Geriatrics for paramedics-assessment-common

paramedics

1. Chapter 44
Geriatric Emergencies

2. National EMS Education
Standard Competencies
Special Patient Populations
Integrates assessment findings with principles
of pathophysiology and knowledge of
psychosocial needs to formulate a field
impression and implement a comprehensive
treatment/disposition plan for patients with
special needs.

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

4. 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
−Endocrine diseases

5. 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 (cont’d)
−Alzheimer disease
−Dementia
−Fluid resuscitation in the elderly

6. National EMS Education
Standard Competencies
Normal and abnormal changes associated
with aging, pharmacokinetic changes,
psychosocial and economic aspects of aging,
polypharmacy, and age-related assessment
and treatment modifications for the major or
common geriatric diseases and/or
emergencies
−Cardiovascular diseases
−Respiratory diseases
−Neurologic diseases

7. National EMS Education
Standard Competencies
Normal and abnormal changes associated
with aging, pharmacokinetic changes,
psychosocial and economic aspects of aging,
polypharmacy, and age-related assessment
and treatment modifications for the major or
common geriatric diseases and/or
emergencies (cont’d)
−Endocrine diseases
−Alzheimer disease
−Dementia

8. National EMS Education
Standard Competencies
Normal and abnormal changes associated
with aging, pharmacokinetic changes,
psychosocial and economic aspects of aging,
polypharmacy, and age-related assessment
and treatment modifications for the major or
common geriatric diseases and/or
emergencies (cont’d)
−Fluid resuscitation in the elderly
−Herpes zoster
−Inflammatory arthritis

9. National EMS Education
Standard Competencies
Patients With Special Challenges
•Recognizing and reporting abuse and
neglect
•Health care implications of
−Abuse
−Neglect
−Homelessness
−Poverty
−Bariatrics

10. National EMS Education
Standard Competencies
•Health care implications of
−Technology
−Hospice/terminally ill
−Tracheostomy care/dysfunction
−Home care
−Sensory deficit/loss
−Developmental disability

11. National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan for
an acutely injured patient.

12. National EMS Education
Standard Competencies
Special Considerations in Trauma
Recognition and management of trauma in
−Pregnant patient
−Pediatric patient
−Geriatric patient

13. National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of trauma in the
−Pregnant patient
−Pediatric patient
−Geriatric
−Cognitively impaired patient

14. Introduction
•Geriatrics: Assessment and treatment of
disease in those 65 years or older
•Geriatric patients account for 36% of all
hospital stays in the United States.
−Receive more care outside of hospitals

15. Introduction
•Old-age dependency ratio
−Number of older people for every 100 younger
adults
−Used to:
•Compare differences in age structure between time
periods in a single society
•Compare age structures between societies

16. Introduction
•“Graying of America”—describes increasing
number of older Americans
−As number of older Americans increases, need
for physicians increases
−Need for cost-effective/efficient services

17. Introduction
•Most prehospital geriatric patients will not
reside in nursing homes.
−Nursing home admissions increasing as
numbers of elderly increase.
−Countertrend—older persons maintaining
independent lives

18. Introduction
•Considerations in deciding living
arrangements:
−Marital status
−Financial resources
−Religious beliefs
−Ethnicity
−Gender
−General health

19. Introduction
•Grown children affected by decision
−May seek help from
•Medical social workers
•Professional care managers
•Discharge planners at health care facilities
•Other private and public resources

20. Introduction
•Available services
include:
−Delivered meals
−Personal care
−Housekeeping
−Transportation
−Caregiver support

21. Introduction
•Financial situation affects living
conditions/decisions
−Older Americans are:
•More likely to have assets
•May have delayed retirement
•More likely to have health insurance

22. Introduction
•Psychosocial factors influencing aging:
−May feel useless or unproductive in society,
leading to self-esteem issues
−Might mourn/feel frustrated over loss of ability
−May feel freedom, sense of accomplishment

23. Introduction
•Crisis of integrity versus despair:
−Integrity—pride in accomplishments
−Despair—haven’t accomplished goals
•Bereavement over loss of friends and loved
ones.
−Leads to isolation and loneliness

24. Geriatric Anatomy and
Physiology
•Aging process begins in late 20s, early 30s
•Organ and tissue aging may be accelerated
by:
−Genetics
−Preexisting disease
−Diet and activity levels
−Toxin exposure

25. Geriatric Anatomy and
Physiology
•Aging rate varies
from person to
person.
•Decrease in
functional capacity
is normal
−Affects how body
responds to illness
© Photodisc

26. Changes in the Respiratory
System
•Reduction of respiratory capacity in aging
−Lung elasticity decreases
−Size/strength of muscles decreases
−Costochondral cartilage calcifies
•Causes chest wall to stiffen

27. Changes in the Respiratory
System
•Vital capacity decreases and residual
volume increases.
•Changes in blood flow distribution in the
lungs results in declining partial pressure of
oxygen (PaO
2).

28. Changes in the Respiratory
System
•Decreased sensitivity/CNS response to
arterial blood gases changes
•Slower reaction to hypoxia and hypercarbia
•Limited lung volume and maximal
inspiratory pressure
•Limited chest expansion

29. Changes in the Respiratory
System
•Ability to modify respiratory rate/tidal
volume in response to changes is limited.
•Defense mechanisms less effective
−Cough and gag reflex decreased
−Ciliary mechanisms slowed

30. Changes in the Cardiovascular
System
•Cardiovascular system decreases efficiency
with age
−Heart hypertrophies
−Cardiac output declines

31. Changes in the Cardiovascular
System
•Arteriosclerosis
adds to systolic
hypertension, as a
consequence of:
−Diabetes
−Atherosclerosis
−Renal compromise

32. Changes in the Cardiovascular
System
•Vascular stiffening occurs as collagen and
elastin production changes with age.
−Causes widening pulse pressure, decreased
coronary artery perfusion, changes in cardiac
ejection efficiency

33. Changes in the Cardiovascular
System
•Aortic sclerosis—aortic valve thickens from
fibrosis and calcification
−Obstructs blood flow from left ventricle
−Leads to aortic stenosis
•Peripheral vessel walls lose elasticity.
−Leads to higher blood pressure, other risks

34. Changes in the Cardiovascular
System
•Heart’s electrical conduction system
deteriorates over time.
−Number of pacemaker cells decreases with age.
−Bradycardia can occur.
−Primary pacemaker can fail.

35. Changes in the Cardiovascular
System
•Aging makes cardiovascular system more
vulnerable to dysfunction
−Heart less efficient at baseline
−Effects of acute circulatory change much worse
•Potential cardiac compromises should be
recognized and treated quickly.

36. Changes in the Nervous
System
•Normal neurological findings in elderly
commonly include changes in:
−Thinking (cognitive) speed
−Memory
−Postural stability
•Brain decreases in weight and volume.

37. Changes in the Nervous
System
•As mental function declines, so does
regulation of:
−Respiratory rate and depth
−Pulse rate
−Blood pressure
−Hunger and thirst
−Temperature

38. Sensory Changes
•Most sensory organs decline with age.
−Decreased ability to see and hear
−Decreased ability to taste
−Decreased tactile sensation
•Do not assume the elderly are deaf or blind.

