Chapter 44: Geriatric Emergencies

What is the most common dysrhythmia among geriatrics and what complications are associated with it?

A-fib. The fibrillating atria allows for the stasis of blood which encourages clot formation and increases one's risk of stroke and heart failure.

What are the two major features of *normal* age-related cognitive changes in geriatrics?

1. They are relatively isolated. Meaning, they're not associated with multiple abnormal neurologic findings that suggest a specific disease state. 2. The onset and progression of the findings are "in time" with the individual's aging process. Meaning, the findings are not sudden or extreme, and they do not extend to other abnormalities.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *digestive system*?

A decrease in the number of taste buds and changes in olfactory receptors diminish one's sense of taste and the enjoyment of food, consequently leading to a decreased appetite and potential malnourishment. There's additionally a decrease in salivary production. While dental loss is not a cause of old age, it's nonetheless common in the elderly. If the individual has dentures, the increased difficulty in chewing one's food can lead to choking, heartburn, and abdominal pain. There's also a decrease in gastric acid production, the esophageal sphincter weakens, and there's decreased gastric motility, all of which increase the risk of heartburn, acid reflux, and aspiration. While the risk of developing certain diseases such as diverticulitis increases with age, there's little change in small and large intestinal function. There is, however, a slowing of peristalsis which can lead to constipation. The difficulty in bowel movement can lead to straining which can cause hemorrhoids, as well as potentially syncope or bradycardia due to vagal stimulation. The rectal sphincter additionally decreases in size and strength resulting in possible incontinence. Enzymatic activity changes in the liver as well, and as a general rule the detoxification of drugs slows as one ages. This can complicate drug absorption and lead to toxicity. Similarly, when multiple drugs are prescribed, the risk of hepatic damage and drug toxicity increases.

What is the GEMS diamond?

A mnemonic made to help recall key features of a geriatric assessment. *G*eriatric Patient: Recognize that geriatrics often present atypically, deserve respect, and experience normal changes with age. *E*nvironmental Assessment: Check the physical condition of the home. How is its condition? Are there any odd smells or signs of urine/feces in the home? Are pets being cared for? Is there food? Does the patient have access to a telephone? Etc. *M*edical Assessment: Older patients tend to have comorbidities making an assessment challenging. Always obtain a medical history, perform a primary survey, and reassess. *S*ocial Assessment: Assess ADLs. Is the patient being cared for, and if so are there delays in obtaining food, medicine, or toiletries? Does the patient have family that visits? Is the patient able to feed himself? Does the patient appear to have been sitting in urine for a while? Does the patient have a social network? Etc.

What type of abuse is unique to geriatrics?

Financial abuse - the improper use of an older person's funds, property, or assets. The abuser is often known to the individual and is often a family member.

How does heart failure commonly present in geriatrics and how should it be managed in the field?

Acute exacerbation of heart failure results in pulmonary edema that decreases the ability of the lungs to exchange gases. Thus, EtCO2 should be monitored and will likely reflect hypercapnia. It may present with dyspnea or orthopnea, and because of the decreased oxygenation, mental status changes may be noted. Peripheral edema may also indicate heart failure, but be mindful of the fact that in the absence of other symptoms it may indicate a number of other circulatory, integumentary, or infectious diseases. Also, note that bed-bound patients may present with sacral edema rather than pedal edema. Acute exacerbations are often correlated to poor diet, medication noncompliance, MI, and an onset of a dysrhythmia (such as A-fib). The presentation of heart failure in older patients may be masked by chronic diseases which share similar symptoms - for example, dyspnea on exertion, easy fatiguability, confusion, rales, orthopnea, a dry cough that progresses to a productive cough, dependent peripheral edema, etc. The treatment is the same as in young adults: EtCO2 should be monitored, fluids should be closely monitored for overload, oxygen and CPAP use should be considered, and diltiazem (Cardizem) should be considered in patients with A-fib or A-flutter. If hypotension persists, consider the use of vasopressors.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *musculoskeletal system*?

Aging causes a decrease in bone mass in men and women, but particularly in post-menopausal women. Bones become more brittle and break more easily. Tendons and ligaments begin to lose elasticity, the synovial fluids in joints thickens, and the cartilage that ordinarily cushions the joints decreases. Narrowing of the intervertebral discs and compression fractures of the vertebrae leads to a decrease in height and a change in posture. Arthritis may further limit joint movement, and a decrease in muscle mass leads to immobility. When immobile for a prolonged time, muscular atrophy can occur. Geriatrics are thus more likely to fall and are then more likely to sustain fractures from falling. Geriatrics may lose the ability to care for themselves, and a loss of fine-motor skills can lead to inability to perform tasks such as taking their medications. Loss of bone density and muscle mass may be slowed by remaining physically active throughout one's lifetime, and people with a history of performing strenuous labor and rigorous exercise are the least susceptible to musculoskeletal decline.

What are pressure ulcers and what causes them? What are the different stages? How is it treated?

