. Document assessment, treatment, and reassessment, including any changes in the patient’s status.

Assessment of Falls Falls can be caused by a medical condition such as fainting, a cardiac rhythm disturbance, or a medication interaction. Whenever you assess a geriatric patient who has fallen, it is important to find out why the fall occurred. Consider that the fall may have been caused by a medical condition, possibly life-threatening. Lecture Outline XXI. Assessment of Falls A. Falls can be caused by a medical condition such as fainting, a cardiac rhythm disturbance, or a medication interaction. 1. Whenever you assess a geriatric patient who has fallen, it is important to find out why the fall occurred. 2. Consider that the fall may have been caused by a medical condition. a. Look carefully for clues from the patient, bystanders, and the environment. b. Consider that if a medical condition caused the fall, it may be life threatening.

Response to Nursing and Skilled Care Facilities (1 of 3)
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?” Lecture Outline XXII. Response to Nursing and Skilled Care Facilities A. With many of your geriatric patients with whom you interact, the call will occur at a nursing home or other skilled care facility. 1. The kind of facility will depend on the type of care needed. 2. Nursing homes are facilities that serve patients who need 24-hour care and are sometimes a step down from an acute care hospital. a. Patients require assistance with daily living and need therapeutic or rehabilitation services. 3. Calls to these types of facilities can sometimes be challenging. a. Patients often have an altered level of consciousness and may not be able to give you a nature of illness or mechanism of injury. b. The staff is usually spread thin. c. The most important piece of information you need to establish immediately is, “What is wrong with the patient that is new or different today that made you call 9-1-1?” d. Talk to the staff who directly care for the patient on a daily basis. e. With potentially limited information, you need to do an assessment to determine if the patient’s problem is life threatening and/or requires ALS-level care.

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. Lecture Outline 4. Infection control needs to be a high priority for EMTs when visiting these facilities. a. Good handwashing and standard precautions can inhibit the spread of infectious pathogens to people who already have compromised immune systems. b. An infection in an older patient can lead to life- threatening sepsis. B. There are many risks to the patients and the EMTs. 1. Methicillin-resistant Staphylococcus aureus (MRSA) infections are common among people who are living in close quarters such as nursing homes. a. The organism can be found in decubitus ulcers, on feeding tubes, and on indwelling urinary catheters. b. Can cause mild infections on the skin or invade the bloodstream, lungs, or the urinary tract c. Primarily spread by broken skin-to-skin contact, but is also acquired by touching objects that have the bacteria on them d. To protect yourself and reduce the spread of MRSA infections, you should wash your hands before and after every patient contact, properly dispose of or disinfect all medical equipment, and take appropriate standard precautions with every patient. 2. Many infections in hospitals are caused by vancomycin- resistant enterococci (VRE). a. Enterococci are bacteria that are normally present in the human intestines and the female reproductive tract. b. Some of the enterococci have become resistant to the antibiotic commonly used to treat these infections, which is vancomycin. 3. The respiratory syncytial virus (RSV) causes an infection of the upper and lower respiratory tracts. a. The symptoms are similar to the common cold but can be more severe and last longer. b. The virus is highly contagious and is found in discharges from the nose and throat of an infected person. c. Also transmitted by direct contact with droplets from coughs or sneezes and by touching a contaminated surface d. MRSA and respiratory syncytial virus infections can be life threatening, especially in an immune-compromised patient. i. Wear appropriate PPE and decontaminate your ambulance and diagnostic equipment. ii. Document the infection control issue. iii. Advise the receiving facility of infectious disease in the patient. iv. Report an infectious disease to your company or the local health department.

Infection control (cont’d) 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. Lecture Outline 4. Clostridium difficile is a bacterium responsible for the most common cause of hospital-acquired infectious diarrhea. a. It is a bacterium that normally grows in the intestines. b. Health care workers may carry this bacterium following contact with contaminated feces. c. It can also be found on environmental surfaces such as: i. Furniture ii. Floors iii. Toilets iv. Sinks v. Bedding d. Symptoms can range from minor diarrhea to a life- threatening inflammation of the colon. e. Typical alcohol-based hand sanitizers do not inactivate or kill C. difficile. Contact precautions with gowns and gloves and handwashing with soap and water after each and every patient contact is essential to prevent transmission.

