Geriatric Emergencies

Pathophysiology of Gastrointestinal Issues: Diverticulosis

- A condition in which the walls of the gut weaken, small pouches protrude from the colon along those weakened segments, and inflammation develops - A geriatric patient with diverticulitis generally presents with left lower quadrant pain and fever. - Fever suggests a condition that requires immediate attention.

Pathophysiology of the Respiratory System: Pulmonary Embolism

- A condition that causes a sudden blockage of an artery by a venous clot - A patient with a pulmonary embolism will present with shortness of breath and sometimes chest pain. - Major risk factors include: > Living in a nursing home > Recent hospitalization for medical illness or surgery (especially in a lower extremity) > Trauma > Cancer > History of blood clots or heart failure > Presence of a pacemaker or central venous catheter > Paralyzed extremities > Obesity > Use of birth control pills > Smoking > Infection with COVID-19 > Recent long-distance travel - Patients present with: > Tachycardia > Sudden onset of dyspnea > Shoulder, back, or chest pain > Cough > Syncope in patients in whom the clot is larger > Anxiety, which may be communicated as a sense of impending doom > Apprehension > Low-grade fever > Hemoptysis - Also look for leg pain, redness, and swelling in just one ankle and foot for the source of the clot. - The patient may present with profound fatigue and may go into cardiac arrest in a worst-case scenario. - Treatment should focus on airway, ventilatory, and circulatory support. > Clear any blood that has been coughed up from the airway. > Supplemental oxygen is mandatory in a patient with a pulmonary embolism. > Place the patient in a comfortable position, usually sitting, and apply high-flow oxygen via a nonrebreathing mask. > Aggressive airway management may be necessary. Ventilate with a bag-mask device, using an oropharyngeal or nasopharyngeal airway. > If the patient is in respiratory and/or cardiac arrest, follow the current emergency cardiovascular care guidelines and your local protocols.

Changes in the Endocrine System

- A significant change that occurs in older people is decreased metabolism of thyroxine. - A reduction in thyroid hormones can cause hypothyroidism. Most of the signs and symptoms people experience are attributed to the process of aging and include: > Slower heart rate > FatigueDrier skin and hair > Cold intolerance > Weight gain - Other endocrine system changes include: > Increased secretion of antidiuretic hormone, causing fluid imbalance > Hyperglycemia > Increased levels of norepinephrine, possibly having a harmful effect on the cardiovascular system

The Acute Abdomen: Nongastrointestinal Complaints

- Abdominal aortic aneurysm (AAA) tends to develop in people who have a history of hypertension and atherosclerosis. - The walls of the aorta weaken, and blood begins to leak into the layers of the vessel, causing the aorta to bulge like a bubble on a tire. > If enough blood loss occurs into the vessel wall itself, shock occurs. > If the vessel wall bursts, it will rapidly lead to fatal blood loss. - A patient with an AAA commonly reports abdominal pain radiating through to the back, with occasional flank pain. - If the AAA becomes large enough, it can be felt as a pulsating mass just above and slightly to the left of the navel during your physical examination. > If you see or palpate a pulsating mass, stop your manipulation. - Occasionally, the AAA causes a decrease in blood flow to one of the legs, and the patient reports some discomfort in the affected extremity. > Assessment may reveal diminished or absent pulses in the extremity. - Compensated and decompensated shock as a result of blood loss are common occurrences. - Because of a decrease in blood volume and decreased blood flow to the brain, the patient may experience syncope. - Treat the patient for shock, including high-flow oxygen and thermal regulation, and ensure prompt transport to the hospital.

Pathophysiology of Gastrointestinal Issues

- Age-related changes in the gastrointestinal system include: > Dental problems > Decrease in saliva and sense of taste, leading to poor nutrition > Poor muscle tone of the smooth muscle sphincter between the esophagus and stomach, which can cause regurgitation and lead to heartburn and acid reflux > A decrease in hydrochloric acid in the stomach > Alterations in absorption of nutrients > Slowing of peristalsis, which can cause constipation > Weakening of the rectal sphincter, resulting in fecal incontinence (lack of bowel control) - The liver, which is responsible for removing toxins and breaking down drugs in the body, shrinks with age. > Blood flow to the liver declines, and there is decreased metabolism. > This has a direct effect on how medications may affect the patient. - Serious gastrointestinal issues that affect older people include: > Gastrointestinal bleeding caused by disease processes ~ Usually heralded by hematemesis > Inflammation, infection, and obstruction of the upper and lower intestinal tract > Bleeding that travels through the lower digestive tract usually manifests as melena, whereas red blood usually means a local source of bleeding, such as hemorrhoids.