Also called decubitus ulcers or pressure sores, they're areas of necrosis (commonly on the lower legs, sacrum, greater trochanter, and gluteus maximus) caused by pressure being applied to body tissue resulting in a lack of perfusion. They're common in bed-bound patients, and they're exacerbated by fecal and urinary incontinence. Stage 1: A persistent area of skin redness that does not disappear when pressure is relieved. Skin is intact. Stage 2: A partial thickness of skin is lost and the area might appear as an abrasion, blister, or shallow crater. Stage 3: A full thickness of skin is lost resulting in exposed subcutaneous tissue. It presents as a deep crater with or without undermining adjacent tissue. Stage 4: A full thickness of skin and subcutaneous tissue are lost, exposing muscle or bone. Prehospital care is BLS, but be mindful of the possibility of sepsis which obviously requires ALS intervention.

How do acute coronary syndromes (ACSs) present differently in the geriatric population?

Although chest pain is a common complaint, it may be decreased in intensity or it may not be present at all. The patient may instead report dyspnea, syncope, weakness, confusion, nausea, vomiting, or fatigue. Providers should maintain a high index of suspicion for anyone in this age-range who has a complaint between their waist and their nose, and any complaint within this region merits a 12-lead ECG.

What is Alzheimer's disease and how is it classified? How is it diagnosed? How is it treated?

Alzheimer's disease is characterized by a progressive loss of function that begins with subtle symptoms (such as frequently losing items or forgetting people's names) that progresses to an inability to think, reason clearly, problem solve, and concentrate. Symptoms may present as confusion, changes in personality or judgement, and extreme difficulty with daily activities (such as feeding, bathing, and bladder/bowel control). Its progression is classified into stages. The earliest stage, mild cognitive impairment, is characterized by language problems, misplacing items, getting lost on familiar routes, personality changes, a loss of social skills, a loss of interest is previously enjoyed activities, and difficulty performing moderately difficult tasks that were once easy. Symptoms become more profound as the disease progresses. Forgetting details about one's life, changes in sleep patterns, speaking nonsensically, and dangerous or violent behaviors develop. Severe or end-stage Alzheimers is defined as a loss of skills obtained within the first 2 - 3 years of life, such as understanding language, recognizing family members, and interacting verbally. Alzheimers is typically diagnosed by excluding other possible causes of the dementia. The only true diagnosis is via autopsy to confirm the presence of tau, the neurofibrillary proteins which entangle and obscure the nuclei of neurons. Treatment is typically supportive. Antipsychotics and benzodiazepines can be considered if the patient is combative and is a danger to him/herself. Chemical restraint should only be considered after verbal containment has proven ineffective. Daily medication regimens commonly include antidepressants and cholinesterase-inhibitors to prevent further deterioration and decline. Memantine is a commonly prescribed medication which acts as a NMDA-inhibitor, as is galantamine, an acetylcholinesterase-inhibitor. A specific cause has not been discovered and Alzheimer's is not considered to be a normal part of aging.

What is cellulitis and what causes it? How is it treated?

An acute bacterial infection of the skin, signs and symptoms include: fever, chills, and general malaise, and warmth, swelling, redness, tenderness, and enlarged nodes in the affected area. Treatment includes antibiotics, ensuring adequate fluid intake, and dressing open wounds.

What is included in the term "biliary disease"? What signs and symptoms are commonly associated it? How should it be managed in the field?

Biliary diseases include cirrhosis, hepatitis, and cholecystitis. They typically present with jaundice, fever, RUQ abdominal pain with possible radiation to the upper back or shoulder, and vomiting or nausea. Jaundice may be more profound in geriatrics because less melanin is produced. Remember that the fever may be blunted in older adults and the patient may present with an atypical pain. Pain management should be considered for acute cholecystitis, but be careful with opioid administration in this population as geriatrics may not be able to compensate for the cardiovascular and respiratory changes.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *nervous system*?

Brain weight may shrink by 10 - 20% by the age of 80. It is not clear, however, what effect this truly has, since the brain has a large reserve capacity and relies heavily on its sulci and gyri more than its actual size. Nonetheless, mental function declines with age, as does the regulation of respiratory rate and depth, pulse rate, blood pressure, hunger, and thirst. Reflexes often slow, and temperature regulation and perception decrease, resulting in an increased likelihood of injury. The performance of most of the sense organs decreases with age. Visual and auditory decline is natural in many older adults, and tear production decreases with age, leading to dry and itchy eyes and an increased risk of eye injury and infection. Cataracts (a hardening of the lens which eventually becomes opaque preventing light from being transmitted through it clearly) and glaucoma (an increase in intraoccular pressure which can damage the optic nerve) are both common. Decreased visual acuity, impaired night vision, presbyopia (far-sightedness, caused by a lack of elasticity in the lens of the eye), and a difficulty in differentiating between colors are also common. Hearing loss is common, with the most common type being presbycusis (a progressive hearing loss, particularly in the high frequencies, along with a lessened ability to differentiate between a particular sound and background noise). Hearing loss leads to decreased communication which can lead to isolation and depression, as well as an increased risk of injury. Appetite and taste perception decrease, as does the sense of touch (from aging-related loss of nerve fibers). The sense of smell is the last of the senses to diminish, but it can be compromised with upper-airway infections. For many older adults, physiologic changes make it more difficult to promote speech that is loud enough, clear, and well-spaced. Changes in cognition can be frustrating for the elderly and their caregiver(s). Lastly, impaired proprioception leads to an increased likelihood of falls and injury.

What is Chronic Obstructive Pulmonary Disease (COPD)? How does this commonly present in geriatrics and how should it be managed in the field?

