Alexander ch45 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 45
Geriatrics

• Applies a fundamental knowledge of growth,
development, and aging and assessment findings
to provide basic and selected advanced
emergency care and transportation for a patient
with special needs.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Summarize age-related anatomic and physiologic
changes for each of the major systems of the body.
3. Relate the anatomic and physiologic changes associated
with aging to anticipated differences in complaints and
assessment findings for geriatric patients.
4. Discuss the presentation, assessment, and management
of common medical emergencies in the elderly
population.
5. Describe the elderly patient’s altered response to trauma.
Objectives (1 of 2)

6. Recognize signs and risk factors of elder abuse.
7. Describe modifications that may be necessary to assess
and treat geriatric patients effectively.
Objectives (2 of 2)

Introduction (1 of 2)
• U.S. population age 65 years and older
increasing, expected to continue to increase
– Post–World War II baby boom, increasing life
expectancy
• Define each of the following terms:
– Geriatrics
– Gerontology

Introduction (2 of 2)
• Common reasons older adults require EMS:
– Cardiac and respiratory problems
– Neurologic problems
– Injuries from falls
– Nonspecific complaints

Think About It
• How does knowledge of the patient’s age and
details of the collision contribute to the clinical-
reasoning process?
• What age-related differences should Eddie and
Harper consider in the assessment and
management of this patient?
• What are some initial thoughts about potential
causes of the patient’s reported confusion and
difficulty breathing?

• Life expectancy: 77.9 years
– Influencing factors: gender, genetics, environment,
lifestyle
• Age-related decline of body system function:
decreased ability to maintain homeostasis due to
anatomical and physiologic changes
Anatomy and Physiology Review
(1 of 11)

Table 45-1 (1 of 2)
Age-Related Changes and Their Significance
Body System Change Possible Consequences
Senses Thickening of the lens of the eye
Cataracts
Macular degeneration
Glaucoma
Change in inner ear structures
Decreased pain sensitivity
Decreased taste and smell
Decreased accommodation resulting in difficulty with near
vision
Clouding of vision, difficulty seeing
Loss of central vision
Loss of peripheral vision
Decreased hearing, especially for high tones; dizziness
Decreased ability to detect illness and injury
Decreased enjoyment of food
Neurologic Structural and functional brain
changes
Brain atrophy (shrinkage), dementia, memory impairment,
slowed learning, depression, slowed reactions, and impaired
proprioception
Cardiovascular Atherosclerotic changes
Cardiac conduction system
changes
Myocardial changes
Hypertension, acute coronary syndrome, stroke, mesenteric
infarction, renal infarction, aortic dissection or aneurysm
Dysrhythmia, decreased maximum heart rate
Decreased cardiac output
Respiratory Changes in chest wall compliance
Decreased cough and gag
reflexes; decreased ciliary function
Decreased gas exchange
Impaired ventilation
Increased risk of aspiration and infection
Decreased ability to compensate for increased oxygen
demand

Table 45-1 (2 of 2)
Age-Related Changes and Their Significance
Body System Change Possible Consequences
Gastrointestinal Decreased stomach acid and
digestive enzymes
Decreased gastrointestinal motility
Decreased liver function
Impaired digestion and nutrient absorption
Constipation, bowel obstruction
Decreased production of proteins and enzymes, decreased
clearance of drugs metabolized by the liver; may contribute
to drug toxicity
Genitourinary and
renal
Decreased renal function
Impaired bladder function
Decreased clearance of substances eliminated in the urine;
may contribute to drug toxicity
Urinary retention, urinary tract infection
Immune system General decline in function Increased risk of infection, may lack fever with infection
Musculoskeletal
system
Loss of muscle mass, weakness
Osteoporosis
Osteoarthritis
Decreased mobility, increased risk of falls, may not be able
to get up after falling
Pathologic fractures
Pain, decreased mobility

(2 of 11)
• Neurologic system
– Brain changes with age
– Clinical depression, altered mental status common
• Cardiovascular system
– Hypertension common
– Changes in heart rate and rhythm

(3 of 11)
• Gastrointestinal system
– Constipation common
– Deterioration of structures in mouth
– General decline in efficiency of liver
– Impaired swallowing
– Malnutrition (deterioration of small intestine)

(4 of 11)
• Musculoskeletal system
– Osteoporosis and osteoarthritis common
• Respiratory system
– Cough power diminished
– Increased tendency for infection
– Less air and less exchange of gases
• Renal system
– Drug toxicity problems common
– General decline in efficiency

(5 of 11)
• Skin
– Perspires less
– Tears more easily
– Heals slowly
• Immune system
– Fever often absent
– Lessened ability to fight disease

(6 of 11)
• Changes in vision
• Age-related hearing loss
• Weight control more difficult
– Type II diabetes
• Increase in incidence of cancer

(7 of 11)
• Menopause in women in late 40s/early 50s can
increase cardiovascular disease.
• Skin paler; loss of elasticity of connective tissues
• Muscle mass decreases; skeletal muscles
weaken.