Changes in the Renal System

- Age-related changes in the genitourinary system specific to the kidney include: > A reduction in renal function > A reduction in renal blood flow > Tubule degeneration - Other changes in the genitourinary system include: > Decreased bladder capacity > Decline in sphincter muscle control > Decline in voiding senses > Increase in nocturnal voiding > In men, benign prostatic hypertrophy (enlarged prostate) - In a young adult, the kidneys weigh 8 to 9 oz (250 to 270 g); in a healthy 70-year-old, they weigh 6 to 7 oz (180 to 200 g). > This decline results from a loss of functioning nephron units (tubule degeneration), which translates into a smaller effective filtering surface. - Renal blood flow decreases by as much as 50% as a person age

Pathophysiology of the Respiratory System: Pneumonia

- An inflammation of the lung from bacterial, viral, or fungal causes. > One of the leading causes of death from infection in Americans older than 65 years - The process of aging causes immune suppression and increases the risk of contracting infections like pneumonia. - Increased mucus production, pulmonary secretions, and the inflammatory effects of infection interfere with the alveoli's ability to oxygenate the blood. - Maintain a high index of suspicion for any geriatric patient with signs and symptoms of possible pneumonia. - Wear respiratory protection, including an N95 mask, when you are assessing a patient with a potentially infectious respiratory disease. > You can also place a surgical mask on the patient.

Changes in the Nervous System (continued): Touch

- An older person may have a decreased sense of touch and pain perception from the loss of the end nerve fibers. > This loss, in conjunction with slowing of the peripheral nervous system, can create situations in which an older person may be injured and not know it. > Specifically, it leads to decreased sensations of hot and cold. > A delayed response to pain could result in a burn. - This is an especially acute problem in people with diabetes, who also lose sensation because of diabetic neuropathy or nerve damage.

Changes in the Respiratory System

- As a person gets older, the alveoli in lung tissue can become enlarged and the elasticity decreases, making it harder to expel used air (air trapping). > The lack of elasticity results in a decreased ability to exchange oxygen and carbon dioxide. - The body's chemoreceptors slow with age. > This can make the body respond more slowly to hypoxia. - Loss of the mechanisms that protect the upper airway include decreased cough and gag reflexes, which result in a decreased ability to clear secretions. - The number of cilia that line the bronchial tree decrease with age, which lessens an older person's ability to cough and clear secretions and increases the chance of infection.

Changes in the Skin

- Bedsores (decubitus ulcers) are pressure ulcers that form when a patient is lying or sitting in the same position for a long time. > The pressure from the weight of the body cuts off the blood flow to the area of skin. > With no blood flow to the skin, a sore develops. > These sores can develop in as little as 45 minutes. - To help prevent decubitus ulcers, take special care to pad under any bony prominences and in the voids in a patient who may be immobilized for an extended period. - You may see these ulcers in various stages of development: > Stage I: Nonblanching redness with damage under the skin > Stage II: Blister or ulcer that can affect the dermis and epidermis > Stage III: Invasion of the fat layer through to the fascia > Stage IV: Invasion to muscle or bone - Decubitus ulcers can be painful and cause complications like bleeding, sepsis, and a bone inflammation called osteomyelitis.

Pathophysiology of the Renal System

- Bowel and bladder continence require: > Anatomically correct gastrointestinal and genitourinary tracts > Functioning and intact sphincters > Properly working cognitive and physical functions - Incontinence is a normal part of aging and can lead to skin irritation, skin breakdown, and urinary tract infections. - As people age, the capacity of the bladder decreases. - There are two major types of incontinence: > Stress incontinence occurs during activities such as coughing, laughing, sneezing, lifting, and exercise. > Urge incontinence is triggered by hot or cold fluids, running water, and even thinking about going to the bathroom. - Treatment consists of medications, physical therapy, and surgery. - The opposite of incontinence is urinary retention. > Patients may have difficulty voiding or absence of voiding as a result of many medical causes. > In men, enlargement of the prostate can place pressure on the urethra, making voiding difficult. > Bladder and urinary tract infections can also cause inflammation. > In severe cases, patients may experience renal failure.

Changes in the Nervous System

- Changes in thinking speed, memory, and posture stability are the most common normal findings in older people. - The brain decreases in weight (10% to 20%) and volume as a person ages. > This increases the amount of space in the cranium, which in turn increases the risk for head injuries. > Head injuries with a minimal MOI are commonly missed in older people. - Older people experience a 5% to 50% loss in the number of neurons, so the motor and sensory neural networks slow down with age. > This affects the body's control of the rate and depth of breathing, heart rate, blood pressure, hunger, thirst, and body temperature. > The functional significance of these changes is not clear. - As many as 50% of patients older than 65 years have vision problems. > Causes of visual impairment in older people may include diabetic retinopathy and age-related macular degeneration.