COPD is the name given to a set of diseases including chronic bronchitis, asthma, and emphysema, all of which are characterized by bronchial obstruction and airway inflammation. The effects of COPD represent senile emphysema (the age-related loss of elastic tissue in the lungs) and a decreased ability to defend against infection. Patients with COPD may experience dyspnea with minor exertion, and later stages of the disease are characterized by fatigue and a decreased activity level. Preventative measures include: smoking cessation, avoiding environmental pollutants, and immunization for influenza and pneumococcal pneumonia. Treatment goals are simply to reduce the symptoms and complications. Immediate oxygen administration is appropriate and CPAP has shown to be beneficial. Bronchodilators and steroids aid in breathing and decreasing inflammation, and antibiotics are often considered in the ED.

In what ways in the assessment of a geriatric diabetic more complicated than that of a younger adult diabetic patient? What should the assessment of geriatrics with a suspected diabetic emergency include?

Changes in peripheral vasculature make the assessment of skin signs more difficult, as geriatrics are more likely to be pale and cool at baseline. Diaphoresis may also be less prominent due to decreased secretory function of the skin. Lastly, the patient may be altered at baseline, making a confused mentation less of an obvious indicator of an abnormal blood glucose. The assessment of these patients should include a full set of vitals retaken every 15 minutes, a 12-lead ECG, and EtCO2 monitoring throughout transport. The management of these patients is ultimately the same as it would be for a younger adult.

What injuries are geriatrics at an increased risk of following chest and abdominal trauma, respectively?

Chest trauma is much more likely to produce rib fractures and a flail chest due to the brittleness of the bones and the calcification of the costochondral cartilage. Liver damage is also more likely in cases of abdominal trauma due to the decrease in protective musculature.

What is herpes zoster and what signs and symptoms are associated with it? How is it treated?

Commonly known as "shingles," it's caused by the reactivation of the varicella virus on nerve roots. It's common in the older population, particularly if they have a history of chickenpox during early life. Shingles can affect any nerve in the body, but the thoracic nerves and the ophthalmic division of the trigeminal nerves are the most commonly affected. The disease usually starts with pain in the affected area. A tiny cluster of vesicles that look like blisters erupts on reddened skin on the same area. It's usually unilateral and the patient may have severe pain in the acute phase. Care ultimately consists of pain management and antivirals at the hospital.

What factors increase a geriatric diabetic patient's risk of a hypoglycemic event?

Confusion about the patient's medications or dosages, irregular or inadequate dietary intake, an inability to recognize the warning signs of hypoglycemia, and blunted warning signs all increase the risk of hypoglycemia. Delirium may be the only sign of hypoglycemia in geriatrics. Other symptoms may include: mental status changes, confusion, diaphoresis, and decreased respiratory effort.

What is delirium? What signs and symptoms are associated with it? What are common causes of delirium in geriatrics?

Delirium (also known as acute brain syndrome and acute confusional state) is a symptom - not a disease. It's a temporary state which is generally reflective of an underlying disturbance to a person's well-being and is usually reversible. Delirium is characterized by disorganized thoughts, inattention, memory loss, disorientation, striking changes in personality and affect, hallucinations, delusions, and a decreased level of consciousness. The confusion and disorientation fluctuate with time and hallucinations may lead to bizarre, uncharacteristic or confusing behaviors. The patient will often experience a rapid alteration between mental states, such as lethargy and agitation. Symptoms may mimic those of intoxication, drug abuse, or severe psychologic disorders such as schizophrenia. In older adults, delirium often replaces or confounds the typical presentation caused by a medical problem, an adverse medication effect, or drug/alcohol withdrawal. Causes may include: medications, poisons, electrolyte imbalances, nutritional deficiencies, medical conditions, hyper-/hypoglycemia, environmental emergencies, trauma, and infections such as UTIs and pneumonia. Use the mnemonic DELIRIUMS to identify other causes of delirium: *D*rugs or toxins *E*motional (psychiatric) or electrolyte imbalances *L*ow PaO2 (CO poisoning, COPD, heart failure, ACS, pneumonia) *I*nfection (pneumonia, UTI, sepsis) *R*etention of stool or urine *I*ctal state (seizures) *U*ndernutrition (including vitamin deficiencies) or underhydration *M*etabolism (thyroid or endocrine, electrolytes, kidneys) *S*ubdural hematoma

How does dementia differ from delirium? What causes dementia? What risk factors are associated with it and how is it diagnosed?

Dementia produces irreversible brain failure, unlike delirium which has a reversible cause. Signs and symptoms may include: short-term memory loss, a short attention span, jargon aphasia (talking nonsense), hallucinations, confusion, disorientation, and a difficulty in learning and retaining information. Personality changes may also occur, including social withdrawal and inappropriate behavior. Disorders that cause dementia include conditions that impair vascular and neurologic structures within the brain (such as infections, strokes, head injuries, poor nutrition, and medications). The two most common types of dementia in geriatrics are (a) Alzheimer's disease and (b) multi-infarct or vascular dementia, both of which cause structural damage to the brain. Dementia may also be the result of tumors, emotional disorders, Parkinson's disease, and Huntington chorea. Risk factors include a low level of education, female sex, and African American ethnicity, although these appear to be correlates - not causes. Dementia is typically diagnosed when two or more cognitive and psychomotor functions are impaired, including language, memory, visual perception, emotional behavior and/or personality, and cognitive skills. These patient develop a loss of communication skills, an inability to perform daily activities, an increased tendency to become lost in familiar areas, and changes in temperament.

