EMT: Chapter 35 [geriatric emergencies]
MI
"silent" MIs common in women and people w diabetes (1/3 of all) symptoms: - dyspnea - abdominal pain - loss of bladder/bowel control - nausea/vomiting - dizziness & syncope - fatigue - confusion
signs of physical abuse
- bruises on ears, buttocks, lower back, genitals, inner thighs, etc. - pressure bruises (pinch marks, handprints) - bites on extremities - burns from cigarettes, matches, etc. - failure to thrive (look at weight, appetite, medication) - neglect (poor hygiene, poor temperature regulation, lack of amenities in the home)
changes to vision
- cataracts - drier eyes - inability to differentiate colors - eyeglasses - glaucoma (damage to optic nerve) - macular degeneration (deterioration in central retina) - retinal detachment (retina pulls away from choroid)
how to perform a trauma assessment
- check if medical conditions may have been responsible (especially in single vehicle crashes, falls) - suction and place supine - put padding under spinal curvature - check for evidence of a pacemaker or previous cardiac surgery - check for signs of beta blocker medication (would cause no tachycardia in shock) best splinting mechanisms = vacuum mattresses - pad everywhere to decrease likelihood of bed sores - consider KED for pts with CHF
leading causes of death in geriatric pts
- heart disease - cancer - COPD - stroke - Alzheimer's - diabetes - influenza, pneumonia
common conditions in geriatric pts
- hypertension - arthritis - heart disease - cancer - diabetes - asthma - chronic bronchitis/emphysema - stroke
tips for interviewing an older pt
- identify yourself - avoid showing frustration or crossing your arms - look pt at eye level - speak slowly and distinctly in a lower voice - have one person talk to pt, asking one question at a time - do not assume all older pts are hard of hearing - give pt time to respond - listen to answer pt gives you - explain everything - do not talk about pt in front of them
how to complete a secondary assessment:
- look for normal HR - look for higher than normal BPs (normal adult range in elders can indicate stroke) vitals: - cap refill NOT a good assessment - pulse oximetry will likely not be accurate due to lack of perfusion make sure to keep pt warm and not to remove dentures unless necessary
depression
3x more common in women higher suicide rate in geriatric population signs can mimic dementia risk factors: history of depression, chronic disease, loss of function
You are working on a geriatric patient who reports severe abdominal pain radiating through her back and flank. She also reports discomfort in her right leg and your assessment reveals a diminished pulse in the extremity. What should you suspect?
AAA
kyphosis
AKA hunchback forward curling of the spine in 2/3 older pts
DKA & HHNS
DKA: overproduction of ketones -> ketosis HHNS: hyperglycemia does not cause ketosis (b.g. > 600 mg/DL) signs/symptoms: - hyperglycemia - polydipsia - polyuria - polyphagia - altered mental status - seizures
GEMS diamond
G: geriatric E: environmental (room too hot or cold, well kept or secure) M: medical (medications may mask assessment findings) S: social
Which of the following groups are most likely to commit suicide?
White males older than 85 years
Osteoporosis is defined as:
a decrease in bone mass and density
During the natural process of aging, the number of functional cilia in the respiratory system decreases, resulting in:
a decreased ability to cough
arteriosclerosis
a disease that causes the arteries to thicken, harden and calcify -- contributes to systolic hypertension in older pts people limit physical activity when older complications: hypertension, MI, stroke, heart disease
You receive a call for a sick person. When you arrive, you find the patient, a 75-year-old male, lying unresponsive in his bed. His respirations are slow and irregular and his pulse is slow and weak. His daughter tells you that he fell the day before, but refused to allow her to call 9-1-1. His past medical history is significant for hypothyroidism, deep vein thrombosis, heavy alcohol use, and liver cirrhosis. His medications include blood thinners and vitamins. You should be MOST suspicious that this patient is experiencing:
a subdural hematoma
delirium
a sudden change in mental status, consciousness, or cognitive processes marked by inability to focus, think logically, and maintain attention acute onset due to reversible physical ailment look for: - intoxication or alcohol withdrawal - sedative withdrawal - conditions like UTI - psychiatric disorders like depression - malnutrition - environmental emergencies
An 84-year-old male fell a week ago and has been bedridden since then. Today, he presents with an altered mental status. His skin is pale and cold and his respirations are rapid and shallow. The EMT should suspect:
a systemic infection
When assessing an older patient who has multiple bruises in various stages of healing, the EMT should do all of the following, EXCEPT:
accuse a caregiver of physical abuse
Which of the following would be part of the "S" component of the GEMS diamond?