39. Sensory Changes
•Vision problems affect 50% of seniors.
−Most common visual disturbances in elderly:
•Cataracts—hardening of lenses over time
•Glaucoma—optic nerve damaged due to intraocular
pressure

40. Sensory Changes
•Visual acuity decreases even without
disease:
−Difficulty seeing at night
−Inability to adjust to rapid changes
−Presbyopia (far-sightedness)
−Difficulty differentiating between colors

41. Sensory Changes
•Gradual hearing loss is common with aging.
−Presbycusis: Inhibited ability to discriminate
between background noise and particular sound
−Results in decreased ability to interpret speech
−May threaten safety

42. Sensory Changes
•Hearing aids are
very common
assistive devices in
the United States
−Consist of
microphone and
amplifier
−May fit in ear canal
−Mainly battery
operated
© Maxx-Studio/ShutterStock, Inc.

43. Sensory Changes
•Meniere disease: hearing-related
impairment
−Two out of 1,000 people, onset in middle age
−Symptom cycles last several months:
•Vertigo
•Hearing loss and tinnitus
•Pressure in ear

44. Sensory Changes
•Other sensory changes:
−Decrease in number of taste buds
−Decrease in sense of touch
−Sense of smell last to diminish

45. Sensory Changes
•Changes may make it difficult to produce
speech that is loud enough, clear, and well
spaced.
•Sense of body position may become
impaired.

46. Changes in the Digestive
System
•Changes may be first noted in the mouth.
−Fewer taste buds: lower appetite
−Reduction of saliva: dry mouth
−Dental loss: tooth and gum disease
•Not directly from aging

47. Changes in the Digestive
System
•Ill-fitting dentures may cause risk of:
−Choking
−Heartburn
−Abdominal pain

48. Changes in the Digestive
System
•Gastric secretions are reduced.
−Esophageal sphincter weakens.
−Slower gastric emptying

49. Changes in the Digestive
System
•Slight changes in small and large bowel
functions from aging
−Rectal sphincter decreases in size, strength
•Fecal incontinence
−Increased constipation from slowing peristalsis

50. Changes in the Digestive
System
•Constipation also caused, worsened by:
−Some medications
−Diet changes and decreased physical activity
•Can cause straining bowel movements

51. Changes in the Digestive
System
•Hepatic enzyme changes—some system
activity declines and other systems
increase.
−Activity that detoxifies drugs declines,
complicating drug absorption, leads to toxicity
−If numerous medications, risk for hepatic
damage or drug toxicity increases

52. Changes in the Renal System
•Kidneys are responsible for:
−Maintaining fluid and electrolyte balance
−Helping maintain body’s long-term acid-base
balance
−Eliminating drugs from the body

53. Changes in the Renal System
•Kidneys decline in weight with age.
−Loss of function nephrons, causing smaller
filtering surface
−Decrease in renal blood flow by up to 50%

54. Changes in the Renal System
•Aging kidneys respond slowly to sodium
deficiency, causing electrolyte imbalance.
−Results in severe dehydration
•Exacerbated by decreased thirst mechanism

55. Changes in the Renal System
•At risk of overhydration with large sodium
loads
−Aging kidneys have lower glomerular filtration
rate
−Capability of handling potassium reduced by
same factors

56. Changes in the Endocrine
System
•Elderly have greater risk for developing type
2 diabetes:
•Difficulty metabolizing carbohydrates
•Often have comorbid disorders (medications can
affect glucose metabolism)

57. Changes in the Endocrine
System
•Increase in antidiuretic hormone (ADH) as
people age:
−Causes electrolyte and fluid imbalances
−May present as pedal or other peripheral edema
•Menopause—decrease in hormone
secretion

58. Changes in the Immunologic
System
•Every immune system function affected by
aging
−More prone to infection and secondary
complications
−Infections manifest differently in older people.

59. Changes in the Integumentary
System
•Wrinkling and resiliency loss in skin
−Skin thinner, drier, less elastic, more fragile
−Subcutaneous fat thinner, bruising
−Elastin and collagen decrease
−Skin more prone to tenting in skin turgor tests

60. Changes in the Integumentary
System
•Sebaceous glands produce less oil, skin
drier.
−Sweat gland activity decreases.
−Hair follicles produce thinner or no hair.
−Follicles produce less melanin, causing gray or
white hair.

61. Changes in the Integumentary
System
•Atherosclerosis affects blood vessels.
−Less oxygenated blood to skin
•Producing new skin takes longer.
•Fingernails and toenails thinner and more brittle

62. Homeostatic and Other
Changes
•Process by which the body maintains a
constant internal environment
−Feedback principle—change in internal
environment feeds back to induce corrective
response

63. Homeostatic and Other
Changes
•Homeostatic capabilities decrease with age.
−Thirst mechanism
•Dehydration
−Temperature regulating mechanism
•Absence of febrile response
−Blood glucose regulatory system
•Elevated blood glucose levels

64. Changes in the
Musculoskeletal System
•Decrease in bone mass in men and women
−Causes brittle, easily breakable bones
•Joint problems
−Tendons and ligaments lose elasticity.
−Synovial fluids thicken
−Cartilage decreases

65. Changes in the
Musculoskeletal System
•Height decreases, posture changes
−Intervertebral disks narrowing
−Vertebrae compression fractures
•Arthritic joints increase.
•Muscle mass and strength decrease.
•Muscles atrophy.

66. Changes in the
Musculoskeletal System
•More susceptible to bone fractures from
falls
−Falls more likely because:
•Joint stiffness
•Loss of tendon and ligament elasticity
•Muscle weakness
•Difficulty with tasks requiring fine motor
coordination or hand and finger strength

67. Geriatric Patient Assessment
•Illness not inevitable with aging
−Getting old is not a disease, does not produce
symptoms of disease by itself
•Widespread incorrect belief that elderly
people are hypochondriacs
−Older patients tend to not complain, even with
real symptoms.

68. Geriatric Patient Assessment
•Signs, symptoms altered from aging
−MIs may not accompany chest pain
−Pneumonia may not include fever.
−Uncontrolled diabetes may present as HONK or
HHNC.
−Some afflictions present as delirium.

69. Geriatric Patient Assessment
•Debilitating health problems include:
−Hypertension and heart disease
−Arthritis
−Cancer
−Diabetes
−Stroke or COPD

70. Geriatric Patient Assessment
•Multiple pathologic conditions:
−Symptoms of one disease may hide or alter
symptoms of another.
−Disturbance in one body system may cause a
domino effect.
−May be difficult to determine which condition is
causing which symptoms

71. Scene Size-Up
•Ensure scene safety.
•Determine mechanism of injury or illness.
•Be aware of factors affecting assessment:
−Sensory alterations
−Verbal communication skills
−Mental and physical capabilities

72. Primary Assessment
•Use GEMS diamond to form a general
impression.
−G—Geriatric patient
−E—Environmental assessment
−M—Medical assessment
−S—Social assessment

73. Primary Assessment
•Airway and breathing
−Geriatric patients are predisposed to airway
problems.
−Ensure airway is not obstructed.
−Anatomic changes lessen effective breathing.
−Treat airway and breathing issues with oxygen
ASAP.