What signs and symptoms are suggestive of dehydration in older adults?

Dry tongue, longitudinal furrows in the tongue, dry mucus membranes, weak upper body musculature, confusion, difficulty in speech, and sunken eyes.

What injuries are geriatrics at an increased risk of following pelvic trauma?

Due largely to osteoporosis, hip fractures can occur as the result of even minor trauma. In older patients, hip fractures are more likely to cause hemorrhage, and geriatric are nearly 4x more likely to require blood transfusions than younger adults.

What are the concerns of a geriatric patient who calls 9-1-1 for GERD.

Gastroesophageal reflux disease (GERD) is common in the geriatric community and many patients manage it with a proton-pump inhibitor, calcium carbonates, or both. Typically, patients with GERD have been managing it for years, and therefore when a patient call for GERD you should be suspicious of a more dangerous underlying issue. GERD is a diagnosis of exclusion so a full cardiac workup should be performed by EMS and the ED before it's determined to simply be an exacerbation.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *endocrine system*?

Geriatrics are at an increased risk of diabetes from a number of reasons ranging from a slowed metabolism of carbohydrates, to a decrease in insulin production and glucose metabolism, to comorbid disorders whose medications may affect glucose metabolism. Additionally, geriatrics produce more antidiuretic hormone so they're predisposed to increased salt-wasting and hyponatremia. Lastly, for women who go through menopause, the decrease in estrogen (which plays an important role in the preservation of bone mass) leads to decreased bone density and possibly osteoporosis, increasing the risk of fracture from otherwise harmless falls.

What are geriatric diabetics more at risk of: DKA or HHS/KONK? What is the most frequent cause of this? How do these patients commonly present?

HHS/HONK. Recall that DKA is a condition primarily associated with Type I diabetes, and Type II diabetes is far more prevalent in the geriatric population. The most frequent cause is infection, but other potential risk factors include hypo-/hyperthermia, cardiac disease, pancreatitis, and stroke. The patient is likely to present with a blood glucose > 600 mg/dL, acute confusion, and dehydration. Recall that with HHS/HONK, hyperglycemia and hyperosmolarity lead to osmotic diuresis and an osmotic shift of fluid into the intravascular space resulting in further intracellular dehydration. Signs and symptoms include: dizziness, confusion, AMS, and polydipsia. Prehospital treatment remains the same as that of younger adults, but be mindful of the possibility of fluid overload.

What is the leading cause of death among older adults?

Heart disease, the most common type being coronary artery disease (CAD). MIs are the major cause of death and disability in those over 65, and its potential for mortality increases significantly over the age of 70.

What factors commonly cause urinary retention? What effects can urinary retention have on an individual?

In men, benign prostatic hyperplasia (prostate enlargement) can place pressure on the urethra, making voiding difficult and frequent. Bladder infections and UTIs can also cause inflammation that results in urinary retention. Additionally, inserting and subsequently removing a urinary catheter can lead to urinary retention. Temporary urinary retention can lead to pain and abnormal distention, while severe or prolonged retention can lead to renal failure.

When should caregiver theft of medications be suspected?

If the patient reports immense pain and his/her vitals correspond to an undermedicated state.

What should be done with dentures following a trauma?

If they're intact, leave them be. Dentures that are properly adhered to a patient's gum-line do not interfere with bag-mask ventilations. That being said, if they're not intact, remove them and bring them with to the ED as they can dislodge and cause an airway obstruction.

What signs and symptoms should make you suspicious of sepsis in a geriatric patient?

In older patients, the first sign of sepsis may be confusion or an otherwise altered mental status. Because of the systemic nature of sepsis and the polypharmacy and comorbidities that exist in many geriatrics, keep in mind that an AMS and an elevated temperature may not be present. You should be thinking sepsis whenever you see a hot, flushed patient who is also tachycardic and tachypneic. Other signs of sepsis include an oral temp > 100.4° or < 96.8° F, a respiratory rate > 20 breaths/min, or a PaCO2 < 32 mmHg.

What questions pertaining to SAMPLE are particularly important to know in instances of geriatric trauma?

Inquire in particular about beta-blockers, antihypertensives, and medications for diabetes, all of which may affect the patient's response to anesthesia and resuscitation.

What factors increase the severity of spinal injuries in geriatrics?

Known as "spondylosis," degenerative changes occur in the cervical spines of geriatrics. Arthritic "spurs" develop and the cervical canal narrows resulting in compression of the spinal cord. Thus, even minor injuries place geriatrics at risk of cervical injury.

What are common causes of large bowel obstructions in geriatrics? What about small bowel obstructions?

Large bowel: Cancer, impacted stool, and sigmoid volvulus. Small bowel: The risk of an obstruction secondary to a gallstone increases with age. Following an episode of cholecystitis, the gallbladder can adhere to the small bowel and, over time, create a fistula (opening). Gallstones can then drop into the small intestine and create an obstruction. Both, the large and small intestine, are at risk of obstruction following surgery, infection, or when a segment of bowel is forced into a fascial defect (hernia) in the abdominal wall.