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. Lecture Outline XXIII. Dying Patients A. As older patients are living longer, more terminally ill patients are choosing to die at home rather than in a hospital. 1. Often the patient comes to terms with his or her impending death before the family does. 2. Dying patients receive what is called palliative, or comfort, care. a. Palliative care recognizes that death is a normal part of the life cycle. b. It does not hasten or prolong death, but focuses on relieving pain and providing emotional support and comfort for the patient and his or her loved ones. 3. Your interaction with a dying patient will have a long-term effect on the family. a. Be understanding, sensitive, and compassionate. b. Determine if the family wishes for the patient to go to the hospital or stay in the home.

Advance Directives (1 of 3)
Specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves Dealing with advance directives has become more common for EMS providers. Lecture Outline B. Advance directives are specific legal papers that direct relatives and caregivers about what kind of medical treatment may be given to patients who cannot speak for themselves. 1. Dealing with advance directives has become more common for EMS providers because more people are electing to use hospice services and spend their final days at home.

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. Lecture Outline B. Advance directives may take the form of a do not resuscitate (DNR) order. 1. A DNR order gives you permission not to attempt resuscitation for a patient in cardiac arrest. 2. For a DNR order to be valid, the form must be signed by the patient or legal surrogate and by one or more physicians or other licensed health care providers. 3. DNR does not mean “do not treat.” a. If the patient is still alive, you are obligated to provide supportive measures that may include oxygen delivery, pain relief, and comfort. b. Basic airway, breathing, and circulatory support should be provided. c. Cardiopulmonary resuscitation may not be provided. 4. A health care power of attorney is an advance directive that is exercised by a person who has been authorized by the patient to make medical decisions for him or her.

When transporting patients from nursing facilities, consider these guidelines: Patients have the right to refuse treatment. A DNR order is valid only if it is in the form of a written order by a physician. Review state and local protocols. When in doubt, try to resuscitate the patient. Lecture Outline 5. When transporting patients from nursing facilities, consider the following general guidelines: a. Patients have the right to refuse treatment, including resuscitative efforts, provided that they are able to communicate their wishes. b. A DNR order is valid in a health care facility only if it is in the form of a written order by a physician. c. You should periodically review state and local protocols and legislation regarding advance directives. d. When you are in doubt or when there are no written orders, you should try to resuscitate the patient.

Elder Abuse and Neglect (1 of 7)
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 Lecture Outline XXIV. Elder Abuse and Neglect A. Elder abuse is defined as any action on the part of an older person’s family member, caregiver, or other associated person that takes advantage of the older person’s person, property, or emotional state. 1. Abuse can result from acts of commission (words or actions that cause harm), such as verbal, physical, or sexual assault. 2. Abuse can also result from acts of omission (failure to act), such as denying an older person adequate nutrition or medical care.

The extent of elder abuse is not known for several reasons: It has been largely hidden from society. Definitions of abuse and neglect among the geriatric population vary. Victims are often hesitant to report the problem. Lecture Outline 3. The exact extent of elder abuse is not known for several reasons, including the following: a. Elder abuse is a problem that has been largely hidden from society. b. The definitions of abuse and neglect among the geriatric population vary. c. Victims of elder abuse are often hesitant to report the problem to law enforcement agencies or human and social welfare personnel.

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. Lecture Outline 4. The abused person may feel traumatized by the situation or be afraid that the abuser will punish him or her for reporting the abuse. a. The abused person may be frail and have multiple chronic medical conditions or dementia. 5. Elder abuse occurs most often in women older than 75 years. a. The physical and emotional signs of abuse, such as rape, spouse beating, and nutritional deprivation, are often overlooked or not accurately identified. b. Older women in particular are not likely to report incidents of sexual assault to law enforcement agencies. c. Patients with sensory deficits, dementia, and other forms of altered mental status may not be able to report abuse. 6. Abusers of older people are sometimes products of child abuse themselves, and the abuse that is inflicted on the older person may be retaliatory. a. Most of these abusers are not trained in the particular care that older people require and have little relief time. b. Their lives are now significantly complicated by the constant, demanding needs of the older person they have to care for. c. The abuser may also have marked fatigue, be unemployed with financial difficulties, or abuse one or more substances. 7. Environments such as nursing, convalescent, and continuing care centers are also sites where older people sustain physical, psychological, financial, or pharmacologic harm. a. Often, care providers in these environments consider older people to be management problems or categorize them as obstinate and undesirable patients. b. Consult local authorities, but in general you should assume that you have the same obligation to report suspected elder abuse as you do suspected child abuse. i. Notify receiving hospital personnel of your concerns. ii. Report to the proper authorities based on local protocols. iii. Factually document your findings.