74. Primary Assessment
•Circulation
−If circulation is normally compromised, fewer
reserves in a circulatory crisis.
•Lower heart rate
•Radial pulse difficult to find
•Heart rhythm issues lead to irregular pulse.
−Treat with oxygen as soon as possible.

75. Primary Assessment
•Transport decision
−Provide transport to priority patients:
•Poor general impression
•Airway or breathing problems
•Altered level of consciousness
•Shock, severe pain
•Uncontrollable hemorrhage

76. History Taking
•Use good communication skills.
−Be respectful.
−Speak slowly and distinctly.
•Attempt a thorough history if possible.

77. History Taking
•Listen to patient, wait for answers.
−Be patient.
−Pay attention to tone for fear and confusion.
−Be aware of nonverbal communication.
•Explain plan.
•Preserve patient’s dignity.

78. History Taking
•Comprehensive history includes:
−Chief complaint
−Present illness or injury
−Pertinent medical history
−Current health care status and needs

79. History Taking
•Determining chief complaint may be difficult
because patients might:
−Believe symptoms just part of getting old
−Ignore legitimate symptoms because they don’t
want to be labeled a hypochondriac
−Underreport symptoms or report vague
symptoms

80. History Taking
•If the chief complaint seems trivial, use a
standard list of screening questions to
evaluate major organ systems functions.
−Follow up on any positive answers.

81. History Taking
•After deducing chief complaint, conduct
history of present illness:
−May be difficult to separate from chronic
problems. Ask:
•How does this differ from last week?
•What happened today to make you call?

82. History Taking
•Obtain detailed history of medications.
−Have patient list by name, dosing and
frequency, and provider.
−Obtain permission to bring medications to
hospital.

83. Secondary Assessment
•Adjust usual methods to fit elderly patient.
−Limit physical manipulation.
−Be aware of body temperature.
−Only remove clothing as necessary for
inspection and palpation, and re-cover
immediately.

84. Secondary Assessment
•Systematically check patient.
•Postural BP changes vary with older
people.
−Marked BP changes and pulse rate—possible
hypovolemia or overmedication
•Normal BP tends to be higher.

85. Secondary Assessment
•Observe respiratory rate:
−Tachypnea can indicate acute illness.
−Take lung sounds in all fields.
−Listen for carotid bruits, and note jugular vein
distention.
•Note any dentures.

86. Reassessment
•Reassess often—conditions deteriorate
quickly.
−Repeat primary assessment.
−Reassess vital signs.
−Reassess patient’s complaint.
−Recheck interventions.
−Treat changes.

87. Respiratory Conditions
•Top five causes of geriatric death include:
−Chronic lower respiratory disease
−Influenza
−Pneumonia (most common)

88. Pneumonia
•Inflammation of the lung from infection by:
−Bacteria
−Viruses
−Other organisms

89. Pneumonia
•Biggest impact on very young and elderly
•Those considered at risk include:
−The elderly
−Those with underlying health problems
−Those with a depressed immune system
−Those who are generally immobile, confined to
bed, or have conditions that limit deep breathing

90. Pneumonia
•Pneumonia symptoms in the elderly include:
−Acute confusion (delirium)
−Normal temperature
−Wheezing instead of cough
−Abdominal pain
−Auscultated rhonchi in affected lobes

91. Pneumonia
•Treatment is supportive, including:
−Fluids
−Oxygen via nasal cannula or mask
−Analgesics for fever

92. Pneumonia
•Preventive measures:
−Pneumococcus vaccine
•Booster doses after 3 to 5 years
−Cessation of smoking
−Respiratory exercises

93. Chronic Obstructive
Pulmonary Disease
•Set of diseases characterized by bronchial
obstruction and airway inflammation:
−Chronic bronchitis
−Emphysema
−Asthma

94. Chronic Obstructive
Pulmonary Disease
•Difficult to distinguish between diseases
•Complicated by age-related loss of lung’s
elastic tissue and decreased ability to fight
infection
−Baseline disability of COPD exacerbated

95. Chronic Obstructive
Pulmonary Disease
•Preventative measures include:
−Cessation of smoking
−Avoidance of certain environmental pollutants
−Immunization for influenza and pneumococcal
pneumonia

96. Chronic Obstructive
Pulmonary Disease
•Presenting
symptoms:
−Shortness of
breath
−Fatigue
−Decreased activity
level
•Treatment:
−Supplemental
oxygen
−CPAP
−Bronchodilators
−Inhaled or oral
steroids
−Antibiotics

97. Asthma
•Onset can occur in old age, with symptoms:
−Shortness of breath
−Chronic or nocturnal cough
−Wheezing
•If worsens with exertion, more susceptible
to attacks.

98. Asthma
•Management is the
same for all patient
groups.
−Except when
cardiac disease
coexists
•Beta-adrenergic
agents exacerbate
cardiac symptoms.

99. Pulmonary Embolism
•Clot blocks blood vessel supplying lung
−Results in irreversible damage or infarction
−Commonly caused by deep venous thrombosis
•Prevention is based on risk level.
−Highest risk is surgical patients

100. Pulmonary Embolism
•Risk increases with age:
−Increased immobility
−Increased vascular stasis in lower extremities
−Increased diseases associated with pulmonary
embolus

101. Pulmonary Embolism
•Classic triad (dyspnea, chest pain,
hemoptysis) is often altered or absent.
−If suspected, check lower leg for:
•Swelling
•Erythema
•Warmth or tenderness

102. Pulmonary Embolism
•Prehospital treatment supportive after
ensuring airway and ventilation
−Consider lysing the thrombus and the use of
anticoagulation.
−Rapid transport

103. Cardiovascular Conditions
•The heart’s lifetime
workload affects
the cardiovascular
system throughout
the entire body.
•Heart attack or
myocardial
infarction is major
cause of morbidity
and mortality

104. Myocardial Infarction
•Death of part of the
heart muscle from
blockage of one of the
coronary arteries
•Chest pain may be
absent or not as
intense in elderly.
•Elderly may report:
−Dyspnea
−Syncope
−Weakness
−Confusion
−Nausea
−Vomiting

105. Myocardial Infarction
•Major risk factors:
−Tobacco use
−Hypertension
−Diabetes
−Obesity
−Lack of physical
exercise
−High cholesterol
•Preventive strategies:
−Smoking cessation
−Healthy diet
−Blood glucose control
−Exercise
−Weight control
−Hypertension control

106. Congestive Heart Failure
•Most common reason for hospitalization in
the older population
•On the rise because:
−People living longer
−Getting better treatment for other diseases

107. Congestive Heart Failure
•Risk factors:
−Gender
−Ethnicity
−Family history and
genetics
−Long-term alcohol
abuse
−Multiple medical
conditions
•Prevention:
−Smoking cessation
−Healthy diet
−Blood glucose control
−Exercise
−Weight control
−Hypertension control

108. Congestive Heart Failure
•Acute exacerbation results in pulmonary
edema.
−May present with dyspnea or orthopnea
−Decreased oxygenation to all organ systems
leads to mental changes.
−Peripheral edema may indicate worsening CHF.