(8 of 11)
• Fractures occur with minimal force.
• Blood vessels thicken: increases systemic
vascular resistance, decreases organ perfusion,
increases workload of heart
• Anemia and decreased response to infection

(9 of 11)
• Decline in respiratory system; chest wall becomes
less compliant.
• Decreased senses of taste and smell; leads to
malnutrition and vitamin deficiencies.
• Less insulin production; decreased glucose
metabolism.

(10 of 11)
• Liver function decreases; inefficient elimination
from the body.
• Decreased sensory function, reaction time, and
proprioception.
• Vascular disease and inflammatory processes can
lead to dementia.
• Pain perception decreases.

(11 of 11)
• Living below poverty line: 9.7% 65 years and
older, 13% 85 years and older
• Lack of adequate income and social support can
result in potentially dangerous situations.
• Losses of function, independence,
companionship, and financial burdens are
common.

Table 45-2
Factors Associated with Increased Risk for Elder Abuse
Patient Factors Abuser Factors
 Age 80 or older
 Female
 Physically or financially dependent on others
 Immobile
 Incontinent
 Dementia
 Sleep disturbances
 Multiple medical problems
 May have numerous stressors in addition to caring for
the patient
 May be a family member or other caregiver (nursing
home, hospital personnel)

Psychosocial Aspects of Aging
• Financial and physical dependence on others
increases vulnerability and risk of abuse/neglect.
• Depression and suicide may occur.
• Majority of elderly live independently, with minimal
assistance, or with family members.

General Assessment and Management
(1 of 19)
• Scene size-up
– Look for potential hazards; indications of violence.
– Determine number of patients, need for additional
resources.
– Determine nature of illness or MOI.
– Obtain chief complaint, develop general impression.
– Pay attention to patient’s surroundings and indications
of chronic illness.
– Assess degree of mobility.
– For responsive patients, obtain chief complaint.

(2 of 19)
• Scene size-up (continued)
– Always attempt to communicate directly with patient
first; turn to others only if you cannot obtain history
from patient or to collect additional information.
– Get single, specific chief complaint.
– Avoid attributing signs and symptoms of disease to
aging process.
– Determine patient’s normal or baseline condition.

(3 of 19)
• Primary assessment
– If unresponsive and does not appear to be breathing
normally, confirm unresponsiveness; check carotid
pulse.
– If you do not detect pulse within 10 seconds, begin
chest compressions, unless presented with current,
valid, signed do not resuscitate (DNR) order in timely
manner.
– If responsive, or unresponsive but has pulse, assess
airway, breathing, and circulation.

(4 of 19)
• Primary assessment (continued)
– Treat airway compromise, difficulty breathing, hypoxia,
and bleeding before continuing.
– Opening and maintaining airway can be made difficult
by absence of teeth or presence of poorly fitting
dentures, or kyphosis.

(5 of 19)
– Jaw-thrust maneuver or modified-jaw-thrust maneuver;
padding under the head may also be necessary
– Use positioning, suction, manual maneuvers, and basic
and advanced airway adjuncts as needed.
– Look for signs of respiratory distress.
 Assist with or provide ventilations as needed.

(6 of 19)
– Irregular pulse is a common finding in elderly patients;
increased incidence of atrial fibrillation.
– Irregular pulse can be associated with hypoperfusion
and lethal dysrhythmia.
– Control bleeding using direct pressure.
– Determine priority for treatment; transport.

Table 45-3 (1 of 3)
Common Complaints in the Elderly and Their
Significance
Complaint or Presentation Conditions to Consider
Abdominal pain or discomfort Acute coronary syndrome
Aortic dissection or aneurysm
Bowel infarction or obstruction
Gastroenteritis
Gastrointestinal bleeding
Pneumonia
Altered mental status Dementia
Delirium
Hepatic failure
Hypoglycemia or hyperglycemia
Hypoperfusion (shock, acute coronary syndrome, heart failure)
Hypothermia or hyperthermia
Hypoxia
Infection
Medications or toxins
Renal failure
Seizure
Stroke
Substance abuse (alcohol, prescription drugs, recreational drugs)
Trauma (traumatic brain injury, hypoperfusion, hypoxia)