Pathophysiology of Gastrointestinal Issues: Peptic Ulcer Disease

- Common in older adults, especially people who use NSAIDs - The patient will report a gnawing, burning pain in the upper abdomen that improves after eating but returns later. - Complications include bleeding, anemia, and bowel perforation, which are medical emergencies.

Anatomic Changes and Fractures (continued)

- Compression fractures of the spine are more likely to occur in older adults. - Be suspicious of the possibility of other fractures and complicating issues. - Acute subdural hematomas are among the deadliest of all head injuries. > Blood fills the skull rapidly, compressing brain tissue, which often results in brain injury. > This type of bleeding can go unnoticed initially because the blood has a void to fill before it produces pressure in the skull; only then will the familiar signs of head trauma appear. > Serious head injuries are often missed in older patients because the mechanism may seem relatively minor. - Other factors that predispose an older patient to a serious head injury include: > Long-term abuse of alcohol > Recurrent falls or repeated head injury > Anticoagulant medication (blood thinners, including aspirin)

Delirium

- Delirium is a sudden change in mental status, consciousness, or cognitive processes, and is marked by the inability to focus, think logically, and maintain attention. > This condition is generally the result of a reversible physical ailment, such as a tumor or fever. - Anytime a patient has an acute onset of delirious behavior, consider the evaluation of pathophysiology through history, possible risk factors, and current medications. - Other important things to look for in the history include: > Intoxication or withdrawal from alcohol > Withdrawal from sedatives > Medical conditions such as a urinary tract infection (UTI), bowel obstruction, dehydration, fever, cardiovascular disease, and hyperglycemia or hypoglycemia > Psychiatric disorders such as depression; malnutrition or vitamin deficiencies > Environmental emergencies - Assess the patient for: > Hypoxia > Hypovolemia > Hypoglycemia > Hypothermia ~ Any of these four conditions, if unrecognized or untreated, can be rapidly fatal. ~ In patients with these conditions, delirium has a rapid onset and is usually curable if identified early.

Dementia

- Dementia is the slow onset of progressive disorientation, shortened attention span, and loss of cognitive function. - This chronic, generally irreversible condition causes a progressive loss of cognitive abilities, psychomotor skills, and social skills. - Dementia develops slowly over a period of years rather than a few days. - Dementia can be the result of many neurologic diseases such as: > Alzheimer disease > Parkinson disease > Cerebrovascular accidents > Genetic factors - On assessment, the patient might: > Exhibit loss of cognitive function ~ It helps to determine if this change was gradual or acute. > Have short- and long-term memory problems and a decreased attention span > Be unable to perform daily routines > Show a decreased ability to communicate and appear confused > Be unable to describe areas of pain and current symptoms > Be unable to follow commands > Exhibit disorganized thoughts: inattention, memory loss, disorientation, hallucinations, delusions, and a reduced level of consciousness - Exercise tolerance and patience with patients who have altered mental status or are experiencing dementia.

Infection Control: Vancomycin-resistant enterococci (VRE)

- Enterococci are bacteria that are normally present in the human intestines and the female reproductive tract. > Under the right circumstances, these bacteria can cause infection. - Some enterococci have become resistant to vancomycin, the antibiotic commonly used to treat these infections.

Pathophysiology of the Cardiovascular System (continued)

- Geriatric patients are at risk for: > Alteration of the heart's electrical conduction system ~ The sinoatrial node is the normal pacemaker of the heart. ~ By age 75 years, the number of the cells in the sinoatrial node will decrease by 90%. ~ This decline, combined with fibrosis and fatty deposits, makes it likely that the patient will have some kind of heart rhythm disturbance, or dysrhythmia. > Orthostatic hypotension (postural hypotension) ~ Because older people become less sensitive to rapid changes in blood pressure, you may see a drop in the systolic blood pressure of 20 mm Hg when an older patient moves from a sitting position to a standing position. > Venous stasis ~ This condition creates problems such as blood clots in the superficial veins (superficial phlebitis) and deep venous thrombosis. ~ Deep venous thrombosis can lead to pulmonary embolism. ~ People with venous stasis usually exhibit edema of the legs and ankles. ~ Patients report a feeling of fullness, aching, or tiredness in their legs, especially when standing. ~ This condition eventually causes a red-brown discoloration on the skin and, in some cases, skin ulcers.

