Geriatric Introduction by shuifanglj

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									  Geriatrics

Provena Regional EMS
Who is the oldest person you know?

 How is this older person
  different than someone
  younger?
 How should EMS
  approach the assessment
  of an older person?
True or False
 Medical achievements have increased
  life expectancy but not life span.
 Older people are living healthier for
  longer.
 Aging begins with
decline at the cell
level.
 The majority of older people over the
 age of 65 live at home not in assisted
 living or nursing home institutions.
 Changes from aging do not increase our
 vulnerability to die, but predispose us to
 disease.
 Aging involve a loss in the ability to
  maintain homeostasis, or a constant
  internal environment.
 The leading cause of death in people
  over the age of 65 is cardiovascular
  disease.
 Most elderly people have progressive
  hypoxemia.
 Elderly adults lose up to 45% of their
  brain cells over time.
 Even if they do not have diagnosed
 diabetes, most elderly are glucose
 intolerant and have slowed insulin
 response that will lower blood sugar
 levels in stressful situations.
Believe it or not

All of these
 statements are true.
New Old Age
 Older people are not as old as they
  used to be.
   More Active
   Healthier




 Sixty Five is the new Fifty
 Eighty is the new Sixty Five
2009 Advanced Directives/Living Will
(according to some Young/Old)
 I, Marilyn, being of sound mind and
 body, do not wish to be kept alive
 indefinitely by artificial means.
 Under no circumstances should my fat
 ass be put in the hands of pinhead
 politicians who could not pass ninth
 grade biology if their lives depended on
 it,
 Or lawyers and/or doctors interested in
 simply running up the bills.
 If a reasonable amount of time passes
  and I fail to ask for at least one of the
  following:
 Glass of wine
 Chocolate




 Margarita
 Martini




 Cold beer
 Chocolate




 Steak
 Chocolate




 Gravy
 Chocolate




 Mexican food
 Chocolate




 French Fries
 Chocolate




 Pizza
 Chocolate




 Ice cream
 Chocolate




 Vanilla Latte
 Chocolate




Sex
 Chocolate




 It should be presumed that I won’t get
 any better.
 When such a determination is reached,
 I hereby instruct my appointed person
 and attending physicians to pull the
 plug, reel in the tubes, turn off the lights
 and call it a day. I’m done.
Advice from Aunt Maude aged 94:

 Always eat dessert first in case you die
 during dinner.
But seriously
 How do we age and why do we age?
 “We are like an old Chevy, if you take
  care of it, it will run until you are out of
  replacement parts.” -- there are limited
  replacement parts.
 Never intended to last
 more than 50-60 years
What is aging? – begins as young as age 20
 Loss of ability to adapt to change or
  stressors
 Loss of ability to maintain a constant
  environment in the body
 Loss of ability to fight off disease
Aging – same way a car ages
 Deterioration of connective tissues
   Arteries   and veins –like hoses and pipes in a car
   Skin – body of the car
   Bones – frame of the car
   Fat – upholstery
   Ligaments,      tendons, cartilage – shocks and
    suspension (anything made of plastic or rubber)
Loss of warranty

 Dries up, cracks or falls apart
Who are geriatrics?
 Geriatric patients are individuals older
  than 65 years of age.
 In 2000, the geriatric population was
  almost 35 million.
 By 2020, the geriatric population is
  projected to be greater than 54 million.
Why are there more old people?
 Life expectancy increases from
    1935 68 years
    2009 78 years men   84 years women