activities of daily living
Which of the following is a nonpreventable factor in stroke?
age
changes in the respiratory system
air trapping: alveoli in lung tissue enlarge and elasticity decreases -> reduced gas exchange ability chemoreceptors slow (less response to hypoxia) loss of mechanisms to protect upper airway (i.e. coughing, gagging) and decreased number of cilia
Common causes of depression in the elderly include all of the following, EXCEPT:
an acute onset of dementia
A 73-year-old female experienced a syncopal episode while watching TV. She is now conscious, but is diaphoretic, tachycardic, and hypotensive. Your assessment reveals abdominal tenderness and a pulsating mass to the left of her umbilicus. You should suspect:
an aortic aneurysm
Because of the complexity of the older patient and the vagueness of his or her complaint, you should:
attempt to differentiate between chronic and acute problems
VRE
bacteria present in human intestines and female reproductive tract
C diff
bacterium responsible for the most common cause of hospital-acquired infectious diarrhea and sporadic cases of diarrhea in nursing homes can be found on environmental surfaces organism not inactivated by alcohol-based sanitizers
DVT
blood clots in deep veins caused by loss of proper functions in leg circulation in older people
changes in the musculoskeletal system
brittle bones decreased height due to narrowing between vertebrae less flexible joints due to arthritic changes (> 50% of older people) decreased muscle mass *all decrease person's ability to breathe effectively
Clouding of the lenses of the eyes is called:
cataracts
suicide
caucasian men > 65 y.a. are 8x more likely than women - highest in 85 y.a. and older suicide rate in Caucasian male elders 2x all other males rate of completed suicide very high
Syncope in the older patient is
caused by an interruption of blood flow to the brain
syncope
caused by interruption of blood flow to the brain due to: - dysrhythmias and MI (heart beating too fast/slow) - vascular, volume changes (venous pooling, hidden bleeding) - neurologic issues (ex. TIA, stroke)
As a person ages, the heart may enlarge as a result of
chronically increased afterload
Many patients do not present with ____________ when experiencing a heart attack.
classic chest pain
peptic ulcer disease
common in NSAID-using older adults burning pain in upper abdomen upon eating
changes in the cardiovascular system
compliance of vascular walls depends on production of collagen and elastin (too much collagen -> stiffening -> higher systolic BP) degradation of heart valves impedes blood flow heart's electrical conduction system altered (SA node function decreases by 90%) orthostatic hypotension (drop in BP as much as 20 mm Hg due to change in position) venous stasis - edema - aching, tiredness in legs - skin discoloration *lower, weaker HRs w/ irregular pulses are common
diverticulitis
condition in which the walls of the gut weaken and small pouches protrude from the colon in weakened segments -> inflammation
osteoporosis
decrease in bone mass leading to reduction in bone strength and greater susceptibility to fracture; reduction in cartilage 35-45% of older pts risk factors: genetics, smoking, sedentary lifestyle, diet, alcohol consumption, body weight
changes in the immune system
decreased ability to fight infections systemic infection -> hypothermia pneumonia and UTIs common in bed-ridden pts
changes in the nervous system
decreased brain weight (10-20%) - increases possibility for head injuries 5-50% loss of neurons - rate of breathing, HR, BP, hunger/thirst/BT are less easily controlled
In arteriosclerosis, overproduction of abnormal collagen and decreased quantities of elastin lead to what?
decreased coronary artery perfusion
changes to taste & touch
decreased sense of taste -> less hunger -> malnutrition decreased sense of touch -> less pain/sensation of temperature -> delayed response to pain
elder abuse
defined as any action on the part of an older person's family member, caregiver, or associated person that takes advance of the older person's person, property, or emotional state acts of commission vs. omission possible abusers: - are products of child abuse - are upset by constant demands of elders - are fatigued - are unemployed - have substance abuse issues suspect when... - elders conceal what caused the injury - they give unbelievable answers
_______________________ are both abnormal processes and must be carefully evaluated in geriatric patients
dementia and delirium
how to assess a pt's history:
determine baselines for mental status and vital signs assess whether chief complaint is related to a chronic medical problem
You are dispatched to a skilled nursing care facility for an 80-year-old female with abnormal behavior. The patient is clearly confused and asks you if you are her husband. You should
determine the pt's baseline mental status
Upon arriving at the residence of an elderly female who apparently fainted, you find the patient lying supine on her living room floor. She is not moving and her eyes are closed. A neighbor tells you that she found the patient this way but did not move her. When you gently tap the patient, she does not respond. You should:
direct your partner to manually stabilize her head while you quickly visualize her chest for signs of breathing
neuropathy
disorder of the nerves of the PNS in which function and structure of PMS functions are impaired different types of impairment: - motor neurons: weakness, spasms, loss of coordination - sensory neurons: tingling, numbness, extreme sensitivity to touch - autonomic: issues with involuntary functions like BP, HR, constipation
On auscultation of a patient's lungs, you hear crackles. These lung sounds are caused by air passing through what?