Pathophysiology of the Cardiovascular System

- Geriatric patients are at risk for: > Atherosclerosis ~ Major complications include myocardial infarction (heart attack) and stroke. ~ The presence of atherosclerosis makes stroke, heart disease, hypertension, and bowel infarction more likely. > Aneurysm ~ Severe blood loss can occur when an aneurysm ruptures. - The blood vessels become stiffer with age, which results in a higher systolic blood pressure. - The left ventricle becomes thicker and eventually loses elasticity, resulting in decreased filling, which in turn causes decreased cardiac output. - Stiffening and degeneration of the heart valves may impede normal blood flow in and out of the heart.

Changes in the Body

- Human growth and development peaks in the late 20s and early 30s, at which point the aging process begins. - The aging process can vary dramatically from one person to another. - It is accompanied by changes in physiologic function, such as a decline in the function of the liver and kidneys. - The decrease in the functional capacity of the various organ systems is normal, and it can affect the way a patient responds to illness. - There is a widespread tendency to attribute genuine disease symptoms to "just getting old" or infection with COVID-19, and to neglect their treatment.

Pathophysiology of the Endocrine System

- Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a diabetic complication in older people that occurs more often in people with type 2 diabetes than in those with type 1 diabetes. - Unlike with diabetic ketoacidosis (DKA), the high blood glucose level from HHNS does not cause ketosis. > Instead, it leads to osmotic diuresis and a shift of fluid to the intravascular space, which results in dehydration. - The signs and symptoms of HHNS and DKA often overlap. They include: > Hyperglycemia > Polydipsia (thirst) > Polyuria (urination) > Polyphagia (hunger) > Dizziness, confusion, and altered mental status > Seizures (in some cases) - On assessment, you may see changes in circulation such as: > Warm, flushed skin > Poor skin turgorPale, dry, oral mucosa > A furrowed tongue - The patient may present with signs and symptoms of hypotension and shock, including tachycardia. - The blood glucose level will be variable in DKA, whereas this level is typically 600 mg/dL or higher in HHNS. - Patients with DKA will present with Kussmaul respirations, whereas patients with HHNS will not. - Assessment should include obtaining blood pressure and distal pulses, auscultation of breath sounds, temperature measurement, and assessment of blood glucose level if permitted by local protocol. - Treatment should include airway, ventilatory, and circulatory support.

Infection Control: Methicillin-resistant Staphylococcus aureus (MRSA)

- MRSA infections are common among people who live in close quarters like nursing homes. - The S aureus organism can be found in decubitus ulcers (bedsores), on feeding tubes, and on indwelling urinary catheters. - The symptoms of MRSA depend on the type of infection. > It can cause mild infections on the skin or invade the bloodstream, lungs, or urinary tract. - MRSA is primarily spread by broken skin-to-skin contact, but is also acquired by touching objects that have the bacteria on them. - To protect yourself and reduce the spread of MRSA infections, wash your hands before and after every patient contact, properly dispose of or disinfect all medical equipment, and take appropriate standard precautions with every patient.

Neuropathy

- Neuropathy is a disorder of the nerves of the peripheral nervous system in which function and structure of the peripheral motor, sensory, and autonomic neurons are impaired. - Symptoms depend on whether the nerves affected are motor, sensory, or autonomic and where the nerves are located. > Motor nerves: muscle weakness, cramps, spasms, loss of balance, and loss of coordination > Sensory nerves: tingling, numbness, itching, and pain; burning, freezing, or extreme sensitivity to touch > Autonomic nerves: affect involuntary functions that include changes in blood pressure and heart rate, sensation of hunger, and the fight-or-flight reflex

Pathophysiology of Gastrointestinal Issues: Lower Gastrointesticnal Bleeding

- Occurs in the colon or rectum -Such bleeding can be serious, especially when the patient presents with tachycardia and hypotension.

Pathophysiology of Gastrointestinal Issues: Upper Gastrointesticnal Bleeding

- Occurs in the esophagus, stomach, or duodenum - These bleeding episodes are sometimes seen in people who are long-term users of nonsteroidal anti-inflammatory drugs (NSAIDs) such as celecoxib (Celebrex), ibuprofen, and naproxen or in people who are long-term alcohol users. - Irritation of the lining of the stomach or ulcers can cause forceful vomiting that tears the esophagus. - Hepatitis and cancer can also contribute to bleeding problems.