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. Lecture Outline B. Assessment of elder abuse 1. 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. 2. You should suspect abuse when answers to questions about what caused the injury are concealed or avoided. 3. 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 caregiver Caregiver does not allow patient to answer questions Repeated visits to the ED or clinic A history of being accident-prone Unbelievable or vague explanations of injuries Lecture Outline 4. Information that may be important in assessing possible abuse includes the following: a. Caregiver apathy about the patient’s condition b. Overly defensive reaction by caregiver to your questions c. Caregiver does not allow patient to answer questions d. Repeated visits to the emergency department or clinic e. A history of being accident-prone f. Soft-tissue injuries g. Unbelievable, vague, or inconsistent explanations of injuries

Information that may be important in assessing abuse includes (cont’d): 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 Lecture Outline h. Psychosomatic complaints i. Chronic pain without medical explanation j. Self-destructive behavior k. Eating and sleep disorders l. Depression or a lack of energy m. Substance and/or sexual abuse history 5. Many patients who are being abused are so afraid of retribution that they make false statements.

Repeated abuse can lead to a high risk of death. Lecture Outline 6. Repeated abuse can lead to a high risk of death. a. A preventive measure in reducing additional maltreatment of the patient is identification of the abuse. © Jones and Bartlett Learning

Signs of Physical Abuse (1 of 4)
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. Lecture Outline C. Signs of physical abuse 1. Injuries may be the result of acute or chronic abuse or neglect. 2. Inflicted bruises are usually found on the: a. Buttocks and lower back, genitals, and inner thighs b. Cheeks or earlobes c. Neck d. Upper lip e. Inside the mouth 3. Pressure bruises caused by the human hand may be identified by oval grab marks, pinch marks, or handprints. 4. Human bites are typically inflicted on the upper extremities and can cause lacerations and infection. 5. Inspect the patient’s ears for indications of twisting, pulling, or pinching, and evidence of frequent blows to the outer ears. 6. Investigate multiple bruises in various states of healing.

Typical abuse from burns is caused by contact with: Cigarettes Matches Heated metal Forced immersion in hot liquids Chemicals Electrical power sources Lecture Outline 7. Typical abuse from burns is caused by contact with: a. Cigarettes b. Matches c. Heated metal d. Forced immersion in hot liquids e. Chemicals f. 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 Lecture Outline 8. Observe the patient’s weight and try to determine whether he or she appears undernourished or has been unable to gain weight in the current environment. 9. Check for signs of neglect, such as evidence of: a. Lack of hygiene b. Poor dental hygiene c. Poor temperature regulation d. Lack of reasonable amenities in the home © Brian Eichhorn/Shutterstock.

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 report sexual abuse. Many women do not report cases of sexual abuse because of shame and the pressure to forget. Lecture Outline 10. Regard injuries to the genitals or rectum with no reported trauma as evidence of sexual abuse in any patient. a. Geriatric patients with altered mental status may never be able to report sexual abuse. b. Many women do not report cases of sexual abuse because of shame and the pressure to remain silent.

Review The LEAST common cause of death in patients over 65 years of age is: stroke. diabetes. heart attack. drug overdose.

Review Answer: D Rationale: The leading causes of death in patients over 65 years of age are heart disease, diabetes, stroke, cancer, pulmonary diseases, and trauma. Drug overdose—intentional or unintentional—is not a leading cause of death in this age group.

Review The LEAST common cause of death in patients over 65 years of age is: stroke. Rationale: This is one of the common causes of death. diabetes. Rationale: This is one of the common causes of death. heart attack. Rationale: This is one of the common causes of death. drug overdose. Rationale: Correct answer

Review According to the GEMS diamond, a person’s activities of daily living are evaluated during the: SAMPLE history. social assessment. medical assessment. environmental assessment.

Review Answer: B Rationale: The GEMS diamond was created to help you remember what is unique to older people. During the social assessment (the “S” in the GEMS diamond), the patient’s activities of daily living (eg, eating, dressing, bathing, toileting) are evaluated. Are these activities being provided? If so, by whom? Are there delays in obtaining food, medication, or other necessary items?

Review (1 of 2) According to the GEMS diamond, a person’s activities of daily living are evaluated during the: SAMPLE history. Rationale: This is a mnemonic used when obtaining information during a focused history and physical exam. social assessment. Rationale: Correct answer

Review (2 of 2) According to the GEMS diamond, a person’s activities of daily living are evaluated during the: medical assessment. Rationale: “M” is obtained by a thorough medical history. It is important and is completed before the social assessment. environmental assessment. Rationale: “E” is the assessment of the environment. It considers if the home is well kept, too hot or too cold, or poses any hazards.