 Baby boomers (born 1945-1964) getting
 older
   Healthierall their lives
   Fewer diseases that kill at a young age
Common Stereotypes
 Common
  stereotypes
  include mental
  confusion, illness,
  sedentary
  lifestyle, and
  immobility
 Older people can
  stay fit; most
  older people lead
  very active lives.
Older Active Adults
 Some age 80 look and act age 65
 Some age 65 look and act age 80
Oldest of the Old
 Over age 85
 Real problems begin
 Unable to cope with
 any stressors on body
   Flu
   Injury
   Low   oxygen
Geriatrics –our major customer base
 Older people are major users of EMS
  and health care in general.
 Effective treatment will require an
  increased understanding of geriatric
  care issues.
Geriatric Assessment
  Geriatric assessment has unique
   challenges.
  The GEMS diamond can be a helpful
   tool.
  Preexisting conditions may affect
   findings.
The GEMS Diamond
       Geriatric patients:
        Normal aging, atypical
        presentation
       Environmental
        assessment: Safety,
        neglect
       Medical assessment:
        Past history,
        medications
       Social assessment:
        Basic needs, social
        network
Geriatric patients:
 Normal aging
 Atypical presentation


   Does the person look their age?
   Older?
   Younger
Environmental assessment

 Safety
 Neglect




   Where are they living?
   How are they living?
Medical assessment:
 Past history
 Medications




 What conditions do they have all the
  time?
 Is there something new?
Social assessment
 Basic needs
 Social network




 What and who are their support
 systems?
Communications




Older patients may need a little more time
to process your question.
Communications
  Show the patient respect.
  Position yourself at eye level in front of the
   patient.
  Speak slowly and distinctly.
  Give the patient time to answer.
  Be patient.
Changes of Aging
 Aging is changes of the body tissue
 beginning at the cell level.
Physiologic Changes
    Skin
      Susceptibleto injury;
      longer healing time
    Senses
      Dulling   of the senses
    Respiratory system
      Decreased    ability to exchange
      gases
Physiologic Changes
  Cardiovascular system
    Increased risk of
     cardiovascular disease
  Renal system
    Decline in kidney function
  Nervous system
    Memory impairment, decreased
     psychomotor skills
Physiologic Changes
  Musculoskeletal system
    Decrease  in muscle mass
     and strength
  Gastrointestinal system
    Decrease  in ability of body to digest
     food properly
Polypharmacy

 Older people account for a large portion of overall
    medication usage.
   Many medications can have interactions or counter
    actions when taken together.
   Polypharmacy refers to the use of multiple
    prescriptions by a single patient.
   Too many doctors, too many pharmacies too many
    drugs
   Polypharmacy = 30% of geriatric hospital admissions
Geriatric Assessment
 Same assessment format
 High index of suspicion
Scene Size Up
 Be keenly aware of the
  environment and why you were called.
 Scene safety should include
  looking for unsafe conditions.
 Look for hazards.
   Steep stairs, missing handrails, poor
   lighting, other fall hazards, loose rugs
              Scene Size-up (2 of
              2)




 The general condition of the home will provide clues.
      Cleanliness, heat, lighting, food

 Look for signs of activities of daily living.
      Personal hygiene, getting dressed, food
       preparation

 Scene size-up continues throughout call.


 How are they coping?
Initial Assessment
 Never assume altered mental status is
  normal.
 May have to rely on family or caregiver to
  establish patient’s baseline LOC
 Assess the patient’s chief complaint and
  ABCs.
Focused History and Physical
 History is usually the key in helping to assess
  a patient’s problem.
 Patience and good communication skills are
  essential.
 Treat the patient with respect.
 Face the patient and speak in a normal tone.
Don’t forget Polypharmacy
 Medication history
   Often have multiple medications
   Obtain a list of medications and doses.
   Ask about medications recently started or
    stopped.
   Determine if the patient has taken other
    medications.
The average geriatric patient takes
 four or more medications.
Ongoing Assessment
 Normal aging may affect physical findings.
   Increased BP, respiratory changes

 Chronic changes can mask acute problems.
 Ongoing assessments will help determine
  changes.
     Geriatric patients have decreased ability to
      compensate for illness
Leading Causes of Death
   Heart disease
   Cancer
   Stroke
   COPD and other respiratory
    illnesses
   Diabetes
   Trauma
Common Complaints
   Dyspnea         Fever
   Chest pain      Trauma
   Altered mental  Falls
    status          Generalized pain
   Dizziness or    Nausea, vomiting,
    weakness         and diarrhea
Geriatrics and Trauma