109. Congestive Heart Failure
•Presentation in elderly may mimic signs and
symptoms of old age or other illnesses.
•Acute exacerbation often linked to:
−Poor diet
−Medication noncompliance
−Onset of dysrhythmias
−Acute myocardial ischemia

110. Congestive Heart Failure
•Prehospital treatment same as with other
populations
−Need to familiarize yourself with medications
and their implications for treatment
−Complete evaluation of ETCO
2 immediately.

111. Congestive Heart Failure
•Other treatment includes:
−Fluid monitoring; avoidance of fluid overload
−CPAP
−If atrial fibrillation or flutter—digoxin or diltiazem
−If atrial dysrhythmias—anticoagulation to
prevent thromboembolism

112. Dysrhythmias
•Occur when heart electrical system has an
interruption or malfunction
−Causes heartbeats that are:
•Too fast
•Too slow
•Irregular
•Absent

113. Dysrhythmias
•In older population, usually result of:
−Age-related heart changes
−Existing cardiac disease
−Adverse drug effects
−Combination of factors

114. Dysrhythmias
•Classified where they originated in the heart
−Tachydysrhythmias, bradydysrhythmias speed
up or slow down heart
−Premature beats alter regularity.
−Atrial fibrillation increases risk of stroke, heart
failure.

115. Dysrhythmias
•Bradycardias more common in elderly
−Sinus abnormalities from aging conduction
system
−High-degree blocks produced by CAD.
−Heart slowed by beta blockers or calcium
channel blockers

116. Dysrhythmias
•Treatment same as younger adults
•Survival depends on:
−Prearrest health of patient
−Early deployment of links in chain of survival

117. Hypertension
•More than 50% of elderly are hypertensive.
•Controlling systolic and diastolic
hypertension helps prevent stroke and MIs.

118. Hypertension
•Requires controlled blood pressure decline
—often cannot be done in the field
−Nitroglycerin for hypertensive emergencies
highly debated
•If rapid onset of systolic hypertension, use
antihypertensive therapy

119. Aneurysms
•Weakness in artery produces balloon defect
that weakens wall
−Congenital or acquired
−Contributing factors:
•Hypertension
•Atherosclerotic disease
•Obesity

120. Aneurysms
•Can develop in brain, chest, or abdomen
−New headache or change in chronic headache
could indicate early cerebral bleeding.
−Can cause stroke
−Anticoagulants increase damaging effects.

121. Aneurysms
•Preventive measures:
−Proper diet
−Exercise
−Smoking cessation
−Cholesterol control
•Asymptomatic until
large or rupture
•Early symptoms
related to
compression:
−Difficulty swallowing
−Hoarseness

122. Aneurysms
•Treatment of abdominal emergencies is
surgery, so it is essential to:
−Recognize problem early
−Assess
−Stabilize
−Transport rapidly

123. Traumatic Aortic Disruption
•Also known as aortic dissection
•Interior wall tears and blood collects
between arterial wall layers.
−Makes arterial wall prone to rupture.
−Thoracic dissection can cause chest pain, and
mimic cardiac ischemia.

124. Stroke
•More than 80% of all stroke deaths are in
persons older than 65 years.
−Leading cause of long-term disability
−Risk doubles each decade after 35 years.

125. Stroke
•Reduce risk factors
for prevention.
−Improve diet.
−Exercise.
−Lower cholesterol.
•Prehospital care
includes:
−Early recognition
−Discovery of
conditions that mimic
stroke
−Timely transport
−Use of stroke
assessment tool

126. Stroke
•Family members/caregivers give
information about:
−Baseline cognitive status, physical status
−Personality
−ADL
•Evaluate patient’s ability to perform basic
cognitive functions.

127. Transient Ischemic Attack
•Temporary disturbance of blood to brain
resulting in sudden, temporary decrease in
brain function
−Symptoms same as stroke
−Warning sign of future stroke
−No long-term brain damage

128. Neurologic Conditions
•Normal age-related cognitive changes:
−Relatively isolated
−Not sudden or extreme

129. Delirium
•A symptom, not a
disease
−Temporary
−Reflects underlying
disturbance
•Characterized by:
−Disorganized thoughts
−Inattention
−Memory loss
−Disorientation
−Personality changes
−Hallucinations
−Delusions

130. Delirium
•Symptoms may mimic:
−Intoxication
−Drug abuse
−Severe psychological disorders

131. Delirium
•Assess for recent changes in
−Level of consciousness or orientation
−Vital signs
−Temperature
−Glucose level
−Medications

132. Delirium
•Often replaces or confounds typical
presentations caused by:
−Medical problems
−Adverse medication effects
−Drug or alcohol withdrawal

133. Delirium
•D: Drugs or toxins
•E: Emotional
•L: Low PaO
2
•I: Infection
•R: Retention of stool
or urine
•I: Ictal (seizures)
•U: Undernutrition or
underhydration
•M: Metabolism
•S: Subdural
hematoma

134. Delirium
•Onset is abrupt (hours to days).
•Usually resolves with treatment of
underlying problem
−Treatment may be complicated by
uncooperative behavior.

135. Dementia
•Produces irreversible brain failure
•Symptoms include:
−Short-term memory loss, short attention span
−Jargon aphasia
−Confusion and disorientation
−Difficulty retaining new information
−Personality changes

136. Dementia
•May be caused by conditions that impair
vascular and neurologic brain structures:
−Infection
−Stroke
−Head injury
−Poor nutrition
−Medications

137. Dementia
•Two most common degenerative
dementias:
−Alzheimer disease
−Multi-infarct or vascular dementia
•6% to 10% of elderly will eventually have
dementia; risk increases with age.

138. Dementia
•Diagnosed when two or more cognitive or
psychomotor brain functions are impaired:
−Language
−Memory
−Visual perception
−Emotional behavior/personality
−Cognitive skills

139. Dementia
•Symptoms:
−Progressive loss of cognitive function
−Impairment of long- or short-term memory
−Loss of communication skills
−Inability to perform daily activities
−Change in temperament and affect

140. Dementia
•No treatment, but can treat underlying
medical problem
•Obtain baseline abilities from caregivers.
•Ask about new changes that prompted call.
•Be cautious of patients.

141. Alzheimer Disease
•Most common form of dementia
•Progressive function loss with subtle
symptoms:
−Lose things, have difficulty recalling names
−Lose ability to think and reason clearly.
−Forget identities and own experiences.

142. Alzheimer Disease
•About 4 million people diagnosed
•Risk factors:
−Family history
−African American
−Latino (earlier onset)
−Less than 12 years of school

143. Alzheimer Disease
•Stages
−Mild cognitive
impairment
•Forgetfulness
•Difficulty in
performing more
than one task
•Diminished
problem-solving
skills
−Early-stage
disease
•Language
problems
•Misplacing items
•Getting lost
•Personality
changes

144. Alzheimer Disease
•Stages (cont’d)
−Progressed
disease:
•Forget current
events
•Change sleep
patterns
•Difficulty reading
and writing
−Severe or end-
stage, cannot:
•Understand
language
•Recognize close
family members
•Perform self-care
•Interact verbally

145. Alzheimer Disease
•Diagnosed by excluding other dementia
•Prehospital treatment—supportive care and
treating symptoms
−Communicate slowly.
−Check for other illnesses.
−Consider antipsychotics if combative or
dangerous.