How should asthma be managed in the geriatric population?

Management is similar to that of other age groups, but be mindful of the effect beta-adrenergic agents may have on the heart in cardiac patients. On rare occasion, epinephrine may be appropriate for life-threatening asthma exacerbation.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to maintaining *homeostasis*?

Many homeostatic processes work on a feedback mechanism. With aging, there is a gradual loss of these homeostatic capabilities. For example, the thirst mechanism that normally protects a person from dehydration becomes depressed in the elderly. Similarly, thermoregulatory mechanism failure, in conjunction with the changes in the integumentary system, predispose geriatrics to harm from environmental stressors such as extreme heat and cold. The mechanisms normally responsible for maintaining a normal blood-glucose level also deteriorate so it is not uncommon for geriatric to have a higher-than-normal blood sugar. Of note, as mentioned previously, geriatric fevers are different than young adult fevers. A high fever in a geriatric should be very concerning, but an infection which prompts a high fever in young adults may only prompt a low-grade fever in geriatrics. So basically, a fever is an indicator of infection but its absence doesn't rule it out.

What is the most common sign of a GI bleed?

Melena (not pain, as is often assumed).

How should hypertensive geriatric patients be managed in the field?

More than one-half of all geriatrics have hypertension. Most commonly, it's isolated systolic hypertension resulting from a loss of arterial elasticity. Controlling blood pressure helps to reduce one's risk of MI and stroke. That being said, it needs to be done gradually. Giving nitro is typically not indicated due to the risk of rebound hypertension. Place the patient at a 30° incline to minimize ICP and transport according to presentation.

Compare and contrast myxedema and thyrotoxicosis. What is myxedema coma?

Myxedema: The term used to refer to adult hypothyroidism, it's manifested as a generalized slowing of the body's metabolic processes due to a reduction of thyroid hormone. It's often only detected with bloodwork, as the signs and symptoms match those of natural aging: cold intolerance, constipation, dry skin, weakness, and weight gain. Hypothyroid conditions can lead to decreased respiratory effort and may eventually lead to myxedema coma - an extreme manifestation of hypothyroidism accompanied by physiologic decompensation. vs. Thyrotoxicosis: The term used to refer to acute-onset hyperthyroidism, its presentation is often blunted in geriatrics. Tremors, anxiety, and hyperactive reflexes are less pronounced in geriatrics. A smaller percentage present with the exact opposite: weakness, lethargy, and depression. Of note, A-fib can be induced by an overactive thyroid.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *immunologic system*?

Older individuals are more prone to infection than younger adults due to a decrease in immune function as well as from complications of chronic conditions such as diabetes and malnutrition. Of note, while a fever in a young adult is often indicative of a minor infection, a fever in geriatrics commonly indicates severe infection. However, not all geriatrics with a serious infection will have a fever, as the immune system may not be strong enough to initiate the increase in body temperature.

Compare and contrast osteoarthritis and rheumatoid arthritis. What causes each and how are they treated?

Osteoarthritis: A progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs, and leads to joint stiffness, often thought of as a "wear-and-tear" disease. Commonly affected joints are the hands, knees, hips, and spine. Patients report pain and stiffness that gets worse with exertion, and some report changes in pain depending on the temperature and humidity. Management involves anti-inflammatory meds with physical therapy, and topical lidocaine, opioids, and/or herbal supplements for pain management. vs. Rheumatoid Arthritis: A long-term autoimmune disorder that is characterized by inflammation of the joints and surrounding tissues. Patients may note pain and stiffness in the joints with smaller joints in the fingers and toes being affected before larger ones such as the shoulders, knees, or hips. Prehospital care is strictly supportive.

What is osteoporosis? What are the two classes and what fractures are associated with each? How is it treated?

Osteoporosis is a decrease in bone mass leading to a reduction in bone strength and an increased risk of fracture. Generally speaking, women are more likely to develop osteoporosis than men. Type I: The most rapid loss of bone mass which typically occurs in post-menopausal women due to decreases in estrogen. Radius and hip fractures are common. Type II: Seen in both men and women over the age of 50. Hip and vertebral fractures are common which often result in dorsal kyphosis. Hormone replacement therapy was a common treatment in the past, but today bisphosphonates such as alendronate (Fosamax) and ibandronate (Boniva) are commonly prescribed. The MOA of these drugs is fascinating: Bisphosphonates attach to hydroxyapatite binding sites on bony surfaces, especially surfaces undergoing active resorption. When osteoclasts begin to resorb bone that is impregnated with bisphosphonate, the bisphosphonate released during resorption impairs the ability of the osteoclasts to form the ruffled border, to adhere to the bony surface, and to produce the protons necessary for continued bone resorption, effectively inhibiting bone breakdown.

How does the prevalence of peptic ulcer disease (PUD) differ in the geriatric population? How does it classically present?

PUD is more common in geriatrics due to (a) the population's regular use of NSAIDs and (b) increased infection rates with Heliobacter pylori (an ulcer-associated bacterium of the stomach). The main symptom of PUD is dyspepsia - a gnawing, burning pain in the upper abdomen - which usually improves immediately after eating but returns several hours later. Other causes of dyspepsia include acid reflux, gastritis, and gastric cancer.