Pathophysiology of Gastrointestinal Issues: Gallbladder Disease

- Older adults have a higher risk of complications from gallstones. - The risk of death from surgery to remove the gallbladder increases with age. - Patients with inflammation of the gallbladder (cholecystitis) will have fever and right upper quadrant pain that may radiate to the shoulder. - Patients may also have jaundice. - This condition is dangerous because infection can spread to the blood, causing sepsis and shock.

Changes in the Gastrointestinal System

- Oral secretions and gastric secretions are reduced as a person ages. - Changes in gastric motility occur, which may lead to slower gastric emptying. - The function of the small and large bowels changes little, although the incidence of certain diseases involving the bowel (such as diverticulosis) increases as a person grows older. - Nutrients from food are not as readily absorbed. - Blood flow to the liver declines. - Changes occur in hepatic enzyme systems, with some systems declining in activity and others increasing their activity. - The ability of the liver to detoxify and remove drugs from the bloodstream declines as a person ages.

Anatomic Changes and Fractures

- People with osteoporosis may fracture a hip from a standing fall. > This is considered a pathologic fracture because it would not occur in a person with normal bone density. - Not all hip fractures are the result of trauma; some may result from the stresses of ordinary activity such as getting in and out of a chair. - Other contributing factors include: > Vitamin D and calcium deficiencies > Metabolic bone diseases > Tumors - Injuries to the hip tend to be recurring.A previous fracture increases the likelihood of a future injury. - Older people with osteoporosis are also at risk for pelvic fractures. - A pelvic fracture may be caused by a low-energy mechanism or a standing fall. > These injuries do not usually damage the structural integrity of the pelvic ring but may fracture an individual bone.

Polypharmacy

- Polypharmacy is the use of multiple prescription medications by one patient. > Negative effects may include overdosing and adverse medication interactions. > Patients can forget which medications they have taken and overdose, or forget to take medications and underdose. - Medication noncompliance in older patients may occur because of: > Financial challengesInability to open containersImpaired cognitive, vision, and hearing ability - If you suspect medication noncompliance, check prescription dates and the number of pills available. - Physiologic factors related to the hepatic and renal functions of excretion and metabolism of medications change in the face of multiple prescriptions being consumed at once. > Always be mindful of this issue when obtaining the patient's medication history.

Infection Control: Respiratory syncytial virus (RSV)

- RSV causes an infection of the upper and lower respiratory tracts. -Although more typically seen in children, the virus can also cause serious illness in older people, especially those with lung disease or weakened immune systems. -Symptoms are similar to the common cold but can be more severe and last longer. - The virus is highly contagious and is found in discharges from the nose and throat of an infected person. - RSV is also transmitted by direct contact with droplets from coughs or sneezes and by touching a contaminated surface. - Look for isolation signs or ask about contagious disease when you approach a patient. - Wear appropriate personal protective equipment and decontaminate your ambulance and diagnostic equipment after contact with nursing home residents, whether a history of infectious disease is known or not. - Document the infection control issue.

Infection Control: SARS-CoV-2

- SARS-CoV-2 is a strain of coronavirus that causes the disease COVID-19, a respiratory illness. - The virus spreads from person to person through airborne droplets created by speaking, coughing, and sneezing. - When you are in contact with a patient whom you suspect may have COVID-19, your personal protective equipment should include an N95 mask, gloves, and eyewear.

Immobilization

- Splinting devices, such as vacuum mattresses that conform to body contours, may be a good choice for immobilization when indicated. - In hip and pelvic fractures, avoid log rolling the patient because you risk causing the patient increased pain. -When immobilization is indicated, patients with kyphosis will often need padding. > Padding should be done for comfort and to help decrease the likelihood of decubitus ulcer formation. - Patients with chronic cardiac or respiratory disorders, particularly congestive heart failure, may have immense difficulty lying supine. > An alternative solution may be to consider a spinal immobilization device such as a KED, which is intended for a patient in a seated position.

Pathophysiology of the Cardiovascular System (continued): Stroke

- Stroke (cerebrovascular accident) is a leading cause of death in older people. > Preventable risk factors include smoking, hypertension, diabetes, atrial fibrillation, obesity, and a sedentary lifestyle. > Noncontrollable factors include age, race, and gender. - Signs and symptoms of stroke include: > Acute altered LOC > Numbness, weakness, or paralysis on one side of the body > Slurred speech or aphasia Visual disturbances > Headache and dizziness > Incontinence > Seizure (in the worst cases) - Hemorrhagic stroke, in which a broken blood vessel causes bleeding into the brain, is less common and more likely to be fatal. - Ischemic stroke occurs when a blood clot blocks the flow of blood to a portion of the brain. > Brain tissue distal to this clot will die if the clot is not broken down. > The treatment goal is to salvage as much of the surrounding brain tissue as possible. - Determining the onset of the symptoms of stroke is important. > If the symptoms occurred within the past few hours, the patient will be a candidate for stroke center therapy and has a higher chance for recovery. - Transient ischemic attack (TIA) can have the same signs and symptoms as a stroke. - Always manage the patient as if he or she is having a stroke unless medical control directs otherwise.