Table 45-3 (2 of 3)
Significance
Dyspnea Acute coronary syndrome
Anemia
Asthma
COPD
Heart failure
Infection (pneumonia, influenza)
Lung cancer
Pneumothorax
Pulmonary embolism
Chest pain or discomfort Acute coronary syndrome
Hiatal hernia
Musculoskeletal pain
Pneumonia
Pulmonary embolism

Table 45-3 (3 of 3)
Significance
Syncope Acute coronary syndrome
Cardiac dysrhythmia
Hypovolemia
Medications
Vasovagal syncope
Weakness, fatigue Acute coronary syndrome
Anemia
Dehydration
Electrolyte imbalance
Infection
Medications
Hypothyroidism
Stroke

(7 of 19)
• Secondary assessment
– Determined by whether nature of problem is medical or
traumatic, whether critical or noncritical
– Medical problems and trauma can overlap in elderly
patient.
– Assessing mental status can be challenging; older
people with dementia have altered mental status as
part of baseline condition.

(8 of 19)
• Secondary assessment (continued)
– Determine level of responsiveness according to
AVPU mnemonic.
– Perform Mini-Mental State Exam (MMSE).
– Introduce yourself, speak slowly and clearly, position
yourself where patient can see you.
– If patient is answering questions slowly, give additional
time to answer.
– Use responses to monitor mental status.

(9 of 19)
– Confabulation: patient unknowingly fills in gaps in
memory with information that seems to fit
– Spouse, family members, and caretakers can be a
source of information about medications, past medical
history, and history of present illness.
– Obtain complete history, using mnemonics SAMPLE
and OPQRST.

(10 of 19)
– Obtain complete medication history.
– Polypharmacy (taking multiple drugs) is common in
elderly.
– Always consider medications as potential cause of, or
contributing factor to, problem.

(11 of 19)
– Vital signs are similar to those of other adults.
– Normal vital signs do not rule out presence of
significant illness or injury.
– Medications for hypertension or other conditions can
lead to hypotension, orthostatic hypotension, syncope,
or near-syncope.

(12 of 19)
– For critical patient, perform rapid medical exam or rapid
trauma exam.
– Chief complaint and medical history guide focused
physical exam for noncritical medical complaints.
– For trauma patients, MOI and chief complaint guide
focused physical exam.

(13 of 19)
– Elderly have difficulty staying warm; may wear several
layers of clothing.
– Do not cut clothing unless necessary.
– Elderly may have limited range of motion (ROM); some
movements painful; be patient and gentle.
– Some elderly have decreased sensitivity to pain; may
not complain of level of pain expected.

Figure 45-2
Cataracts appear as cloudiness of the lens of the eye.
(© SPL/Photo Researchers, Inc.)

Figure 45-3
Place padding beneath the head of a patient with kyphosis when placing the patient in a
supine position.

(14 of 19)
– Some patients have a decreased sensitivity to pain;
other times preexisting conditions can increase pain on
exam.
– Consider all findings in context; be aware of possibility
of altered pain perception.
– Preexisting eye problems and eye surgery can result in
pupil changes or cloudiness of lens.
– Do not force neck beyond normal ROM.
 Use towels beneath head to maintain alignment.

(15 of 19)
– Breath sounds can be diminished due to decreased
lung capacity and chest wall movement.
– Wheezes, rhonchi, and crackles (rales) are indications
of respiratory or cardiac problems.
– Check lower extremities for edema; indication of
cardiovascular, renal, or liver disease.

(16 of 19)
• Clinical-reasoning process
– Be aware of variations in presentations of illnesses and
injuries in elderly.
– Can be very ill yet complain of little pain; may have
severe infections without fever.
– Consider effects of aging; drug side effects and
interactions.
– Do not assume unreliable source of information.
– Carefully assess mental status.

(17 of 19)
• Treatment
– Same in elderly patients as younger patients
– Airway management and ventilation can be
challenging.
– Control most external bleeding by direct pressure.
– Elderly patient can easily be overloaded with fluids; use
caution when administering IV fluids.
– Spinal motion restriction requires padding to reduce
pressure on tissues.

(18 of 19)
• Reassessment
– Reassess critical patients every 5 minutes.
– Reassess noncritical patients every 15 minutes.
– Monitor patient for changes in mental status,
complaints, and vital signs; assess effects of treatment.
 Adjust clinical impression, patient’s priority, and treatment plan
as needed.

(19 of 19)
• Additional considerations
– Give elderly patient the respect deserved.
– Do not speak to family or caregivers instead of
speaking to patient.
– Make eye contact; listen patiently to responses.
– Be empathetic; do not minimize fears.
– Keep patient warm and protect from elements.