 An older patient may have
  decreased ability to localize even
  simple injuries. – walking on a
  broken hip
 Assessment must include all past
  medical conditions. Why did you
  fall?
Trauma Assessment
 Common mechanisms of
 injury
   Falls
   Motor vehicle trauma
   Pedestrian accidents
   Burns
Trauma Assessment
 Priorities in rapid trauma are the same.
 Confounding factors:
   Medical conditions or previous injuries
   Dentures or other dental implants
   Decreased ability to compensate
   Changes associated with aging
   (30% of hip fracture patients are dead
    within 90 days)
Injuries to the Spine
 Classified as stable or
  unstable
 Osteoporosis is a
  contributing factor to
  spinal injuries.
 Prompt spinal
  immobilization can
  reduce further damage
  and pain.
    Pad void spaces.
Head Injuries
 Assume a significant
  injury in older patients
  who have signs and
  symptoms of head
  injury.
 Suspect brain injury in
  patients who take blood
  thinners and who suffer
  head injury.
 Maintain oxygen delivery
  to brain.
 Injuries to Pelvis and
 Hip Fractures
 Often present as hip or buttock pain
 Pelvic ring disruption can lead to
  hemorrhage or internal organ injury.
 Hip fractures:
      Common debilitating injury
      Maintain leg in static position
       to prevent further injury.
Hip Fracture




   Blanket rolls maintain the leg in a static
   position so that further injury does not
   occur.
Elder Abuse
 This problem is largely hidden
  from society.
 Definitions of abuse and neglect
  among older people vary.
 Victims are often hesitant to
  report an incident.
 Signs of abuse are often
  overlooked.
Assessment of Elder Abuse
 Repeated visits to the emergency
  room
 A history of being “accident prone”
 Soft-tissue injuries
 Vague explanation
  of injuries
 Signs of abuse may
  be obvious or subtle.
Elder Abuse
Physical Abuse
Financial Abuse
Emotional Abuse
     Isolation
Neglect
     Medical care
     Medications
     Food
Assessment of Elder Abuse

 Chronic pain
 Self-destructive behavior
 Eating and sleeping disorders
 Depression or a lack of energy
 Substance and/or sexual abuse
Medical Emergencies
 Determining chief complaint is
 challenging.
   Multiple
           conditions and complaints
   Ask what bothers them most today.
 Sensation of pain may be diminished.
 Fear of hospitalization
 Conditions may present differently --
 vauge
Cardiovascular Emergencies
 Classic symptoms are often not present.
 Many have “silent” heart attacks.
 Common signs and symptoms
   Difficulty
             breathing
   Toothache
   Arm pain
   Back pain
Dyspnea
 Related to many causes
   Asthma
   COPD
   Congestive   heart failure
   Pneumonia