Pathophysiology of Gastrointestinal Issues: Bowel Obstruction

- The ability of the gastrointestinal tract to move feces through the system slows with aging, and patients can experience problems having bowel movements. - When patients strain to have a bowel movement, they can stimulate the vagus nerve, which can cause a vasovagal response. > The heart rate drops dramatically and the patient becomes dizzy or passes out. > The patient will usually be in stable condition on your arrival but requires transport to rule out other conditions.

Common Complaints and the Leading Causes of Death in Older People

- The changing physiology of geriatric patients can predispose this population to a host of problems not seen in youth. - Hip fractures are more likely to occur when bones are weakened by osteoporosis. - Sedentary behavior while healing can predispose the patient to pneumonia and blood clots that may interfere with healing and can cause death. - Many older patients who experience hip fractures don't return to their preinjury levels of activity.

Changes in the Cardiovascular System

- The heart hypertrophies (enlarges) with age. - Arteriosclerosis contributes to systolic hypertension in many older patients, which places an extra burden on the heart. > This phenomenon may be a consequence of disease states such as diabetes, atherosclerosis, and renal compromise. > It is associated with an increased risk of cardiovascular disease, dementia, and death. - Compliance of the vascular walls depends on the production of collagen and elastin. > An increase in pressure leads to overproduction of abnormal collagen and decreased quantities of elastin, which contribute to vascular stiffening. > The result is a widening pulse pressure, decreased coronary artery perfusion, and changes in cardiac ejection efficiency. - Whether because of other disabilities or for behavioral reasons, many people tend to limit physical activity and exercise as they grow older.

Changes in the Nervous System (continued): Taste

- The sense of taste can be diminished for an older person because of a decrease in the number of taste buds. - The negative result might be lessened interest in eating, which can lead to weight loss, malnutrition, and complaints of fatigue.

Pathophysiology of the Cardiovascular System (continued)

- The signs and symptoms of heart failure will differ depending on the extent to which the right and/or left side of the heart is not functioning correctly. - Right-sided heart failure occurs when fluid backs up into the body. > Patients develop jugular vein distention, ascites, and peripheral edema in the body tissues. > An enlarged liver may also be present from blood backing up through the portal vein; this condition may be identified by palpation. -Right-sided heart failure is often caused by left-sided heart failure, so it is common to see signs of both conditions when assessing the patient who has left-sided heart failure. - With left-sided heart failure, fluid backs up into the lungs. > The excess fluid causes pulmonary edema, and the patient will have severe shortness of breath and hypoxia with crackles in the lungs. > Paroxysmal nocturnal dyspnea is a condition that is characterized by a sudden attack of respiratory distress that wakes the patient at night when in a reclining position. > The respiratory distress is caused by fluid accumulation in the lungs. - Patients report coughing, feeling suffocated, and cold sweats, and you will notice tachycardia. - Treatment consists of airway, ventilatory, and circulatory support.

Infection Control: Clostridium difficile (C diff)

- This bacterium is the most common cause of hospital-acquired infectious diarrhea and regularly causes sporadic cases of diarrhea in nursing homes. > It normally grows in the intestines. - Antibiotic use may account for the rapid increase in toxic strains that ultimately cause illness. - Health care workers may carry this bacterium following contact with contaminated feces. > C diff can also be found on environmental surfaces like furniture, floors, toilets, sinks, and bedding. - The symptoms from the resultant colitis can range from minor diarrhea to a life-threatening inflammation of the colon. - Typical alcohol-based hand sanitizers do not inactivate or kill C diff. - Contact precautions with gowns and gloves and handwashing with soap and water after each and every patient contact are essential to prevent transmission.