Respiratory Disorders (1 of 4)
• Causes of dyspnea and hypoxia
– Anemia
– Asthma
– Chronic obstructive pulmonary disorder (COPD)
– Heart failure with pulmonary edema
– Lung cancer
– Myocardial infarction
– Pneumonia
– Pneumothorax
– pulmonary embolism

• Pneumonia is a common cause of death in the
elderly.
• Fever, chills, pleuritic chest pain, tachypnea,
dyspnea, productive cough, altered mental status
• Support airway, ventilation, oxygenation to
maintain SpO2 of 95% or higher; treat
dehydration.

• Suspect pulmonary embolism with sudden onset
of dyspnea.
• Massive pulmonary embolism can quickly lead to
hypoxia and cardiac arrest.
• Treat the patient for hypoxia and hypotension, and
transport without delay to the closest appropriate
facility.

• Pulmonary edema is often the result of left-sided
heart failure.
• Respiratory failure, respiratory arrest, and cardiac
arrest can ensue rapidly.
• Continuous positive airway pressure (CPAP)
helpful in improving oxygenation.
• Use bag-valve-mask device.
• Keep patient in sitting position if possible.

Cardiovascular Disorders (1 of 4)
• Acute coronary syndrome (ACS), hypertension,
heart failure, cardiogenic shock, dysrhythmia,
aortic aneurysm or dissection
• Syncope is common in elderly with cardiovascular
problem.
• Silent myocardial infarction and atypical
presentations increase substantially with age.

• Acute myocardial infarction (AMI): epigastric or
abdominal pain or discomfort instead of chest pain
or discomfort
• Suddenly weak or short of breath, weakness or
fatigue, syncopal episode, dyspnea, faintness,
altered mental status

• Maintain SpO2 of 95% or higher.
• Administer nitroglycerin and aspirin according to
protocols.
• Start IV; transport without delay.

• Consider aortic aneurysm or dissection with
abdominal pain; back pain; unexplained shock; or
loss of pulses, sensation, or function, particularly
lower extremities.
• Consider all causes of shock in elderly patient
presenting with signs of hypoperfusion.

Neurologic Disorders (1 of 3)
• Consider hypoxia, infection, hypoperfusion,
hyperthermia, hypothermia, endocrine disorders,
poisoning, overdose, trauma, and neurologic
causes of altered mental status.
• Neurologic causes of altered mental status:
– Stroke
– Transient ischemic attack (TIA)
– Seizures
– Dementia

• For suspected stroke, complete stroke screening
tool (Los Angeles Prehospital Stroke Screen or
Cincinnati Prehospital Stroke Scale).
• Transport to closest definitive care facility.
• Seizures: epilepsy, stroke, traumatic brain injury,
medications, hypoglycemia, alcohol withdrawal,
tumor
• Vertigo (dizziness): stroke, sudden changes in
position, Ménière’s disease

• Delirium: sudden onset of altered mental status,
often with changes in behavior due to underlying
medical cause.
• Dementia: progressive, irreversible, global
impairment of cognitive function; common cause
is Alzheimer’s disease

Renal and Genitourinary Disorders
• Urinary tract problems: urinary retention, urinary
incontinence, urinary tract infections
• Urinary retention: increases risk of urinary tract
infection
• Urinary incontinence: poor pelvic muscle tone,
decreased sensation, cognitive impairment,
immobility

Gastrointestinal Disorders (1 of 2)
• Nausea, vomiting, diarrhea, and constipation are
common side effects of many drugs.
• Decreased fluid intake and increased fluid losses
lead to dehydration.
• Constipation can lead to bowel obstruction.
• Abdominal pain, regardless of severity, no matter
how vague or specific, is an indication of several
serious, potentially life-threatening disorders.

Gastrointestinal Disorders (2 of 2)
• Gastrointestinal bleeding is a common problem.
• Bowel incontinence can occur; abdominal bloating
can be an obstruction, other serious disorders.

Endocrine Disorders
• Incidence of type II diabetes increases with age.
• Diabetic emergencies are a cause of altered
mental status; obtain blood glucose level.
• Consider hyperthyroidism, hypothyroidism, and
complications of corticosteroid treatment or
withdrawal.
• Major surgery, infection, or illness, such as
myocardial infarction (MI), can increase the risk of
diabetic ketoacidosis (DKA) and hyperosmolar
hyperglycemic nonketotic coma (HHNC).