fluid in the alveoli
Good general communication techniques with the elderly includes
frequently asking the pt if he/she understands
thermoregulation
heat gain/loss is delayed due to slowed circulation and decreased sweat production deaths from hyperthermia x2 greater in older people
The purpose of the GEMS diamond is to
help EMS personnel remember what is different about elderly pts
fractures
hip fractures common from fall due to osteoporosis - can also be caused by ordinary life stresses - can be reoccurring also likely: - pelvic fractures (low-energy mechanism or standing falls) - compression fractures of spine - acute subdural hematomas (deadly because they go unnoticed) complicated by: - lack of vitamin D and calcium - metabolic bone diseases - tumors - anticoagulants
Which of the following questions should you ask if you suspect a patient may have congestive heart failure?
how many pillows do you normally sleep on?
Which of the following is NOT a reason why the exact extent and prevalence of elder abuse is unknown?
human resource agencies fall to investigate
changes in the endocrine system
hypothyroidism (reduction in thyroid hormone), increase in ADH, hyperglycemia signs: - slower HR - fatigue - dry skin/hair - cold intolerance - weight gain
bleeding in the upper GI tract
in esophagus, stomach, duodenum can be due to NSAID users or alcoholics OR cancer leads to forceful vomiting
MRSA
infection common among people who live in close quarters like nursing homes organisms can be found on bedsores, feeding tubes, urinary catheters spread by broken skin-to-skin contact
pneumonia
inflammation of the lung from bacterial, viral or fungal causes leading cause of death from infection in Americans older than 65 y.a. increased risk by aging processes that decrease immunity (increased mucus production, pulmonary secretions, inflammatory response)
An abdominal aortic aneurysm:
is often the result of hypertension and atherosclerosis
In contrast to delirium, dementia:
is usually considered irreversible
changes in the renal system
kidney: - reduced renal function - reduced renal blood flow (by 50%) - reduced weight (6-7 oz) genitourinary: - decreased bladder capacity - decline in muscle control (incontinence) - decline in voiding senses, increase in nocturnal voiding - urinary retention - enlarged prostate
Which interview technique should you use when addressing a geriatric patient?
listen carefully to the answers the pt provides
Which of the following is true regarding delirium?
memory remains intact
bleeding in the lower GI tract
occurs in colon or rectum
Which of the following statements regarding suicide in the older patient is correct?
older pts tend to use more lethal means than younger pts
changes in the GI system
oral and gastric secretions reduced poor muscle tone in smooth muscle sphincter b/w esophagus and stomach (causing regurgitation, heartburn) slower gastric emptying, nutrients not readily absorbed changes to hepatic system slows activity of detoxifying enzymes slower peristalsis -> constipation bleeding, either via hematemesis or melena signs of disease: - pale or yellow skin - frail muscles - edema - hypertension
You are assessing an 80-year-old patient who explains that he was awakened by a sudden feeling of suffocation and respiratory distress. What are his symptoms a characteristic of?
paroxysmal nocturnal dyspnea (caused by fluid accumulation in lungs)
DNR
permission not to attempt resuscitation for a pt in cardiac arrest IF form signed by pt/legal surrogate and a physician you still should provide supportive measures if pt still alive
Poor maintenance of home, poor personal care, and dietary neglect are all possible indicators of ____________ elder abuse.