Pathophysiology of the Musculoskeletal System

- Two of every three older patients show some degree of kyphosis (a forward curling of the spine, also called humpback or hunchback). - A loss of height in older adults generally results from compression in the spinal column, first in the disks and then from the process of osteoporosis in the vertebral bodies. - Osteoporosis is characterized by a decrease in bone mass leading to a reduction in bone strength and greater susceptibility to fracture. - The extent of bone loss that a person undergoes is influenced by: > Genetics > Smoking > Level of activity > Diet > Alcohol consumption > Hormonal factors > Body weight - Osteoarthritis is a progressive disease of the joints that destroys cartilage, promotes the formation of bone spurs in joints, and leads to joint stiffness. > This type of arthritis is thought to result from "wear and tear" and, in some cases, from repetitive trauma to the joints. > It affects 35% to 45% of the population older than 65 years. > Typically, osteoarthritis affects several joints, most commonly those in the hands, knees, hips, and spine.Patients report pain and stiffness that gets worse with exertion. > The end result is often substantial disability and disfigurement. > Patients are typically treated with anti-inflammatory medications and physical therapy to improve their range of motion.

Changes in the Nervous System (continued): Hearing

- Typical hearing problems cause changes in the inner ear and make hearing high-frequency sounds difficult. - Changes in the ear can also cause problems with balance and make falls more likely. - Presbycusis is age-related hearing loss. - Over time, the wear and tear on the ears from noise damages the inner ear. - Heredity and long-term exposure to loud noises are the main factors that contribute to hearing loss. When assessing a patient, check for the use of hearing aids. > If the patient wears hearing aids, ensure that the aids are properly in place and turned on. - Some patients may want you to talk into their "good ear."

Changes in the Nervous System (continued): Vision

- Visual acuity, depth perception, and the ability of the eyes to accommodate to light change with age. - The pupils require more time to adjust. Cataracts interfere with vision and make it difficult to distinguish colors and see clearly, increasing the likelihood of falls, accidents, and mistakes in taking medications. - Decreased tear production leads to drier eyes. - An inability to differentiate colors and decreased night vision may affect older people's ability to drive. - Other disease processes that affect the vision of older adults include: > Glaucoma ~ Increased intraocular pressure is a risk factor for glaucoma, which can cause damage to the optic nerve. ~ It sometimes causes headache with nausea and vomiting and visual disturbances. > Macular degeneration ~ Deterioration occurs in the central portion of the retina. ~ This condition generally affects adults older than 50 years. ~ It causes a vision loss in the central part of the visual field. > Retinal detachment ~ Requires prompt surgical treatment to preserve vision ~ The retina is pulled away from the choroid, depriving retinal cells of oxygen. ~ The patient may report floaters, debris in the visual field, sudden flashes of light or shadow, or visual blurring.

Pathophysiology of Gastrointestinal Issues (continued)

- When assessing patients with gastrointestinal problems, ask about NSAID and alcohol use. - The patient may present with: > Pale or yellow, thin skin > Frail musculoskeletal system > Peripheral, sacral, and periorbital edema > Hypertension > Fever > Tachycardia > Dyspnea - Take the blood pressure and pulse rates with the patient lying, sitting, and then standing. > Note any drop in blood pressure and increase in heart rate that occurs as the patient moves to an upright position. - Do not attempt to assess orthostatic vital signs on a patient with obvious signs of shock, hypotension, altered LOC, or possible spinal injury. -ABC's

Changes in the Musculoskeletal System

- With greater age, bones become more brittle and tend to break more easily. - The disks between the vertebrae of the spine begin to narrow, and a decrease in height between 2 and 3 inches (5 and 8 cm) may occur over the lifespan, along with changes in posture. - Joints lose their flexibility and may be further immobilized by arthritic changes. - More than half of all older people have some form of arthritis. - A decrease in the amount of muscle mass often results in less strength.

Changes in the Immune System

- With increasing age, systemic and cellular immune responses become less effective at fighting infection. - Although many older patients will not develop fevers, they may be hypothermic as a manifestation of severe systemic infection. - Anorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptoms of infection in these patients. - Pneumonia and urinary tract infections are common in patients who are bedridden. - When infection occurs, signs and symptoms may be decreased or minimized by the patient because of a loss of sensation, lack of awareness, or fear of being hospitalized.

Pathophysiology of the Cardiovascular System (continued) : Myocardial Infarction (heart attack)

-As many as one-third of older patients have "silent" heart attacks in which the usual chest pain is not present. - Do not assume that a patient is not having a myocardial infarction because he or she does not report the classic, pressure-type, substernal chest pain. - Any of the following symptoms may be a manifestation of acute cardiac disease in the older patient and should be evaluated by ALS personnel for an underlying cardiac disorder: > Dyspnea > Epigastric and abdominal pain > Loss of bladder and bowel control > Nausea and vomiting > Weakness, dizziness, light-headedness, and syncope > Fatigue > Confusion - Other signs and symptoms that can indicate a cardiovascular problem include: > Issues with circulation > Diaphoresis (profound sweating) > Pale, cyanotic, or mottled skin > Abnormal or decreased breath sounds > Increased peripheral edema (swelling) - Obtain baseline vital signs to get an initial picture of the severity of the patient's condition. - At the EMT level, treatment mostly consists of airway, ventilatory, and circulatory support. - Give oxygen with adjuncts appropriate to the patient's condition. > Some EMS system protocols allow EMTs to administer aspirin or assist patients with the administration of medications such as nitroglycerin. - Continue to evaluate the patient's response to treatment through reassessment.