Infectious Disease
• Pneumonia, influenza, sepsis, and herpes zoster
(shingles) are causes of illness in elderly.
• Consider infection with altered mental status,
weakness or fatigue, and signs of poor perfusion.
• Risk factors: Foley catheter or indwelling catheter
in place, residing in extended care facility,
immunosuppressant medications, preexisting
illnesses

Musculoskeletal Disorders (1 of 2)
• Musculoskeletal pain is common in elderly.
• Disorders: osteoarthritis, osteoporosis, pain, and
decreased ROM
• Weakened bones can fracture with little force.
• Best way to splint hip fracture in elderly is to use
pillows for padding and support; use scoop
stretcher.

Musculoskeletal Disorders (2 of 2)
• Arthritis is a major source of discomfort.
• Spondylosis, degeneration of vertebrae and
intervertebral discs, can affect neck and back.
• Be gentle when assessing, treating, and moving
elderly patients.

Hematologic Disorders
• Anemia, leukemia, coagulopathies
• Anemic patient: weakness, fatigue, dyspnea on
exertion, pale skin and mucosa
• Coagulopathies result from immobility and
circulatory stasis with increased risk for blood
clotting, or from medication side effects or
illnesses.
• Many medications impair blood clotting.

Behavioral Emergencies (1 of 2)
• Underlying psychiatric illness, dementia, delirium
due to illness or medications
• Consider hypoxia, hypoglycemia, stroke, infection,
toxicologic emergencies, and trauma.
• Never assume abnormal behavior is a result of
dementia.

Behavioral Emergencies (2 of 2)
• Determine baseline behaviour and mental status.
• Patient is confused, disoriented, and frightened.
• Do not underestimate the patient to harm himself
or others; be prepared to restrain patient, if
necessary.

Toxicologic Emergencies (1 of 2)
• Increased plasma levels of drugs:
– Diminished liver and kidney function
– Decreased plasma proteins
– Decreased total body water
– Decreased adipose tissue
• Polypharmacy can result in unanticipated drug
interactions.
• Do not overlook intentional overdose.

Toxicologic Emergencies (2 of 2)
• Check dates on prescriptions. Compare the
amount of medication present with the expected
amount for clues to possible inadvertent or
intentional overdose.

Trauma in the Geriatric Population
(1 of 4)
• Shock
– Consider all causes of shock in elderly presenting with
signs of hypoperfusion.
– Sepsis, cardiogenic shock, hypovolemic shock
– Rely heavily on MOI for potential of shock.
– Ensure open airway, adequate ventilation, oxygenation.
– Obtain IV access using large-bore catheters.
– Infuse isotonic crystalloids according to protocol;
monitor breath sounds and vital signs for signs of fluid
overload.

(2 of 4)
• Fractures
– Occur easily in elderly; maintain high IOS based on
MOI
– Use padding with splints to prevent injury to skin.
– Cervical collar: Ensure placement does not force neck
into position unnatural for patient.
– Pad under head to prevent spinal extension in patient
with kyphosis

(3 of 4)
• Burns
– Skin of elderly thin; lower temperature and shorter
exposure time needed to cause significant burns
– Decreased sensation may not allow elderly to realize
they are being burned.
– Impaired mobility: unable to remove from source of
heat
– Administer fluids, monitor for fluid overload, and keep
patient warm and covered.

(4 of 4)
• Environmental emergencies
– Impaired thermoregulatory function increases risk for
heat- and cold-related emergencies.
– Limited ability of elderly to maintain homeostasis in
response to environmental changes
– Maintain high index of suspicion for hyperthermia and
hypothermia.

Chapter Summary (1 of 3)
• Number of elderly in the United States at highest
level in history; projected to rapidly increase.
• Increasing age associated with increasing risk for
illnesses and injuries.
• Patience, respect, gentleness, efforts to overcome
challenges to communication all are important
parts of providing high-quality, professional care to
elderly patients.

• Communication difficulties minimized by retrieving
patient’s hearing aid or dentures.
• Normal age-related changes, medications, and
illnesses can create diagnostic challenge.
• Illness and injuries present differently in elderly
than in younger patients.
• Elderly patient might not complain of level of pain
expected; might not exhibit expected homeostatic
responses.

• Elderly at increased risk for complications from
illnesses and injuries.
• Common complaints: dyspnea, weakness, chest
pain or discomfort, dizziness, injuries from motor
vehicle collisions and falls
• Medication side effects, toxicity, and interactions
common
• Principles of assessment and management apply.
• Elderly patient may be reluctant to leave home.

Alexander ch45 lecture

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Alexander ch45 lecture

Similar to Alexander ch45 lecture (20)

More from corynava00

More from corynava00 (10)

Recently uploaded

Recently uploaded (20)

Alexander ch45 lecture