physical
signs of elder abuse
physical - assault - neglect or abandonment - malnutrition - poor maintenance of home - poor personal hygiene - sexual assault psychological - benign neglect - verbal - treating person like an infant - deprivation of sensory stimulation financial - theft of valuables - embezzlement
A productive cough, fever, and chills in an 80-year-old patient with a compromised immune system should make you MOST suspicious for:
pneumonia
Sedentary behavior while healing from a hip fracture would MOST likely predispose the older patient to
pneumonia
The use of multiple prescription drugs by a single patient, causing the potential for negative effects such as overdosing or drug interaction, is called:
polypharmacy
changes to hearing
presbycusis: age-related hearing loss check for use of hearing aids
decubitis ulcers
pressure ulcers that form when a pt is lying or sitting in the same position for a long time - weight of body cuts of blood flow to skin - can develop in as little as 45 min 4 stages: I: redness II: blister/ulcer III: invasion of fat layer IV: invasion of muscle/bone
When performing your secondary assessment on an older patient who has been injured, it is important to:
recall that it will take a less severe mechanism of injury to cause significant injuries
Blood levels of medications may rise in the elderly, sometimes to toxic levels. This is MOST likely due to:
renal insufficiency
toxicology
risk factors for toxicity: - decreased kidney function (by 50%) - altered GI absorption - decreased blood flow to liver (less elimination of medication and alcohol) - polypharmacy (use of multiple prescription medications) polypharmacy -> OD, negative medication interactions medical non-compliance also an issue
pulmonary embolism
risk factors: nursing home life, recent hospitalization pts present with: - tachycardia - dyspnea (sudden) - shoulder, back, chest pain - cough - syncope - hemoptysis - leg/ankle/foot pain or swelling
stroke
risk factors: smoking, hypertension, diabetes, atrial fibrillation, obesity signs: - LOC - numbness/paralysis on one side - slurred speech/aphasia - visual disturbances - headache/dizziness - incontinence - seizure hemorrhagic vs. ischemic (more common, less fatal) TIA can have same signs/symptoms
trauma
risk for serious injury due to: - slow homeostatic mechanisms - effects of aging - medical conditions - renal compromise (issues with fluid replacement) 1/2 of falls result in a TBI
gallbladder disease
risk of complications from gallstones cholecystitis (inflammation of the gallbladder): fever, RUQ pain that radiates jaundice
aneurysm
severe blood loss can occur when it ruptures
You are dispatched to a residence for an 80-year-old female who fell. When you arrive, you find the patient conscious, lying in a recumbent position on the floor in her living room. In addition to providing the appropriate treatment, you should ask the patient if:
she became dizzy or fainted before falling
dementia
slow onset of progressive disorientation, shortened attention span, and loss of cognitive function result of Alzheimer's, Parkinson's, cerebrovascular accidents, genetics
bowel obstruction
straining for a bowel movement can cause syncope upon stimulation of the vagus nerve
The EMT should suspect left-sided heart failure in the geriatric patient who presents with:
tachypnea and paroxysmal nocturnal dyspnea
abdominal aortic aneurysm
tends to develop in people with hypertension and atherosclerosis when walls of the aorta weaken and blood leaks into layers of the vessel, causing it to bulge signs: - abdominal pain radiating to back with occasional flank pain - pulsating mass above and left of navel
In contrast to younger patients, older patients are more prone to a decrease in blood pressure (BP) upon standing because:
the body is less able to adapt the BP to rapid postural changes
When caring for a geriatric patient with a traumatic injury, it is important to consider that:
the injury may have been preceded by a medical condition
Which of the following statements regarding the aging process is correct?
the process of aging is gradual, and the rate at which a person loses function does not increase with age
In contrast to a living will, a "do not resuscitate" (DNR) order becomes valid when:
the pt develops cardiac arrest
A 77-year-old female presents with an acute onset of altered mental status. Her son is present and advises that she has a history of hypertension, atrial fibrillation, type 2 diabetes, and glaucoma. He further advises that she takes numerous medications and that she is normally alert. When you assess this patient, it is important to note that:
the pt is experiencing delirious behavior, which suggests a new health problem
RSV
transmitted by direct contact with droplets from coughs or sneezes and by touching a contaminated surface respiratory infection with symptoms similar to cold that are more severe and last longer typically seen in children but can affect immunocompromised adults
right-sided heart failure
when fluid backs up into the body; often caused by left-sided signs: - jugular vein distention - ascites (abdominal fluid) - peripheral edema
left-sided heart failure
when fluid backs up into the lungs - pulmonary edema (w/ SOB, hypoxia) - nocturnal dyspnea - respiratory distress ask "do you sleeping sitting up?"