146. Alzheimer Disease
•Daily medication may include:
−Antidepressants
−Cholinesterase inhibitors to prevent further
decline
•No single cause identified, not believed to
be part of the normal aging process

147. Parkinson Disease
•Age-related neurologic disorder with two or
more of these symptoms:
−Resting tremor of extremity
−Slowness of movement
−Rigidity or stiffness of extremities or trunk
−Poor balance

148. Parkinson Disease
•Caused by degeneration of substantia
nigra, area of brain that produces dopamine
•Wide range of functional loss, presenting
as:
−Dyskinesia
−Dementia
−Depression
−Autonomic dysfunction
−Postural instability

149. Seizures
•Incidence increased in elderly because of
increase in risk factors:
−Stroke
−Dementia
−Primary or metastatic brain tumors
−Acute metabolic disorders

150. Gastrointestinal Conditions
•Constipation frequent problem, but should
not be initial assumption in acute abdominal
pain
−Investigate causes with high mortality first.
•Bleeding from acute abdominal aneurysm
•Dead bowel from mesenteric ischemia

151. Gastrointestinal Conditions
•When assessing, ask for:
−Food and fluid intake
−History of abdominal complaints
−Current bowel and bladder habits
−Medications and supplements

152. Bowel Obstruction
•Large bowel
obstructions likely
from:
−Cancer
−Impacted stool
−Sigmoid volvulus
•Small bowel
obstruction secondary
to gallstones
(cholelithiasis)

153. Bowel Obstruction
•Large and small intestine obstruction from:
−Adhesions from previous surgery
−Infection
−Fascial defect (hernia)

154. Biliary Disease
•May present with or
without small bowel
obstruction, and
include:
−Cirrhosis
−Hepatitis
−Cholecystitis
•Signs and symptoms:
−Jaundice
−Fever
−Right upper quadrant
pain
−Vomiting or nausea

155. Peptic Ulcer Disease
•Main risk factors:
−Regular NSAID use
−Helicobacter pylori
−Other medications
−Stress
•Main symptom:
−Dyspepsia that
improves immediately
after eating

156. Gastrointestinal Bleeding
•Almost always from physiologic changes or
pathologic processes
•Decreased peristalsis increases likelihood
of irritating substances damaging gastric
lining.
•Older patients often take medication that
alters coagulation.

157. Gastrointestinal Bleeding
•Pathologic processes causing GI bleeding:
−Ulcers and varices
−Cancers of the GI tract
−Diverticulitis
−Cirrhosis
−Bowel obstruction

158. Gastrointestinal Bleeding
•Esophagus:
−Varicies and alcohol
abuse
−Violent vomiting, large
amount of red,
uncoagulated blood
•Stomach:
−Peptic ulcer disease
−Red or darker, coffee-
ground emesis

159. Gastrointestinal Bleeding
•Bloody stool:
−Bleeding from lower
GI
−Digested blood from
stomach
•Stool dark and tarry
•Bright red blood in
stool:
−Diverticulitis
−Large bowel
obstruction
−Anal fissures
−Hemorrhoids

160. Gastrointestinal Bleeding
•Upper GI
hemorrhage from:
−Esophagus
−Stomach
−Duodenum
•Older people more
prone

161. Gastrointestinal Bleeding
•Lower GI
hemorrhage—
bleeding from
colon and rectum
−Hemorrhoids
−Colon polyps
−Cancer

162. Gastrointestinal Bleeding
•Risk factors:
−History of previous lower GI bleeds
−Signs or symptoms of colon cancer
−Recent constipation or diarrhea
−Use of blood thinners

163. Gastrointestinal Bleeding
•If hematocrit and hemoglobin decrease
significantly during interfacility transport,
may need to give blood
•Severe lower GI bleeding requires
immediate transport.

164. Gastrointestinal Bleeding
•Signs and symptoms
from hypovolemia:
−Agitation
−Dizziness
−Syncope
−Hypotension
−Changes in mental
status
•Signs and symptoms
from underlying
disease:
−Jaundice
−Hepatomegaly
−Constipation or
diarrhea
−Pain with voiding
−Abdominal pain

165. Gastrointestinal Bleeding
•Bleeding severity more important than
cause in prehospital setting.
−Slower bleeding
•Pulse rate and systolic BP normal
−Brisk bleeding
•Hematemesis
•Melena

166. Urinary Tract Infections
•Urinary tract infections most common
hospital-associated infection causing
sepsis.
−Usually develop in lower urinary tract where
normal flora grow in the urethra
•More common in women
−After age 50, risk increases for men.

167. Urinary Tract Infections
•Common risk factors:
−Diabetes
−Prostratitis
−Cystocele
−Urethrocele
−Kidney obstruction
−Indwelling urinary
catheters
•Present with:
−Fever
−Shortness of breath
−Poor urinary output
−Increased urinary
frequency
−Painful urination
−Gastrointestinal
symptoms

168. Urinary Tract Infections
•If indwelling catheter,
check for:
−Sediment
−Opacity
−Color
−Presence of blood
•Later signs and
symptoms:
−Hypotension
−Tachycardia
−Diaphoresis
−Pale skin

169. Renal Failure
•Sudden decrease in rate of filtration through
the glomeruli, leading to toxin accumulation
in the blood
•Develops if kidneys are no longer able to:
−Excrete waste.
−Concentrate urine.
−Control electrolytes, pH, or blood pressure.

170. Renal Failure
•Risk factors:
−Diabetes
−Cardiac disease
−Pyelonephritis
−Hypertension
−Autoimmune disorders
−Polypharmacy
•May need
hemodialysis or
kidney transplant
•If hemodialysis is
missed, can become
an ALS emergency

171. Renal Failure
•Symptoms from missed hemodialysis
treatment include:
−Hypertension
−Headache and fatigue
−Anxiety
−Anorexia and vomiting
−Increased dark urination

172. Renal Failure
•Obtain a 12-lead ECG
to check electrolytes.
•Monitor:
−All vital signs
−ETCO
2
−Breath and bowel
signs
•Transport to a facility
with hemodialysis
capabilities.
•Administer fluids as
necessary.
•Treat any
dysrhythmias.

173. Incontinence
•Few admit the problem, and fewer seek
help.
−Social and emotional impact
•Can lead to:
−Skin irritation and breakdown
−UTIs

174. Incontinence
•As people age:
−Bladder capacity decreases.
−Sphincter muscle strength decreases.
•Urinary sphincter pressure triggers need to urinate
•Sphincter tone decrease means less indication of a
full bladder.

175. Incontinence
•Treatment includes:
−Bladder training programs
−Medications
−Physical therapy
−Surgery (depending on cause)

176. Incontinence
•Be discreet and nonjudgmental.
−If possible, help patients gather incontinence
supplies before transport.
−Cover patient until clothes can be changed.
−Try to reduce time patients wear urine-soaked
clothing during transport.