Toxicology

-Pathophysiologic changes that cause older people to be susceptible to toxicity include: > Decreased kidney function > Altered gastrointestinal absorption > Decreased vascular flow in the liver that alters metabolism and excretion - The rate of filtration in the kidneys decreases an average of 50% between the ages of 50 and 90 years. - Decreased liver function makes it harder for the liver to detoxify the blood and eliminate substances such as medications and alcohol. > These metabolic issues can make it difficult for physicians to find the appropriate dosage for new medications. - Many people believe OTC medications and herbal supplements are not dangerous, but these medications can have negative effects when mixed with each other and/or with alcohol and prescription medications.

Pulmonary Embolism

A condition in which a venous clot causes a sudden blockage of the pulmonary artery.

Arteriosclerosis

A disease that causes the arteries to thicken, harden, and calcify.

Syncope

A fainting spell or transient loss of consciousness.

Kyphosis

A forward curling of the back caused by an abnormal increase in the curvature of the spine.

Osteoporosis

A generalized bone disease in either sex, but commonly associated with postmenopausal women, in which there is a reduction in the amount of bone mass, leading to fractures after minimal trauma.

Abdominal Aortic Aneurysm (AAA)

A rapidly fatal condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the vessel, causing it to bulge.

Jugular Vein Distention

A visual bulging of the jugular veins in the neck that can be caused by fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax

Special Populations

Alzheimer disease is a common cause of dementia. Although its cause is unknown, this disease results in loss of brain tissue. Symptoms include memory loss, lack of spontaneity, subtle personality changes, disorientation, impaired thinking, restlessness, agitation, wandering, impaired judgment, and inappropriate social behavior. In late stages of the disease, patients exhibit indifference to food, an inability to communicate, incontinence, and seizures. Patients with Alzheimer disease may live at home with a spouse or child who is also the caregiver, or they may live in a specialized nursing facility. As with all patients, you must treat patients with Alzheimer disease with patience and respect.

Ascites

An abnormal accumulation of excess fluid in the peritoneal cavity.

Anatomic Changes and Fractures: Words Of Wisdom

An inability of the blood to clot normally can become a big issue in trauma and will be seen in patients who take warfarin (Coumadin), apixaban (Eliquis), or other blood-thinning medications.

pneumonia

An infectious disease of the lung that damages lung tissue.

Cataracts

Clouding of the lens of the eye or its surrounding transparent membranes.

The GEMS Diamond

G: - Geriatric patients - When responding to an emergency involving an older patient, you should consider that older patients are different from younger patients and may present atypically. - Be familiar with the normal changes of aging and treat older patients with compassion and respect. E: - Environmental assessment - Assessment of the environment can help give clues to the patient's condition and the cause of the emergency. > Is the home too hot or too cold? > Is the home well kept and secure? > Are there hazardous conditions? - Preventive care is also very important for a geriatric patient, who may not carefully study the environment or realize where risks exist. M: - Medical assessment. - Older patients tend to have a variety of medical problems and may be taking numerous prescription, OTC, and herbal medications. - Obtaining a thorough medical history is very important in older patients. S: - Social assessment - Older people may have a smaller social network because of the death of a spouse, family members, and friends. - Older people may need assistance with activities of daily living (ADLs), such as dressing and eating.

Toxicology: Street Smarts

Many supplements are safe, but some can pose a risk. For example, St. John's wort can create serious symptoms when mixed with antidepressants, and ginkgo biloba should not be taken with blood thinners such as warfarin due to a potential increased risk of bleeding.

Pathophysiology of the Respiratory System: Street Smarts

Placing a mask on a patient with a respiratory infection such as pneumonia, tuberculosis, or COVID-19 helps stop the transmission of the pathogen, but it can also increase the patient's difficulty breathing and produce anxiety. Consider placing the mask over the nonrebreathing mask.

Dyspnea

Shortness of breath or difficulty breathing.

Geriatrics

The assessment and treatment of disease in someone who is age 65 years or older.

Deep Venous Thrombosis

The formation of a blood clot within the larger veins of an extremity, typically following a period of prolonged immobilization.

orthopnea

difficulty breathing when lying down