Review A condition that clouds the lens of the eye is called:
cataract. nystagmus. astigmatism. glaucoma.

Review Answer: A Rationale: As people get older, cataracts, or clouding of the lens of the eye, may interfere with vision. Glaucoma is a condition caused by increased intraocular pressure (IOP). Nystagmus is characterized by involuntary movement of the eyes. Astigmatism is an optical defect that causes blurred vision due to the inability of the eye to focus an object into a sharp, focused image on the retina.

Review A condition that clouds the lens of the eye is called:
cataract. Rationale: Correct answer nystagmus. Rationale: This is a horizontal, involuntary movement of the eyes. astigmatism. Rationale: This is an optical defect that causes blurred vision. glaucoma. Rationale: This is a condition caused by increased intraocular pressure (IOP).

Review You are called to a neatly kept residence for an 80-year-old woman who lives by herself. She burned her hand on the stove and experienced a full-thickness burn. When treating this patient, it is important to note that: there is a high likelihood that she has been abused. isolated full-thickness burns to the hand are not critical burns. this patient should probably be placed in an assisted-living center. slowing of reflexes causes a delayed pain reaction in older people.

Review Answer: D Rationale: In older patients, the sense of touch decreases due to a loss of the end-nerve fibers. This loss, in conjunction with slowing of the peripheral nervous system, causes a delayed reaction to pain. In this particular scenario, there is no indication that the patient has been abused. Partial- and full-thickness burns to the hands, feet, face, and genitalia are considered critical burns, regardless of the patient’s age.

Review (1 of 3) You are called to a neatly kept residence for an 80-year-old woman who lives by herself. She burned her hand on the stove and experienced a full-thickness burn. When treating this patient, it is important to note that: there is a high likelihood that she has been abused. Rationale: There is no indication of abuse in this situation.

Review (2 of 3) You are called to a neatly kept residence for an 80-year-old woman who lives by herself. She burned her hand on the stove and experienced a full-thickness burn. When treating this patient, it is important to note that: isolated full-thickness burns to the hand are not critical burns. Rationale: Any full-thickness burns of the hands, face, feet, or genitalia are considered critical.

Review (3 of 3) You are called to a neatly kept residence for an 80-year-old woman who lives by herself. She burned her hand on the stove and experienced a full-thickness burn. When treating this patient, it is important to note that: this patient should probably be placed in an assisted-living center. Rationale: This is no indication that the patient cannot take care of herself. slowing of reflexes causes a delayed pain reaction in older people. Rationale: Correct answer

Review The slow onset of progressive disorientation, shortened attention span, and loss of cognitive function is called: senility. delirium. dementia. delusion.

Review Answer: C Rationale: Dementia is defined as the slow onset of progressive disorientation, shortened attention span, and loss of cognitive function. Alzheimer disease is an example of dementia. In contrast to dementia, delirium is an acutely altered mental status, such as that caused by hypoglycemia.

Review (1 of 2) The slow onset of progressive disorientation, shortened attention span, and loss of cognitive function is called: senility. Rationale: Senility causes forgetfulness and confusion. The person is mentally less acute in later life. delirium. Rationale: Delirium is an acutely altered mental status.

Review (2 of 2) The slow onset of progressive disorientation, shortened attention span, and loss of cognitive function is called: dementia. Rationale: Correct answer delusion. Rationale: Delusion is a fixed belief that is not shared by others and cannot be changed by reasonable argument.

Review A 71-year-old man with a history of hypertension and vascular disease presents with tearing abdominal pain. His blood pressure is 80/60 mm Hg, his heart rate is 120 beats/min, and his respirations are 28 breaths/min. Your assessment reveals that his abdomen is rigid and distended. Considering his medical history and vital signs, you should be MOST suspicious for a(n): aortic aneurysm. hemorrhagic stroke. acute myocardial infarction. infarction of the large intestine.

Review Answer: A Rationale: Arteriosclerosis is a vascular disease in which the arteries thicken, harden, and calcify. This places the patient at risk for stroke, heart disease, bowel infarction, and hypertension, among other conditions. Hypertension and vascular disease are significant risk factors for an aneurysm—a weakening in the wall of an artery. The patient’s vital signs; abdominal pain; and rigid, distended abdomen should make you highly suspicious for a leaking abdominal aortic aneurysm.

Review (1 of 3) A 71-year-old man with a history of hypertension and vascular disease presents with tearing abdominal pain. His blood pressure is 80/60 mm Hg, his heart rate is 120 beats/min, and his respirations are 28 breaths/min. Your assessment reveals that his abdomen is rigid and distended. Considering his medical history and vital signs, you should be MOST suspicious for a(n): aortic aneurysm. Rationale: Correct answer hemorrhagic stroke. Rationale: This is when the patient complains of the worst headache of his life, loses the ability to speak, and eventually becomes difficult to arouse. It tends to worsen over time.