 Provide oxygen for all patients
 experiencing dyspnea.
Syncope -- dizziness
 Can occur for many reasons
 in geriatric patients
   Standing  up too fast
   Straining to have bowel
    movement
   Myocardial infarction
   Diabetic shock
   Dehydration
   Irregular heart beat
Altered Mental Status
 Acute onset is not normal in any patient.
 Most sudden changes are caused by a
  reversible condition.
 Evaluate and treat for hypoxia or
  hypoglycemia if present.
Confusion is not normal!!!
New onset confusion is a
 serious sign of a medical
 emergency!!
Altered Mental Status
  Delirium
    Recent onset
    Usually associated
   with underlying cause
  Dementia
    Develops slowly over a period of years
    Alzheimers
Psychiatric Emergencies
  Depression is common among older
   adults Too many funerals, too few friends, isolation
  Physical pain, psychological
   distress, and loss of loved ones can
   lead to depression.
  Women are more likely to suffer
   depression.
Psychiatric Emergencies
 Older men have the highest
  suicide rate.
 Older patients use much
  more lethal means.
 EMT-Bs should consider all suicidal
  thoughts or actions to be serious.
Acute Abdomen
Older patients with
abdominal pain have
higher chances of
hospitalization,
surgery, and death
than younger
patients.
Acute Abdomen
   Acute abdominal aneurysm
     Walls of the aorta weaken.
     Treat for shock and provide prompt
      transport.
   Gastrointestinal bleeding
     Blood in emesis
     Blood in stools
     May cause shock
Acute Abdomen
 Complaints of abdominal pain in older
  patients usually indicate a serious
  event.
 Nervous system response to pain is
  lessened.
 Consider gastrointestinal problems or
  abdominal aortic aneurysm.
Septicemia 90% fatal
 Results from presence of
  microorganisms or their toxic products
  in bloodstream --
 Patients may present with:
   Hot, flushed appearance
   Tachycardia and tachypnea
   Hypotension
   Chills, cough
Response to Nursing and
Skilled Care Facilities
 Important information to know from
 staff:
   What  is the patient’s chief complaint
    today?
   What initial problem caused the
    patient to be admitted to the facility?
 Ask the staff about the patient’s
  overall condition.
 Obtain any type of transfer papers.
 Advance Directives
 Do not resuscitate (DNR) orders give you
  permission not to attempt to resuscitate.
 DNR does not mean “do not care”!
 You should know state and local protocols
  regarding advance directives.
 When in doubt, initiate
  resuscitation.
To Learn More About the Elderly

 Recommended movies:
   Second   Hand Lions
   Up
                   Review
 Answer the following questions as a group.
 If doing this CE individually, please e-mail
  your answers to:
 shelley.peelman@provena.org
 Use “September 2010 CE” in subject box.
 You will receive an e-mail confirmation. Print
  this confirmation for your records, and
  document the CE in your PREMSS CE record
  book.
Post Quiz
 1. Aging can be described as:
   A.  A chronic disease state
   B. Loss of functional reserve to respond to
    illness or injury
   C. Increases of body water with decreases
    in body mass.
   C. Increased metabolism with decreasing
    caloric intake.
2.
2.    Fred is 80 years old and lives at home with is
      sister. Fred has called you to his house on a
      February morning because he feels weak and
      dizzy. Fred’s vague symptoms could be caused
      by:
     A. GI bleeding
     B. Hypoglycemia
     C. Myocardial infarction
     D. Hypothermia
     E. Sepsis
     F. All of the above
3.
3.
3.   Fred’s sister tells you he is hard of hearing. The
     best way to facilitate communications with Fred is
     to:
     A. Get very close to Fred and shout in his good
     ear.
     B. Make sure you have good eye contact with
     freed and speak clearly and slowly
     C. Whisper directly at Fred so that it is easy for him
     to lip read.
     D. Talk only with Fred’s sister so you don’t
     frustrate Fred.
4.
 Fred’s sister says he was fine yesterday
 and today his is confused. This is an
 example of:
 A. Early onset senility
 B. Dementia, which is a permanent
 condition.
 C. Delirium, which will go away when
 Fred’s medical problem is corrected
 D. Alzheimer’s disease
5.
 Fred has a bag containing bottles of
 medications from 3 different
 pharmacies, from 3 different doctors.
 This situation is called:
 A. Polypharmacy
 B. Multipharmacy
 C. Endopharmacy
 D. polydose
True/False
 6. A legal document prepared when a
  person is well, competent, and able to
  make informed decisions about future
  health care needs is called an advanced
  directive.
 7. Individuals over the age of 85 are
  referred to as the “young-old”.
8. The most common fall related
fracture in the geriatric population is the
clavicle.
9. Many elderly are complicated to
assess because they have more than 1
disease process going on at the same
time.
10. Unlike younger cardiac patients, the
elderly are more likely to suffer from a
silent or “painless” heart attack.
Answers
 1.   B       2.    F
 3.   B       4.    C
 5.   A       6.    True
 7.   False   8.    False
 9.   True    10.   True
Live Long and Prosper

								
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