What is pneumonia? What risk factors predispose geriatrics to the illness? How does this commonly present in geriatrics and how should it be managed in the field?

Pneumonia involves an inflammation of the lungs secondary to an infection by bacteria, viruses, or other organisms. Pneumonia most commonly affects the very old and very young, and is more common in the colder seasons. Aside from being old, risk factors include: having an underlying health disease (such as COPD, diabetes, and vascular disease), having a depressed immune system (commonly secondary to AIDS, cancer therapy, or organ transplantation), having a tracheostomy, being ventilator-dependent, general immobility, bed confinement, and having a condition that makes it difficult to take a deep breath (such as rib fractures). Older patients with pneumonia often do not have the classic presentation of chills, fever, and productive cough - particularly if they're taking an NSAID regularly for joint pain or another comorbidity. Instead, symptoms are often supplanted by acute confusion, a normal temperature, and a minimal to absent cough. Some patients will complain of abdominal pain. Rhonchi may be heard in the affected lobe, and inflammation of the bronchi may produce wheezing. Treatment is primarily supportive, consisting of placing the patient in a position of comfort that allows for adequate ventilation, administering fluids, giving oxygen via a nasal cannula or mask to relieve dyspnea, and analgesics to reduce fever. These patients may benefit from CPAP. Preventatively, geriatrics should all receive the Pneumococcus vaccine. The admitting facility will determine when antibiotics are appropriate.

What accounts for the increased risk of urinary incontinence in the geriatric population, and what complications can occur from this? What are the two types of incontinence?

Pressure on the urinary sphincter is what signals the need to urinate and since the sphincter weakens with age, sometimes the individual won't know s/he needs to urinate until it's too late. Similarly, due to this decrease in sensitivity, it's possible that the patient won't wake up due to inadequate stimulation. Lastly, it's possible that due to mobility decline, the patient is aware of the need to use to bathroom but can't get there in time. In any case, urinary incontinence is is highly underreported due to embarrassment and long-term effects can lead to skin irritation, skin breakdown, and UTIs. The two types of incontinence are: 1. Stress Incontinence: Occurs during activities such as coughing, laughing, sneezing, lifting, and exercise. 2. Urge Incontinence: Is triggered by hot or cold fluids, running water, and sometimes the thought of going to the bathroom.

How do individuals with Parkinson's disease commonly present?

Resting tremors of an extremity, bradykinesia, rigidity or stiffness of an extremity or the trunk, and poor balance are all common. Parkinson's can affect one or both sides of the body and it can lead to a wide range of functional losses. It may present as dyskinesia (involuntary movements), dementia, depression, autonomic dysfunction (bladder and GI problems), and postural instability.

How do seizures and their management differ in geriatrics?

Seizures are more common in older adults, largely because this population is more susceptible to stroke, dementia, brain tumors, and acute metabolic disorders. Their presentation is the same as in young adults and the prehospital treatments are the same.

What signs and symptoms should you watch for in a patient who misses his/her dialysis appointment? What should be done in the field?

Signs and symptoms of such a renal emergency include: hypertension, headache, anxiety, fatigue, anorexia, vomiting, increased dark urination, altered mental status, and seizures. A thorough assessment should include obtaining a 12-lead ECG given the possibility of electrolyte imbalance. In addition to regular vitals, EtCO2 should be monitored and lung/bowel sounds be auscultated. If a dysrhythmia develops, treat it per ACLS guidelines. The patient should be transported to a facility capable of hemodialysis.

What is the leading cause of disability in geriatrics and what risk factors predispose one to the disease?

Stroke is a significant cause of death and the leading cause of disability at any age. Hypertension is the primary risk factor for stroke, but additional factors include: age, family history, smoking, diabetes, high cholesterol, and heart disease. The risk of stroke doubles every decade after 55 years, mirroring the incidence of hypertension and A-fib.

What factors increase the severity of head trauma in geriatrics? What signs and symptoms should you look for?

The increased fragility of the cerebral blood vessels, enlargement of the subdural space, and a decrease in the supportive tissues of the meninges all combine to make an older adult more vulnerable to intracranial bleeding - particularly subdural hematomas. The most important early symptom of a subdural hematoma is a headache which is often worse at night. Sometimes the headache occurs on the same side of the head as the blood clot. As ICP increases, the patient's level of consciousness will become depressed and the patient will become drowsy.

What is geriatrics?

The assessment and treatment of disease and/or injury in someone 65 years or older.

How do pulmonary emboli present differently in geriatrics?

The classic triad of dyspnea, chest pain, and hemoptysis may not be present. Rather, the only sign may be tachypnea. If you suspect a pulmonary embolus, check for swelling, erythema, and warmth or tenderness of the lower leg - all of which are signs of a DVT. If a DVT might be present, handle the leg gently and monitor for respiratory changes. Prehospital management is largely supportive after ensuring that the airway and ventilations are adequate.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *renal system*?

The kidneys grow in size and weight until the age of 40 when they start to decline. The decline is due to a decrease in nephron units, effectively meaning there is a smaller filtering surface. Aging kidneys also respond slowly to sodium deficiency so a large amount of sodium and water may be lost before the kidneys halt salt excretion, predisposing geriatrics to fluid and electrolyte imbalance and dehydration. Conversely, if exposed to a large amount of salt and water, such as via IV administration, they're less able to excrete the excess predisposing them to fluid overload. The same factors responsible for salt retention and excretion also affect a geriatric's ability to maintain normal potassium levels. Thus, they're prone to hyperkalemia if the patient becomes acidotic or if the potassium load is increased from any source.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *respiratory system*?