177. Incontinence
•Urinary retention opposite of incontinence
−Difficulty or absence of voiding may come from
many medical causes:
•Benign prostate enlargement
•Inflammation from bladder and UTI infection
•Placement and removal of urinary catheter
•Loss of bladder wall elasticity

178. Incontinence
•Temporary retention may lead to:
−Pain
−Abdominal distention
−Acute or chronic renal failure

179. Endocrine Conditions
•Geriatric patients may present with:
−Grave disease (hyperthyroidism)
−Addison disease (hypoadrenalism)
−Cushing syndrome (hyperadrenalism)
−Osteoporosis
−Diabetes

180. Diabetic Disorders
•Inability to oxidize complex carbohydrates
because of impaired ability to produce
insulin
−Body cannot handle all the glucose in the blood.
•People over age 65 years often have type 2
diabetes.

181. Diabetic Disorders
•Risk factors:
−Normal aging contributes
−Having more than one chronic disease
−Family history
−Genetics
−Diet
−Obesity
−Sedentary lifestyle

182. Diabetic Disorders
•Causes two life-threatening conditions:
−Hypoglycemia—blood glucose levels drop to
45 mg/dL or less
−Hyperglycemia—blood glucose exceeds normal
range of 70 to 120 mg/dL

183. Diabetic Disorders
•Geriatric patients at increased risk for
hypoglycemia:
−Confusion about medication doses or usage
−Inadequate or irregular dietary intake
−Inability to recognize warning signs due to
cognitive problems
−Blunted warning signs

184. Diabetic Disorders
•Symptoms of
hypoglycemia:
−Delirium
−Mental status changes
and confusion
−Diaphoresis
−Decreased respiratory
effort
•Symptoms of
hyperglycemia:
−Fatigue
−Poor wound healing
−Blurred vision
−Frequent infections

185. Diabetic Disorders
•Symptoms of chronic hyperglycemia:
−Polyuria (excessive urine output)
−Polydipsia (excessive thirst)
−Polyphagia (excessive eating)

186. Diabetic Disorders
•Geriatric patients more prone to
HONK/HHNC
•Risk factors for HONK/HHNC:
−Infection
−Hyperthermia
−Hypothermia
−Cardiac disease or stroke
−Pancreatitis

187. Diabetic Disorders
•Signs and symptoms of HONK/HHNC:
−Dizziness
−Confusion
−Altered mental status
−Polydipsia

188. Diabetic Disorders
•Assess vital signs every 15 minutes.
−Obtain a 12-lead ECG.
−Monitor ETCO
2
and ventilatory status
throughout transport.
−Monitor fluid resuscitation and electrolyte
balance.

189. Diabetic Disorders
•Prevention lifestyle
changes:
−Dietary restrictions
−Exercise
−Controlling obesity
•Long-term
management:
−Limiting carbs
−Taking insulin and
antihyperglycemics

190. Thyroid Disorders
•Many older patients are asymptomatic.
•Manifests by general slowing of metabolic
process from reduction or absence of
thyroid hormone

191. Thyroid Disorders
•Signs and symptoms may look like aging:
−Cold intolerance
−Constipation
−Dry skin
−Weakness
−Weight gain

192. Thyroid Disorders
•May require supplemental oxygen
−Hypoglycemia—may need 50% dextrose (D50)
−Hypothyroid—often diminished respiratory effort
−Continued hormone level decrease may cause
myxedema coma and physiologic
decompensation.

193. Immunologic Conditions
•Infections can be severe and dangerous in
the elderly.
•Sepsis may occur.
−Results from microorganisms in the
bloodstream

194. Immunologic Conditions
•Patient may be:
−Hot and flushed
−Tachycardic
−Tachypneic
•Other signs:
−Oral temp greater
than 100.4°F or less
than 96.8°F
−Respiratory rate more
than 20 breaths/min
−Pulse rate more than
90 beats/min

195. Toxicologic Conditions
•Elderly prone to adverse reactions from
changes in:
−Drug metabolism—diminished hepatic function
−Drug elimination—diminished renal function
−Body composition—altered drug distribution
−Responsiveness of drugs that affect the CNS

196. Toxicologic Conditions
•Body changes may affect medication use:
−Vision decline leads to errors in administration
of medicine.
−May take more than normal doses:
•Short-term memory loss leads to taking dose twice.
•Inability to distinguish flavors

197. Polypharmacy and Medication
Noncompliance
•Polypharmacy becomes problematic when
medications interact:
−Dosages not adjusted for multiple medications
−Multiple organs affected
−Increased likelihood of adverse reactions

198. Polypharmacy and Medication
Noncompliance
•Chances of being hospitalized increases
with number of medications.
−Best dosage—lowest drug that achieves
therapeutic effect
•Medications may not be received because
of caregiver theft.

199. Polypharmacy and Medication
Noncompliance
•Noncompliance includes:
−Failing to fill prescription
−Administering medication improperly
−Taking inappropriate medication

200. Polypharmacy and Medication
Noncompliance
•Other issues:
−Taking medication prescribed by different
doctors who don’t know full medication regimen
−Taking medication prescribed for someone else
−Difficulty understanding drug regimen
−Difficulty opening medication containers

201. Pharmacokinetics
•Toxic effects of drugs from aging-related
alterations in pharmacokinetics
•Predisposed to reactions by physiologic
changes in body systems and composition
−Medications affecting CNS most common
source of adverse reactions.

202. Pharmacokinetics
•Reduction in nervous system response
increases risk of adverse anticholinergic
effects.
•Reduced beta-adrenergic receptor
sensitivity—most bronchodilators ineffective

203. Pharmacokinetics
•Diuretics, antihypertensive
−Cause hypotension and orthostatic changes
from reduced cardiac output, total body water
decrease
•Decreased glucose tolerance
−Hyperglycemic effects from diuretics and
corticosteroids

204. Pharmacokinetics
•Pharmacokinetics can be influenced by:
−Diet
−Smoking
−Alcohol consumption
−Other drug use

205. Pharmacokinetics
•Dosages often
needs to be
reduced in elderly.
•Toxic effects
present with:
−Psychiatric
symptoms
−Cognitive
impairment

206. Drug and Alcohol Abuse
•Alcohol is preferred substance of abuse
among older people.
•One third develop abuse problem after 65
years because of:
−Loss of spouse
−Declining health
−Low self-esteem

207. Drug and Alcohol Abuse
•Prevalence attributed to:
−Number of prescribed medications
−Heightened vulnerability to abuse
−Decreased body mass and total body water
leads to higher blood alcohol concentrations.
−Slower alcohol elimination from body

208. Drug and Alcohol Abuse
•Recognizing abuse can be difficult:
−Well hidden or accepted by family and friends
−Ask about issue—can complicate assessment

209. Psychological Conditions
•Depression not a part of normal aging.
−Medical disease in about 6% of the elderly
−May be normal, short-term reaction to event
−Concern when persists for weeks
•Sadness and restlessness
•Fatigue and hopelessness

210. Depression
•Incidence growing in relation to progressive
population aging
•Treatable with medication and therapy
•Can mimic effects of other medical
problems

211. Depression
•Risk factors:
−History of
depression
−Chronic disease
−Loss of function,
independence,
significant others

212. Depression
•Elderly tend to not complain about feelings
—may be difficult to recognize
•Majority of elderly suicides in people who:
−Were recently diagnosed with depression
−Had seen primary care physician with month of
event

213. Depression
•Completed suicide disproportionately high
•A “way out” from terminal or debilitating
illness or neurologic condition

214. Depression
•Behavioral crisis
−Cannot cope
−Overwhelmed
•Behavioral
emergency:
−Significant risk of
serious harm
−Suicidal state
−Potentially violent

215. Mental Illness
•If mental illness or psychotic episode,
patient is out of touch with reality
•Symptoms may include:
−Angry or excited for no reason
−Antisocial or loner behavior
−Sleeping during day, awake at night

216. Integumentary Conditions
•Older patients at higher risk for secondary
infection
•Wounds take longer to heal.
•Cumulative sun and toxin exposure
increase chance of developing skin cancer.