Review (2 of 3) A 71-year-old man with a history of hypertension and vascular disease presents with tearing abdominal pain. His blood pressure is 80/60 mm Hg, his heart rate is 120 beats/min, and his respirations are 28 breaths/min. Your assessment reveals that his abdomen is rigid and distended. Considering his medical history and vital signs, you should be MOST suspicious for a(n): acute myocardial infarction. Rationale: Although the patient history could predispose him to an acute MI, the symptoms would be pain in the chest or shoulder, nausea, vomiting, a feeling of shortness of breath, and sweating.

Review (3 of 3) A 71-year-old man with a history of hypertension and vascular disease presents with tearing abdominal pain. His blood pressure is 80/60 mm Hg, his heart rate is 120 beats/min, and his respirations are 28 breaths/min. Your assessment reveals that his abdomen is rigid and distended. Considering his medical history and vital signs, you should be MOST suspicious for a(n): infarction of the large intestine. Rationale: If the large intestine ruptures, it would present with signs of peritonitis.

Review Which of the following is a physiologic change that occurs during the process of aging? Increased elasticity of the alveoli A gradual decrease in blood pressure A decline in kidney function 10% to 15% increase in brain weight

Review Answer: C Rationale: As a person gets older, certain anatomic and physiologic changes occur. The alveoli in the lungs become less elastic, even though their overall size increases. Blood pressure gradually increases secondary to the process of arteriosclerosis (hardening of the arteries). A decline in kidney function occurs because of a decrease in the number of nephrons. By the age of 85 years, a 10% reduction in brain weight occurs, which causes an increased risk of head trauma.

Review (1 of 2) Which of the following is a physiologic change that occurs during the process of aging? Increased elasticity of the alveoli Rationale: With aging, alveoli lose some of their elasticity. A gradual decrease in blood pressure Rationale: Blood pressure generally increases due to arteriosclerosis.

Review (2 of 2) Which of the following is a physiologic change that occurs during the process of aging? A decline in kidney function Rationale: Correct answer 10% to 15% increase in brain weight Rationale: The brain decreases in weight by 5% to 10%.

Review Which of the following conditions makes the elderly patient prone to fractures from even minor trauma? Hypertension Osteoporosis Arteriosclerosis Rheumatoid arthritis

Review Answer: B Rationale: Osteoporosis, a decrease in bone density that causes the bones to become brittle, makes elderly patients prone to fractures, even from minor trauma. It is especially common in postmenopausal women.

Review (1 of 2) Which of the following conditions makes the elderly patient prone to fractures from even minor trauma? Hypertension Rationale: This is high blood pressure. Osteoporosis Rationale: Correct answer

Review (2 of 2) Which of the following conditions makes the elderly patient prone to fractures from even minor trauma? Arteriosclerosis Rationale: This is the stiffening or hardening of the arteries. Rheumatoid arthritis Rationale: This is an inflammatory disorder that affects the entire body and leads to degeneration and deformation of joints.

Review Polypharmacy is a term used to describe a patient who takes:
multiple medications. other people’s medications. a medication more than once a day. medication only when he or she feels the need to.

Review Answer: A Rationale: Polypharmacy is a term used to describe a patient who takes multiple medications every day. The more medications a patient takes, the greater the risk of a negative drug interaction.

Review Polypharmacy is a term used to describe a patient who takes:
multiple medications. Rationale: Correct answer other people’s medication. Rationale: This is incorrect. a medication more than once a day. Rationale: Many medications are taken more than once a day. medication only when he or she feels the need to. Rationale: This is considered noncompliant.

Review Inflicted bruises are commonly found in all of the following areas, EXCEPT: the buttocks. the lower back. the inner thighs. the forearms.

Review Answer: D Rationale: Inflicted bruises are typically found on the buttocks and lower back, genitalia and inner thighs, cheek or earlobe, upper lip and inside the mouth, and neck. Bruises to these areas should increase your index of suspicion for abuse.

Review Inflicted bruises are commonly found in all of the following areas, EXCEPT: the buttocks. Rationale: This is an area where bruises are typically inflected. the lower back. Rationale: This is an area where bruises are typically inflected. the inner thighs. Rationale: This is an area where bruises are typically inflected. the forearms. Rationale: Correct answer

Geriatric Emergencies

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