The lung's elasticity decreases, as does the size and strength of respiratory muscles. Additionally, there is calcification of the costochondral muscles which results in a stiffening of the chest wall. This all results in a decrease in vital capacity (the amount of air that can be exhaled following a maximal inhalation) and an increase in residual volume (the amount of air left in the lungs after a maximal exhalation). Thus, the amount of air actually used for gas exchange decreases. Airflow, which is dependent on airway size and resistance, also deteriorates. As a result, normal respiratory rates increase to 16 - 25 breaths/minute, with breathing also becoming shallower. As blood distribution in the lungs changes, PaO2 (a measure of the amount of oxygen in the blood) decreases. This places an added challenge on maintaining homeostasis and further dulls the patient's respiratory drive which becomes less sensitive to changes in arterial blood gases. Natural musculoskeletal changes, such as kyphosis, may limit lung volume and maximal chest expansion. The thoracic cage also becomes increasingly stiff due to calcification of the costal cartilage. Coupled with decreased muscle mass and strength, it takes a relatively great amount of energy for geriatrics to breathe adequately. Lastly, cough and gag reflexes decrease with age increasing the risk of aspiration. Further, the ciliary mechanisms responsible for removing bronchial secretions are markedly slowed. Retention of mucus and secretions effectively creates a culture for bacterial growth making the elderly more susceptible to respiratory infection.

What is the old-age dependency ratio?

The ratio of geriatrics in society as compared to adults ages 18 - 64 who constitute the working class (and thus serve as potential caregivers of the elderly).

What are common causes of GI bleeding in geriatrics? How do these patients commonly present and how should they be managed in the field?

The signs and symptoms of a GI bleed vary significantly based on the location of the bleed: Esophagus: Bleeding is mostly commonly caused by varices and alcohol abuse. Patients commonly present with violent vomiting of emesis with almost no food and lots of bright red, uncoagulated blood. Stomach: The blood may be either bright red or coffee-ground depending on how fast the bleed is (the coffee-grounds indicate that the blood has been in the stomach long enough to be partially digested) and it's most commonly associated with PUD. It's often vomited out but it can also be digested and excreted as dark, tarry stool. Lower GI Tract: Bright red blood in stool typically comes from the large intestine or rectum and may be caused by diverticulitis, a large bowel obstruction, anal fissures, or hemorrhoids. Signs and symptoms of a GI bleed are associated with hypovolemia: agitation, syncope, hypotension, dizziness, and changes in mental status. Abdominal pain, jaundice, hepatomegaly, constipation, and diarrhea may all be present. Regardless of the cause, treatment is based on shock. Keep in mind that the patient ultimately needs blood and surgery.

What is polypharmacy? What is the best dosage for a drug given to an elderly person?

The use of multiple medications. It may be therapeutic in that the drugs help to manage different medical problems, but issues can arise when the medications interact and/or when dosages aren't adjusted to account for the toll multiple medications are taking on the liver/kidneys. As a general rule, the best dose of a drug to give to a geriatric patient is the lowest dose that provides therapeutic effect.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *cardiovascular system*?

The wall of the left ventricle thickens and elastin in the vessel walls decrease, resulting in thickening and rigidity of the vasculature, particularly in the coronary arteries. Vascular stiffening leads to a widening of pulse pressure and a decrease in cardiac ejection efficiency. In many geriatrics, an S4 heart sound can be heard. Aortic sclerosis occurs when the aortic valve thickens due to fibrosis and calcification. This thickening obstructs blood flow from the left ventricle and ultimately leads to aortic stenosis which decreases blood flow from the heart. In addition to the heart, the walls of the peripheral vasculature loose their elasticity as well, leading to hypertension and increased risk of peripheral vascular disease, venous pooling, and stasis ulcers. Changes occur to the electrical conduction system of the heart as well. The SA node, AV node, and Bundle of His become fibrotic and the number of pacemaker cells in the SA node decrease. In many cases, this either leads to bradycardia or atrial dysrhythmias, such as A-fib (which may then cause clots to be distributed within the body). Additionally, it is much harder for a geriatric heart to produce a compensatory tachycardia when needed. Normal ECG changes may include: a notched P-wave, a prolonged P-R interval, decreased amplitude of the QRS-complex, and a notched or slurred T-wave. Lastly, likely the effects of a sedentary lifestyle more so than aging, physical activity tends to decrease. This results in a heart rate that takes longer to increase during exertion and then takes longer to return to baseline at rest. In older adults, cardiac output may decline by as much as 30 - 40%. Ultimately, all of this means that a geriatric patient's cardiovascular system is vulnerable to dysfunction, and its ability to compensate for circulatory changes is diminished.

What patients are at an increased risk of UTI? What signs and symptoms are typically associated with it?