217. Herpes Zoster
•Also known as shingles
•Caused by reactivation of varicella virus on
nerve roots
−Commonly affects thoracic nerve and
ophthalmic division of the trigeminal nerve

218. Herpes Zoster
•Symptoms:
−Pain in affected area
−Cluster of tiny blisters
on reddened skin
−Usually unilateral rash
•Treatment:
−Narcotic pain relievers
−Antiviral medications

219. Cellulitis
•Acute inflammation
in skin caused by
bacterial infection.
•Usually affects
lower extremities
© Dr. P. Marazzi/Science Photo Library

220. Cellulitis
•Symptoms include:
−Fever and chills
−Warmth, swelling,
redness, tenderness,
and enlarged nodes in
affected area
−Elevated white blood
cell count
−Presence of bacteria
•Treatment includes:
−Antibiotic therapy
−Fluid intake
−Local dressing on any
open sores

221. Pressure Ulcers
•Occur from pressure applied to body tissue,
resulting in lack of perfusion and necrosis
•Possible risk factors:
−Brain or spinal cord injury
−Neuromuscular disorders
−Nutritional problems

222. Pressure Ulcers
•Most commonly located on:
−Lower legs
−Sacrum
−Greater trochanter
−Glutes

223. Pressure Ulcers
•Classified as:
−Stage 1—persistent
skin redness that does
not disappear when
pressure is relieved
−Stage 2—partial
thickness lost;
appears as abrasion,
blister, shallow crater
−Stage 3—full skin
thickness lost,
exposing
subcutaneous tissue
−Stage 4—full
thickness and
subcutaneous tissue
lost, exposing muscle,
bone

224. Pressure Ulcers
•More than 10% of US nursing home
patients have some stage of ulcer.
•Prehospital treatment mostly BLS
−Monitor body temperature and vital signs.
−Administer oxygen, IV line, and consider a fluid
bolus.

225. Musculoskeletal Conditions
•Physical ability changes and affects
confidence in mobility
−Muscles atrophy and weaken.
−Muscle fibers become fewer and smaller.
−Motor neuron numbers decline.
−Strength declines.

226. Musculoskeletal Conditions
•Stooped posture from atrophy of body’s
supporting structures
−2 of 3 older patients will have some degree of
kyphosis.
−Lost height from spinal column compression

227. Osteoporosis
•Decrease in bone
mass, leading to:
−Bone strength
reduction
−Greater susceptibility
to fractures
•Influenced by:
−Genetics
−Smoking
−Activity level
−Diet
−Hormonal factors
−Body weight and
structure

228. Osteoporosis
•Type I
−Rapid bone loss
occurring in women
during years after
menopause
−Most common
fractures:
•Radius
•Hip
•Type II
−In both men and
women 50+
−Most common
fractures:
•Hip
•Vertebrae
•Vertebral fractures
may lead to dorsal
kyphosis

229. Osteoporosis
•Treatment:
−Bisphosphonates
−Calcium and vitamin D supplementation
−Activity and low-impact exercise

230. Arthritis
•Progressive joint disease
−Formation of bone spurs in joints, leading to
stiffness
−Thought to result from:
•Joint wear and tear
•Repetitive joint trauma

231. Arthritis
•Patients report pain:
−Worsens with exertion
−Worsens with temperature/humidity
•Treatment includes:
−Anti-inflammatory medications
−Physical therapy

232. Arthritis
•Rheumatoid arthritis
(RA): Long-term
autoimmune disorder
with inflammation of
joints and surrounding
tissue
•Symptoms bilateral,
affecting:
−Hands
−Feet
−Wrists
−Ankles
−Knees

233. Management of Medical
Emergencies in Elderly People
•Most prehospital care is supportive:
−Pain relief
−Palliative support
−Treatment for emergency and chief complaint

234. Geriatric Trauma Emergencies
•Deaths from injury in people older than 65
account for one quarter of all trauma deaths
in the United States.
−7th leading cause of death in the elderly
•Slower reflexes and reduction in agility
•Visual and hearing deficits
•Equilibrium disorders

235. Geriatric Trauma Emergencies
•Less favorable outcomes in trauma
because:
−Changes in homeostatic compensatory
mechanisms
−Aging effects on body systems
−Preexisting conditions

236. Geriatric Trauma Emergencies
•Successful treatment when trauma-related
blood loss is compensated enough for:
−Increased pulse rate
−Increased respirations
−Adequate vasoconstriction

237. Geriatric Trauma Emergencies
•Unsuccessful recovery likely if:
−Decreased respiratory function
−Impaired renal activity
−Ineffective vasoconstriction

238. Geriatric Trauma Emergencies
•Most cases involve falls or motor vehicles
−Increased mortality from falls related to:
•Patient’s age
•Preexisting disease processes
•Complications related to trauma

239. Geriatric Trauma Emergencies
•Falls are divided into two categories:
−Extrinsic causes: tripping or slipping
−Intrinsic causes: dizzy spell, syncopal attack
•Risk increases with preexisting gait
abnormalities and cognitive impairment.

240. Geriatric Trauma Emergencies
•Home safety assessment by EMS
−Check for:
•Clear pathway to and from bathroom
•Handrails in bathtubs and on steps
•No loose rugs or other objects on floor
•Wheelchair ramps with grip tape

241. Geriatric Trauma Emergencies
•Elderly are five times more likely to be
fatally injured in a motor vehicle crash.
−At higher risk for crashes due to:
•Vision impairment
•Errors in judgment
•Underlying medical conditions

242. Pathophysiology
•Head trauma: increased fragility of cerebral
blood vessels, enlarged subdural space
−Hematoma often develops over days or weeks.
•Headache is the early symptom.
−As intracranial pressure increases:
•Consciousness depressed
•Patient drowsy

243. Pathophysiology
•Spinal cord injury and compression: arthritic
spurs, vertebral canal narrows
−Even a sudden movement of the neck may
cause spinal cord injury.

244. Pathophysiology
•Chest injuries: rib brittleness, stiffening of
the chest wall
•Abdominal trauma often causes liver injury.
•Orthopaedic injuries common results of
falls.

245. Pathophysiology
•Burns have significant risk of morbidity and
mortality, especially if:
−Preexisting medication conditions
−Weakened defense mechanism against
infection
−Fluid replacement complicated by renal
compromise
•Monitor hydration status.