UTIs usually develop when normal flora enters the urethra and begins to grow, causing a lower urinary tract infection. Because of this, UTIs are more common in women due to the shorter urethra and its closer proximity to the vagina and rectum. That being said, the risk of UTI increases in men over the age of 50 due to compression of the urethra by the prostate. Common risk factors for UTI include: diabetes, prostatitis, cystocele (prolapse of the bladder into the vagina), urethrocele (prolapse of the urethra into the vagina), kidney obstruction, and indwelling catheter use. Fever, shortness of breath, GI symptoms, neurologic symptoms, poor urinary output, increased urinary frequency, and hematuria are all common signs/symptoms. The patient will usually report pain upon urination, a frequent urge to urinate, and difficulty urinating. If applicable, inspect the patient's indwelling catheter for sediment, opacity, color, and the presence of blood. A strong odor may be associated with the urine. Late signs and symptoms of the infection include: hypotension, tachycardia, diaphoresis, and pallor.

What anatomic and physiologic changes naturally occur in the geriatric population secondary to aging with regard to the *integumentary system*?

Wrinkling and loss of resiliency of skin are the most visible signs of aging. Wrinkling occurs due to the thinning, drying, and loss of elasticity of skin. Additionally, as subcutaneous fat decreases, the risk of bruising increases. Both elastin and collagen decrease with age. The decreased elastin allows skin to tear more easily, and the decreases collagen allows for persistent bleeding. It's a result of the decreased resiliency that tenting may be noted during episodes of dehydration. As the body ages, sebaceous glands produce less oil and the skin become drier. Similarly, sweat gland activity decreases resulting in decreased thermoregulation. Hair follicles produce less melanin resulting in hair changing to gray or white, and eventually the hair follicles may stop growing entirely resulting in baldness. The number of melanocytes in the skin decreases so the skin will appear more pale than in younger adult life. As the number of melanocytes decrease, existing ones grow larger leading to benign pigmentation changes in sun-exposed areas (i.e. age or "liver" spots). The blood vessels that supply the skin are affected by atherosclerosis and provide less oxygen to the tissue. As a result, metabolism and epidermal tissue growth slows. Fingernails and toenails become thinner and more brittle, and they can become a source of infection - particularly in those with peripheral vascular disease or diabetes.

In what ways is the pharmacokinetics of medications different in geriatrics and how should this be managed?

i. An increase in the proportion of adipose tissue can prolong the half-life of drugs in the body. Benzodiazepines and barbiturates, and medications that act on the CNS, are the most common medications associated with toxic effects. So rather than administering an "adult" dose, consider a reduced dose (i.e. 25 mcg of fentanyl instead of 50 mcg). ii. A decrease in parasympathetic activity increases the risk of anticholinergic ( i.e. acetylcholine-blocking) effects. Coupled with reduced beta-adrenergic sensitivity, most bronchodilators are less effective in older patients. iii. The use of diuretics and antihypertensives can cause hypotension and orthostatic changes due to reduced cardiac output and a decrease in total body water. iv. Decreased glucose tolerance can cause diuretics and corticosteroids to have hyperglycemic effects in older adults. v. Drugs that depend on the liver and kidneys for excretion (i.e. digoxin) are particularly likely to accumulate to toxic levels. Because most pharmaceutical drug testing is done on younger adults, there really isn't much info out there on proper dosing for geriatrics. That being said, the classes of medications most commonly implicated in causing toxic effects are: antibiotics, anticoagulants, digoxin, diuretics, antineoplastic agents, and NSAIDs.

What 5 conditions double the mortality rate for an individual involved in a trauma?

i. Cirrhosis ii. Congenital coagulopathy iii. COPD iv. Ischemic heart disease v. Diabetes mellitus

What physiologic factors increase the incidence of adverse drug reactions in geriatrics?

i. Diminished hepatic function which slows drug metabolism. ii. Diminished renal function which slows drug metabolism. iii. Increased body fat and decreased body water which alter drug distribution. iv. Changes in older patient's CNS affects the way in which drugs affect the body.

What factors place an older person at greater risk of trauma than a younger person?

i. Slower reflexes, visual and hearing deficits, equilibrium disorders, and an overall reduction in agility increases one's risk of trauma. ii. Compensation in trauma is successful when pulse rate, respirations, and vasoconstriction can compensate for blood loss. Reduced cardiac reserve, decreased respiratory function, impaired renal activity, and ineffective vasoconstriction can lead to poor outcomes. iii. The stiffer blood vessels and fragile tissue of geriatrics is readily tearable, and demineralized bones are prone to fracture.

What additional principles should be kept in mind while treating a geriatric trauma patient?

i. Use caution when inserting IV catheters and administering IV fluids. It' very easy to overload these patients with fluids and sodium. Use small boluses and reassess frequently for pulmonary edema. ii. Monitor the patient's cardiac rhythm throughout care of the patient. Previous or continuous cardiac diseases predispose this population to dysrhythmias. iii. Regulation of body temperature is poor in geriatrics and blood in cold patients does not coagulate well. Make sure to keep them warm. iv. Frail geriatrics tend to not tolerate traction splints well. Consider placing him/her on a padded board buttressed with pillows secured firmly in place. v. Consider the use of pain medication but remember that a lower dose is often sufficient in reaching a therapeutic level. vi. Immobilize the cervical spine before transporting the patient. Pad the board generously in order to prevent skin damage, targeting areas where bone is near the surface (occiput, scapula, spinous processes, elbows, sacrum, and heels). A pressure ulcer can develop in as little as 45 minutes complicating the injury.