246. Pathophysiology
•Internal
temperature
regulation slows
with age:
−Delayed ability to
recognize
temperature
fluctuations
•Heat gain/loss
slowed by:
−Atherosclerotic
vessels
−Slowed circulation
−Decreased sweat
production

247. Pathophysiology
•Thermoregulation
affected by:
−Chronic disease
−Medications
−Alcohol use
•Half of
hypothermia
deaths are older
people.
•Hyperthermia
death rates more
than double in the
elderly.

248. Pathophysiology
•Check for environmental emergencies in
extreme hot and cold.
•May need to keep patient compartment at
higher-than-normal temperature.

249. Assessment and Management
of Trauma
•Check mechanism of injury.
•Check for possible medical problem before
the trauma.
•Initial management follows ABCs first.

250. Assessment and Management
of Trauma

251. Assessment and Management
of Trauma
•Check for rib fracture when assessing
breathing.
•Obtain baseline BP.
−Normal blood pressure may be hypotension in
an older person.

252. Assessment and Management
of Trauma
•Do neurologic
status assessment
according to AVPU
scale.
•Try to obtain
complete history of
event from patient
and bystanders.

253. Assessment and Management
of Trauma
•Obtain list of regular medications, especially
those that may affect treatment:
−Beta blockers
−Antihypertensives
−Diabetes medications

254. Assessment and Management
of Trauma
•Conduct secondary assessment, watching
for signs of injury to:
−Head
−Cervical spine
−Ribs and abdomen
−Long bones
•Remember patient’s pain perception may
be decreased.

255. Assessment and Management
of Trauma
•Additional treatment based on injuries.
−Be cautious about isotonic solutions.
−Monitor cardiac rhythm throughout.
−Preserve temperature.
−Consider pain medication.
−Immobilize the cervical spine before
transporting.

256. Elder Abuse
•Any form of mistreatment that results in
harm or loss to an older person
−Physical
−Sexual
−Emotional
−Neglect
−Financial

257. Elder Abuse
•Average victim:
−80 years old
−Female
−Has multiple chronic conditions
−Is unable to function on their own
−Is dependent for at least part of their care

258. Elder Abuse
•Abuser is almost always known to the
abused:
−Often a family member
−Often occurs in patient’s or caregiver’s home
−Sometimes in long-term care facilities

259. Elder Abuse
•Clues:
−Unexplained
injuries that do not
fit stated cause
−Poor hygiene
−Patient interacting
with caregivers
•Listen to patient’s
concerns about
their care.

260. Elder Abuse
•If stable but in unsafe situation, see if
patient will allow transport.
−If they refuse, suggest local adult protective
services.
−If immediately unsafe, notify law enforcement.

261. Elder Abuse
•Many states have elder abuse statutes.
−Reporting suspected abuse may be mandatory.
−Definition may vary state by state.
−If suspected as cause of injury:
•Objectively document observations.
•Report findings and suspicions to receiving facility.

262. End-of-Life Care
•Paramedics will be involved with end-of-life
care for patients.
−Do not resusciate (DNR) does NOT mean “do
not respond to the needs of a terminal patient”

263. End-of-Life Care
•Paramedics should:
−Treat various disorders.
−Administer medication.
−Perform other treatments.
−Be caring and concerned.

264. End-of-Life Care
•Community may
have a local
hospice:
−Terminal care for
patients
−Support for families
© Photofusion Picture Library/Alamy Images

265. Summary
•Elderly people constitute an ever-increasing
proportion of patients in health care
systems, especially the emergency area.
•Health problems of the elderly are
quantitatively and qualitatively different than
those of younger people, and require
special approaches.
•The aging process is accompanied by
physiologic function changes.

266. Summary
•With age, the respiratory capacity is
significantly reduced because of decreases
in lung elasticity and size/strength of
respiratory muscles, calcification of
costchrondral cartilage, and
musculoskelatal changes.

267. Summary
•A variety of cardiovascular system changes
occur as the person ages. The heart
hypertrophies, arteriosclerosis develops,
and the electric conduction system
deteriorates.
•Nervous system changes lead to a
decrease in sense organ performance,
leading to hearing and visual changes.

268. Summary
•Digestive system changes include a
decrease in taste buds and a reduction in
saliva and gastric secretions.
•Geriatric patients may experience renal
system changes that make it difficult to
handle unusual challenges from illness, so
acute illness is often accompanied by fluid
and electrolyte balances.

269. Summary
•Endocrine system changes may lead to
diabetes and thyroid abnormalities.
•Nearly every immune system function is
affected by aging, so the elderly are more
prone to infection and secondary
complications.

270. Summary
•Integumentary system changes include
thinner skin and elasticity loss, causing
more bleeding and skin to tear more easily.
•Aging causes a progressive loss of
homeostatic capabilities.
•A decrease in bone mass accompanies
aging, especially in postmenopausal
women, so bones break more easily.

271. Summary
•Signs and symptoms of disease may be
altered in older people.
•The GEMS diamond was designed to assist
in assessment and treatment of elderly
patients.
•The primary assessment addresses
immediately life-threatening pathologic
problems; the secondary assessment is a
systematic assessment of the body.

272. Summary
•The physical exam of older patients may be
difficult because of poor cooperation and
easy fatigability.
•More than 80% of all stroke deaths occur in
persons older than 64 years.
•Heart disease remains the leading cause of
death among older adults in the United
States.

273. Summary
•Delirium often replaces or confounds the
typical presentation of a medical problem,
adverse medication effect, or drug
withdrawal.
•Dementia produces irreversible brain
failure.
•Gastrointestinal problems in the elderly
include peptic ulcer disease, small bowel
obstruction from gallstones, and stomach or
duodenal ulcers.

274. Summary
•The most common hospital-associated
infection to cause sepsis in the United
States is urinary tract infection.
•An elderly patient with diabetes is at
increased risk for hypoglycemia.
•Older diabetic patients who tend to have
high blood glucose levels are prone to
hyperosmolar nonketotic coma (HONK)
(hyperglycemic nonketotic coma [HHNC]).

275. Summary
•Elderly people are particularly prone to
adverse drug reactions because of changes
in drug metabolism, drug elimination, and
body composition.
•Alcohol abuse among the elderly is on the
rise. A much smaller, but growing, segment
of the elderly uses illicit drugs.
•Depression in the elderly can mimic many
other medical problems, such as dementia.

276. Summary
•Osteoarthritis is a progressive disease of
the joints that destroys cartilage, promotes
formation of bone spurs in joints, and leads
to joint stiffness.
•An elderly person is at higher risk of trauma
because of slower reflexes, visual and
hearing deficits, equilibrium disorders, and
an overall reduction in agility.

277. Summary
•Most geriatric trauma is from falls or motor
vehicle crashes.
•Elder abuse is any form of mistreatment
that results in harm or loss, and can be
either physical, sexual, emotional, neglect,
or financial.
•Hospice care allows people with terminal
illnesses to receive palliative care in their
own homes.

278. Credits
•Chapter opener: © Glen E. Ellman
•Backgrounds: Gold – Jones & Bartlett Learning.
Courtesy of MIEMSS; Purple – Jones & Bartlett
Learning. Courtesy of MIEMSS; Orange – © Keith
Brofsky/Photodisc/Getty Images; Green – Jones &
Bartlett Learning.
•Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.